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Bikram yoga is a style of hatha yoga involving a standarized series of asanas performed to an instructional dialogue in a heated environment (40.6°C, 40% humidity). Several studies evaluating the effect of Bikram yoga on health-related outcomes have been published over the past decade. However, to date, there are no comprehensive reviews of this research and there remains a lack of large-scale, robustly-designed randomised controlled trials (RCT) of Bikram yoga training. The purpose of this review is to contextualise and summarise trials that have evaluated the effects of Bikram yoga on health and to provide recommendations for future research. According to published literature, Bikram yoga has been shown to improve lower body strength, lower and upper body range of motion, and balance in healthy adults. Non-RCTs report that Bikram yoga may, in some populations, improve glucose tolerance, bone mineral density, blood lipid profile, arterial stiffness, mindfulness, and perceived stress. There is vast potential for further, improved research into the effects of Bikram yoga, particularly in unhealthy populations, to better understand intervention-related adaptations and their influence on the progression of chronic disease. Future research should adhere to CONSORT guidelines for better design and reporting to improve research quality in this field.
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Review Article
The Effects of Bikram Yoga on Health: Critical Review and
Clinical Trial Recommendations
Zoe L. Hewett,1Birinder S. Cheema,1,2 Kate L. Pumpa,3and Caroline A. Smith2
1SchoolofScienceandHealth,WesternSydneyUniversity,CampbelltownCampus,Campbelltown,NSW2560,Australia
2e National Institute of Complementary Medicine, Western Sydney University, Campbelltown Campus,
Campbelltown,NSW2560,Australia
3University of Canberra Research Institute for Sport and Exercise, University of Canberra, Bruce, ACT 2617, Australia
Correspondence should be addressed to Zoe L. Hewett; @student.uws.edu.au
Received  July ; Revised  September ; Accepted  September 
Academic Editor: Hirofumi Tanaka
Copyright ©  Zoe L. Hewett et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Bikram yoga is a style of hatha yoga involving a standarized series of asanas performed to an instructional dialogue in a heated
environment (.C, % humidity). Several studies evaluating the eect of Bikram yoga on health-related outcomes have been
published over the past decade. However, to date, there are no comprehensive reviews of this research and there remains a lack
of large-scale, robustly-designed randomised controlled trials (RCT) of Bikram yoga training. e purpose of this review is to
contextualise and summarise trials that have evaluated the eects of Bikram yoga on health and to provide recommendations
for future research. According to published literature, Bikram yoga has been shown to improve lower body strength, lower and
upper body range of motion, and balance in healthy adults. Non-RCTs report that Bikram yoga may, in some populations,
improve glucose tolerance, bone mineral density, blood lipid prole, arterial stiness, mindfulness, and perceived stress. ere
is vast potential for further, improved research into the eects of Bikram yoga, particularly in unhealthy populations, to better
understand intervention-related adaptations and their inuence on the progression of chronic disease. Future research should
adhere to CONSORT guidelines for better design and reporting to improve research quality in this eld.
1. Introduction
Bikram yoga is a popular, standardized system of hatha
yoga developed by Choudhury [], and, today, there are
over  Bikram yoga studios worldwide []. ree factors
together distinguish Bikram yoga from other forms of hatha
yoga: () the set sequence of  asanas and two breathing
exercises (Figure ), () the heated environment (.C, %
humidity), and () the instructional dialogue. Every  min
class begins with standing pranayama (deep breathing)
followed by the standing asanas (– min, Figures (a)–
(l)). e standing sequence is followed by a  min savasana
(supine relaxation, i.e., corpse pose, Figures (l) and (m))
and a sequence of oor asanas (– min, Figures (n)–
(aa)). A -second savasana is taken between each asana
in the oor series. Class nishes with a seated kapalabhati
breathing exercise (i.e., quick, strong exhalations) and a nal
savasana. Choudhury suggests that the heated environment
helps warm and prepare the body for movement and assists
with removing impurities from the body [].
Several studies have investigated the eects of Bikram
yoga practice on health using various study designs [–];
however, to our knowledge, these studies have never been
synthesized and critiqued and, accordingly, there is no con-
sensus in the scientic literature regarding the eectiveness of
Bikram yoga on health. erefore, the purpose of this review
is twofold: () to summarize studies that have investigated
the eect of Bikram yoga practice on health-related outcomes
and()toproviderecommendationsforthedevelopmentof
more robust trials and novel research questions to address the
limitations of the existing literature.
2. Review of the Literature
Several studies have examined the chronic and acute eects
of Bikram yoga practice in apparently healthy adults [–,
Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2015, Article ID 428427, 13 pages
http://dx.doi.org/10.1155/2015/428427
Evidence-Based Complementary and Alternative Medicine
(a) (b) (c) (d) (e) (f) (g)
(h) (i) (j) (k) (l) (m)
(n) (o) (p) (q) (r)
(s) (t) (u) (v) (w) (x)
(y) (z) (aa)
F : Bikram yoga series.
, ] and obese adults []. Health-related outcome measures
that have been assessed include measures of physical tness,
cardiovascular disease risk factors, psychological health, pul-
monary function, sleep quality, bone density, and metabolic
cost.Onlyonetrialreviewedusedarandomisedcontrolled
trial (RCT) study design. A summary of these studies can be
found in Table .
2.1. Physical Fitness. Physical tness consists of ve health-
related domains (cardiovascular tness, muscular endurance,
muscular strength, exibility, and body composition) and
six skill-related domains (balance, reaction time, speed,
agility, power, and coordination) []. e health-related
components of physical tness are particularly interesting
as they are associated with better health status and QoL
and lower risk of chronic diseases, disability, and mortality
[–].
Four studies to date have evaluated the eect of Bikram
yoga training on measures of health- and/or skill-related
physical tness [–, , ]. Hart and Tracy [, ] exam-
ined the eects of an -week Bikram yoga intervention
( classes/week) on body composition, exibility, muscular
strength and steadiness (neuromuscular control), cardiores-
piratory tness (VO2max), and balance in  apparently
healthy adults. us far, this study is the only one to use
an RCT design. Participants were randomised to a Bikram
yoga group (𝑛=10)orcontrolgroup(𝑛=11)and
were instructed to maintain their current physical activity
and dietary habits during the study. Upon completion of the
-week intervention, the yoga group signicantly increased
lower body range of motion assessed by the standard sit-
and-reach test as compared to the control group (𝑝<
0.001). e yoga group signicantly improved balance, as
assessed by a single-leg balance test (𝑝 < 0.05), and
Evidence-Based Complementary and Alternative Medicine
T : Characteristics of Bikram trials reviewed.
Study
identication Country Sample
size
Population Sex
(M/F)
Mean age
(years) Treatments Control
conditions
Tri a l
duration
(weeks)
Outcome measures Main ndings
Major inclusion
criteria Major exclusion criteria
Randomized controlled trial
Tra c y an d Har t ,
 [];
Hart and Tracy,
 []
USA 
Apparent ly he alt hy,
relatively sedentary
(<hours/week
purposeful exercise
<moderate intensity,
oneactivesubjectin
the yoga group and
one in the control
group)
Medical condition or
medication that could
inuence participation or
dependent measures and
yoga practice within 
months prior to study
M/F 
Bi k r am’s beg i n ner ’s y oga
class (room heated to C,
%humidity, same 
asanas and breathing
exercises each class),
 min/class,  classes/week.
Average attendance .
classes
No treatment
Physical strength (isometric
deadli, hand grip strength,
MVC of knee
extensors/elbow exors,
concentric/eccentric
steadiness), functional
tness (sit-and-reach and
shoulder exibility,
single-leg balance),
cardiovascular tness
(VO2max,restingBP),body
composition (fat mass and
lean body mass using
DEXA)
Increased isometric deadli
strength (𝑝 = 0.04 between
groups), increased knee
extensor MVC within and
between groups (𝑝 < 0.05,
𝑝 < 0.01), increased balance
yoga group (𝑝 < 0.05),
increased back/hamstring
exibility (𝑝 < 0.001
between groups), trend
towards signicance for
shoulder exibility and for
decreased fat mass in yoga
group (𝑝 = 0.069)
Controlled trials
Hunter et al.,
 [] USA
Yo u ng =

Older = 
Sedentary (<
days/week physical
activity for past 
months), lean
participants BMI
.–. and obese
participants BMI >
Smoking within last 
months, uncontrolled
diabetes, personal history of
stroke, prior myocardial
infarction, and known
coronary heart disease
M/F Yo u ng =  
Older = 
Bi k r am’s beg i n ner ’s y oga
class (room heated to C,
%humidity, same 
asanas and breathing
exercises each class),
 min/class,  classes/week
No nonyoga
control
Glucose tolerance ( g
GTT, FPG) body
composition (fat mass and
lean body mass using
DEXA,BMI,bodymass)
Increased glucose tolerance
in obese subjects (𝑝 < 0.05),
decreased body mass
(𝑝 < 0.05)andBMI
(𝑝 < 0.05)inobesesubjects
Hunter et al.,
 [] USA
Yo u ng =

Older = 
Sedentary (no
habitual activity over
last  months),
young participants
aged – and older
participants aged
–
Pregnancy, uncontrolled
hypertension, infection
within last  weeks, renal
disease, adrenal or
endocrine tumours, prior
myocardial infarction,
known coronary heart
disease, chronic heart
failure, personal history of
stroke or cardiac
arrhythmias, diabetes, heat
intolerance, and
cardiovascular or hormone
replacement therapy
medications
M/F Yo u ng =  
Older = 
Bi k r am’s beg i n ner ’s y oga
class (room heated to C,
%humidity, same 
asanas and breathing
exercises each class),
 min/class,  classes/week
No nonyoga
control
Arterial stiness (carotid
artery compliance, carotid
pulse pressure), body
composition (body mass, fat
mass using DEXA), blood
glucose measures (HbAc,
FBG, plasma insulin,
HOMA-IR), cardiovascular
health (total, LDL, and HDL
cholesterol, triglycerides,
BP), exibility
(sit-and-reach)
Increased carotid artery
compliance in young adults
(𝑝 < 0.05), decreased
arterial stiness in young
adults (𝑝<0.05), decreased
plasma insulin and
HOMA-IR in older group
(𝑝 < 0.01), decreased total
and LDL cholesterol in older
group (𝑝 < 0.05), decreased
total and HDL cholesterol in
young group (𝑝 < 0.05),
increased exibility in both
groups (𝑝 < 0.01)
Evidence-Based Complementary and Alternative Medicine
T : Continu e d.
Study
identication Country Sample
size
Population Sex
(M/F)
Mean age
(years) Treatments Control
conditions
Tri a l
duration
(weeks)
Outcome measures Main ndings
Major inclusion
criteria Major exclusion criteria
Uncontro lle d tr ial s
Hewett et al.,
 [] USA  NR
Bikram yoga practice at all
in past  months and long
termwithinlastyearsand
medical conditions that did
not pass medical clearance
for participation
M/F 
Bi k r am’s beg i n ner ’s y oga
class (room heated to C,
%humidity, same 
asanas and breathing
exercises each class),
 min/class,
classes/week. Average
attendanc e . classes
No control
Psychological health
(perceived stress,
mindfulness),
cardiovascular tness
(predicted VO2max,RHR),
physical tness
(sit-and-reach and shoulder
exibility, single-leg
balance)
Increased mindfulness
(𝑝 < 0.01,𝑑=0.89),
perceived stress (𝑝 < 0.01,
𝑑=−0.79), predicted VO
(𝑝 < 0.01,𝑑=0.24),
exibility (𝑝 < 0.01,
𝑑 = 0.63), balance
(𝑝 < 0.01,𝑑=0.53),
correlation between
mindfulness and perceived
stress (𝑟=−0.43,𝑝 < 0.01),
and mindfulness and resting
heart rate (𝑝=−0.30,
𝑝 < 0.04)
Kude sia and
Bianchi, 
[]
USA 
Apparent ly he alt hy,
were planning to
start or already
practicing Bikram
yoga
Medical problems or
medicationsthatmight
interfere with sleep
monitor’s algorithm (e.g.,
epilepsy)
M/F 
Bi k r am’s beg i n ner ’s y oga
class (room heated to C,
%humidity, same 
asanas and breathing
exercises each class),
 min/class,  – classes/
days
N/A 
Sleep architecture (time
spent in each sleep-wake
stage, duration of
awakenings)
Decreased duration of
awakenings on days of
Bikram yoga practice (more
rapid return to sleep aer
nocturnal awakenings)
Longitudinal study
Sangiorgio et
al.,  [] USA 
Female (– y),
certied Bikram yoga
instructors,
practicing minimum
 years, good
physical health
NR F  (at -year
follow-up)
Continued practice of
Bi k r am’s beg i n ner ’s y oga
class (room heated to C,
%humidity, same 
asanas and breathing
exercises each class),
 min/class, +
classes/week for  years.
Continued teaching of
Bikram yoga during -year
period.
N/A  years
Bone mineral density (using
DEXA to measure at the
spine and hip, and total
body)
Premenopausal women at
follow-up showed mean
increased BMD at the
femoral neck
(.%±.%), total hip
(.%±.%), and lumbar
spine (%±.%).
Postmenopausal women at
follow-up showed mean
decrease in BMD at the
femoral neck
(.%±.%), total hip
(.%±.%), and lumbar
spine (.%±.%).
Evidence-Based Complementary and Alternative Medicine
T : Continu e d.
Study
identication Country Sample
size
Population Sex
(M/F)
Mean age
(years) Treatments Control
conditions
Tri a l
duration
(weeks)
Outcome measures Main ndings
Major inclusion
criteria Major exclusion criteria
Cross-sectional and acute studies
Pate and
Buono, 
[]
USA 
Healthy a dults
(– y), current
Bikram practitioners
with varying levels of
experience (<
classes and >
classes)
Posit ive res pons es on
PAR-Q and pregnancy M/F  N/A N/A N/A
Acute res ponse to Bikram
yoga session in temperature
controlled chamber (C,
%humidity) including
metabolic (VO),
cardiovascular (HR), and
sweat rate response
Ave ra ge o ve ra ll V O
. mL/kg/min, average
overall intensity . METS,
average overall EE/session
 kcal (–), and
higher relative EE for more
experienced practitioners
Abel et a l.,  
[] USA LE = 
HE = 
Apparent ly he alt hy
adults
Signsorsymptomsofheart,
pulmonary, or metabolic
disease
M/F LE = 
HE =  N/A N/A N/A
Pulmonary function (FVC,
FEV, FVC/FEV, PEFR,
MVV), cardiovascular
tness (VO2max,RHR,BP)
Wea k c o r re l a tio n o f Bik r a m
experience with FEV
(𝑟 = 0.37)andwith%
predicted FVC (𝑟 = 0.38)
Fritz et al. 
[] USA 
Current Bikram yoga
practitioners
attending
classes/week for at
least  year
NR M/F  N/A N/A N/A
Acute res ponse to Bikram
yoga session in temperature
controlled chamber (C,
%humidity) including
metabolic (VO),
cardiovascular (HR), and
thermal (internal
temperature) response and
RPE
Ave ra ge V O mL/kg/min,
average RPE ., average HR
 BPM, average overall
intensity . METs, overall
EE –  kcal, and
elevated core temperature
within safe range (max
.F)
BMI, body mass index; BP, blood pressure; BPM, beats per minute; CV, coecient of variation; DXA, dual-energy X-ray absorptiometry; EE, energy expenditure; EEG, electroencephalogram; F, female; FEV,
forced expiratory volume in one second; FPG, fasting plasma glucose; FVC, forced vital capacity; GTT, glucose tolerance test; HbAc, haemoglobin Ac; HE, high experience; HOMA-IR, homeostasis model of
assessment of insulin resistance; HR, heart rate; LE, low experience; M, male; MRI, magnetic resonance imaging; MVC, maximal voluntary contraction; MVV, maximum voluntary ventilation; NR, not reported;
PAR-Q, physical activity readiness questionnaire; PEFR, peak expiratory ow rate; RHR, resting heart rate; RPE, rate of perceived exertion; VO,volumeofoxygenuptake.
Evidence-Based Complementary and Alternative Medicine
signicantly improved isometric dead-li strength (𝑝 = 0.04)
compared to the control group. Isometric maximal voluntary
contraction evaluated via a load cell device at the knee joint
signicantly increased in the yoga group compared to the
control group (𝑝 < 0.01), which showed a % decrease
(𝑝 > 0.05). No changes were identied in upper body
strength, namely, isometric handgrip strength (𝑝 = 0.30)
or elbow exor strength and steadiness. In support of these
ndings, signicant improvements in sit-and-reach scores
within and/or between groups aer -+ classes a week for
eight weeks were reported in one uncontrolled trial [] and
one controlled trial [] examining apparently healthy cohorts.
Furthermore, the uncontrolled -week trial also reported
signicant improvements in single-leg balance (𝑝 < 0.01)as
well as improved upper body range of motion as assessed by
a total-body rotation test [].
Improvements in range of motion and balance are unsur-
prising given the nature of hatha yoga, and these results
are supported by previous research [–]. e asanas that
emphasize trunk and hamstring exibility in a Bikram class
are held for anywhere between  and  seconds (for specic
asanas see Figures (e)–(h), (o), and (x)–(z)) allowing
for improved passive and active range of motion []. ere
is some evidence to suggest that locally applied moist heat
increases active and passive range of motion of the muscles
comparable to static stretching or an active warm-up [, ].
e heated environment in Bikram yoga (in addition to the
physical activity of the yoga) may impose a similar eect
on the tissues of the muscular system. e asanas that are
performed on one leg for between  and  seconds (for
specic asanas see Figures (c)–(f) and (k)–(l)) would
likely contribute to the improvement in single-leg balance.
An emphasis on asanas involving lower body strength and
frequent isometric contraction of the quadriceps throughout
the class (see Figures (c)–(g), (i), (l), and (s)) likely
explains improved lower body strength and unchanged upper
body strength []. Future recommendations for assessing
tness outcomes include examining a cohort with mus-
culoskeletal conditions that would benet from improved
muscular tness and range of motion (e.g., cohorts with
falls risk and low back pain). Although insignicant, greater
changes in muscular steadiness were observed in participants
with lower baseline values, supporting further investigation
into the eects of Bikram yoga in sedentary individuals [].
Additionally, improved single-leg balance in older adults
aer an Iyengar yoga intervention indicates that it may also
be valuable to assess functional movement outcomes, for
example, a -repetition maximum or Fallscreen assessment
for falls risk [, ]. Improvements in exibility, strength,
and balance have a tremendous impact on QoL, especially
in older adults, given that these aspects of physical tness
decline with age, are necessary for activities of daily living,
and are associated with falls risk [].
Body composition is a health-related component of t-
ness and excess adiposity is a cardiovascular disease risk
(CVD) factor. To date, no Bikram yoga study has reported
signicant changes in adiposity or lean muscle mass when
measured using dual-energy X-ray absorptiometry (DEXA)
[,,].TracyandHart[]reportedatrendtowardreduced
body adiposity in the yoga group (𝑝 = 0.069), which, despite
randomisation, had higher baseline adiposity (. ±%
versus . ±.%, 𝑝 = 0.03). Two controlled trials also
reported no signicant changes in body composition within
or between groups aer an -week Bikram yoga program
(x/week); however, older, obese participations showed a
signicant decrease in BMI from . ±. to . ±.
(𝑝 < 0.05) [, ]. ough no signicant changes have
been observed to date, many factors contribute to alterations
in body composition. Participants in these studies were
asked not to change their current exercise and diet habits;
however, energy intake and expenditure data during the
trial were not collected. erefore, it is dicult to ascertain
whether or not external factors may have contributed to body
composition measures at completion of the trial. Accounting
for confounding factors and prescribing an eective inter-
vention volume should be included in future RCT design
examining the eects of Bikram yoga on body composition.
Potential changes in body composition in certain populations
(i.e., sedentary and unt) aer a Bikram yoga program
could result from increased energy expenditure and/or
increased muscle mass. Furthermore, intervention-related
reductions in stress may improve regulation of hormones in
the hypothalamic-pituitary-adrenal (HPA) axis, like cortisol,
that are known to contribute to visceral adiposity [, ].
Previous research of other styles of hatha yoga reports acute
and chronic intervention-related improvements to stress,
inammation, acute cortisol, leptin, and adiponectin [–].
Future Bikram yoga RCTs could examine additional markers
including leptin, adiponectin, and cortisol to further investi-
gate the eects of Bikram yoga on stress-related components
of metabolism.
Despite the current lack of evidence for Bikram yoga
as a tool to signicantly improve body composition, acute
data still lends valuable insight into the energy expendi-
ture of and potential population-dependent (i.e., unt and
sedentary) body composition adaptations to a Bikram yoga
class. A cross-sectional study of  apparently healthy adults
of varying Bikram yoga experience used an environmental
chamber and metabolic measurement cart (TrueOne, Par-
voMedics) to examine the acute physiological adaptations to
a single Bikram session performed to a standardised audio
recording of a class []. e mean relative VO2for the
whole session was . ±. mLkg−1min−1 and the intensity
of the class was . METS, with postures ranging from light
to moderate intensity (<. to .–. METS) over the class.
Absolute energy expenditure ranged from  to  kcals per
session (mean  ± kcals). e more experienced group
(> classes experience) reported signicantly higher relative
energy expenditure, predicted maximal heart rate, and sweat
rate compared to the novice group (< classes experience).
ese ndings are supported by similar trends in unpublished
data presented at the  Rocky Mountain ACSM Annual
Meeting; however, the unpublished data reports higher values
for energy expenditure and average intensity (– kcals,
. METS) over the whole class in experienced practitioners
(> months experience, 𝑛=19)[].Basedonthisacute
data, and although it appears that Bikram yoga elicits a greater
Evidence-Based Complementary and Alternative Medicine
averagein-sessionMETlevelcomparedtootherformsof
hatha yoga [, ], the prescribed -week interventions
in the studies reviewed may be insucient for weight loss
considering that ACSM recommends building up to –
minutes of moderate intensity aerobic exercise per week for
weight loss and maintenance of long term weight loss [].
Discrepanciesinoxygenconsumptionvaluesbetweenthese
two current reports may be due to the experience level of the
sample and possibly the method of gas analysis, although the
latter is purely speculation. e initial pranayama exercise
isperformedbyinhalingthroughthenoseandexhaling
throughthemouth[],whichwouldbeinterruptedby
wearing a nose clip. Breathing exercises aside, during most of
the asanas in a hatha yoga class, the instruction is to breathe
through the nose only [, ], and although there is no
denitive data to suggest that submaximal measurements of
oxygen consumption are aected by the type of gas analysis
system (i.e., face mask or mouth tube and nose clip), it may be
worth consideration in future oxygen consumption analysis
of hatha yoga postures.
e only study examining aerobic capacity in a controlled
manner reported no signicant change in VO2max over an -
week period in apparently healthy adults (Balke treadmill test,
TrueOne, ParvoMedics). is may explain why the aerobic
capacity of Bikram practitioners is not signicantly dierent
from that of the general population [, ]. Research that has
reported increased aerobic capacity aer an -week Bikram
yoga trial used a predictive VO2max measure (-mile walk),
which is not as reliable as an actual VO2max test. In-session
VO2data shows that the average intensity of a Bikram yoga
session is light to moderate [, ], suggesting that the
cardiovascular adaptation may be great enough to improve
VO2max in certain cohorts such as populations suering from
reduced cardiorespiratory tness (e.g., sedentary individuals,
asthmatics, and older adults), which is signicant, as reduced
cardiorespiratory tness is considered an independent risk
factor for cardiovascular disease []. Furthermore, interven-
tion duration may have been too short to establish signicant
changes in cardiorespiratory tness [].
2.2. Cardiovascular Disease Risk Factors. World Health Orga-
nization reports that % of total deaths in the US are
attributable to CVD and diabetes []. Several controlled
trials have investigated the eect of Bikram yoga training on
various CVD risk factors. One controlled trial examined the
eects of an -week Bikram yoga program ( classes/week)
on arterial stiness, measures of blood glucose regulation
(HbAc, fasting blood glucose, plasma insulin, and insulin
resistance via homeostatic model assessment, i.e., HOMA-
IR), blood lipids (total cholesterol, low density lipoprotein
(LDL), high density lipoprotein (HDL), and triglycerides),
blood pressure, and body composition in healthy young
adults compared with older adults []. As mentioned pre-
viously,thistrialdidnotreportsignicantimprovements
in body composition. In the younger group, carotid artery
compliance signicantly increased (𝑝 < 0.05)andbeta-
stiness signicantly decreased (𝑝 < 0.05)comparedto
baseline. Longer interventions may not necessarily improve
arterial stiness in older adults, yet arterial stiness is an
independent risk factor for CVD []. Seeing as an appropri-
ate prescription for Bikram yoga is still unclear; measuring
arterial stiness in this cohort using a longer Bikram yoga
intervention with more frequent weekly sessions may be
warranted even though there has been no observed change
in this cohort to date [].
Furthermore, HDL and total cholesterol decreased in
young adults (𝑝 < 0.05),whileLDLandtotalcholesterol
decreased in older adults compared to baseline (𝑝 < 0.05).
is nding in young adults is surprising considering that
exercise generally contributes to HDL increases []. Fasting
blood glucose and HbAc did not change in either group;
however, plasma insulin and HOMA-IR both signicantly
decreased in older adults only when compared to baseline
(𝑝 < 0.01). Further investigation is essential to discern the
likely mechanisms responsible for metabolic prole changes.
Potential reasons for the signicant changes include the
stress-reducing eects of yoga [], the heated environment
[], and unrecorded dietary changes. Scientic reviews
report evidence of yoga improving diabetic symptoms and
risk factors (including insulin sensitivity and glucose toler-
ance); however, more research is required to draw stronger
conclusions [, ].
Brachial blood pressure (systolic and diastolic) did not
decrease signicantly, which was also the case in a previous
-week hatha yoga trial in normotensive adults [, ]. ree
additional studies have investigated the eect of Bikram yoga
practice on resting heart rate and systolic and diastolic blood
pressure [, , , ]. All four studies to date have been
conducted with normotensive participants and, as expected,
allreportednosignicantchangeovertime[,,,].
e cross-sectional study reported that, compared to novice
students, regular Bikram yoga practitioners had lower mean
blood pressure and resting heart rates than national US
averages. It is possible that chronic Bikram yoga practice
may help maintain healthy blood pressure values []. e
light to moderate aerobic intensity over a longer duration
(i.e., greater than  weeks) as well as more regular sessions
(i.e., – days/week) may be enough in deconditioned and
hypertensive participants to aect blood pressure [, –].
Another possible inuence on blood pressure could be stress,
andBikramyogahasbeenshowntoreduceperceivedstress
[].
A more recent study by the same research group exam-
ined the eects of an -week Bikram yoga program (
classes/week) on body composition and glucose tolerance
in young, lean (BMI = . ±. kg/m2,±% body fat)
and older, obese (BMI = . ±. kg/m2,±% body
fat) sedentary participants []. Glucose tolerance signicantly
improved in older, obese participants (𝑝 < 0.05)but,as
expected,notinyoung,leanparticipants.Authorssuggest
that this is likely due to the increased insulin resistance
that occurs in obese populations but not in healthy popu-
lations. ere were no signicant changes in fasting plasma
glucoseovertimeineithergroup.Inbothcontrolledtrials,
participants were asked to continue with their normal diet
and exercise routines; however, this data was not collected
[, ]. Changes in diet and exercise would certainly inuence
Evidence-Based Complementary and Alternative Medicine
glucose management outcomes, and exercise and diet data
should be reported in future trials.
2.3. Pulmonary Function. Pulmonary function can be re-
duced as a consequence of aging [] and chronic diseases,
including asthma, emphysema, bronchitis, metabolic syn-
drome, and diabetes [–]. Reduced pulmonary function
can have signicant implications including reduced physical
activity and associated chronic conditions including diabetes
and CVD []. Aerobic exercise, inspiratory muscle training,
diaphragmatic breathing training, and hatha yoga have been
showntoimprovepulmonaryfunctionoutcomesincohorts
withreducedbaselinevalues[],whereas,inapparently
healthy adults, no changes are seen aer a -week aerobic
exercise program [].
A cross-sectional study examining measures of pul-
monary function in  apparently healthy Bikram yoga
practitioners reported no signicant dierence between those
of limited experience (. ±. years) and those of more
experience (. ±. years) []. ere were no dierences in
height, weight, or age between the groups. When classied by
gender, aerobic capacity (VO2max)ofthiscohortwasclassied
as “good” according to ACSM []. It is unsurprising that
pulmonary function and aerobic capacity were not dierent
basedonlevelofexperiencewhencomparedtopopulation
norms; seeing as reduced pulmonary function (e.g., forced
expired volume in one second) is seen only in those with pul-
monary dysfunction []. Furthermore, because pulmonary
function varies according to gender, it would be useful to
have results presented for females and males separately to
better understand the data. ere was a weak but signicant
relationship between Bikram yoga experience and percent
predictedforcedvitalcapacity(𝑟=.,𝑝 < 0.05)andforced
expired volume in one second (𝑟=.,𝑝<.). ese
results could have been inuenced by the nal breathing
exercise in a Bikram yoga class, which uses the abdominal
muscles to repeatedly exhale the breath at a moderate pace
[]. A review reports that, in apparently healthy adults,
changes in pulmonary function in response to hatha yoga
are related to initial tness level and duration of pranayama
exercises [], which perhaps indicates that a Bikram yoga
class does not have enough specic pranayama exercises to
elicit a signicant improvement in pulmonary function in
healthy individuals. Future Bikram yoga RCTs are warranted,
andinordertoinvestigatefurther,futureRCTsshould
address confounding factors, including ethnicity, gender,
and smoking status, and should examine cohorts that have
room to improve function, such as asthmatics or sedentary
individuals.
2.4. Bone Mineral Density. Maintaining BMD throughout
life is critical for health outcomes (osteoporosis, falls-related
fractures) and QoL [, ]. In adults, the emphasis should be
placed on nonpharmaceutical inter ventions such as nutrit ion,
resistance training, and impact based exercise, for example,
running, to minimize BMD loss and reduce the risk of
fractures in later life. Given that Bikram yoga has been shown
to signicantly improve lower limb strength and single-leg
balanceitmayreducetheriskoffallsandfractures,similar
to other hatha yoga interventions [–, ]. As a suitable
weight-bearing exercise for those who cannot engage in high-
impact activities, it could be hypothesized that yoga may, via
various pathways, maintain bone density in some populations
[].
A -year longitudinal study assessed BMD using DEXA
in nine female Bikram yoga teachers (– years) with
+ years of regular teaching and practicing Bikram yoga
[, ]. ose who were premenopausal at the -year
follow-up showed mean increased BMD at the femoral neck
(.% ±.%), total hip (.% ±.%), and lumbar spine
(% ±.%). ose who were postmenopausal at the -
year follow-up showed a mean decrease in BMD at the
femoral neck (.% ±.%), total hip (.% ±.%),
and lumbar spine (.% ±.%). e improved tot al hip
BMD in the premenopausal group was signicantly higher
than the reduction in BMD reported by the postmenopausal
group (𝑝 = 0.02). ese ndings are surprising in the
premenopausal group; however, the results were as expected
inthepostmenopausalgroupduetotheage-relateddecline
in BMD. Possible confounding factors, such as whether or
not participants engaged in additional exercise, altered nutri-
tional intake or took certain medication during the -year
longitudinal period were not reported. More rigorous RCTs
that incorporate measures such as hormone uctuations
during menopause and changes in nutritional intake could
further explain these ndings.
2.5. Sleep Quality. Quality of sleep is aected by several fac-
tors including stress, hormonal imbalances, and obesity [].
Although exact mechanisms are unknown, both exercise and
yoga reportedly encourage healthy sleep patterns [–]. An
uncontrolled, observational study examined the acute eects
of Bikram yoga practice on the sleep architecture (structure
and pattern of sleep) of  apparently healthy males and
females aged between – years []. Participants were asked
to partake in – Bikram yoga classes over a period of
 days to compare sleep patterns (wireless headband and
self-report) on the days when participants attended class
compared with days when participants did not. Total sleep
time, sleep latency (time it takes to fall asleep), and stages of
sleep (i.e., REM cycles) were unchanged between practice and
nonpractice days. On days when participants attended class,
the time to return to sleep aer naturally occurring nocturnal
awakenings was reduced signicantly (𝑝 < 0.03). No study
has examined the eect of Bikram yoga on hormones (e.g.,
melatonin, serotonin, and dopamine), which may inuence
sleep patterns, but this nding could also be inuenced by the
stress-reducing eect of Bikram yoga that has been observed
in a separate study []. Future research should consider using
a cohort prone to sleep disturbances.
2.6. Psychological Adaptations. Chronicstressisnowwidely
acknowledged as being associated with CVD among a wide
range of other chronic conditions. Stress contributes to
systemic inammation via two main pathways, the HPA
axis and the sympathetic nervous system [, ]. It has
been hypothesized that hatha yoga practice may attenuate
HPA axis and sympathetic hyperactivity and the associated
Evidence-Based Complementary and Alternative Medicine
physiological, inammatory response, which could lead to a
reduction in stress- and inammation-related illness [].
An uncontrolled trial examined the eectiveness of 
weeksofBikramyoga(+classes/week)onmindfulness,
perceived stress, and physical tness in  apparently healthy
men and women []. Participants (– y) had varying
physical activity levels at baseline. At the completion of the
trial, mindfulness, evaluated by the Five-Facet Mindfulness
Questionnaire (FFMQ), and perceived stress, evaluated by
the Perceived Stress Scale (PSS), signicantly improved (𝑝<
0.01). Mindfulness was negatively and signicantly correlated
with perceived stress (𝑟=., 𝑝 < 0.05)andwithresting
heart rate (𝑟=.,𝑝 < 0.01). Hatha yoga oers a “meditation
through movement” opportunity much like the practice of Tai
Chi [], which may contribute to the increased mindfulness
and reduction in perceived stress. Although it is hard to
know what is responsible for these changes, hatha yoga
incorporates physical activity as well as relaxation in the
same class and encourages participants to keep the mind
present with the movement of the breath and the body in
dierent asanas. ese qualities may encourage mindfulness,
increase vagal tone, and reduce perceived stress, and they
present opportunities for more robust research examining
stress reduction and associated health risks.
Despite major limitations in this study’s design, these
preliminary ndings provide a starting point for under-
standing Bikram yoga’s relationship to stress and, potentially,
stress-related illnesses and chronic disease. Further recom-
mendations for the investigation of psychological outcomes
should include the collection of more self-report data as
well as physiological outcomes with a known relationship to
psychological stress, including heart rate variability (HRV),
arterial stiness, interleukin- (IL-), CRP, and cortisol [,
, ]. HRV has been shown to improve with some hatha
yogainterventions[,].HRValsorelatestocardiovascular
outcomes and may address the relationship between psycho-
logical stress and chronic disease. Investigating intervention-
relatedbehaviourchangemaybenoteworthytoassessthe
eects of yoga practice on lifestyle. e ndings from this
preliminary research warrant further investigation in RCT
format considering the contribution stress has towards health
and well-being.
2.7. Adherence. Adherence data is important to assess the
feasibility of any physical activity intervention. It is also
crucial in explaining outcome measures that change, or
remain the same, as a result of an intervention. For example,
a participant who attends one exercise session per week will
likely not improve health measures to the same degree that
a participant attending four sessions would []. Only two
of the Bikram yoga studies reviewed reported adherence
data. e RCT reported a retention rate of % in the yoga
group [], with an average attendance of . classes in
eight weeks, and dropouts were attributed to scheduling and
dissatisfaction with the intervention []. An uncontrolled
trial studying mindfulness reported a % retention rate,
with average attendance of . classes in eight weeks, and
the majority of dropouts were due to time commitments
[].
2.8. Adverse Events. Two trials reported no adverse events
[, ], and all other trials failed to report on adverse events
at all; however, Bikram yoga, like any exercise prescription,
may be unsafe for certain individuals and medical clearance
is advised for at riskindividuals [, , , ]. Individual cases
of adverse events have been reported in three separate case
studies [–]. A letter to the editor of the American Journal
of Psychiatry was submitted in  reporting a case study
of a -year-old man with a history of brief hallucinogen-
induced psychosis who experienced a psychotic episode
while participating in the Bikram yoga teacher training.
e subject reported feeling dehydrated and eating poorly
and was lacking sleep leading up to the episode. Hospital
tests (brain MRI, EEG, and urine toxicology) all came back
normal. e authors suggest that despite reported benets for
some individuals more intensive styles of yoga (i.e., Bikram
yoga) may not be suitable for certain individuals such as those
who are psychosis-prone.
e second case study reported on a -year-old woman
who presented to hospital with breathlessness, muscle
cramps, nausea, and general malaise from drinking .
liters of water aer her rst Bikram yoga class []. Initial
testing (blood gas on air) showed severe hyponatremia and
respiratory alkalosis. Aer  days in hospital a full recovery
was made and the woman was discharged. Bikram yoga
instructors should be aware of the risk factors, signs, and
symptoms of hyponatremia given the extreme hot and humid
conditions in the class, and they should be able to make sound
recommendations for rehydration including drinking to one’s
thirst [].
A third case study reported on a healthy -year-old man
with no CVD risk factors who experienced acute coronary
syndrome during a Bikram yoga class []. e man was
admitted to hospital and received surgical intervention before
being discharged  days later. Males aged  years and
women aged  are at increased risk of heart disease []
and practitioners in this age group should exercise cau-
tion, potentially obtaining doctor’s clearance, when starting
Bikram yoga, especially if coming from a sedentary lifestyle.
Although these are isolated events, it is of great impor-
tance to understand the potential risk of participation in any
form of exercise for dierent populations, especially exercise
such as Bikram yoga, which has not yet been thoroughly
examined with repeated, robust research. Future research
should disclose all adverse events and employ satisfactory
preintervention screenings and medical supervision when
required, taking into account the potential risk of Bikram
yoga for the given sample population.
3. Future Recommendations
It appears that Bikram yoga training improves aspects of
physical tness (range of motion, single-leg balance, and
strength), which can be logically explained by the nature
of Bikram yoga, a style of hatha yoga. A deeper, scientic
examination is required to determine the eect of Bikram
yoga on cardiovascular outcomes (cholesterol, fasting blood
glucose, arterial stiness, and carotid artery compliance),
bone mineral density, sleep quality, pulmonary function,
 Evidence-Based Complementary and Alternative Medicine
and psychological health (perceived stress and mindfulness).
e greatest improvement to the current body of scientic
knowledge of Bikram yoga lies in future application of robust
research techniques.
Only one study in this review used an RCT design to
examine the eects of Bikram yoga. Fundamentally, sub-
sequent Bikram yoga studies should adopt an RCT design
in order to add signicant contributions to the discus-
sion on the health benets derived from exercise inter-
ventions. Greater adherence to reporting standards, such
as CONSORT, may improve reporting and assessment of
study quality from current standards and would address the
pervasive study limitations present in the current body of
research including small sample sizes, lack of randomization,
confounding variables, and little mention of the occur-
rence or lack of adverse events, limitations, and compliance
[].
Bikram yoga appears to be an alternative to traditional
exercise modalities that may have favourable eects on
metabolic markers including blood lipids, insulin resistance,
and glucose tolerance. is has signicant clinical impli-
cations for individuals who wish to address dyslipidemia
and glucose management by exploring nonpharmaceutical
options. Additionally, those who are unable or unwilling
to participate in traditional aerobic exercise and strength
trainingmaybeabletoimproveglucoseandcholesterolman-
agement with Bikram yoga training. In order to maximize the
eect of these ndings, trial duration and session frequency
need to be addressed in future research. is is more complex
than adhering to CONSORT or ACSM guidelines. Hatha
yoga is a holistic and oen variable practice making research
hard to quantify and compare to other forms of exercise [].
Further understanding of the acute adaptations to Bikram
yoga is crucial to determine whether or not this form of
exercise is an eective intervention compared to current
ACSM guidelines for exercise and disease management and
prevention.iswouldallowforacomparisonbetween
Bikram yoga and other exercise modalities. e metabolic
cost data reported in this review is very new information
and could be used in future research to determine a specic
Bikram yoga prescription, knowing that the prescription will
vary depending on the desired outcome measure. Additional
acute data, for example, blood glucose before, during, and
aer a session, would also contribute to the development
of Bikram yoga prescription guidelines for specic outcome
measures.
Finally, most of the current studies have examined appar-
ently healthy adults. Unsurprisingly, health-related outcomes,
for example, resting heart rate and blood pressure, remain
unchanged in healthy participants. It is hard to determine
the eects of an exercise intervention in cohorts whose
indicators of health and well-being are within healthy ranges
at baseline. Signicant ndings in one study to the authors
knowledge that has examined the eects of Bikram yoga
on the unhealthy (obese) individual strengthen the rec-
ommendation to examine cardiometabolic adaptations in
unhealthy populations []. Physiological adaptations should
be examined in cohorts with physiological imbalances, such
as dyslipidemia, hypertension, and insulin resistance, to
better understand intervention-related adaptations and their
inuence on the progression of chronic disease.
is review describes the available Bikram yoga literature
in order to better understand the eects of this form of
exerciseandtosuggestwaystoimprovefutureresearchinthis
eld. Topics that have not yet been investigated include the
eects of Bikram yoga on the physiological markers of stress,
cognition, depression and anxiety, inammation, QoL, and
behaviour change. Additionally, further investigation into
the acute eects of Bikram yoga practice would deepen the
understanding of the physiological adaptations. Continued
research will greatly improve the scientic understanding of
Bikram yoga practice, which will help determine whether or
not it can be considered another tool to address the concern-
ing, growing prevalence of chronic disease and stress-related
illness.
Disclosure
e primary author, Zoe L. Hewett, is a coowner of Bikram
Yoga Kingston in Canberra, Australia.
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
References
[] B. Choudhury, Bikram Yoga,HarperCollins,NewYork,NY,
USA, .
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... Class finishes with a seated kapalabhati breathing exercise (i.e., quick, strong exhalations) and a final savasana." [43]. Bikram yoga classes are undertaken in a room held at a constant heat of 40 degrees Celsius and humidity of 40% [43,44]. ...
... [43]. Bikram yoga classes are undertaken in a room held at a constant heat of 40 degrees Celsius and humidity of 40% [43,44]. Bikram yoga postures are classified as light-tomoderate by the American College of Sports Medicine [45], however, Bikram yoga intensities (although highly dependent on posture) have been reported to reach up to 6.0 metabolic equivalence of task [46], the threshold for vigorous activity intensity. ...
... Bikram yoga sequence of asanas (poses). Standing pranayama (a), standing sequence (b-l), savasana (m), floor asanas (n-z) and final savasana (aa)[43] ...
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Background: The neurobiology of persistent pain shares common underlying psychobiology with that of traumatic stress. Modern treatments for traumatic stress often involve bottom-up sensorimotor retraining/exposure therapies, where breath, movement, balance and mindfulness, are used to target underlying psychobiology. Vigorous exercise, in particular Bikram yoga, combines many of these sensorimotor/exposure therapeutic features. However, there is very little research investigating the feasibility and efficacy of such treatments for targeting the underlying psychobiology of persistent pain. Methods: This study was a randomized controlled trail (RCT) comparing the efficacy of Bikram yoga versus high intensity interval training (HIIT), for improving persistent pain in women aged 20 to 50 years. The participants were 1:1 randomized to attend their assigned intervention, 3 times per week, for 8 weeks. The primary outcome measure was the Brief Pain Inventory (BPI) and further pain related biopsychosocial secondary outcomes, including SF-36 Medical Outcomes and heart rate variability (HRV), were also explored. Data was collected pre (t0) and post (t1) intervention via an online questionnaire and physiological testing. Results: A total of 34 women were recruited from the community. Analyses using ANCOVA demonstrated no significant difference in BPI (severity plus interference) scores between the Bikram yoga (n = 17) and the HIIT (n = 15). Women in the Bikram yoga group demonstrated significantly improved SF-36 subscale physical functioning: [ANCOVA: F(1, 29) = 6.17, p = .019, partial eta-squared effect size (ηp2) = .175 and mental health: F(1, 29) = 9.09, p = .005, ηp2 = .239; and increased heart rate variability (SDNN): F(1, 29) = 5.12, p = .013, ηp2 = .150, scores compared to the HIIT group. Across both groups, pain was shown to decrease, no injuries were experienced and retention rates were 94% for Bikram yoga and 75% for HIIT . Conclusions: Bikram yoga does not appear a superior exercise compared to HIIT for persistent pain. However, imporvements in quality of life measures and indicator of better health were seen in the Bikram yoga group. The outcomes of the present study suggest vigorous exercise interventions in persistent pain cohorts are feasible. Trial registration: Australian New Zealand Clinical Trials Registry ( ACTRN12617001507370 , 26/10/2017).
... Em estudo com adultos e idosos, verificou-se que a sauna ioga melhora o equilibrio, a flexibilidade, a força, tendo um grande impacto na qualidade de vida, especialmente nos idosos, dado que esses aspectos da aptidão física diminuem com a idade (40) . ...
... 19,20 Although this intensity level is not high enough to elicit an increase in cardiorespiratory fitness, 21 improvements in lower body strength, neuromuscular control (balance), and flexibility are evident. 21,22 However, there was significant sweat and water loss (1.1 kg/h in experienced yoga practitioners) due to the high temperature and humidity. 19 We speculate that this large sweat loss is accompanied by a large salt and other electrolyte loss. ...
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... It is often associated with Bikram yoga, a variant of Hatha yoga involving a standardized series of 26 physical postures (asanas) and 2 breathing exercises (pranayamas) performed to an instructional dialog in a room conditioned at 40.6°C and 40% humidity for 90 min. 3 Bikram yoga has become more and more popular, partly because its instructors affirm that its habitual practice favors detoxification and elimination of impurities through perspiration. 4 1 N AU2 c ursing School, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile. ...
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... Scientific papers that have been written about Bikram yoga sometimes refer to it as an 'instructional dialogue' but it is much more than this. [31] The instructor actually performs the role of a shaman who is constantly enjoining the participants to perform the asanas to the very best of their ability as well as give it that little bit of something extra, and then during the periods of savasana the perfect practice requires absolute stillness and complete and total concentration on the breath. The tone of the instructor will change during the savasana, but still the message is encouraging the participants to achieve the sublime state. ...
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B ikram yoga (BY) is a specific practice, with thousands of followers over the world, that consists of a series of 26 postures performed in a heated humidified studio (1). It has been reported that exertion may be a possible trigger for plaque rupture and acute coronary syndromes (ACS) (2). We present the case of a healthy 53-year-old man without any cardio-vascular risk factors who developed ACS with ST-segment elevation during a BY session. Intravenous fibrinolysis was administered with clinical success. A coronary angiogram performed the next day revealed a critical stenosis in the proximal left anterior descending artery (arrow, A). Optical coherence tomography (OCT) unraveled the presence of a ruptured plaque (arrow, B) with a residual cavity (D, C) in opposite direction to flow (D). A bioabsorbable vascular scaffold was implanted with good angiographic result (E). OCT showed a well-expanded and fully apposed device (*, F). Hospitalization was uneventful and the patient was discharged 4 days later. REFERENCES 1. Tracy BL, Hart CE. Bikram yoga training and physical fitness in healthy young adults. J Strength Cond Res 2013;27:822–30. 2. Burke AP, Farb A, Malcom GT, Liang Y, Smialek JE, Virmani R. Plaque rupture and sudden death related to exertion in men with coronary artery disease. JAMA 1999;281:921–6.