Role of Yoga in Stroke Management: Current Evidence and Future Directions

Abstract

The experience of stroke can significantly impact the physical health, psychosocial wellbeing of an individual. These consequences make the patients vulnerable to develop mental illnesses, ranging from dysthymia to as serious as severe depression with suicidal tendencies. There is a need for holistic therapies such as yoga-based lifestyle, which aim at improving quality of life on both physical and psychosocial domains. There is growing evidence indicating the potential use of yoga in improving an individual’s functional status post-stroke. This chapter aimed at reviewing the evidence for the effects of yoga in the prevention of stroke and its post-stroke rehabilitative potential. The literature suggests the need for integration of yoga therapy with the conventional treatment to curb the morbidity and mortality associated with stroke and its co-morbidities.

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© Springer Nature Singapore Pte Ltd. 2022
I. Basu-Ray, D. Mehta (eds.), The Principles and Practice of Yoga in Cardiovascular Medicine,
https://doi.org/10.1007/978-981-16-6913-2_20
Role ofYoga inStroke
Management: Current Evidence
andFuture Directions
NishithaJasti, AshokVardhanReddy,
KishoreKumarRamakrishna, HemantBhargav,
andGirishBaburaoKulkarni
20.1 Introduction
Stroke is a preventable and treatable neurological
emergency [1]. Stroke is dened by the World
Health Organization as “Rapidly developing clin-
ical signs of focal (or global) disturbance of cere-
bral function, lasting more than 24h or leading to
death, with no apparent cause other than that of
vascular origin” [2].
In stroke, the damage to the brain parenchyma
is either due to (1) Ischemia, in which the brain
parenchyma is deprived of oxygen due to
decreased blood supply, or (2) Haemorrhage,
where there is rupture of the blood vessels. In the
latter, there is extravasation of blood into the
brain parenchyma and extravascular space, caus-
ing pressure effect on the surrounding paren-
chyma and may lead to disruption of various
connections in the brain.
1. Ischemia: Ischemia can be caused by one of
the three mechanisms: formation of the
thrombus in the vessel narrowing its lumen
(cerebral venous thrombosis or arterial throm-
bosis), dislodgement of the thrombus to a dis-
tant site (emboli) or reduction in the total
perfusion due to cardiac pump failure, hypo-
tension, hypovolemia, or any other cause.
2. Hemorrhage: It includes four subtypes: sub-
arachnoid hemorrhage; intracerebral hemor-
rhage; subdural hemorrhage; and epidural
hemorrhage. Subarachnoid hemorrhages
often originate from bleeding due to aneu-
rysms, arteriovenous malformations, bleeding
diathesis or trauma. Intracerebral hemorrhage
is most commonly due to uncontrolled hyper-
tension. Other causes include the use of anti-
coagulants, drugs, trauma, vascular
malformations and amyloid angiopathy.
Subdural and epidural hemorrhages are typi-
cally caused by head trauma.
Over the last two decades, morbidity and
mortality associated with stroke have changed
due to the advances in acute ischemic stroke
treatment through intravenous thrombolysis,
endovascular thrombectomy and other surgical
procedures. Despite these advances, the signi-
cant number of patients still sustain chronic con-
sequences such as residual decits, cognitive
decline and psychological distress; they are also
vulnerable to stroke recurrence. As per the
Global Burden of Disease (GBD) study (2016),
the lifetime risk of developing a stroke is 24.9%
in those with age more than 25 years [3]. The
adjusted prevalence rate of stroke is more in the
N. Jasti · K. K. Ramakrishna (*) · H. Bhargav
Department of Integrative Medicine, National
Institute of Mental Health and Neurosciences
(NIMHANS), Bengaluru, India
A. V. Reddy · G. B. Kulkarni
Department of Neurology, National Institute of
Mental Health and Neurosciences (NIMHANS),
Bengaluru, India
20

254
urban (334–424/100,000) than in the rural areas
(84–262/100,000). These prevalence rates sug-
gest the need for training manpower and promot-
ing rehabilitation services for stroke-related
morbidity across the globe. Ischemic stroke is
the most common subtype of stroke, which con-
tributes to 75–80% according to various studies
[4]. In a study investigating the functional out-
come in stroke survivors at the end of 28days of
stroke onset, it was found that 42.4% had mild
disability, 43% had a moderate disability, and
14.6% were bedridden (Rankin score 5) [4]. The
incidence of cerebral venous thrombosis (CVT)
is less than 1% globally. However, it is more
common in India, with higher incidence in
females due to exposure to specic risk factors
like postpartum state and hormonal supplemen-
tation. Incidence of Intra-cranial hemorrhage
(ICH) ranges from 20% to 25% among all
strokes. In comparison to patients with arterial
stroke, CVT patients have better recovery and
60% recover completely. About 8% of the CVT
patients report mortality [5].
20.2 Clinical Features
The symptoms at presentation depend on the eti-
ological type of the stroke:Ischemic (IS) or hem-
orrhagic (HS). If symptoms improve within 24h,
it is Transient Ischemic Attack (TIA). Signs and
symptoms depend on the artery involved or area
of hemorrhage in IS and HS, respectively.
Symptoms of IS may include unilateral facial
weakness, weakness of upper limb and/or lower
limb, blurring of vision in one eye, language dis-
turbances like difculty to speak and understand,
loss of consciousness, seizures, sensory loss on
one side of the body, sudden-onset giddiness,
imbalance, speech difculties (dysarthria and
anarthria), swallowing difculties, deviation of
the tongue to one side, excessive sleepiness and
memory loss.
Patients with HS may present with sudden-
onset severe headache followed by neurological
decit, loss of balance, incoordination, unilateral
weakness of limbs, seizures, confusion, and
drowsiness.
The most common symptoms of CVT include
headache, vomiting, seizures, and hemiparesis.
CVT involving the peripheral system usually
presents with headaches, seizures, and focal
motor weakness. When the deep venous system
is involved, the symptoms are more severe,
resulting in altered mental status and bilateral
motor decits. High mortality and morbidity are
observed with the involvement of basal ganglia
and thalamus [5].
20.3 Risk Factors
The risk factors for stroke can be divided into
those which can be modied (modiable) and
those which cannot be modied (non-modiable)
(Refer Table 20.1). It is evident that modiable
risk factors are closely related to lifestyle, and
lifestyle modication programs could be useful
in reducing the risk of stroke.
20.4 Limitations ofConventional
Management Care
Despite the advances in conventional manage-
ment, stroke still continues to signicantly con-
tribute to the global burden in terms of mortality
and morbidity. There seems to be very less aware-
ness on stroke burden, warning signs, acute man-
agement services available, the prevention
Table 20.1 Risk factors of stroke
Modiable risk
factors Non-modiable risk factors
Cigarette smoking Age>65years
Alcohol Positive family history
Hypertension African or South-Asian
ethnicity
Diabetes Mellitus
Type 2
Bleeding disorders
High cholesterol High cholesterol due to genetic
defects
Overweight Head injury
Lack of exercises
Improper diet
Oral contraceptive
pills
N. Jasti et al.

255
strategies, effective rehabilitative therapies that
can be availed [6]. Despite impressive emergency
management, the conventional system of medi-
cine faces some limitations such as limited
resources, costly investigations and treatment
procedures, limited trained professionals and
rehabilitation personnel. It also majorly central-
izes on illness-oriented approach rather than on
the wellness-oriented approach, not directing
much attention towards the holistic health pro-
motion and preventive strategies in the currently
healthy population.
20.5 Need forHolistic
Interventions such asYoga
The life of a patient changes markedly after
stroke. They start to signicantly depend on the
caregivers for their daily needs due to the post-
stroke disabilities. These disabilities make the
patients susceptible to develop mental illnesses
that may range from dysthymia to as serious as
suicidal tendencies. This implicates the need for
holistic therapies such as yoga-based lifestyle,
which aim at improving quality of life on both
physical and psychosocial domains. There is
growing evidence indicating the potential use of
yoga in improving an individual’s functional sta-
tus post-stroke. Moreover, many patients seek
medical assistance in the form of certain herbal
formulations, behavioural, and lifestyle recom-
mendations to prevent stroke occurrence, recur-
rence and also its associated co-morbidities. This
indicates the need to integrate the conventional
and traditional systems of medicine to reduce the
burden of stroke around the globe.
20.6 Introduction toYoga
Therapy andRationale forIts
Use inStroke Management
National Health Interview survey has dened
yoga as a combination of breathing exercises,
physical postures, and meditation to calm the
nervous system and balance body, mind, and
spirit [7]. The practice of yoga includes Yama
(social ethics), Niyama (individual code of con-
duct), Asana (physical postures), Pranayama
(regulated breathing), Pratyahara (restraint of
senses), Dharana (focussed awareness), Dhyana
(defocussed awareness to the state of meditation)
and Samadhi (state of self-absorption). These
practices primarily focus on enhancing the stabil-
ity of one’s body, breath, and mind. Due to this
ability, yoga has emerged as a potent therapeutic
option to address psycho-somatic disorders. Yoga
is a safe, adaptable, and cost-effective therapeutic
option that empowers the subject to be
self-reliant.
20.7 Understanding ofStroke
fromYoga Perspective:
TheConcept ofFive Layers
ofExistence
Yoga therapy (YT) is based on the principle of
Pancha koshas that has been derived from
Taittriya Upanishad [8]. This approach looks
into an individual at ve layers of existence,
namely: physical layer (Annamaya kosha), layer
of the life force (Pranamaya kosha), layer of
mental processes (Manomaya kosha), layer of
intellect (Vijnanamaya kosha), and layer of bliss
(Anandamaya kosha).
According to the Guna theory from Yoga phi-
losophy, stroke is a disorder that is most likely to
occur in rajas (characterized by intense passion
and relentless desires) or tamas (characterized by
inertia and ignorance) predominant personalities
[9]. Rajasic personalities tend to relentlessly
work towards their high-set goals while ignoring
the basic needs of their body and get over-
whelmed with fear, anxiety, and an array of nega-
tive emotions in the due process of achieving so
(kama esa krodha esa rajo guna samudbhavah
B.G 3.37) [10]. This results in cycles of maladap-
tive thoughts and emotions that initiate turbu-
lence in the Manomaya kosha, which graduates
into Pranamaya kosha. This results in the hap-
hazard functioning of prana (life force) at the
level of Pranamaya kosha. Prana functions at
various levels viz., prana (in head region) udana
(thorax) samana (in gastrointestinal tract) vyana
20 Role ofYoga inStroke Management: Current Evidence andFuture Directions

256
(through the whole body) and apana (urogenital
tract). According to the genetic imprints of an
individual and the inuence of his/her lifestyle,
prana tends to accumulate in particular regions
and becomes scanty elsewhere, manifesting as
various symptoms. In stroke, vyana is greatly
vitiated. This disturbance in the Pranamaya
kosha results in a disarray of basic cellular physi-
ology, hemodynamic, and homeostatic processes
of the body (fat metabolism, regulation of blood
pressure, etc.), leading to formation of atheroma,
thrombi, emboli, or aneurysm in the vasculature
at Annamaya kosha. This further manifests as
various disorders such as hypertension, athero-
sclerosis, stroke, and so on. On the other hand,
tamasic personalities are indolent and seem
reluctant about their well-being due to inertia
resulting in the consumption of unwholesome
food, erratic food intake patterns, lack of physical
activity, substance abuse and prolonged sleep
duration. These wrong lifestyle patterns lower
the resilience to cope with stress and renders
Manomaya kosha to be very vulnerable to mal-
adaptive thought patterns and emotions. Further,
the turbulence in Manomaya kosha penetrates
into Annamaya kosha via Pranamaya kosha as
aforementioned (refer Fig. 20.1). Once such dis-
turbances set in, the individual is likely to develop
stroke or related risk factors like hypertension,
diabetes, and coronary heart disease. After such
disorders develop, the morbidity in the Annamaya
kosha starts to intensify the turbulence in
Manomaya kosha leading to elevated levels of
psychological stress, depression, anxiety, and
fear of death. This vicious cycle keeps function-
ing and negatively inuences the prognosis of the
Rajasik Personality Tamasik Personality
High-set goals, relentless desires, fear,
anxiety, anger and an array of negative
emotions
Indolence, consumption of unwholesome
food, physical inactivity, substance abuse
and erratic sleep-wake patterns
Maladaptive thoughts and emotions that initiate turbulence in
the Manomaya kosha (Adhi)
Haphazard distribution of prana at the level of Pranayama
kosha leading to disarray of basic cellular physiology,
hemodynamic and homeostatic processes of the body
Manifests as atheroma, thrombi, emboli or aneurysm in
the vasculature at Annamaya kosha
ATHEROSCLEROSIS STROKE HYPERTENSION
Fig. 20.1 Understanding Stroke from Yoga Perspective
N. Jasti et al.

257
disorder, highlighting the need for yoga therapy
to address such disorders.
20.8 Yoga forPrevention
ofStroke: Current Evidence
Modern lifestyle disorders such as hypertension,
type 2 diabetes, dyslipidaemia, atherosclerosis,
and latent conditions like oxidative stress and
chronic psychological stress are potential risk
factors that build the foundation for stroke occur-
rence and recurrence. Yoga has been demon-
strated to be useful in signicantly downplaying
these risk factors and positively modulate one’s
health [11]. Chronic mental stress is the common
trigger for Hypertension, Diabetes, Heart dis-
eases and other lifestyle disorders. Yoga fosters
better mental adaptability, efciency, and resil-
ience by increasing the levels of GABA (Gamma
Amino Butyric Acid) and further modulating the
neuroendocrine axis and cortisol levels [12, 13].
Several studies have been conducted to evaluate
the short-term and long-term effects of yoga on
Hypertension. A meta-analysis of nine random-
ized controlled trials (RCTs) has shown that
Transcendental Meditation (TM) could reduce
systolic blood pressure by 4.7 mmHg (CI 1.9–
7.4) and diastolic blood pressure by 3.2mmHg
(CI 1.3–5.6), when compared to controls [14]. In
an RCT, 11-week yoga therapy program was
found to be equally effective as anti- Hypertensive
drug therapy [15]. Specically, the practice of
laghu shankhprakshalana (systematic yogic pur-
gation), shavasana (corpse yogic pose), sukha
pranayama (6 breaths/min, with awareness), and
TM have shown a consistent reduction in both
systolic and diastolic blood pressures [14, 16–
18]. Long-term benecial effects of yoga at
8 weeks, 8 months and after 4 years were also
assessed. There was persistence in reduction of
both systolic and diastolic blood pressures in the
treatment arm in contrast to the health educa-
tion—control group across the timepoints [19].
Even though evidence suggests moderate reduc-
tions in blood pressure with yoga, it still trans-
lates into a signicant reduction in the risk of
CVD.It is estimated that a reduction in systolic
blood pressure by 5mmHg in a healthy popula-
tion results in a fall of stroke mortality by 14%
and coronary heart disease (CHD) by 9% [20].
Considering the dearth of evidence on the useful-
ness of yoga in the management of hypertension,
AHA has classied TM, Yoga and other medita-
tion techniques under second and third classes of
recommendation for its implementation in clini-
cal practice. Manchanda etal. have demonstrated
the potential of yoga therapy in decelerating and
reversing atherosclerotic processes that could
prospectively result in cardiovascular or
cerebrovascular accidents [21–23]. Carotid
intimal- medial thickness (cIMT) was shown to
reduce in patients with metabolic syndrome with
1 year of yoga practice [22]. Positive changes
have been observed on coronary angiography and
parameters like body mass index (BMI), waist
circumference, LDL (low-density lipoprotein),
triglycerides (tgy), angina and exertion induced
ischemia have signicantly reduced with the
simultaneous increase in HDL (high-density
lipoprotein) in advanced cases of atherosclerosis
following the practice of yoga-based lifestyle
[21, 22]. Appreciating the association of dyslipi-
daemia with coronary heart disease and ischemic
stroke, many RCTs have been conducted to
understand the role of yoga in dyslipidaemia. The
results report that the total cholesterol has shown
a variation of 5.8–25.2%, tgy by 22.0–28.5% and
LDL-c by 12.8–26% across 6weeks to 12months
in these studies [24–26]. Similar trend in lipid
prole has been demonstrated in a population
with type 2 diabetes also [24]. A metanalysis of
12 RCTs investigating effects of yoga in adults
with type 2 diabetes showed signicant reduc-
tions in glycosylated hemoglobin, fasting blood
glucose, postprandial blood glucose, total choles-
terol and LDL levels with an increase in the lev-
els of HDL [27]. In addition to the above,
oxidative stress worsens the scenario. Regular
practice of yoga for about 3 months has been
found to reduce the malondialdehyde levels (an
indicator of oxidative stress) and increase the lev-
els of glutathione, superoxide dismutase and
vitamin-C (antioxidants) in patients with diabetes
and hypertension [28–30]. From the above stud-
ies, evidence suggests a signicant protective
20 Role ofYoga inStroke Management: Current Evidence andFuture Directions

258
role of yoga towards the prevention of stroke and
cardiovascular disorders.
20.9 Current Evidence: Yoga
forPost-Stroke
Rehabilitation
Stroke results in considerably severe physical and
psychosocial distress leading to compromise on
the quality of life and loss of independence of an
individual [31]. Post-stroke hemiparesis, aphasia,
headaches, falls, pain, and depression stand as
major concerns, towards which yoga has a poten-
tial role to play. Bastille etal., studied the effect of
yoga on balance, timed mobility and quality of
life on the Berg Balance Scale (BBS), Timed
Movement Battery [TMB] and Stroke Impact
Scale [SIS], respectively in 4 cases of chronic
post-stroke hemiparesis. 1.5-h yoga session twice
weekly over 8weeks, improved timed mobility in
3 cases and balance in 2 cases [32]. A prospective
randomized controlled trial conrmed the results
of the above study on post- stroke balance and fear
of falling [33]. Further, another pilot study dem-
onstrated substantial improvement in pain, range
of motion at neck and hip, upper limb strength
and 6-min walk scores in patients with chronic
stroke with 8-week Yoga intervention [34].
Besides hemiparesis, aphasia is another physical
symptom that is greatly distressing and seeks
attention. 12weeks of Kundalini yoga was shown
to improve aphasia on Boston Aphasia Exam and
ne motor coordination on O’Connor Tweezer
Dexterity Timed Test in patients with stroke [35].
In the similar context, a case study that involved
practice of Alternate nostril breathing (20min/day
for 17weeks) and consumption of coconut oil (1
tablespoon a day) have translated into a signi-
cant improvement in anomic aphasia and para-
phasia on Western Aphasia Battery-Revised
(WAB-R) tool [36]. Uni-nostril yogic breathing
alongside traditional speech therapy has been
found benecial in improving the affect and lan-
guage abilities in stroke patients [37]. The long-
term debilitating effects of stroke is very
devastating for the patient making them vulnera-
ble to mental illnesses. There is sufcient evi-
dence demonstrating the potential of yoga in
reducing anxiety and improving mood [28, 38].
The results of an RCT exploring the role of
6week yoga program on post-stroke anxiety and
depression displayed greater improvements in the
depression on Geriatric Depression Scale
(GDS15) and state trait anxiety on State Trait
Anxiety Inventory (STAI) in the intervention
group (yoga and exercise) than the control group
(exercise) [29]. Another study exploring multiple
array of symptoms in stroke patients has dis-
played improvement in quality of life associated
with memory, perceived motor function and per-
ceived recovery [30]. Garrett etal. and Portz etal.
qualitatively studied the experiences of patients
with stroke after 10-week yoga intervention. The
participants reported greater sensitivity, calmness,
acceptance, and connectedness to the present self
and with others. Improvement was reported in
perceived strength, range of motion, walking abil-
ity, endurance, gait speed, exibility, and balance
[39, 40]. These ndings conform to the necessity
of inclusion of yoga and meditation techniques
into post-stroke rehabilitation programs.
20.10 General Guidelines toAdapt
Yoga Therapy forStroke
Rehabilitation
Yoga therapy involves the practice of physical
postures, controlled breathing techniques,
mindfulness- based chanting practices, devo-
tional sessions and yogic counseling sessions to
enhance physical, cognitive, and psychosocial
functioning. However, yoga for post-stroke indi-
viduals has to be greatly modied considering
the general physical disabilities to improve
compliance, feasibility, and self-reliance.
Below- listed are few points to be considered
while adapting the yoga module for post-stroke
patients.
• The module should be brief, but should
include all the components of YT.
• Instructions should be short and clear. Multiple
short sessions should be conducted rather than
one long session.
N. Jasti et al.

259
• Graduated yoga module: only easy to perform
and very essential practices are introduced in
the rst week of therapy; gradually necessary
practices are introduced in succession accord-
ing to the performance of the patient. (see the
module below)
• The sequence should be well planned. It will
be wise not to change postures frequently
from standing to sitting or lying abruptly.
• Involvement of whole body in each session.
This will ensure proper circulation and will
prevent bedsores and deep vein thrombosis
due to inactivity.
• Avoid inversions in the module.
• Avoid postures that exert extreme pressure
and sudden movements of the neck like
Sarvangasana and Halasana.
• Avoid acute forward and backward bends in
the module like Ardhachakrasana,
Padahasthasana, Chakrasana, etc.
• Avoid balancing postures like Vrikshasana,
Garudasana, etc.
• Avoid fast breathing practices like Kapalbhati
and Bhastrika as it might lead to episodes of
dizziness.
• Avoid the practices involving breath retention
like Kumbhakas and Bandhas as they might be
strenuous to the subject.
• Encourage repetitions of each practice in the
rst week. The short module can be repeated
for three times interspaced with sufcient
resting periods.
• The patient should be encouraged to memo-
rize the yoga module in the correct sequence
and be self-reliant.
• Inclusion of instructions on breath
awareness.
• Inclusion of instructions to enhance their
mindfulness during the practice.
• Inclusion of visualization techniques, espe-
cially when mobility is greatly compromised
will aim at improving motor learning, plan-
ning, and coordination [41]. The patient
should be encouraged to visualize the practice
mentally if he/she is incapacitated to perform
any specic practice.
• Inclusion of instructions sensitizing the sub-
ject about the sensory awareness.
• Acknowledge even the minute improvements
and communicate to the patient.
• It is best to include a 15-min counseling ses-
sion every day at the end of the yoga practice
to encourage the patient and promote the prac-
tice of yoga through positive reinforcement.
• Use of support is strongly recommended dur-
ing the initial phases of the practice. However,
the effort has to be made to slowly discontinue
the usage of support according to the func-
tional improvement in the subject.
• Therapist/ caregiver should assist the passive
range movements in severe cases.
20.11 Graduated Yoga Module
forStroke
Generally, a yoga module can be split into six
components: loosening exercises, breathing tech-
niques, Asanas, Pranayama, chanting, and
guided meditation. Of the six components, sub-
stantial emphasis should be laid on the
Pranayama, chanting, and guided meditation
techniques as these practices target the deeper
koshas, i.e., Pranamaya and Manomaya koshas.
Moreover, these practices can be done even in a
severe degree of immobility.
Considering the positive impacts of yoga ther-
apy on overall well-being of patients with stroke,
a graduated 4-week yoga protocol has been
designed based on the available scientic evi-
dence. This 4-week yoga training program might
serve as an adjunct therapy for enhancing func-
tional independence and recovery of patients in
the post-stroke rehabilitation phase.
Details of the graduated yoga program for
post-stroke rehabilitation are as follows:
1. First week (to be practiced three times a day
for the rst week, once a day after week-1)
• Whole body joint loosening with mindful-
ness and breath synchronization: Feet,
ankles, knees, hips, ngers, wrists, elbows,
shoulders, and neck—10 rounds each
while sitting in a chair. If these practices
cannot be done actively, the therapist can
administer passive joint movements.
20 Role ofYoga inStroke Management: Current Evidence andFuture Directions

260
2. Second week (preparatory breathing prac-
tices in sitting + instant relaxation tech-
nique+rst week practices)
• Preparatory breathing practices in sitting
using chair support: Twisting, side bend-
ing, hand stretch breathing, hands in and
out breathing with “M-kara” chanting—10
rounds of each practice.
• Instant relaxation technique in the supine
pose: Quick and sequential tightening of
all body parts from toes to head followed
by letting go and relaxation (2 rounds).
3. Third week [asanas (physical postures)—rst
5 rounds without holding the pose, sixth round
hold the pose for 10 breaths+ rst and sec-
ond week practices]
• Prone: Bhujangasana (cobra pose), Ardha
Shalabhasana (half locust pose),
Makarasana stretch (crocodile pose).
• Supine: Utthita Padasana (alternate
straight leg rising), Ardha
Pavanamuktasana kriya (half-wind releas-
ing pose), Setubandhasana (bridge pose),
Shavasana (corpse pose).
4. Fourth week [asanas (physical postures)—
rst 5 rounds without holding the pose, sixth
round hold the pose for 10 breaths+rst, sec-
ond week and third week practices]
• Standing with wall support (holding for
support if required): second week practices
in standing position + Padasanchalana
(alternate leg movements with breath syn-
chronization). Trikonasana (triangle pose),
Ardha Kati Chakrasana (half-waist pose).
• Sitting with wall support: Vakrasana (sit-
ting twisted pose), Patangasana (buttery
apping 100 counts), Ardha-
baddhakonasana (half buttery pose),
Moola bandha (anal lock).
5. Pranayama practice (yogic controlled breath)
in sitting meditative pose, as a regular com-
mon practice after physical postures from the
rst to fourth week
• Nadishuddi Pranayama (alternate nostril
breathing)
• Bhramari in Shanmukhi Mudra (humming
bee breath)
• Nadanusandhana (chanting of sounds—
AAA, UUU, MMM, and AUM 9 rounds
each, while being mindful and feeling the
vibrations in the body)
6. Relaxation in Shavasana (corpse pose) as a
regular common practice after pranayama
from the rst to fourth week
• Deep abdominal breathing with prolonged
exhalation in Shavasana (the duration of
inhalation and exhalation for each respira-
tory cycle should be maintained at a 1:3
ratio, respectively).
• Part by part relaxation of the body from
head to toes.
Precautions to be Taken
– Do not encourage overdoing the practice. This
might result in adversities like myalgia,
fatigue, and cramps.
– Avoid frequent changes in starting posture
through the course of the module. Changes in
the posture should be assisted by a caregiver
or therapist.
– Avoid strenuous practices in the rst few
weeks and gradually increase the complexity
of the postures.
– Ensure empty bladder and bowel before yoga
practice.
– Ensure light stomach conditions while prac-
ticing yoga.
N. Jasti et al.

261
20.12 Yoga andAyurveda-Based
Lifestyle Advices forPost-
Stroke Care
Besides improvement in functional status of the
patient, therapy also aims at regulating one’s life-
style to reduce the risk of recurrence of stroke
and its associated co-morbidities. Table20.2 pro-
vides Yoga and Ayurveda-based lifestyle advices
that are to be followed Post-stroke. These recom-
mendations can be classied under three major
headings; ahara (dietary regimen), vihara
(behavioral changes) and vichara (mental
changes).
Table 20.2 Yoga and ayurveda-based lifestyle advices for stroke
Ahara (dietary regimen) Vihara (behavioral changes)
Vichara (mental
changes)
Do’s
– Sattvik food: fresh, sweet, juicy, and
nourishing foods like fresh fruits, leaves and
vegetables. Whole grains and cereals should be
preferred.
– Easily digestible, seasonal, and locally
available foods should be preferred.
– Include foods rich in vitamins, minerals, and
antioxidants, especially Beta carotene,
anthocyanins, avonoids, and lycopene rich (e.g.;
black grapes, papaya, tomatoes, black rice, cocoa)
– Intake of sesame oil and moderate
consumption of fat.
– Warm milk is recommended.
– The temperature of food being consumed
should be warm
– Yuktahara: moderate food consumption
– Mitahara: the quantity of food taken should
ll half of the stomach, liquids should ll another
quarter, and the last quarter of the stomach is to
be left free to ensure proper digestion.
– Physical activity involving whole
body mobilization
– Exposure to fresh air breeze
– Sleeping on hard bed
– Proper sleep-wake pattern
– Warm water bath everyday
– Regular evacuation of bowels
– Gentle massage to the whole body
with warm sesame oil every day.
– Steam bath once a week after
gentle massage
– Lukewarm sesame oil enema at
least once a week under supervision
– Adherence to therapy
recommendations
– Mindfulness with each activity
– Reading and imbibing traditional
wisdom from prominent ancient
scriptures like Bhagavad Gita, Bible,
or Quran, etc.
– Attitude of surrender
towards the higher
principle of life
– Being
compassionate
– Strong will and
perseverance
– Unshakeable faith
– Enthusiasm and
optimism
– Feeling of
connectedness to self
and others
– Contentment and
peace
– Introspection into
one’s own life and his
spiritual growth
– Ability to stay
tranquil in the odds.
Do nots
– Excess intake of food
– Long-term fasting and starvation
– Red meat
– Cold and reheated food
– Food items that have lost their natural oil.
– Processed food
– Excess salt and sodium intake
– White sugar
– Alcohol
– Recreational Drugs
– Smoking
– Daytime sleep
– Excess comforts leading to
compromise on minimal physical
activity
– Indolence
– Avoid hot water for head bath
– Staying awake late in the night
– Overexertion
– Exposure to extreme temperatures
– Excess sensual indulgences of
taste, touch, smell, vision, and
sound.
– Suppression of natural urges like
hunger, thirst, urination, defecation,
etc.
– Avoid the company of vicious and
pessimistic company
– Excess mentation
– Irritability, anger,
and hatred
– Fear, specially the
fear of death
– Lust and relentless
desires
– Low mood and
sadness
– Helplessness and
hopelessness
– Procrastination
– Dejection
– Guilt feelings
20 Role ofYoga inStroke Management: Current Evidence andFuture Directions

262
20.13 Probable Mechanism
ofAction
The denite mechanisms of how yoga helps in
post-stroke rehabilitation are not lucidly under-
stood. In physical domain, it enhances microcircu-
lation in the joints and facilitates restoration of
proper tone in the muscle bers resulting in
improvement of strength, range of motion and gait
with a reduction in stiffness [42, 43]. It further
improves balance, coordination of ne and com-
plex movements. These improvements empower
the patient and improve their functional indepen-
dence. Studies suggest that yoga regulates the HPA
axis resulting in the reduction of cortisol levels.
This enhances well-being through alleviation of
stress, promotion of better neuro- endocrine-
immune functioning and metabolic prole of an
individual [12, 13]. There is extensive evidence on
the efcacy of yoga in bringing balance in the func-
tions of the autonomic nervous system. Its ability to
maintain the vagal tone transcribes into better car-
diovascular functioning, which reduces the risk of
stroke, associated risk factors and co-morbidities
[12]. There are a few studies that demonstrate the
efcacy of yoga on signicantly increasing the lev-
els of brain- derived neurotrophic factor (a key-reg-
ulator of neuroplastic processes), which might play
some role in the recovery of brain lesions, improve
the functional status of the individual and offer fur-
ther neuroprotection [44–47]. The improvement in
mood and reduction in anxiety with the practice of
yoga could be attributed to the upregulation of
GABAergic (Gamma Amino Butyric Acid) activity
in addition to the reduction in cortisol levels [48].
Further, yoga philosophy and meditative practices
bring changes in the perception and behavior of an
individual that allows them to accept their current
shortcomings [39]. This enhances the condence
levels of an individual and empowers them to
establish a proper bio-psychosocial domain with
the external.
20.14 Limitations ofCurrent
Evidence inYoga andFuture
Directions toOvercome
theLimitations inYoga
Research inStroke
There are many brief reports, case series and only
two randomized control trials exploring the
effects of yoga therapy on stroke in comparison
to waitlist controls. Moreover, these trials study a
very small sample because of which the results
lack generalisability. Large multicentric trials are
needed to study this area systematically with a
subsequent period of follow-up. The current lit-
erature has very few comparable studies to per-
form a metanalysis, suggesting the need for a
standard protocol for conducting further studies
in terms of detailing all characteristics of the
intervention, outcome measures and utility of
standard tools of assessment, reporting compli-
ance and adverse events of the intervention.
Further, long-term effects have not been investi-
gated, which could be explored in the forthcom-
ing studies. Cochrane review of literature on
stroke reveals a high risk of bias in performance,
attrition outcomes, detection, and reporting [49].
On the basis of GRADE (Grading of
Recommendations Assessment, Development,
and Evaluation) criteria, the overall quality of the
evidence available seems to fall between low and
moderate [50].
20.15 Conclusion
The literature suggests Yoga-based lifestyle prac-
tices play a signicant role in the prevention of
stroke and post-stroke rehabilitation. This sug-
gests a dire need for the integration of Yoga ther-
apy with the current conventional medical
systems to reduce morbidity and mortality due to
stroke, its risk factors and co-morbidities.
N. Jasti et al.

263
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