Embed Size (px)
Citation preview
A Research Project of
CENTRAL COUNCIL FOR RESEARCH IN YOGA & NATUROPATHY
(Deptt. of AYUSH, Ministry of Health & F. W., Government of India)
61-65, Institutional Area, Janakpuri, New Delhi - 110058 (India)
R E S E A R C H P U B L I C A T I O N - N o. 9
AUTONOMIC FUNCTION TESTS IN EPILEPSY :
EFFECT OF HATHA YOGA
Editor-in-Chief :Prof. Dr. B.T.Chidananda MurthyDirector
Published by :CENTRAL COUNCIL FOR RESEARCH IN YOGA & NATUROPATHY(Deptt. of AYUSH, Ministry of Health & F. W., Government of India)
61-65, Institutional Area, Janakpuri, New Delhi - 110058 (India)
Website : www.ccryn.org Email : [email protected]
Phone : 011-2852 0430, 31, 32 Fax : 011-2852 0435
Central Council for Research in Yoga & Naturopathy
Compiled by :
Dr. Rajiv Rastogi
Asstt. Director ( Naturopathy)
Dr. H.S. Vadiraj B.N.Y.S, Ph.D.
Consultant (N & Y)
First Edition : 1000 copies, 2010
Produced by :GUIDE OFFSET PRINTERS
D-11, DSIDC COMPLEX,
KIRTI NAGAR, NEW DELHI - 110015
FOREWORD
¼LokLF; vuqla/kku foHkkx½LokLF; ,oa ifjokj dY;k.k ea«kky;oh- jkefyaxLokeh Òou] valkjh uxj
ubZ fnYyh & 110029 ¼Hkkjr½
Hkkjrh; vk;qÆoKku vuqla/kku ifj’kn
Indian Council of Medical Research
Ministry of Health & Family Welfare
V. Ramalingaswami Bhawan, Ansari Nagar
New Delhi - 110029 (INDIA)
(Department of Health Research)
I am pleased to see the publication entitled, “Autonomic function tests in Epilepsy: Effect of Hatha Yoga” based on the findings of a research project completed at Department of Neurophysiology, National Institute of Mental Health and Neurosciences, Bengaluru funded and monitored by Central Council for Research in Yoga & Naturopathy, New Delhi.
Epilepsy is a common disabling neurological disorder affecting sizeable population in India. Stress is one of the important precipitating factors to cause Autonomic dysfunction and is noted to trigger seizures.
Yogic practices are known to help in the amelioration of stress since ancient times and may play an important role in reducing seizure frequency. This study highlights the beneficial role of Yoga in this condition.
I am sure this monograph will benefit not only the general public but also the Yoga and Naturopathy practitioners and other medical practitioners. Research in alternate medical system will find strong basis to carry out more work.
I congratulate the Council for bringing out this informative publication for increasing the awareness about Yoga among the public.
(V. M. Katoch)
M‚ fo“o eksgu dVksp,e Mh] ,Q , ,e ,l] ,
lfpo] Hkkjr ljdkj¼LokLF; vuqla/kku foHkkx½
LokLF; ,oa ifjokj dY;k.k ea«kky; ,oa
egkfUkns”kd] vkbZ lh ,e vkja
,Q ,u , ,llh] Q , ,llh] ,Q ,u ,
Dr. Vishwa Mohan KatochMD, FNASc, FAMS, FASc, FNA
Secretary to the Government of India(Department of Health Research)
Ministry of Health & Family Welfare &
Director-General, ICMR
PREFACE
Yogic practices produce deep psychosomatic relaxation and improvement of cardio-respiratory
efficiency. These techniques produce consistent physiological changes and tend to restore the
autonomic balance which is altered due to the pathophysiology of the existing conditions. Yogic
practice modulates brain functioning in different ways and different levels like shift of autonomic
balance towards relative parasympathetic dominance. Meditation significantly improves clinico-
electroencephalographic measures in drug resistant chronic epilepsy.
It is the Ninth research publication in series of research publications of research findings. The earlier
Eight publications were accepted and appreciated by the Yoga enthusiast, Naturopaths and Medical
brethrens, which promoted the Council to reprint them.
This is the first study from India to evaluate autonomic functions in refractory epilepsy patients. I hope
the findings will be valued by the Scientific Community.
(Prof. Dr. B.T.Chidananda Murthy)
Director
Epilepsy is one of the most common neurological disorders. It is a condition of being overcome or
seized. Epilepsy affects approximately 40-50 million people worldwide. India is also not behind the
race with about 5.5-6.0 million Epilepsy patients. The disease encompasses a heterogenous group of
disorders with multiple causes and manifestations. Among the most disabling aspects of epilepsy is
anticipation of seizures–the uncertainty of when and where the next seizure will occur.
Stress is one of the important precipitating factors to cause autonomic dysfunction and has direct
influence with increased frequency of seizures. Anxiety, anger and certain antecedent events are
noted to trigger seizures. There is a deep relation between epilepsy and cerebro vascular disease.
Sudden unexplained death is an important category of mortality with epilepsy. Epilepsy impairs
learning and interferes with normal responses. Hence, an individual living with epilepsy suffers not
only from normal stresses that a chronic illness imposes but is also handicapped in terms of responding
to those stresses by the illness itself and by its treatment.
To deal with the above disorder, the Central Council for Research in Yoga & Naturopathy (CCRYN)
conducted a study on “Autonomic Function Tests in Epilepsy: Effect of Hatha Yoga” at Deptt. of
Neurophysiology, National Institute of Mental Health & Neuro Sciences, Bengaluru. The study was
concluded during the period of 2002-04. The important findings of the study have been included in the
monograph.
Dr. T.N.Sathyaprabha. M.D.
Principal Investigator,
Additional Professor, Dept of Neurophysiology,
NIMHANS, Bengaluru- 560029
Dr. T.N. Sathyaprabha is additional professor of Neurophysiology at India's premier institute – National Institute of Mental Health and Neurosciences ( NIMHANS). She had started state of art Autonomic function lab in 2003,which matches with international level. Her lab caters research facilties for PhD scholars, Super specialty course like DM Neurology, M Ch Neuro surgery and for post graduates. She has contributed significantly to research in alternative medicine.
Dr. Sathyaprabha has been awarded prestigious “ICMR International Young Scientist fellowship award- 2009”. Other award for her credits include Sushila Thakur Prakruthi Mandir award given by APPI for her work in field of naturopathy and yoga in management Bronchial asthma, Sir M Visheshwaraya parisara rathna award by Kuvempu University and few more awards for research work as co author.
Her research work has been translated in to many international publications. She has 32 publications which includes national, international, Conference proceedings and book chapters. Dr. Sathyaprabha is reviewer for national and international journals of Elviser publications, Journal of Chinese Clinical Medicine, Acta Neurol Scand, Clinical & experimental hypertention and few more national Journals.
Dr. Sathyaprabha along with neuroscientist has started first local branch of Society for Neuroscience in Asia called SfN – Bangalore Chapter. She is also active member of many scientific organization. Her hobby is to serve people by attending medical camps in remote villages.
CONTENTS
Foreword.............................................................................................................iii
Preface................................................................................................................ v
Project Profile.................................................................................................... xi
Abbreviations....................................................................................................xiii
Introduction.........................................................................................................1
Aims & Objectives.............................................................................................. 5
Material and Method...........................................................................................5
Protocol............................................................................................................... 9
Results...............................................................................................................11
Discussion.........................................................................................................33
Conclusion........................................................................................................ 36
Summary........................................................................................................... 38
References.........................................................................................................41
Appendix...........................................................................................................46
1.
2.
S.No. Page No.
3.
4.
5.
6.
7.
8.
9.
10.
11.
(Publications emanated out of this research project)
12.
13.
14.
PROJECT PROFILE
1. Title of Project : Autonomic Function Tests in Epilepsy:
Effect of Hatha Yoga
2. Research Centre :
3. Principal Investigator : Dr. T. N. Sathyaprabha, M.D.,
Additional Professor of Neurophysiology,
NIMHANS, Bengaluru
4. Co- Investigator :
5. Period : Started - March, 2002
Completed - February, 2004
Deptt. of Neurophysiology,
National Institute of Mental Health &
Neuro Sciences, Bengaluru
ii) Dr. Sanjib Sinha, D.M.,
Assoc. Professor of Neurology, NIMHANS,
Bengaluru
6. Reviewed by : Dr. Krishna Dalal,
Associate Professor, Deptt. of Biophysics,
All India Institute of Medical Sciences,
New Delhi
iii) Dr. T.R. Raju, Ph.D.,
Professor & Head of Neurophysiology,
NIMHANS, Bengaluru
SUDEP : Sudden Unexplained Death
NIDDM : Non Insulin Dependent Diabetes Mellitus
ECG : Electro Cardio Gram
SD : Standard Deviation
EEG : Electro Encephalo Gram
DBD : Deep Breathing Difference
SBP : Systolic Blood Pressure
DBP : Diastolic Blood Pressure
SMR : Sensory Motor Rhythm
REM : Rapid Eye Movement
AD : Autonomic Dysfunction
ABBREVIATIONS
Introduction
The term “Epilepsy” is derived from a Greek word, which means a condition of being
overcome or 'seized'. Epilepsy affects approximately 40-50 million people worldwide. In
India, the number of people affected is estimated to be about 5.5-6.0 million (Sridharan
1999). It is one of the most common neurological disorders. Epilepsy encompasses a
heterogenous group of disorders with multiple putative causes and manifestations. Among
the most disabling aspects of epilepsy is anticipation of seizures–the uncertainty of when
and where the next seizure will occur.
Activation of the autonomic nervous system is common with seizures. No biological
markers of impending seizures have been found; hence evaluation of autonomic nervous
system changes might help. A number of studies have examined the role played by
autonomic dysfunction as it is related to epileptogenic discharge and as an explanation for
the cause of death in these patients (Terrence CF et al 1975, Jay and Leestma 1981). P.
Sathishchandra et al (1988) demonstrated a positive association between epilepsy and
cerebro vascular disease and myocardial ischemia in a case-control study associated with
death among subjects with epilepsy from USA. Sudden unexplained death (SUDEP) is an
important category of mortality in the population with epilepsy and is a well recognized
phenomenon (Hirsch et al 1971, Claire M 1982). SUDEP is responsible for 2-17% of all deaths
in patients with epilepsy, depending on the type of study (Ficker DM). The mechanism(s) of
SUDEP is not fully understood. Most of seizures are accompanied by apnea and fall in
oxygen tension in human and animal model (Nashef, 1996, Johnston 1995). Johnston et al
studied an animal model and concluded that hypoventilation and pulmonary edema are
important causes of death during seizure. Many SUDEP victims had pulmonary edema on
post mortem examination, and some have ischemic damage of the heart despite normal
coronary arteries, which possibly arises as a result of repeated episodes of
1
Findings of the Research Project
Autonomic Function Tests in Epilepsy: Effect of Hatha Yoga
2
vasoconstriction from seizure related catacholamines bursts, which indicates increase
sympathetic activity (Mc Gugan FA).
The possible risk factors have been identified from an epidemiological study of this
phenomenon. Seizure severity appears to be the strongest risk factor of SUDEP. Other
potential risks factors include younger age at onset, male sex, generalized seizures and
certain anti epileptic drugs. (S. Shorvon 1997).
Incidence of increased SUDEP is correlated with the number of antiepileptic drugs
prescribed and with the use of psychotropic drugs (Tennis P et al 1995, Anaskorpi et al
2000). Alternate methods like behavioral approaches of seizure control (Mostofsky &
Balaschak 1977, Whitman et al 1990, Puskarich CA, 1992) have recently evoked
considerable interest, as epilepsy is now being considered as neuropsychological or a
behavioral neurology problem, rather than a purely neurological disorder.
The word Yoga is derived from the Sanskrit root 'Yuj' meaning to bind, join, attach and yoke,
to direct and concentrate ones attention on, to use and apply (Iyengar 1997). Yoga is a
holistic science whose function is to integrate personality at all levels of existence. Yoga is
our ancient Indian culture and way of life, which is claimed to endow perfect physical and
mental health to one who practices it. The Bhagawad Gita gives different aspects of Yoga,
namely, Bhakti Yoga, Gnana Yoga and Karma Yoga. Hatha Yoga is one of the sub divisions of
Karma Yoga. The scientific literature mainly deals with reports on the physiological effects
of Hatha Yoga. Hatha Yoga lays emphasis primarily on the physical aspects such as asanas
and pranayama. Asanas are modified physical postures. They bring steadiness, mental
equilibrium, health and lightness of body and mind. They also correct psychosomatic
imbalance in diseased. (Sathyaprabha 2001). Pranayama, which is a part of Hatha Yoga,
is a yogic exercise in respiration (Nagendra 1997). It is defined in the yogasuthra of
Pathanjali as the science of cleansing, balancing and gaining control over the prana
in the human system. Yogic exercise improves body functions through the
modification of cardiovascular, respiratory, metabolic and other control
mechanisms. (Sathyaprabha et al 1998, Ray et al 1986, Staneseu 1981).
3
With increased awareness and interest in health and natural remedies, yogic techniques
are gaining importance and becoming increasingly acceptable to the scientific community.
There is evidence that Yoga training produces deep psychosomatic relaxation
(Madanmohan et al, 1983; Rai et al, 1982) and improvement of cardio-respiratory
efficiency (Gopal et al, TN Sathyaprabha et al ). Chhina has reported that yogis are capable
of controlling their autonomic functions (Chhina, 1974). The role of Yoga in promoting
health and prevention and cure of diseases, especially psychosomatic disorders has been
established by the recent scientific studies. Yogic techniques produce consistent
physiological changes and have sound scientific basis (Madanmohan et al, 1983; Wallace et
al, 1971). Chhina (1974) has reported that yogis are capable of controlling their autonomic
functions. There are many studies in which Yoga has been used for its therapeutic as well as
preventive potentials for many of psychosomatic diseases like essential hypertension,
diabetes mellitus, bronchial asthma, epilepsy etc. Vijayalaksmi et al have shown Yoga
training optimizes the sympathetic response to stressful stimuli like isometric handgrip
test and restores the autonomic regulatory reflex mechanisms in hypertensive patients.
Yogic study on diabetes patients conducted by Jain et al have concluded that Yoga, a simple
and economical therapy, may be considered a beneficial adjuvant for NIDDM patients.
Studies of Yoga and various relaxation therapies conducted by Blazek have shown that
these therapies may have a role for treatment of asthmatics. Recent study by Bijlani et al
have suggested that a short lifestyle modification and stress management education
program based on Yoga leads to favorable metabolic effects within a period of 9 days thus
reducing the risk factors for cardiovascular disease and diabetes mellitus. In most of these
disorders Yoga tends to restore the autonomic balance which is altered due to the
pathophysiology of the existing conditions.
It has been well documented, that practice of Yoga induces a shift in the autonomic
balance towards relative parasympathetic dominance (Anand 1961, Wallace 1972,
Selvamurthy 1983). Since there is hypo function of parasympathetic activity in epilepsy
patients, we aim to evaluate the effect of Hatha Yoga on autonomic function test in
epilepsy subjects.
EPILEPSY AND YOGA
STRESS AND EPILEPSY
Stress is one of the important precipitating factors to cause autonomic dysfunction and has
direct influence with increased frequency of seizures. Stress is defined as 'Physical,
mental and emotional reaction experienced as a result of changes and demands in life
due to modern civilization'. The association between stress and the occurrence of
seizures is generally accepted on the basis of clinical observation (Gastaut and Tassinari,
1966, Currie et al 1971). Anxiety, anger and certain antecedent events (Feld and Paul
1976) are noted to trigger seizures. Nancy (1992) have demonstrated the association
between stress and seizures. Stress is not commonly addressed in management of epilepsy.
It is suggested that reduction in stress may be an important factor in reducing seizure
frequency and has been recommended as one of the additional method of treatments in
the management of chronic intractable epilepsy (Puskari, 1992, Temkin, 1994).
Deepak et al have observed that meditation significantly improve clinico-
electroencephalographic measures in drug resistant chronic epilepsy, and the mechanism
explained is anxiety alleviating/relaxation induction and meditation is known to enhance
alpha activity and inhibits high amplitude discharges.
4
Kalviainen (1990) from Finland documented mild parasympathetic hypofunction in 'Baltic
Myoclonus'. Recently Novak et al (1999) demonstrated parasympathetic withdrawal and
activation of sympathetic system just before the seizure by time frequency analysis.
It is known that autonomic dysfunction is associated with epileptogenic activity. Its
importance as a contributory risk factor to potential fatal outcomes for epileptic
population is yet to be determined. Hence a detailed evaluation of cardiovascular
autonomic functions in patients with epilepsy can provide valuable information on the
mechanisms of SUDEP & prognosis of epilepsy. Fifteen percent of epileptic patients are
refractory to all methods of treatment. To this group, non-pharmacologic intervention of
Yoga will be of great use.
AIMS AND OBJECTIVES :
5
MATERIALS AND METHODS :
COLLECTION OF NORMATIVE DATA :
Establishing normative data is the basic requirement for any study. For this purpose,
subjects who could be taken as normative healthy volunteers were recruited by putting up
notices on the notice boards in the Institute out patient department, stating the
requirement of volunteers for the study. The information was also passed on by word of
mouth. 163 volunteers came forward in response to the notices. Out of 163 volunteers, 142
volunteers were recruited for formation of normative data. The remaining 21 volunteers
were not taken for the study as they fulfilled a few exclusion criteria. The recruited
volunteers were either friends or relatives of the patients or volunteers from the Institute.
The subjects were in the age group of 15 yrs to 60 yrs. They were recruited after ensuring
that they did not meet with any of the exclusion criteria. All the subjects were screened
for hypertension, diabetes, asthma, cardiac ailments, psychiatric disorders, substance
abuse and any other long-term medications. Female subjects who were pregnant and
lactating were not included in the study. Women who were included in the study were in
the follicular phase of menstrual cycle. The subjects were asked to come at 10 AM. A gap of
two hours was ensured between the consumption of the last meal and performing the test.
The subjects were asked to not to consume any beverages such as tea or coffee and not to
smoke for twelve hours before the test. Informed consent was taken from all subjects. The
autonomic function tests were performed under the ideal conditions maintaining a
temperature range of 22° C to 26°C in a quiet environment. Basal ECG, Breathing response
and Heart rate were recorded for ten minutes. After that, the patients were explained to
about the various tests and the series of tests namely, Sinus Arrhythmia, Postural change
(tilt), Valsalva maneuver, Isometric exercise and Postural change (standing) were
The objectives of the study were :
a. To collect and prepare normative data using healthy controls as volunteers.
b. To evaluate autonomic functions in chronic epilepsy subjects
c. To study effect of Hatha Yoga in patients with epilepsy and autonomic dysfunction.
performed. AD Instruments (Australia) 16-channel data acquisition system was used to
perform the tests. Breathing was recorded using a respiratory belt. The ECG and breathing
signals passed through a transducer and were processed at the rate of 1024/second. The
data was analyzed manually and reported.
PROCEDURE OF TESTS :
The tests were performed in the following way :
1. Normal breathing : ECG, breathing and heart Rate variation were recorded during
normal breathing. The consecutive RR intervals were measured from the ECG for a
period of one minute, and standard deviation (SD) of the intervals used as the test
variables. Three readings of BP and heart rate were taken randomly during the rest
data recording. The lowest of these values was taken as the basal BP and basal heart
rate respectively.
2. Deep breathing : The HR variation during deep breathing (6 breaths /minute- five
seconds inhalation and five seconds exhalation) was recorded. The mean ratio of the
longest (expiration) to the shortest (inspiration) RR interval of five consecutive
breathing cycles was calculated. The test was performed twice, and higher RR interval
ratios were used as “maximum/minimum ratio”.
3. Valsalva maneuver : The HR response to Valsalva maneuver was recorded. The ratio of
the longest RR interval after blowing (at the pressure of 40 mm Hg for 15 sec) to the
shortest RR interval during blowing or immediately after it was calculated. The highest
ratio of three maneuvers was used as “Valsalva ratio”. A small hole in the mouthpiece
attached to mercury manometer during the Valsalva maneuver ensured that thoracic
pressure was used for blowing.
6
4. Isometric work: Basal BP was recorded before starting the test. The patient was asked
to press the BP cuff to the maximum possible extent and then was asked to maintain
handgrip at 30 percent of the maximum voluntary contraction up to two mins, using a
handgrip dynamometer. The systolic and diastolic BP increase during isometric work.
The rise in the diastolic BP was noted just before the end of two minutes (pre- release
BP). This was compared with BP at rest.
5. Postural change (standing): The HR and BP responses to quick postural change
(standing from supine position) were recorded. The ratio of the longest RR interval
around beat-30 (beats 20-40) to the shortest RR interval around beat-15 (beats 10-20)
after standing was used as the “30:15 ratio”. Systolic and diastolic BP was measured at st nd th
rest and at 1 , 2 and 5 minute after standing. The difference between the systolic BP
at rest and the systolic BP after standing was calculated.
6. Postural change (tilt): The HR and BP responses to slow postural change i.e. a slow tilt
to 60° from supine were recorded. The tilt takes about 45 to 60 seconds. The subject st th
was secured to the table with the help of denim belts. BP was recorded at 1 , 2nd and 5
minute after completion of tilt. The ratio between the first rise in heart rate and the
heart rate 30 seconds after the tilt was calculated and expressed as Max: Min ratio or
30:15 ratio.
All the autonomic function tests were performed under standardized conditions in a silent o
room with temperature 22-26 C between 9.00 a.m.– 12.00 a.m. The interval between the
various tests was standardized so the next test would not start until HR and BP returned to
baseline level after the previous test.
Autonomic Functions in Refractory Epilepsy
Seventy three epileptic patients, aged between 15-50 years, who attended refractory
epilepsy clinic of National Institute of Mental Health and Neuro Sciences (NIMHANS), which
is a Deemed University, those who met the inclusion criteria and did not fulfill the exclusion
criteria, were studied.
7
Subjects were recruited for the study after they gave informed consent to participate in
the study. All patients were maintained on antiepileptic drug(s), in consultation with the
treating neurologists.
The criteria for recruiting the patients for the study were as follows :
INCLUSION CRITERIA :
1. Adult patients (>15 yrs) of both genders with clinical diagnosis of active epilepsy
(partial or generalized)
2. Epilepsy of at least two years duration
3. On one or more standard antiepileptic drugs
4. Normal intellectual function
EXCLUSION CRITERIA :
1. Epileptics suffering from any known cardio respiratory and other neurological disorder
2. Chronic alcoholics and substance abuse.
3. Those who did not give consent to undergo Yoga studies
4. Female patients who were pregnant or lactating
5. Those with symptomatic seizure/ epilepsy due to underlying lesion
Their diagnosis was based on clinical manifestation, family history and EEG analysis
(unresponsiveness to single anti epileptic).
The demographic data (e.g. Age, sex, height, weight, socioeconomic status, occupation
etc.) as well as specific seizure information (e.g. Age at onset, frequency, duration of
medication etc) were entered in a predesigned proforma. All the selected subjects were
subjected to EEG recording with Nihon Kodhen 16 channel EEG machine with 10-20 system
of electrode placent using both unipolar and bipolar montages. Resting and activation
procedures such as hyperventilation (HV) for 3 min and post HV phase 3 min, photic
stimulation at various frequencies. 12 lead ECG recording was done for all subjects.
8
9
These patients were subjected to a series of tests for assessment of their cardiac
autonomic functions as described earlier. The Refractory epileptic patients with autonomic
dysfunction were divided into two groups. A control group and Yoga group.
PROTOCOL
The data collection spanned a period of twenty-four weeks as depicted above. The
Autonomic functions were recorded at the time of recruiting subjects for the study, after
eight weeks of performing Yoga in the hospital and after eight weeks of performing Yoga at
home. The same pattern will follow for control / sham Yoga group.
During the treatment period, the experimental Yoga group patients practiced Hatha Yoga,
which includes Pranayama, and yogasana for one hour daily for two weeks, and this was
considered as training period, later yoga therapy was given at NIMHANS for the period of 8
weeks from Monday to Friday. All the experimental group patients were requested to
perform Hatha yoga for one hour at home on Saturday and Sunday. During this one-hour,
the subjects performed meditation and pranayama for 20 minutes and yogasanas for 40
minutes.
The pranayama : Sukha pranayama ------------- min7
3 min Om meditation -------------
Cyclic meditation ------------- 10 min
The Yogasanas were performed in the following order :
Suryanamaskara in 12 counts ------------ 3 rounds
Ardhakati chakrasana ------------- 1 min
Ardha chakrasana ------------ 1 min
PadaHastasana ------------ 3 mins
Bhujangasana ------------ 1 min
Shalabhasana ------------ 1 min
Viparita Karani ------------ 3 mins
Sarvangasana ------------ 3 mins
Matsyasana ------------ 1 min
Ardha sirasana ------------ 1-2 mins
Shashankasana or Yoga mudra ------------ 3 mins
Ushtrasana ------------ 1 min
Shavasana ------------ 10 mins
10
All the patients were made to perform Hatha Yoga under the guidance of a qualified Yoga
instructor. The control group/sham Yoga group patients were asked to sit quietly for 20
minutes followed by simple physical exercise for 40 minutes from Monday to Friday under
the guidance of a research associate.
During the follow-up period, the experimental Yoga group patients were asked to continue
the Yoga and meditation for one hour at their residence. The control group patients were
also advised to perform 20 min quite sitting and 40 min slow exercise at their home during
follow up period.
The EEG, ECG and a battery of Autonomic function tests were recorded for experimental
Yoga group and the control group at three different levels
- At the time of enrolling the patient to the study
- At the end of eight weeks
- At the end of follow up period for eight weeks.
A Quality of life questionnaire was administered before and after starting Yoga therapy.
11
DATA ANALYSIS
Cardiovascular autonomic reflexes have been shown to be dependent on both age and
baseline HR (Bannister R 1988). Therefore, the values the HR and BP response (after
logarithmic transformation) were corrected for age and base line values separately for the
treatment group and the control group by using multiple regression. The significance levels
for the comparison between the treatment and control group was obtained by analysis of
covariance (ANCOVA).
Student' 't' test was applied to determine whether the experimental Yoga group and the
control group were comparable before treatment in terms of demographic and seizure
characters.
RESULTS
NORMATIVE DATA : The mean age of 142 normal volunteers was 35.05 + 3.57 yrs with
gender ratio of M:F–74: 68. The Normative data of cardiovascular autonomic function tests
that was collected was tabulated as shown below. The values were represented by mean ±
standard mean error (SEM). The values in parentheses indicate the 95% confidence interval
of mean.
Comparison of Autonomic Parameters in different age groups
12
<20 (n=14) 21-30 31-40 41 - 50 + Total (n=142) P Value
Age (Years)
19.17± 1.11 26.35 ± 2.32 36.3 ± 3.01 47.28 ± 3.57 35.05 ± 10.03
.000
Sex (M:F) 8:7 20:20 20:20 20:20 74:68 N.S Height (cm) 161.25 ± 5.94 164.1 ± 8.72 161.2 ± 8.71 162.33 ± 8.03 162.42 ± 8.29
.436 Weight (Kg)
51.83 ± 6.85
59.58 ± 10.41
63.59 ± 10.33
64.93 ± 10
61.69 ± 10.6
.000 §,#,¶,‡
SUP_SYS
106.67 ± 8.92
109.9 ± 11.41
111.05 ± 13.49 119.05 ± 15.45
112.73 ± 13.77
.004 ¶,‡, ф
SUP_DIA
66.33 ± 6.97
70.1 ± 12.89
74.3 ± 8.83
78.85 ± 11.54 73.68 ± 11.56
.001 #,¶,‡
SUP_HR
72.75 ± 12.86
71.15 ± 11.06
73.75 ± 8.03
70.98 ± 13.75 72.03 ± 11.29
.671
TILT_SYS
3.45 ± 4.99
2.28 ± 3.79
3.05 ± 4.4
1.78 ± 7.38
2.48 ± 5.44
.708
TILT_DIA
10.73 ± 10.67
10 ± 7.67
9.51 ± 4.74
7.24 ± 5.52
9.02 ± 6.57
.232
MIN5_SYS
0.36 ± 5.78
2.14 ± 4.56
4.03 ± 6.74
2.7 ± 8.03
2.76 ± 6.66
.393 MIN5_DIA
10.73 ± 9.56
8.93 ± 6.61
9.11 ± 5.1
6.84 ± 4.64
8.48 ± 5.97
.177
Mx:Mi30:15
1.12 ± 0.07
1.14 ± 0.09
1.1 ± 0.12
1.03 ± 0.19
1.09 ± 0.14
.010 ¶,‡, ф
^HR Max
18.15 ± 7.81
17.65 ± 8.47
15.45 ± 10.32
10.96 ± 7.42
14.81 ± 9.1
.010 ¶,‡, ф
^HR 2 min
9.58 ± 8.68
7.64 ± 6.99
6.82 ± 7.02
4.54 ± 5.94
6.56 ± 6.95
.112
RSA_E1
22.56 ± 7.09
23.73 ± 8.02
22.86 ± 7.91
17.82 ± 8.1
21.57 ± 8.24
.006 ‡, ф
RSA cycle
1.31 ± 0.18
1.39 ± 0.28
1.35 ± 0.18
1.29 ± 0.22
1.34 ± 0.23
.249
STA_SYS
4.5 ± 5.92
3.25 ± 5.3
3.8 ± 4.94
2.95 ± 9.35
3.44 ± 6.7
.885
stan min2 dia
15 ± 4.22
10.58 ± 6.36
11.08 ± 5.54
9.33 ± 7.46
10.75 ± 6.45
.061
stan min5 sys
-1.83 ± 6.9
2.13 ± 5.49
2.73 ± 5.72
1.45 ± 9.27
1.74 ± 7.06
.259
stan 5min dia
13.67 ± 3.6
10.05 ± 6.09
10.05 ± 4.94
7.68 ± 6.91
9.66 ± 6.03
.017 ¶
stan max:min
1.4 ± 0.21
1.34 ± 0.18
1.31 ± 0.18
1.26 ± 0.19
1.31 ± 0.19
.098
stan ^hr max
38.51 ± 7.79
35.85 ± 9.97
30.61 ± 9.48
25.54 ± 7.01
31.38 ± 9.87
.000 #,¶,†,‡,ф
stan ^hr2 min
23.54 ± 12.2
26.01 ± 11.3
21.47 ± 10.16
18.85 ± 8.87
22.24 ± 10.62
.021 ‡
valsa ratio
1.58 ± 0.28
1.55 ± 0.31
1.52 ± 0.29
1.48 ± 0.25
1.52 ± 0.28
.614
ISOM_SYS
12.67 ± 9.92
13.73 ± 8.36
12.35 ± 7.26
10.88 ± 7.31
12.35 ± 7.87
.453
ISOM_DIA 15.83 ± 6.18 12.4 ± 7.62 11.53 ± 5.86 10.05 ± 6.85 11.73 ± 6.87 .067
ISOM_HR 10.58 ± 3.03 12.25 ± 6.53 9.43 ± 5.39 8.38 ± 4.2 10.07 ± 5.46 .011 †,‡
P< 0.05: § <20 years Vs 21-30 years; # <20 years Vs 31-40 years; ¶ <20 years Vs >40 years; † 21-30 years
Vs 31-40 years; ‡ 21-30 years Vs >40 years; ф 31-40 years Vs >40 years
13
<20 years
21-30
31-40
40 & above
Total
P Value
Age (Years)
19.6 ± 0.55 26.4 ± 2.46
36.85 ± 2.41
46.7 ± 4.14
35.34 ± 9.7
.000
Height (cm)
158.2 ± 5.02
158.5 ± 7.45
155.85 ± 6.59
156.75 ± 6.72
157.12 ± 6.75
.640
Weight (Kg)
52 ± 7.58
55.85 ± 11.55
59.42 ± 8.91
61.9 ± 11.88
58.5 ± 10.89
.168
SUP_SYS
104 ± 6.63
105.1 ± 8.87
110.1 ± 14.28
121 ± 15.9
111.45 ± 14.41
.002 ¶,‡,ф
SUP_DIA
66.8 ± 8.44
65.95 ± 15.16
73.85 ± 8.29
80.1 ± 12.21
72.8 ± 13.11
.003 ¶,†,‡
SUP_HR
72.2 ± 14.27
71.15 ± 12.18
74.1 ± 7.4
72.45 ± 13.66
72.54 ± 11.39
.884
TILT_SYS
3.6 ± 4.34
2.07 ± 3.69
4 ± 3.89
3.89 ± 7.09
3.46 ± 5.05
.712
TILT_DIA
18 ± 5.66
11.07 ± 7.86
8.95 ± 4.45
6.78 ± 5.15
9.58 ± 6.4
.003 §,#,¶,‡
MIN5_SYS
2.4 ± 5.73
1.21 ± 3.93
4.9 ± 6.66
4.11 ± 7.04
3.53 ± 6.18
.359
MIN5_DIA
17.6 ± 4.98
9.79 ± 6.6
8.4 ± 4.37
6.28 ± 4.68
8.88 ± 5.85
.001 §,#,¶
Max:Min(30:15)
1.14 ± 0.09
1.16 ± 0.1
1.1 ± 0.08
1.05 ± 0.08
1.1 ± 0.09
.005 ¶,†,‡
^HR Max
18.58 ± 10.49
17.26 ± 9.77
12.63 ± 8.65
9.36 ± 6.09
13.26 ± 8.85
.036 ¶,‡
^HR 2 min
8.92 ± 9.79
8.38 ± 8.25
6.66 ± 6.81
5.01 ± 6.76
6.76 ± 7.37
.557
RSA_E1
22.02 ± 6.71
26.24 ± 7.29
21.34 ± 6.41
18.11 ± 9.8
21.9 ± 8.35
.018 ‡
RSA cycle
1.32 ± 0.15
1.46 ± 0.37
1.32 ± 0.13
1.3 ± 0.28
1.36 ± 0.27
.243
STA_SYS
7.6 ± 6.69
1.05 ± 3.56
3.9 ± 5.24
2.2 ± 8.04
2.78 ± 6.09
.131
stan min2 dia
15.2 ± 4.6
10.3 ± 5
8.55 ± 4.12
9.5 ± 6.58
9.89 ± 5.43
.099
stan min5 sys
-1.2 ± 10.16
1 ± 4.9
3.25 ± 5.57
0.55 ± 6.99
1.38 ± 6.26
.390
stan 5min dia
14.4 ± 2.61
10.6 ± 6.49
7.55 ± 3.78
7.95 ± 6.03
9.14 ± 5.66
.040 #,¶
stan max:min
1.4 ± 0.21
1.34 ± 0.17
1.29 ± 0.19
1.25 ± 0.17
1.3 ± 0.18
.241
stan ^hr max
40.28 ± 6.52
33.63 ± 9.6
30.47 ± 10.4
24.47 ± 7.75
30.35 ± 10.09
.002 #,¶,‡, ф
stan ^hr2 min
27.94 ± 11.41
25.38 ± 8.52
19.75 ± 11.36
19.53 ± 10.53
22.04 ± 10.52
.127
valsa ratio
1.4 ± 0.14
1.53 ± 0.29
1.45 ± 0.22
1.49 ± 0.24
1.48 ± 0.24
.649
ISOM_SYS 11.6 ± 12.76 13.3 ± 10.12 10.95 ± 6.99 8.9 ± 6.38 11.09 ± 8.38 .435
ISOM_DIA 12.8 ± 5.22 12.05 ± 6.99 10.65 ± 5.28 9 ± 6.28 10.74 ± 6.17 .390
ISOM_HR 9.8 ± 3.9 11.35 ± 5.67 9.9 ± 4.62 8.75 ± 4.23 9.98 ± 4.82 .410
Comparison of Autonomic parameters in different age groups among females
P< 0.05: § <20 years Vs 21-30 years; # <20 years Vs 31-40 years; ¶ <20 years Vs >40 years; † 21-30 years
Vs 31-40 years; ‡ 21-30 years Vs >40 years; ф 31-40 years Vs >40 years
14
<20 years
21-30
31-40
40 & above
Total
P Value
Age (Years) 18.86 ± 1.35 26.3 ± 2.23 35.75 ± 3.49 47.85 ± 2.87 34.78 ± 10.4 .000
Height (cm)
163.43 ± 5.88
169.7 ± 5.87
166.55 ± 7.21
167.9 ± 4.66
167.57 ± 6.15
.100
Weight (Kg)
51.71 ± 6.9 63.3 ± 7.73
67.55 ± 10.22
67.95 ± 6.7
64.75 ± 9.42
.000 §,#,¶
SUP_SYS
108.57 ± 10.31
114.7 ± 11.83
112 ± 12.96
117.1 ± 15.14
113.97 ± 13.1
.424
SUP_DIA
66 ± 6.43
74.25 ± 8.64
74.75 ± 9.54
77.6 ± 11.01
74.54 ± 9.85
.061
SUP_HR
73.14 ± 12.92
71.15 ± 10.14
73.4 ± 8.8
69.5 ± 14.04
71.54 ± 11.24
.721
TILT_SYS
3.33 ± 5.89
2.47 ± 4
1.94 ± 4.8
-0.21 ± 7.27
1.51 ± 5.69
.420
TILT_DIA
4.67 ± 10.25
9 ± 7.63
10.18 ± 5.11
7.68 ± 5.95
8.46 ± 6.75
.348
MIN5_SYS
-1.33 ± 5.75
3 ± 5.06
3 ± 6.89
1.37 ± 8.86
2 ± 7.07
.558
MIN5_DIA
5 ± 8.74
8.13 ± 6.75
9.94 ± 5.88
7.37 ± 4.67
8.09 ± 6.11
.346
Max:Min(30:15)
1.11 ± 0.04
1.12 ± 0.09
1.11 ± 0.16
1.01 ± 0.25
1.08 ± 0.18
.225
^HR Max
17.8 ± 5.8
18.01 ± 7.38
18.76 ± 11.37
12.47 ± 8.38
16.36 ± 9.16
.155
^HR 2 min
10.13 ± 8.56
6.95 ± 5.78
7.02 ± 7.47
4.09 ± 5.2
6.35 ± 6.56
.210
RSA_E1
22.94 ± 7.85
21.22 ± 8.11
24.38 ± 9.08
17.53 ± 6.21
21.24 ± 8.18
.057
RSA cycle
1.3 ± 0.21
1.31 ± 0.13
1.38 ± 0.23
1.27 ± 0.12
1.32 ± 0.17
.315
STA_SYS
2.29 ± 4.54
5.45 ± 5.9
3.7 ± 4.76
3.7 ± 10.67
4.07 ± 7.22
.747
stan min2 dia
14.86 ± 4.3
10.85 ± 7.62
13.6 ± 5.71
9.15 ± 8.42
11.58 ± 7.24
.141
stan min5 sys
-2.29 ± 4.23
3.25 ± 5.94
2.2 ± 5.96
2.35 ± 11.21
2.09 ± 7.79
.452
stan 5min dia
13.14 ± 4.3
9.5 ± 5.77
12.55 ± 4.75
7.4 ± 7.84
10.16 ± 6.37
.036 ¶,ф
stan max:min
1.39 ± 0.23
1.34 ± 0.19
1.33 ± 0.16
1.28 ± 0.21
1.32 ± 0.19
.531
stan ^hr max
37.24 ± 8.85
38.07 ± 10.08
30.75 ± 8.73
26.62 ± 6.2
32.38 ± 9.62
.000 ¶,†,‡
stan ^hr2 min
20.4 ± 12.59
26.65 ± 13.73
23.18 ± 8.75
18.16 ± 7.05
22.43 ± 10.8
.086
valsa ratio
1.71 ± 0.28
1.58 ± 0.34
1.58 ± 0.33
1.48 ± 0.27
1.56 ± 0.31
.366
ISOM_SYS 13.43 ± 8.38 14.15 ± 6.38 13.75 ± 7.42 12.85 ± 7.79 13.57 ± 7.19.954
ISOM_DIA 18 ± 6.22 12.75 ± 8.36 12.4 ± 6.4 11.1 ± 7.38 12.7 ± 7.41.209
ISOM_HR 11.14 ± 2.41 13.15 ± 7.32 8.95 ± 6.15 8 ± 4.24 10.15 ± 6.06 .035 †,‡
Comparison of Autonomic parameters in different age groups among males
P< 0.05: § <20 years Vs 21-30 years; # <20 years Vs 31-40 years; ¶ <20 years Vs >40 years; † 21-30 years Vs 31-40 years; ‡ 21-30 years Vs >40 years; ф 31-40 years Vs >40 years
15
Comparison of Autonomic parameters between males and females in <20 years age group
Male Female t Value P Value
Age (Years) 18.86 ± 1.35 19.6 ± 0.55 -1.155 .275
Height (cm) 163.43 ± 5.88 158.2 ± 5.02 1.608 .139
Weight (Kg) 51.71 ± 6.9 52 ± 7.58 -.068 .947
SUP_SYS
108.57 ± 10.31
104 ± 6.63
.865 .407
SUP_DIA
66 ± 6.43
66.8 ± 8.44
-.187
.855
SUP_HR
73.14 ± 12.92
72.2 ± 14.27
.120
.907
TILT_SYS
3.33 ± 5.89
3.6 ± 4.34
-.084
.935
TILT_DIA
4.67 ± 10.25
18 ± 5.66
-2.584
.029
MIN5_SYS
-1.33 ± 5.75
2.4 ± 5.73
-1.074
.311
MIN5_DIA
5 ± 8.74
17.6 ± 4.98
-2.846
.019
Max:Min(30:15)
1.11 ± 0.04
1.14 ± 0.09
-.704
.499
^HR Max
17.8 ± 5.8
18.58 ± 10.49
-.157
.879
^HR 2 min
10.13 ± 8.56
8.92 ± 9.79
.220
.831
RSA_E1
22.94 ± 7.85
22.02 ± 6.71
.212
.836
RSA cycle
1.3 ± 0.21
1.32 ± 0.15
-.231
.822
STA_SYS
2.29 ± 4.54
7.6 ± 6.69
-1.650
.130
stan min2 dia
14.86 ± 4.3
15.2 ± 4.6
-.132
.897
stan min5 sys
-2.29 ± 4.23
-1.2 ± 10.16
-.257
.802
stan 5min dia
13.14 ± 4.3
14.4 ± 2.61
-.578
.576
stan max:min
1.39 ± 0.23
1.4 ± 0.21
-.028
.978
stan ^hr max
37.24 ± 8.85
40.28 ± 6.52
-.648
.531
stan ^hr2 min
20.4 ± 12.59
27.94 ± 11.41
-1.061
.313
valsa ratio
1.71 ± 0.28
1.4 ± 0.14
2.245
.049
ISOM_SYS
13.43 ± 8.38
11.6 ± 12.76
.301
.769
ISOM_DIA 18 ± 6.22 12.8 ± 5.221.521
.159
ISOM_HR 11.14 ± 2.41 9.8 ± 3.9.742 .475
P< 0.05: § <20 years Vs 21-30 years; # <20 years Vs 31-40 years; ¶ <20 years Vs >40 years; † 21-30 years Vs 31-40 years; ‡ 21-30 years Vs >40 years; ф 31-40 years Vs >40 years
16
Comparison of Autonomic parameters between males and in 21-30 yrs age group
females
Male
Female
t Value P value
Age (Years) 26.3 ± 2.23 26.4 ± 2.46 -.135 .893 Height (cm) 169.7 ± 5.87 158.5 ± 7.45 5.281 .000 Weight (Kg) 63.3 ± 7.73 55.85 ± 11.55 2.398 .022 SUP_SYS 114.7 ± 11.83 105.1 ± 8.87 2.904 .006 SUP_DIA 74.25 ± 8.64 65.95 ± 15.16 2.127 .040 SUP_HR 71.15 ± 10.14 71.15 ± 12.18 .000 1.000 TILT_SYS 2.47 ± 4 2.07 ± 3.69 .276 .785 TILT_DIA 9 ± 7.63 11.07 ± 7.86 -.720 .478 MIN5_SYS 3 ± 5.06 1.21 ± 3.93 1.057 .300 MIN5_DIA
8.13 ± 6.75
9.79 ± 6.6
-.666
.511
Max:Min(30:15)
1.12 ± 0.09
1.16 ± 0.1
-1.195
.242
^HR Max
18.01 ± 7.38
17.26 ± 9.77
.232
.818
^HR 2 min
6.95 ± 5.78
8.38 ± 8.25
-.544
.591
RSA_E1
21.22 ± 8.11
26.24 ± 7.29
-2.061
.046
RSA cycle
1.31 ± 0.13
1.46 ± 0.37
-1.717
.094
STA_SYS
5.45 ± 5.9
1.05 ± 3.56
2.856
.007 stan min2 dia
10.85 ± 7.62
10.3 ± 5
.270
.789
stan min5 sys
3.25 ± 5.94
1 ± 4.9
1.307
.199 stan 5min dia
9.5 ± 5.77
10.6 ± 6.49
-.566
.575
stan max:min
1.34 ± 0.19
1.34 ± 0.17
.116
.909 stan ^hr max
38.07 ± 10.08
33.63 ± 9.6
1.425
.162
stan ^hr2 min
26.65 ± 13.73
25.38 ± 8.52
.350
.728 valsa ratio
1.58 ± 0.34
1.53 ± 0.29
.483
.632
ISOM_SYS
14.15 ± 6.38
13.3 ± 10.12
.318
.752
ISOM_DIA
12.75 ± 8.36
12.05 ± 6.99
.287
.775
ISOM_HR 13.15 ± 7.32 11.35 ± 5.67 .869 .390
P< 0.05: § <20 years Vs 21-30 years; # <20 years Vs 31-40 years; ¶ <20 years Vs >40 years; † 21-30 years Vs 31-40 years; ‡ 21-30 years Vs >40 years; ф 31-40 years Vs >40 years
17
Comparison of Autonomic parameters between males and females in 31-40 yrs age group
Male Female t Value P Value Age (Years) 35.75 ± 3.49 36.85 ± 2.41 -1.159 .254 Height (cm) 166.55 ± 7.21 155.85 ± 6.59 4.898 .000 Weight (Kg) 67.55 ± 10.22 59.42 ± 8.91 2.642 .012 SUP_SYS 112 ± 12.96 110.1 ± 14.28 .441 .662 SUP_DIA 74.75 ± 9.54 73.85 ± 8.29 .318 .752 SUP_HR 73.4 ± 8.8 74.1 ± 7.4 -.272 .787 TILT_SYS 1.94 ± 4.8 4 ± 3.89 -1.441 .159 TILT_DIA 10.18 ± 5.11 8.95 ± 4.45 .780 .441 MIN5_SYS
3 ± 6.89
4.9 ± 6.66
-.851
.401
MIN5_DIA
9.94 ± 5.88
8.4 ± 4.37
.913
.367
Max:Min(30:15)
1.11 ± 0.16
1.1 ± 0.08
.336
.739
^HR Max
18.76 ± 11.37
12.63 ± 8.65
1.860
.071
^HR 2 min
7.02 ± 7.47
6.66 ± 6.81
.152
.880
RSA_E1
24.38 ± 9.08
21.34 ± 6.41
1.222
.229
RSA cycle
1.38 ± 0.23
1.32 ± 0.13
.888
.380 STA_SYS
3.7 ± 4.76
3.9 ± 5.24
-.126
.900
stan min2 dia
13.6 ± 5.71
8.55 ± 4.12
3.208
.003 stan min5 sys
2.2 ± 5.96
3.25 ± 5.57
-.575
.568
stan 5min dia
12.55 ± 4.75
7.55 ± 3.78
3.684
.001 stan max:min
1.33 ± 0.16
1.29 ± 0.19
.649
.520
stan ^hr max
30.75 ± 8.73 30.47 ± 10.4
.093
.927
stan ^hr2 min
23.18 ± 8.75 19.75 ± 11.36
1.070
.291
valsa ratio
1.58 ± 0.33
1.45 ± 0.22
1.482
.146
ISOM_SYS
13.75 ± 7.42
10.95 ± 6.99
1.228
.227
ISOM_DIA
12.4 ± 6.4
10.65 ± 5.28
.943
.352
ISOM_HR
8.95 ± 6.15
9.9 ± 4.62
-.552
.584
P< 0.05: § <20 years Vs 21-30 years; # <20 years Vs 31-40 years; ¶ <20 years Vs >40 years; † 21-30 years Vs 31-40 years; ‡ 21-30 years Vs >40 years; ф 31-40 years Vs >40 years
18
Comparison of Autonomic parameters between males and females in>40 yrs age group
Male Female t Value P value Age (Years) 47.85 ± 2.87 46.7 ± 4.14 1.020 .314
Height (cm) 167.9 ± 4.66 156.75 ± 6.72 6.100 .000
Weight (Kg) 67.95 ± 6.7 61.9 ± 11.88 1.983 .055 SUP_SYS 117.1 ± 15.14 121 ± 15.9 -.794 .432 SUP_DIA 77.6 ± 11.01 80.1 ± 12.21 -.680 .501 SUP_HR 69.5 ± 14.04 72.45 ± 13.66 -.674 .505 TILT_SYS -0.21 ± 7.27 3.89 ± 7.09 -1.736 .091 TILT_DIA
7.68 ± 5.95
6.78 ± 5.15
.494
.624
MIN5_SYS
1.37 ± 8.86
4.11 ± 7.04
-1.039
.306
MIN5_DIA
7.37 ± 4.67
6.28 ± 4.68
.710
.483
Max:Min(30:15)
1.01 ± 0.25
1.05 ± 0.08
-.653
.518
^HR Max
12.47 ± 8.38
9.36 ± 6.09
1.284
.207
^HR 2 min
4.09 ± 5.2
5.01 ± 6.76
-.461
.648
RSA_E1
17.53 ± 6.21
18.11 ± 9.8
-.224
.824
RSA cycle
1.27 ± 0.12
1.3 ± 0.28
-.326
.746
STA_SYS
3.7 ± 10.67
2.2 ± 8.04
.502
.618 stan min2 dia
9.15 ± 8.42
9.5 ± 6.58
-.146
.884
stan min5 sys
2.35 ± 11.21
0.55 ± 6.99
.609
.546 stan 5min dia
7.4 ± 7.84
7.95 ± 6.03
-.249
.805
stan max:min
1.28 ± 0.21
1.25 ± 0.17
.562
.577 stan ^hr max
26.62 ± 6.2
24.47 ± 7.75
.967
.340
stan ^hr2 min
18.16 ± 7.05
19.53 ± 10.53
-.484
.631
valsa ratio
1.48 ± 0.27
1.49 ± 0.24
-.141
.889
ISOM_SYS
12.85 ± 7.79
8.9 ± 6.38
1.754
.087
ISOM_DIA
11.1 ± 7.38
9 ± 6.28
.969
.339
ISOM_HR
8 ± 4.24
8.75 ± 4.23
-.560
.579
P< 0.05: § <20 years Vs 21-30 years; # <20 years Vs 31-40 years; ¶ <20 years Vs >40 years; † 21-30 years Vs 31-40 years; ‡ 21-30 years Vs >40 years; ф 31-40 years Vs >40 years
19
Effect of gender on AFT parameters
Isometric systolic was significantly low (p= 0.034) among females (10.75 ± 0.89) as
compared to males (13.31 ± 0.81).
Whereas Isometric diastolic showed a trend towards significance (p=0.06) with gender. The
mean diastolic was low among females (10.56 ± 0.68) as compared to males (12.61 ± 0.83).
Tilt 2 mins systolic among males (1.59 ± 0.68) which is significantly low (p=0.043) compared
to females (3.49 ± 0.63).
Tilt Max HR showed a trend towards significance (p=0.09) with gender. The mean HR was
high among males (16.075 ± 1.00) as compared to females (13.36 ± 1.179).
Valsalva ratio for males was (1.588 ± 0.036) and females was (1.483 ± 0.029). These mean
values were statistically high (p=0.024) among males compared to females.
It has been found that there was significant difference between different age groups and in both gender in many parameters of cardiac autonomic function tests, we have tabulated the results in each decades of age for both gender & derived normative data according to 5th and 95th percentile as shown below.
NORMAL ANF VALUES ( MALES & FEMALES )
AGE GROUP(YRS)
<20(N=14)
21-30 YRS(N=40)
NORMAL BORDER LINE ABNORMAL
NORMAL BORDER LINE ABNORMAL
VALSALVA RATIO
>1.45 ----- <1.44
>1.5 ----- <1.4
DBD
>20.31 19.62-20.3 <19.61
>21.41 20.98-21.4 <20.97
MAX:MIN
>1.29 1.28 <1.27
>1.25 ----- <1.24
STANDING ( ↓ SBP )
<8.13 8.14-8.75 >8.76
<5.12 5.13-5.41 >5.42
ISOMETRIC ( ↑ DBP )
>11.89 11.45-11.88 <11.44
>10.15 9.79-10.14 <9.78
20
AGE GROUP(YRS)
31-40 YRS(N=40)
41-50 + YRS(N=40) NORMAL BORDERLINE ABNORMAL
NORMAL BORDERLINE ABNORMAL
VALSALVA RATIO
>1.42 ----- <1.41
>1.42 -----
<1.41
DBD
>21.11 20.68-21.1 <20.67
>16.01 15.58-16 <15.57
MAX:MIN
>1.25 ----- <1.24
>1.25 ----- <1.24
STANDING ( ↓ SBP ) <5.25 5.26-5.51 >5.52 <5.56 5.57-6.02 >6.03
ISOMETRIC ( ↑ DBP ) >9.92 9.59-9.91 <9.58 >8.42 8.09-8.41 <8.08
Normal Values based on non-normal distribution according to 5th and 95th percentile AGE GROUP(YRS) 15 - 35 YRS (n=63) 35 – 50 + yrs (n=71)
NORMAL BORDERLINE ABNORMAL NORMAL BORDERLINE ABNORMAL
VALSALVA RATIO >1.16 ----- <1.15 >1.20 ----- <1.19
DBD
>11.44 10.44-11.44 <10.45
>12.32
10.61-12.32 <10.62
MAX:MIN
>1.10 1.06-1.10 < 1.06 >1.14 1.1-1.14
<1.10
STANDING ( SBP )
<13.2 13.2-16.8 > 16.8 <12.00 12-14 >14
ISOMETRIC ( DBP)
>4.00 2.00-4.00 <2 .0 >4.2 2.6-4.2 <2.6
NORMAL ANF VALUES ( MALES & FEMALES ) 142 irrespective of age and gender
NORMAL
BORDERLINE
ABNORMAL
VALSALVA RATIO
>1.46 ----- <1.45
DBD
>20.52 19.95-20.51 <19.94
MAX:MIN
>1.30 0.53-1.29 <0.52
STANDING ( SBP ) <7.95 7.96-8.45 >8.46
ISOMETRIC ( DBP ) >12.08 11.55-12.07 <11.54
21
Comparison of Autonomic parameters in different age groups
0
2
4
6
8
10
12
14
16
18
IsoM-sys IsoM-dia Isom-HR
<20
21-30
31-40
>40
Del
ta C
hang
e
Results of autonomic functions in refractory epilepsy patients :n=73
The mean age of these refractory epilepsy patients, at evaluation was 31.43+/- 9.84 years
with M: F ratio of 45:28. The mean duration of epilepsy was 19.02 +/ 9.07 yrs. Types of
seizures were complex partial seizures with secondary generalization: 38 (61.3%), primary
generalized tonic seizures: 10 (16.4%), complex partial seizures: 10 (16.4%), simple partial
seizures with secondary generalization: 2 (6.6%), partial seizures with secondary
generalization: 2 (6.6%). The mean frequency of seizures were ranged from 2 month to 15
month. They were on varying combination of more than two anti-epileptic drugs like
phenobarbitone, phenytoin, carbamazepine, sodium valproate, clobazam, lamotrigine
and topiramate. With respect to severity of autonomic dysfunction, 9 (12..32%) out of 73
patients were normal, 23 (31.5%) had early involvement, 25 (34.24%) had definitive
involvement and 16 (21.9%) had severe involvement. There were no significant difference
in different autonomic dysfunction groups with respect to the patient's age, sex height and
weight. The type of epilepsy did not correlate with the severity of autonomic dysfunction
(p>0.05). None of the anti epileptic drugs induced any autonomic dysfunctions. There
waslso no significant difference in different autonomic dysfunction groups on specific
autonomic parameters except standing 5 minutes systolic BP, standing max: min ratio, HR
max, Hr2 max during standing and isometric diastolic B.P. The age of onset and duration of
a epilepsy did not differ significantly between the autonomic dysfunction groups.
22
When it was adjusted using analysis of covariance (ANCOVA) for gender, age of onset was
significantly higher in early involvement as compared to the remaining. The early
involvement was significantly different from normal, atypical and definitive involvement
groups. Twenty-six (35.13%) out of the seventy-four patients consented to undergo Yoga
therapy. Out of this, fourteen (53.85%) were males and twelve (46.15%) were females.
Table 1: Demographic data
Refractory Epilepsy
Group (n = 73)
Healthy Volunteer
group (n = 73)
AGE (yrs) 31.44 ± 9.87 31.89 ± 9.57
Male: Female 45: 28 47: 26 Height (cm)
162.34 ± 7.87
163.81± 8.17
Weight (Kg)
60.34 ± 8.19
62.21 ± 10. 16
Age of onset of epilepsy (yrs)
12.41 ± 8.57
-
Duration of illness (yrs) 19.02 ± 9.07 -
Table 2 : Cardiovascular autonomic functions parameters
Parameters Refractory Epilepsy
Group (n = 73)
Healthy Volunteer group
(n = 73)
Valsalva Ratio 1.56 ± 0.32 1.57 ± 0.3 DBD
18.86 ± 6. 84
23.02 ± 8.20**
Max: min
1.27± 0.18
1.33 ± 0.19*
3.06 ± 5.44
5.12 ± 5.91*
11.98 ± 7.21
12.81± 6.99*
* p< 0.05 , ** p<0.001
DBD: deep breathing difference
SBP: systolic blood pressure
DBP: diastolic blood pressure
23
Respiratory sinus arrhythmia – ( E - I )
Chart Window
ECG
(mV)
-0.4
-0.2
0.0
0.2
0.4
0.6
10 20 30 40 50 1:00
10/7/2003 11:17:37.747 AM
ECG
(µV)
-200
0
200
400
5 10 15 20 25 30 35 40
7/11/2003 5:19:36.849 PM
Chart Window
Standing – (Max: Min)
ECG
(mV)
-0.5
0.0
0.5
1.0
25 30 35 40 45 50 55 1:00 1:055
10/7/2003 11:29:25.500 AM
Chart Window
ECG
(µV)
-400
-200
0
200
400
600
10 15 20 25 30 35 407
7/11/2003 5:25:57.926 PM
Chart Window
Valsalva Ratio
ECG
(mV)
-0.5
0.0
0.5
25 30 35 40 45 50 556 7
10/7/2003 11:36:30.599 AM
ECG
(µV)
-400
-200
0
200
400
600
800
5 10 15 20 25 308 9
7/11/2003 5:29:36.727 PMChart Window Chart Window
24
Distribution of Autonomic Dysfunction
0
5
10
15
20
25
30
35
40
45
Normal Dysfunction
Num
ber
ofC
ases
Normal Definite Severe
Control Definitive involvement Severe involvement
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
valsalva ratio sta max:min
CON Vs DI
P=0.005 CONVs SI P=0.005
Heart rate based tests
25
Blood pressure based tests
Effect of Duration of Illness on Severity of AD
Effect AEDs on AD
0
2
4
6
8
10
12
14
16
18
20
sys(2min) iso dia
Del
taC
han
ge
inB
P(m
m/H
g)
Control Definitive involvement Severe involvement
0
5
10
15
20
25
Dura
tion
(Yea
rs)
Severe Dysfunction Definite Dysfunction
0
10
20
30
40
50
60
70
80
90
PB CBZ CLO DPH
Normal Definite Dysfunction Severe Dysfunction
Perc
enta
ge
26
Results of Autonomic functions following Yoga therapy
The demographic details of both the groups are represented in Table 1. Mean age at
evaluation was 32.2 ±10.2 years with M: F ratio of 15:10 for the Yoga group and mean age at
evaluation 34.6 ±9.2 year and an M: F ratio of 8:7 for the exercise group. The mean duration
of epilepsy was 18.7 ± 9.1 years for the Yoga Group and 19.9 ± 6.1years for the exercise
group. The mean age at onset of seizures was 13.5 ± 8.7 years for the Yoga group and 12.7 ±
8.7 years for the exercise group. The distribution of generalized and partial epilepsy was:
6:19 and 5:11 in each of the two groups respectively.(Table 1.)
On basal Autonomic Function tests, we found 42.5% patients with definite to severe
involvement. Definite and severe involvement comprised of 48% in the Yoga group. Even
with a high percentage of drop outs (40%) in our exercise group, we found similar statistics
with severe and definite grades equaling 40%. This corresponds to values seen in our earlier
study where we have demonstrated cardiac autonomic function abnormality in 56.3% of
refractory epilepsy patients (definite and severe grades) (Sathyaprabha et al 2006 ).After
10 weeks of therapy this dysfunction dropped down to 20% in the Yoga group while there
was no change in the exercise group. (Figure 1). This Change was found to correspond to
p< 0.05) on Mc Nemar test.
On subgroup analysis we found most of our patients presenting with parasympathetic
dysfunction (52.5%), this included patients with Early, Definite and Severe involvement
with only abnormalities in heart rate based tests. Improvement after therapy was seen in
58% of patients with parasympathetic involvement and 100% with sympathetic
involvement. Individual analysis of patients revealed that all patients with combined
involvement in the Yoga group improved. Three patients with initial parasympathetic
involvement in the Yoga group developed combined involvement. The exercise group
showed uniform worsening of autonomic functions after 10 weeks of training,with three
patients with parasympathetic developing combined involvement.
27
Table 1: Demographic details
Parameters Yoga Group (n=25) Exercise Group (n= 15)
M:F 15:10 8:7
Mean age at evaluation
(yrs)
32.2±10.2 34±9.2
Mean age at onset (yrs)
13.5±8.7
12.7±8.7
Duration of illness (yrs)
18.7±9.1
19.9±6.1
Type of seizures
(generalized : partial)
6:19
4:11
Table 2: Autonomic Dysfunction: Pre and Post Yoga/Exercise
Yoga Group (n=25) Exercise Group (n=15)Autonomic function
tests Basal Post Basal Post
Deep breathing
Difference(beats/min)
19.3 ± 1.6 19.8+1.2 20.9±1.6 20.6±1.8
Valsalva ratio
1.5 ± 0.1
1.6±0.1
1.7 ± 0.1
1.7±0.1
30:15 RATIO
1.26 ± 0.03
1.27±0.03 1.35 ± 0.06
1.26±0.03
Orthostatic test
change in delta SBP
(mm Hg)
4.12 ± 1.26
3.76±1.12 3.13 ± 1.47
2.08±0.75
Isometric handgrip
test
change in
delta
DBP(mmHg)
12.72 ± 1.72
14+1.16
11.75 ± 1.86
14.81±0.11
28
Refractory epilepsy is not only characterized by pharmacologically unresponsive seizures,
but also by an assortment of social, economic, physiological and psychological morbidity
that warrants equal attention. An important physiological characteristic of refractory
epilepsy is an altered autonomic function (Ansakorpi H et). This is a key mechanism in the
occurrence of SUDEP in refractory epilepsy patients (Johnston SC et al). In our earlier study
we have demonstrated cardiac autonomic function abnormality in 56.3% of refractory
epilepsy patients. This included Definite and severe groups on autonomic testing. In the
cohort of our current study we found a breakup similar with the final population at analysis
being 48% having definite and severe involvement in the Yoga group while our exercise
group registered an involvement of 40% due to a large number of drop outs. In our study we
have found both sympathetic and parasympathetic dysfunction in chronic epilepsy patients
with most of our patients registering a predominant pure parasympathetic failure (68%).
Early studies demonstrated a predominant sympathetic dysfunction during ictus in new
onset seizur. .Some studies do show a predominant parasympathetic dysfunction during
ictus but this may be due to focal stimulation of parasympathetic areas rather than
functional modulation of the brain by epilepsy(Novak Vet al).Authors generally agree that
long standing epilepsy manifest with predominant parasympathetic dysfunction
(Ansakorpi H et al).
Discussion: Yoga therapy in Refractory Epilepsy
Studies have documented seizure reduction both in frequency and
electroencephalographic parameters through interventions such as Yoga and other stress
alleviating biofeedback mechanisms (Puskarich CA et al).We too have found that Yoga
practice has shown to significantly improve autonomic parameters in patients with
refractory epilepsy. Better response is seen in the pure sympathetic involvement than
parasympathetic involvement. Notably all patients with combined involvement improved
in the Yoga group. This suggests that long term uncontrolled seizures do lead to functional
or structural changes promoting parasympathetic over activity which is not amenable to
intervention. Our results and also similar studies on chronic epilepsy patients (Ansakorpi H
et al) suggests that autonomic involvement in chronic epilepsy patients follows a temporal
progression of sympathetic dysfunction followed by a combined dysfunction due to an
29
emergent parasympathetic component. As the disease progresses there occurs a severe
predominant parasympathetic dysfunction which may mask the sympathetic component.
This could also explain the reason why the key terminal event in SUDEP is often a
parasympathetic paroxysmal event (Berilgen MS, Johnston SC, et al). Refractory epilepsy
patients in the exercise group with parasympathetic involvement or combined
involvement demonstrated worsening of symptoms. There is a predominant sympathetic
shift in this subset of patient. This result was not unexpected as simple hyperventilation
and muscle training is known to cause sympathetic arousal.( Brown R P et al ). The
worsening of autonomic symptoms could account for the selectively high dropouts in the
exercise group.
An ictal episode causes short term disturbances in Autonomic Functions while pervasive
inter ictal dysfunction is a function of chronic epilepsy..Studies have demonstrated
reduced heart rate variability in both refractory as well as longstanding well controlled
epilepsy patients. Significantly there was no dysfunction in newly diagnosed epilepsy
patients. Thus the seizure frequency in our subset of refractory epilepsy patients was not
deemed to be contributory to the baseline autonomic dysfunction and was not included as
a variable in our study. Earlier investigators partly attributed autonomic dysfunction to the
use of anti-convulsants especially Carbamazepine. Studies both by Berilgen and at our
center have shown no significant association between autonomic dysfunction and use of
anti-convulsants and hence in our study there has been no specific emphasis on the nature
or restrictions to concurrent pharmacotherapeutics.
The nature of long-term modulation of central autonomic centers in chronic epilepsy
patients seems to be functional or due to epileptiform discharges. Models of neuronal
plasticity and learning also suggest that seizure discharges in autonomic centers as in any
other area probably initiate a vicious cycle and explains the severity of autonomic
dysfunction in long standing and uncontrolled seizures. The hallmark of refractory epilepsy
is the interictal spike in EEG which suggests sub clinical seizures which can directly
stimulate central autonomic areas. Involvement left insular cortex in the causation of
parasympathetic symptoms and right insular cortex in the causation of sympathetic
symptoms. It has also been noted that seizures activity alter the conduction system of the
30
heart,decreased functional innervation and may cause bundle branch blocks (Mameli O et
al). Sudden unexplained death in epilepsy (SUDEP) remains an important cause of mortality
in refractory epilepsy (Ficker DM et al). Though exact mechanisms for deaths in SUDEP is
not known , autonomic dysfunction leading to central apnea, arrhythmias and failure could
play a central role. The 'lock stem phenomenon' which is synchronization of cardiac
sympathetic and vagal cardiac neural discharges with epileptogenic discharge has been
also proposed as a possible mechanism for SUDEP. Loss of Rapid Eye Movement sleep
protection in refractory epilepsy patients has been suggested to be caused by decreased
heart rate variablilty due to autonomic dysfunction. Studies have indicated that seizure
generalization causes parasympathetic predominance, which holds true to SUDEP where
generalization of seizures has worse outcomes.
Authors have demonstrated reduction in seizure frequency through practice of Yoga and
other methods of biofeedback like the practice of progressive muscle relaxation. Studies
on epilepsy patients practicing meditation showed improvement both in seizure frequency,
duration and electroencephalographic profile (Puskarich CA et al). The relationship
between stress and epilepsy is well known and hence it has been suggested that reduction
in stress might lead to reduction in seizure frequency. It has been recommended as one of
the additional method of treatments in the holistic management of chronic intractable
epilepsy (Puskarich CA et al ).There are many techniques in the practice of Yoga. They can
be described as Pranayama (yogic breathing), Asanas (posture) and Dhyana
(meditation). Yogic breathing and its autonomic effects are easily reproducible, as they
resemble many physiological patterns of strained breathing or hyperventilation.
Sudershan kriya (SKY), one such breathing technique had shown benefit in the treatment of
dysthymia and depression and may be of benefit in epilepsy.
Most authors believe that the biggest benefit of Yoga and other biofeedback interventions
is to push biological systems into of parasympathetic dominance. Seizure control through
Yoga thought to be achieved through experience related plasticity or due to shift in the
autonomic output towards relative parasympathetic dominance (Bijlani RL et al). Yogic
breathing increases Sensory Motor Rhythm (SMR) a 12–15 Hz rhythm often found in waking
states and works on the premises of REM protectionism. Other proposed mechanisms
31
include release of stress hormones and EEG desynchronisation or activation of inhibitory
circuits through vagal nerve stimulation (Brown R P et al). The study reinforces this idea
and we propose that Yoga increases the parasympathetic drive in biological systems.
Biological systems when faced with such stress tend to adapt by raising their stimulation
thresholds or reversing their baseline thresholds. i.e. In case of positive parasympathetic
stress a system will adapt with increased sympathetic tone and vice versa. This resetting of
the sympathetic baseline seems protective due to its increase inherent chaos compared to
parasympathetic drives. Yoga through its positive parasympathetic activity leads to a net
increased inherent sympathetic reserve, increased chaos and hence increased
protectively. Simple exercises that push the system in a sympathetic overdrive tends to
reset the system at a higher parasympathetic baseline which is counterproductive due to
its lower chaos.
32
Autonomic dysfunction (AD) grading following Yoga therapy
Yoga group (n=25) Control group (n=15)AD grading
Basal Post Basal Post
Normal
-
9
5 3
Early 12 10 4 6
Definite 9 4 4 4
Severe 4 2 2 2
AUTONOMIC DYSFUNCTION GRADING FOLLOWING YOGA THERAPY
0
5
10
15
pre Yoga post Yoga pre control post control
Normal
Early
Definite
Severe
Num
ber
of
Pati
ents
*P<0.05, Mc Nemar test
33
Autonomic Dysfunctions in Refractory Epilepsy :
Activation of autonomic nervous system is common with seizures and its symptoms are
related to cortical, limbic and hypothalamic structures (Gleizer 1988, Hilz 1999, Schraeder
1989, Wannamaker 1985). A number of studies have examined the possible role played by
autonomic nervous system as an explanation for the cause of sudden death in people living
with epilepsy (Terrence et al 1975, Jay and Leestma 1981, Lathers 1987). Sathishchandra et
al (1988) demonstrated a positive association between epilepsy and cerebrovascular
disease and myocardial ischemia in a case-control study associated with death among
subjects with epilepsy from US mortality data.
In the present study involving 73 patients with refractory epilepsy on polytherapy, 41
patients (56.2%) had severe and definite involvement of two or more autonomic tests. The
reason for this increased incidence of autonomic dysfunction is not clear. Nei et al (2000)
reported similar observations that abnormal cardiac rhythm and conduction abnormalities
during seizures, more so if prolonged / generalized and in intractable epilepsy. One of the
possible explanations of having autonomic dysfunctions in uncontrolled epilepsy could be
derived from the study of Berilgen et al (2004) who concluded that autonomic dysfunction
improves after control of seizures with anticonvulsants.
Ictal autonomic dysfunctions in epilepsy have been proven earlier by several animal and
human studies. In an experimental work by Mameli et al (1993), epileptiform discharges
from hypothalamic and mesencephalic neurons triggered alterations of conduction system
of the heart and bundle branch blocks. Lathers and Schraeder (1982) in their study on 9 cats
found altered cardiac autonomic discharges associated with mild epileptogenic activity.
Similar observation of association autonomic dysregulation and apnea with epileptogenic
discharges with seizures had been made in children, especially in association with
bradycardia (Lathers et al. 1997). Recently, Novak et al (1999) demonstrated
parasympathetic withdrawal and activation of sympathetic system just before the seizure
by time-frequency analysis.Nei et al detected cardiac arrhythmias during ictus in
Discussion
34
patients with refractory partial seizures and suggested that they might need proper
cardiac evaluation to prevent a lethal event during ictus.
Interictal autonomic dysfunction like one observed in the present study has been
documented earlier. Devinsky et al (1994) analyzed 24 patients of partial epilepsy on
carbamazepine who developed autonomic dysfunction in the interictal period compared
to healthy controls. They attributed it to chronic epilepsy and effect of AEDs. They also
subsequently found that these interictal parasympathetic abnormality improved pari
passu with clinical and EEG improvement. Faustmann et al (1994) reported interictal
parasympathetic changes in patients with EEG abnormalities compared to those with
normal EEG. In this study we did not attempt to correlate with EEG findings as all of them
had longstanding chronic epilepsy. In this study, it is found that interictal parasympathetic
dysfunction among patients with refractory epilepsy and this finding has been reported in
literature in patients with epilepsy. (Berilgen 2004, Isojarvi 1998, Drake 1998, Kalviainen
1990, Faustmann 1994, Devinsky 1994)
Literature pertaining to the effects of AEDs on autonomic system is variable. In this study
all the patients were on multiple AEDs and none of them contributed to autonomic
changes. Berilgen et al (2004) reported restoration of only sympathetic dysfunction and
not parasympathetic dysfunction in patients of partial epilepsy after treatment with
AEDs. Persson (2003) demonstrated that carbamazepine might suppress both
parasympathetic and sympathetic functions in newly diagnosed patients with epilepsy.
The exact mechanisms through which AEDs cause AD is unclear but could be due to its
effect of epileptiform discharges arising from foci.
Sudden unexplained death (SUDEP) is an important cause of mortality in people with
epilepsy and is a well-recognized phenomenon (Hirsch et al 1971, Claire 1982, Annegers
and Coan 1999). Studies by Walczak et al (2001) & Ficker et al (2000), found that SUDEP
accounted for 18% of all the death in patients with epilepsy. Seizure severity appears to be
a very important risk factor for SUDEP. In addition, younger age of onset, male gender, and
generalized seizures and multiple anti-epileptic drugs usage are other factors (Shorvon,
1997). Johnston et al while studying an animal model concluded that hypoventilation and
35
pulmonary edema are important cause of death during seizure. Mc Gugan (1999) in post
mortem examination of SUDEP victims have demonstrated cardiac ischemic damage
despite normal coronary arteries. This possibly arises as a result of repeated episodes of
vasoconstriction from seizure related catecholamines bursts, which might indicate
increase of sympathetic activity. Incidence of increased SUDEP is correlated with the
number of antiepileptic drugs prescribed and with use of psychotropic drugs (Tennis P et al
1995, Anaskorpi et al 2000). SUDEP could be due to multiple underlying factors, but a
generalized autonomic storm involving both sympathetic and parasympathetic arms could
lead to sudden death, which needs further evaluation. But this study did not address the
issue of SUDEP and it will be worthwhile to follow this cohort of patients for SUDEP and
other causes of death in future.
The association between stress and the occurrence of seizures is generally accepted on the
basis of clinical observation (Gastaut and Tassinari, 1966, Currie et al 1971). Anxiety, anger
and certain antecedent events (Feld and Paul 1976) are noted as trigger for seizures.
Nancy (1992) had demonstrated the association between stress and seizures. It is
suggested that reduction in stress may be an important factor in reducing seizure
frequency and has been recommended as one of the additional method of treatments in
the management of chronic intractable epilepsy (Puskari, 1992; Temkin, 1994). Alternate
treatment modalities such as behavioral approaches to seizure control (Mostofsky &
Balaschak 1977, Whitman et al 1990, Puskarich CA, 1992) have recently evoked
considerable interest among epileptologists, as epilepsy is being now considered as
neurophysiological or a behavioral neurology problem, rather than purely neurological
disorder.
The present study has opened up an important area for future studies regarding autonomic
dysfunction and its role in sudden death among patients with chronic refractory epilepsy.
Twenty five patients who had autonomic dysfunctions were subjected to Hatha Yoga for 60
minutes everyday for the period of eight weeks. Yoga therapy included Surya namaskaras
for 10 minutes, Yogasanasa for 25 minutes, Relaxation Techniques for 15 minutes and
Pranayama for 10 minutes.The Asanas include Padahastasana, Ardhachakrasana,
36
Ardhakatichakrasana, Utthitapadasana, Matsyasana, Bhujangasana, Shalabhasana,
Shashankasana, and Ushtrasana. Relaxation techniques include Quick relaxation and Deep
relaxation techniques. Pranayama includes Sukh and Nadishuddhi pranayama. These
twenty five patients were re-evaluated after two months for cardiovascular autonomic
function tests. It is interesting to note that sixty eight percent patient had significant
improvement of their autonomic functions compared to pre Yoga. We also assessed Quality
of Life (QOL) in these patients before and after intervention of Yoga therapy, which showed
significant improvement in seventy two percent.
Conclusion :
Epilepsy is one of the most common neurological disorder. The role of stress in epileptics is
complex. Stress disorders are common in epileptics than general population. Epilepsy
impairs learning and interferes with normal responses. Hence, an individual living with
epilepsy suffers not only from normal stresses that a chronic illness imposes but is also
handicapped in terms of responding to those stresses by the illness itself and by its
treatment. Fifteen percent of epileptics are refractory to all modes of treatments. In such
patients intervention of YOGA might work wonders. Stress being a precipitating factor for
epilepsy, Yoga could be used in its treatment. Yoga induce relaxation and reduce stress.
Practice of Yoga-leads to inner evolution and total transformation of individual
consciousness. The influence of Yoga on brain is due to experienced –related plasticity
(Bijlani,2004). Yoga practices have revealed significant brain wave changes reflecting the
possibilities of conditioning the brain mechanisms. Current scientific research suggests
that Yoga practice modulates brain functioning in different ways and different levels like
shift of autonomic balance towards relative parasympathetic dominance .In the
contemporary world, yogic practices are being utilized to gain individual benefits-physical
health and mental stability.
This study has showed autonomic dysfunction in epilepsy. Out of the seventy three subjects
whose baseline autonomic functions were recorded, about twenty five (34.72%) of them
showed definite involvement, twenty three (31.94%) showed early and sixteen (22.22%)
37
showed severe involvement. Only nine subjects (12.5%) had normal autonomic function at
presentation. Out of the seventy three subjects, only twenty five consented to undergo
Yoga therapy in the hospital. The remaining patients could not come for the therapy for
various reasons such as long distance travel, inability to take leave to come for the therapy,
unwillingness to come for the therapy, etc. The twenty five subjects who consented to
undergo Yoga therapy in the Hospital performed Hatha Yoga for eight weeks in the hospital
under the guidance of a Yoga therapist. Among these twenty five patients, ten patients
(40%) had early involvement, eight (32%) had definite involvement and seven (28%) had
severe involvement.
After eight weeks of Yoga therapy in the Hospital, the findings were as follows: seven
patients (as compared to ten before starting therapy) i.e. (28%), five subjects (20%) had
definite involvement (as compared to the pre Yoga value of eight, only one person (4%)had
severe involvement, as compared to the pre Yoga value of seven and the autonomic
functions of six patients had normalized.
When the patients came for follow up after performing Yoga for eight weeks at home, the
results were as follows: The autonomic functions of seven patients (28%) had normalized,
the autonomic functions of six patients (24%) had reduced to early involvement, seven
patients (28%) had definite involvement and five had severe involvement.
A betterment of the quality of life was also noted, as documented by the questionnaire on
quality of life. The autonomic function tests were repeated after a further period of eight
weeks when the subjects were asked to perform Yoga at home. Those who did not show
significant improvement after the first session, improved after the second session. Very
few subjects did not show any change in their autonomic function status.
38
Summary
AUTONOMIC FUNCTION TESTS IN EPILEPSY : EFFECT OF HATHA YOGA
Introduction :
The Autonomic nervous system is involved in controlling the vegetative functions of the
body. Autonomic Function Test (AFT) forms an integral part of physiological investigations
and is a useful diagnostic tool in neuropsychiatric disorders. However it is essential to
establish normative data for the Indian population.
Sudden unexplained death (SUDEP) is an important cause of mortality in patients with long
standing epilepsy and one of the explanations could be due to autonomic dysfunction (AD).
Yoga is traditional Indian psycho-philosophical-cultural method that has multiple health
benefits. The role of Yoga as an intervention to manage autonomic dysfunction has been
evaluated in this study.
Objective :
1. To determine normal values of cardiovascular functions in normal healthy
individuals and to determine effects of age and gender on these values.
2. To evaluate cardiovascular autonomic functions in refractory epilepsy patients
3. To study the role of Yoga as an intervention to manage autonomic dysfunction has
been evaluated in this study.
Patients and Materials :
To generate normative data, a total number of 142 healthy subjects (M= 72, F=70), of age
15 – 56 yrs were subjected to a battery of cardiovascular autonomic function tests using an
automated data acquisition system. Heart rate (HR) and blood pressure (BP) responses
were recorded at rest and after deep breathing, Valsalva maneuver, postural change and
isometric exercise.
39
Seventy three patients (31.5 ± 9.8years, M: F: 45:28) of intractable epilepsy attending the
“refractory epilepsy” clinic at NIMHANS, India were enrolled. HeartRate (HR) and Blood
Pressure (BP) responses at rest and after deep breathing, Valsalva maneuver, postural
change and isometric work were recorded. AD was graded as 'definite' and 'severe' if two or
more HR and two or more HR with BP based tests were abnormal respectively. Data
obtained were compared with age and gender matched healthy volunteers (n=142).
To study the role of Yoga as an intervention to manage autonomic dysfunction in refractory
epilepsy, twenty five subjects (32.2±10.2years; M:F:15:10) of uncontrolled epilepsy
(GTCS:6, Partial:19) attending the “refractory epilepsy” clinic at a tertiary center, with
Autonomic dysfunction were enrolled in this study. Hatha Yoga, which includes Meditation
and yogasana, were administered as an adjuvant therapy for eight weeks, after which
autonomic functions were re evaluated.
Results :
In healthy volunteers, age and weight had a positive correlation with the resting BP.
However, age and HR responses to deep breathing and standing posture were negatively
correlated. Similarly a negative correlation was also observed between age and BP
responses to standing and isometric exercise. Gender differences were noted in some of
the responses.
Study on 73 refractory epilepsy patients : The mean age at onset and duration of epilepsy
was 12.4 years and 19.02 years respectively. 25 patients (primary generalized: 8, partial:
17) had Definite AD, while 16 (primary generalized: 4, partial: 12) had severe autonomic
dysfunction. ANCOVA results showed expiration – inspiration, standing maximum: minimum
ratio, standing 2 minutes systolic and isometric diastolic BP of the dysfunction group
significantly differ compared to the normal group. Patients with longer duration (23.2
years) had more severe dysfunction (p<0.05) than patients with relatively shorter duration
(17.5 years) of epilepsy. Anticonvulsants used did not show any significance role in
AD.Intervention of Yoga in twenty five refractory epilepsy patients:The mean age at onset
40
and duration of epilepsy was 13.5 and 18.7years respectively. Their autonomic
dysfunctions were classified as early-12, definite-9, and severe-4. The severity in terms of
involvement, pre and post intervention was analyzed using Mc Nemar's test. There was a
significant improvement in autonomic dysfunction–normalized in 9, early-10, definite-4,
severe-2 from baseline to intervention of Yoga (p=0.039).
Conclusion :
This is the first study from India to evaluate autonomic functions in refractory epilepsy
patients. We have documented the variations in autonomic functions with age and gender
and generated normative data for different parameters of cardiac autonomic functions.
Autonomic Dysfunctions was noted in 56.3% of patients. Anticonvulsants were not
associated with autonomic dysfunction. Yoga has a definite role in management of
autonomic dysfunction associated with refractory epilepsy. As autonomic dysfunction is an
important in pathogenesis of SUDEP, Yoga could be used as an adjuvant therapy to possibly
prevent SUDEP.
Longitudinal controlled studies with 'newly diagnosed' in epilepsy patients will enhance
further understanding about the role of autonomic system in epilepsy and adjuvant
therapy with Yoga will produce better quality of life in epileptic patients.
41
References
1. Annegers JF, Coan SP. SUDEP: overview of definitions and review of incidence data.
Seizure 1999; 8: 347-352.
2. Ansakorpi H, Korpelainen JT, Suominen K, Tolonen U, Myllyla VV, Isojarvi JI. Interictal
cardiovascular autonomic response in patients with temporal lobe epilepsy. Epilepsia
2000 Jan; 41(1): 42-47.
nd3. Bannister R, Matthias. Testing autonomic reflexes. In: Bannister S 2 . London: Oxford
University Press, 1988:289-307.
4. Berilgen MS, Sari T, Bulut S, Mungen B. Effects of epilepsy on autonomic nervous system
and respiratory function tests. Epilepsy Behav. 2004;(5): 513- 516.
5. Betts. Epilepsy and stress. Bri Med J 1992: 305: 378-79.
6. Bijlani RL, Vempati RP, Yadav RK, Ray RB, Gupta V, Sharma R, Mehta N, Mahapatra SCA
brief but comprehensive lifestyle education program based on Yoga reduces risk
factors for cardiovascular disease and diabetes mellitus. J Altern Complement Med.
2005; 11(2):267-74.
7. Blazek-O'Neill B. Complementary and alternative medicine in allergy, otitis media, and
asthma. Curr Allergy Asthma Rep. 2005; 5(4):313-8.
8. Brown R P, Gerbarg P L, Muskin P R .Complementary and Alternative Treatments in
Psychiatry In: Tasman A,Kay J, Lieberman J A. editor. Psychiatry, Second Edition,
United Kingdom: John Wiley and Sons, LTD.;2003. P 2147-83.
9. Chhina GS. The voluntary control of autonomic responses in yogis. Proc International
Union Physiol sci 1974; 10: 103-4.
10. Claire M. Lathers and Paul L. Schraeder. Autonomic dysfunction in epilepsy.
Characterization of autonomic cardiac neural discharge association with
pentylenetetrazol induced epileptogenic activity. Epilepsia 1982 (23) 633-646.
11. Currie, S. Healthfield KWG, Henson RA, Scot DF. Clinical course and prognosis of
temporal lobe epilepsy: A survey of 666 patients. Brain 1971 94: 173-90.
12. Currie S, Healthfield KWG, Henson RA, Scot DF. Clinical course and prognosis of
temporal lobe epilepsy: A survey of 666 patients. Brain 1971; 94: 173-190.
13. Devinsky O, Perrine K, Theodore WH. Interictal auto\nomic nervous system function in
patients with epilepsy. Epilepsia 1994; 35:199-204.
42
14. Drake Jr ME, Andrews JM, Castleberry CM. Electrophysiological assessment of
autonomic functions in epilepsy. Seizure 1998; 7: 91 –96 .
15. Faustmann PM, Ganz RE. Central cardio-autonomic disorganization in interictal states
of epilepsy detected by phase space analysis. Int J Neurosci 1994; 78:43-47.
16. FickersDM. Sudden unexplained death and injury in epilepsy. Epilepsia 2000; 41 suppl
2-S7-12.
17. Feldman R, Paul N. Identity of emotional triggers in epilepsy. J. Nerv. Ment. Dise.
1976; 162: 345-53.
18. Gastaut H, Tassinari CA. Triggering mechanisms in epilepsy. Epilepsia. 1966 7: 85-
125.
19. Gleizer MA, Karlov VA. Autonomic dysfunction in patients with temporal lobe epilepsy.
Zh Nevropatol Psikhiatr Im S S Korsakova. 1988;88(6):11-5.
20. Gopal KS, Anantharaman V, Balachander S, Nishith SD. The cardio respiratory
adjustments in pranayams with and without bandhas in vajrasan. Ind J Med Sci 1973;
27: 686-692.
21. Hanna Ansakorni, Juha T. Korpelainen, Kalervo Suominen, Volevitoloness, Vilhov
Myllyla and Jouko I. Isojarvi, T. Interictal cardiovascular autonomic response in
patients with temporal lobe epilepsy. Epilepsia 2000, 41 (1) 42-47.
22. Hilz MJ, Dutsch M, Kolsch C. Epilepsy and autonomic diseases. Forschr Neurol Psychiatr
1999; 67:49-59.
23. Hirsch C, Martin D. Unexpected death in young epileptics. Neurology 1971; 21: 682-
690.
24. Isogarvi JI, Ansakori H, Suomien K, Tolonen U, et al . Interictal cardiovascular
autonomic responses in patients with epilepsy. Epilepsis 1998 ; 39: 420 -426.
th25. Iyengar BSK. Light on Yoga. 11 edition Harper Collin Publisher 1997 Page 1-53.
26. Jay GW, Leestma JE. Sudden death in epilepsy – A comprehensive review of literature
and proposed mechanism. Acta Neurol Scan (Suppl. 82). 1981: 63: 1-66.
27. Jain SC, Uppal A, Bhatnagar SO, Talukdar B. A study of response pattern of non-insulin
dependent diabetics to Yoga therapy. Diabetes Res Clin Pract. 1993; 19(1):69-74.
28. Johnston SC, Horn JK, Valents J et al. The role of hypoventilation in sheep model of
epileptic sudden death . Ann.Neurol 1995; 531-537.
43
29. Kalvianinen R, Keranen T, Mustonen J, Lansimics E, Reikhinen PJ. Autonomic
nervous system function in Baltic myoclonus epilepsy. Epilepsy Res. 1990. April.5(3)
251-4.
30. Lathers CM, Schraeder PL, Boggs JG Sudden unexplained death and
autonomicdysfunction. In : Engel JP Jr, Pedley TA, eds. Epilepsy: a comprehensive text
book. 1997 : 1943 -55.
31. Lathers CM, Schraeder PL. Autonomic dysfunction in epilepsy: characterization of
autonomic cardiac neural discharge associated with pentylenetetrazol-induced
epileptogenic activity. Epilepsia. 1982; 23(6): 633-647.
32. Lathers CM, Schraeder PL. Review of autonomic dysfunction, cardiac arrhythmias and
epileptogenic activity. Clin Pharmacol. 1987; 27:346-356.
33. Madanmohan, Rai UC, Balvittal V, Thombre DP, Swami Gitananda. Cardio respiratory
changes during savitri pranayam and shavasan. The Yoga review 1983; 3: 25-34.
34. Mameli O, Melis F, Giraudi D, Cualbu M, Mameli S, De Riu PL, Mameli P. The brainstem
cardioarrhythmogenic triggers and their possible role in sudden epileptic death:
Epilepsy Res. 1993; 15(3): 171-178.
35. Mastojsky D I, Balaschak BA, Psychobiological control of seizures. Psycho Bull
1977; 84; 723-50.
36. Mc Gugan EA. Sudden unexpected deaths in epileptics- a literature review. Scott.Med.J
1999 Oct 44(5) ; 137-9.
37 .N agendra HR. Pranayama - The art of science. V ivekananda Yoga Kendra Prakashan
1997: 54-85.
38. Nagendra HR, Nagarathna HR. Yoga for epilepsy. 2001 Published by Swami Vivekananda
Yoga Anusandhana Samsthana (in press).
39. Nancy R, Temkin and Gay R. Davis. Stress as a risk factor for seizure among adult with
epilepsy. Epilepsia 1984, 25(4) 450-456.
40. Nashef L. Walker F, Allen P et al . Apnoea and bradycardia duringepileptic
seizures:relation to sudden death in epilepsy. J Neurol. Neurosurg psychiatry 1996; 60:
297-300.
41. Nei M, Ho RT, Sperling MR. EKG abnormalities during partial seizures in refractory
epilepsy. Epilepsia 2000; 41(5): 542-548.
42. Novak V. Reeves AL, Novak P, Low PA, Sharbrough FW. Time frequency mapping of
R-R. interval during complex partial seizures of temporal lobe origin.J. Auton Nerv
System 1999 September 24; 77 (2-3) 195-202.
44
43. Persson H, Ericson M, Tomson T. Carbamazepine affects autonomic cardiac control in
patients with newly diagnosed epilepsy. Epilepsy Res. 2003; 57(1): 69-75.
44. Puskarisch CA, Whitman S. Dell J, Hughes JR, Rosenol, Hermann BP. . Controlled
examination of effects of progressive relaxation training on seizure reduction.
Epilepsia 1992; 33 (4): 675-680.
45. Rai UC, Madanmohan, Subramanian N, Swami Gitananda. Oxygen consumption and
ventilatory changes during savitri pranayam and shavasan. J Res Edn Indian Med 1982;
1: 23-26.
46. Ray US, Hedge KS, Selvamurthy W Improvement in muscular efficiency as related
to standard task after yogic exercises in middle aged men. Ind J Med Res, 1986,
83:343-348.
47. P . Satish chandra, Vijay Chandra, Bruce S. Schoenberg . Case – control study of
Associated Condition at the time of death in patients with epilepsy. Neuroepidemiolgy
1988, 7:109-114.
48. Sathyaprabha TN, HL Murthy, BTC Murthy, INYS Medical Research Society's annual
report 1998; pp 12-13.
49. Satyaprabha TN, Hemalatha murthy, Murthy BTC. Efficacy of naturopathy and Yoga
in bronchial asthama - A self controlled matched study. IJPP 2001 45(1) 80-86.
50. Sathyaprabha TN, Satishchandra P, Netravathi K, Sinha S, Thennarasu K, Raju TR.
Cardiac autonomic dysfunctions in chronic refractory epilepsy. Epilepsy Res.72 ( 2006)
49 – 56.
51. Selwamurthy W, Nayar HS, Joseph NT, Joseph S (1983) Physiological effects of
yogic practice. Natl Inst. Mental Health Neurosci. J 1:71-80.
52. Schraeder PL, Lathers CM. Paroxysmal autonomic dysfunction, activity and sudden
death. Epilepsy Res 1989;3:55-62.
53. S.Shorvan., Risk factor for Sudden unexpected death in epilepsy. 1997, Epilepsia 38
(supp 11) S20-S22.
54. Sridharan and Murthy B.N. 1999. Prevalence and pattern of epilepsy in India. Epilepsia
40 (5) 631-636.
55. Sridharan Ramarathnam, Yoga for epilepsy : Methodological issue. Seizures 2000 Jan,
1-4 .
45
56. Stanescu DC, Nemery B, Veriter C, Marehal C (1981) Pattern of breathing and
ventilatory response to CO2 in subjects practicing hatha Yoga. J Appl Physiol Repir
Environ Physiol 51: 1625-1629.
57. Telles S, NagendraHR, Nagarathna HR., Autonomic changes during 'OM' meditation .
Ind. Jour. Phy and Pharmac. 1995:39:418-20.
58. Temkin NR, Davis GR. Stress as a risk factor for seizures among adults with epilepsy.
Epilepsia 1984; 25: 450-456.
59. Tennis P, Cole TB, Annegers JF, Leestma JE, Mc Nutt M, Rajput A. Cohort study of
the incidence of sudden unexplained death in person with seizure disorder treated
with antiepileptic drugs in Saskatchewan, Canada . Epilepsia 1995; 36(1) 29-36.
60. Terrence CF, Wisotzkey HM, Perper JA. Unexpected unexplained death in epileptic
patients. Neurology 1975, 25: 594-8.
61. Vijayalakshmi P, Madanmohan, Bhavanani AB, Patil A, Babu K.Modulation of stress
induced by isometric handgrip test in hypertensive patients following yogic relaxation
training. Indian J Physiol Pharmacol. 2004; 48(1):59-64.
62. Wallace RK, Benson H (1972). The physiology of meditation. Sci Am 226:85-90.
63. Walczak TS, Leppik IE, D' Amelio M, Rarick J, So E, Ahman P et al. Incidence and risk
factors in sudden unexpected death in epilepsy: a prospective cohort study. Neurology
2001; 56:519 – 525.
64. Wannamaker BB. Autonnomic nervous ysytem and Epilepsy. Epilepsia 1985; 26:31-39.
65. Whitman S, Dell J, Cegion V, Ciblilyn A, Statsinger J. Progressive relaxation for
seizure reduction. J. Epilepsy 1990; 3: 17-22.
66. Wilson GT, Effects of false feed back on avoidance behaviour “Cognitive”
desensitization revisited. J. Pers Soc. Psychol. 1973; 28: 115-22.
46
Publications emanated out of this research project
a b b b a cT.N. Sathyaprabha , P. Satishchandra , C. Pradhan , S.Sinha , B.Kaveri , K.Thennarasu , d
B.T.C. Murthy , T.R.Raju
a) Department of Neurophysiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
b) Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
c) National Institute of Mental Health and Neurosciences Department of Biostatistics,(NIMHANS), Bangalore, India.
d) Central Council for Research in Yoga & Naturopathy (CCRYN), Government of India, New Delhi, India
Abstract : The practice of Yoga regulates body physiology through control of posture, breathing, and meditation. Effects of Yoga on autonomic functions of patients with refractory epilepsy, as quantified by standardized autonomic function tests (AFTs), were determined. The Yoga group (n=18) received supervised training in Yoga, and the exercise group (n=16) practiced simple routine exercises. AFTs were repeated after 10 weeks of daily sessions. Data were compared with those of healthy volunteers (n=142). The Yoga group showed significant improvement in parasympathetic parameters and a decrease in seizure frequency scores. There was no improvement in the blood pressure parameters in either group. Two patients in the Yoga group achieved normal autonomic functions at the end of 10 weeks of therapy, whereas there were no changes in the exercise group. The data suggest that Yoga may have a role as an adjuvant therapy in the management of autonomic dysfunction in patients with refractory epilepsy.
Key words: Autonomic dysfunction; Yoga; Refractory epilepsy; SUDEP
Appendix
a b a b c aT.N. Sathyaprabha , P. Satishchandra , K.Netravathi , S.Sinha , K.Thennarasu ,T.R.Raju
a) Department of Neurophysiology, National Institute of Mental Health & Neurosciences
(NIMHANS), Bangalore, India.
Modulation of cardiac autonomic balance with adjuvant Yoga therapy in patients with refractory epilepsy- published in Journal of Epilepsy & Behaviour 2008; 12: 245-252
1.
2. Cardiac autonomic dysfunctions in chronic refractory epilepsy published in Journal of Epilepsy Research 2006;72:49-56.
47
b) Department of Neurology, National Institute of Mental Health & Neurosciences
(NIMHANS), Bangalore, India.
c) Department of Biostatistics, National Institute of Mental Health & Neurosciences
(NIMHANS), Bangalore, India.
Background :
Sudden unexplained death is an important cause of mortality in patients with epilepsy and cause for this is not fully understood. One of the explanations is autonomic dysfunction (AD), Studies of AD in chronic refractory epilepsy are very few in the literature.
Aim :
To evaluate cardiovascular autonomic function in chronic refractory epilepsy patients.
Methods and materials :
Seventy-three patients (31.5 + 9.8 years M:F :: 45:28) with chronic intractable epilepsy attending the “refractory epilepsy clinic” at a tertiary referral center (National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India) were enrolled. Age and gender matched healthy subjects were recruited as controls. Heart rate (HR) and blood pressure (BP) at rest and HR response after deep breathing, Valsalva maneuver, postural change and BP response to postural change and isometric work were recorded. AD was graded as early if one of HR or BP, definite if two or more HR and severe if two or more HR with BP based tests were detected to be abnormal.
Results :
The mean age at onset and duration of epilepsy was 12.4 + 8.5 years and 19.02 + 9.07 years, respectively. Twenty- three (31.5%) patients of refractory epilepsy had early involvement while 25 patients (primary generalized: 8, partial: 17) had definite AD, and 16 (primary generalized: 4 partial: 12) had severe autonomic dysfunction. ANCOVA results showed
expiration–inspiration, standing maximum: minimum ratio, standing 2 min systolic and isometric diastolic BP of the dysfunction group significantly differ compared to the control group. Patients with longer duration of epilepsy (23.2 years) had more severe dysfunction (p<0.05) than patients with relatively shorter duration (17.5 years) of epilepsy. Antiepileptic drugs (AED) used did not show any significant role on autonomic functions in this study.
Conclusion :
This is the first study from India to evaluate autonomic functions in refractory epilepsy patients. Autonomic dysfunction was noted in 56.3% of patients. Anticonvulsants used were not associated with AD. Longitudinal controlled studies with 'newly diagnosed' epilepsy patients will enhance further understanding about the role of autonomic system in epilepsy.
Keywords : Autonomic function tests; Autonomic dysfunction; Refractory epilepsy
COUNCIL'S PUBLICATIONS
HIGHLY SUBSIDISED & DISCOUNT UPTO 25%
HINDI
1. Sadharan Rogon ki Yogic evam Prakritik Chikitsa 30/-
2. Aadi Urja Prana 100/-
3. Vyavaharik Prakritik Chikitsa 120/-
4. Vidyarthiyon ki liye Swasthya Shiksha 5/-
5. Vaidic Vangmaya mei Prakritik Chikitsa (Vol.I) 175/-
6. Vaidic Vangmaya mei Prakritik Chikitsa (Vol.II) 175/-
7. Prakritik Chikitsa ki Avashyak Upchar Vidhiyan 20/-
8. Patanjal Yog Sutra Bhashya Vivaranam 150/-
9. Manushya mein Prana ke Aayam 180/-
10. Prakritik Chikitsa Darshan evam Vyavahar 160/-
11. Yoga Therapy and Naturopathy (CD) 50/-
12. Research Activities of Council (CD) 50/-
ENGLISH
1. Yogic and Naturopathic Treatment for Common Ailments 30/-
2. Health Education for Students 5/- 3. Important Therapeutic Modalities used in Naturopathy 20/-
4. Yoga Therapy and Naturopathy (CD) 50/-
TAMIL
1. Yoga Therapy and Naturopathy (CD) 50/-
Note: 25% discount is given on purchase of 10 copies or more and 10% on less than
10 copies of books. The publications may be purchased by remitting the cost
through DD/ Cash in favour of Director, CCRYN, New Delhi.
PRICE (Rs.)
