• For conditions in which stress directly affects the symptoms: eg. certain forms of depression and anxiety or where pain, asthma, and blood pressure are made worse with stress
• Patient's pre-existing beliefs, expectations and social support
• Positive or healing/supportive environment
• Good and trusting relationship between patient or client and health professional
• Biocultural factors The word "yoga" means "union". Yoga is a form of exercise based on the belief that the body and breath are intimately connected with the mind. By controlling the breath and holding the body in steady poses or "asanas", yoga creates harmony.
  
  General Considerations for Using Hatha Yoga in The Clinical Setting
  
  The word "yoga" means "union". Hatha yoga is a form of exercise based on the belief that the body and breath are intimately connected with the mind. By controlling the breath and holding the body in steady poses or "asanas", yoga creates harmony. Yoga practice consists of five key elements: proper breathing, proper exercise, proper relaxation, proper diet, and positive thinking and meditation. The exercises, or asanas, are designed to ease tense muscles and to improve the flexibility of the body's joints and ligaments.
  
  As in any form of physical conditioning, all patients who are referred to hatha yoga programs should first be evaluated for overall health status, exercise tolerance, and psychosocial function. Patients with existing cardiovascular disease, eg. angina, post- myocardial infarction, CABG, PTCA, should also be evaluated for exercise related- arrhythmias and/or angina and ventricular function. As a general rule, the more quiescent forms of hatha yoga, restorative and modified Iyengar and vini yoga are appropriate.
  
  A pre-referral evaluation is particularly warranted for those patients beginning more physical forms of hatha yoga because they require greater muscular strength and cardiac work. The author is unaware of any published contraindications of mindful exercise and cardiovascular disease per se as there has been very little research comparing the mind- body exercise modalities in this patient population. Contraindications to more physically demanding yoga exercise, eg. select Iyengar yoga poses and Ashtanga yoga, should be similar to those published by the ACSM (1) AACVPR (2) and for entry into in- and outpatient exercise training programs.
  
  Patient progress should be periodically evaluated at 4-week intervals for the first 60-90 days and at 6-month intervals thereafter. Although there are no tested and published standards for monitoring mindful exercise, particularly hatha yoga, exercise progress for patients with cardiovascular disease it seems reasonable to monitor at least three parameters during the course of therapy: program adherence, cognitive response, and musculoskeletal response such as changes in muscular strength, balance, flexibility and any tendency for musculoskeletal strain or injury. There are also numerous structured- interview prototypes and self-report tools that the clinician or yoga therapist can use to measure changes in mood, psychological well-being and relaxation abilities, eg. Jenkins Activity Survey, Profile of Mood States questionnaire, State-Trait Anxiety Index, Cook Medley Hostility Scale and others described in stress management practice publications (3). Standard quality of life measures, eg. SF-12 and SF-36 forms, are also appropriate and a simplier approach to assessing both psychological and physical parameters.
  
  The form and style of hatha yoga program chosen will depend upon the patient's initial level of musculoskeletal fitness and therapeutic goals. For instance, restorative/therapeutic and integral yoga generally involve less exertion and more of a relaxation component which may more appropriately address stress-related problems of the patient. Patients with mild to moderate hypertension are also candidates for mind- body exercise, especially those who are resistant to comply with drug therapy. Ashtantga and Iyengar yoga generally focus on strength, flexibility, and require considerable mental concentration thus they may be more appropriate for higher functional class patients (eg. >12 MET exercise capacity) who have successfully completed Phase III and IV cardiac rehabilitation. Some yoga postures significantly increase blood pressure and may be inappropriate for stage two-plus hypertension, ie., those with blood pressures greater than 160/105 mmHg. DiCarlo and coworkers recently demonstrated significantly greater systolic and diastolic blood pressures in yoga practitioners practicing Iyengar style yoga when compared to moderate treadmill walking (4).
  
  There are many permutations of style within each form and style of hatha yoga and it is important to personally evaluate the attributes and safety of each prior to referring a patient. The quality of mind-body fitness instructors also varies greatly. For this reason the clinician should look for the following instructor qualifications: those with formal training and/or professionally-certified for the method they use, have at least 4 years experience in teaching a variety of adults, and have an understanding of the specific limitations of the patient referred. Ideally, the instructor would also be familiar with the consensus practice guidelines for the medical condition for which they are working with.
  
  In general, it is wise to refer to yoga practitioners who on the first visit will meet with the patient individually to conduct an individual thorough hands-on evaluation of strength, flexibility, and posture as well as demonstrate initial poses. This evaluation and accompanying individualized posture modifications should be a requirement for all those just beginning yoga. Yoga classes can be challenging and difficult; consequently it is important to refer to beginner's level classes (there is even a wide assortment of beginning levels). Deconditioned patients, especially seniors, will generally have a more favorable response to Alexander, restorative/therapeutic and integral yoga rather more strenuous forms of yoga such as Ashtanga and intermediate-advanced forms of Iyengar. Iyengar and Ashtanga require more strenuous movement patterns and/or poses which can significantly elevate systolic blood pressure and cardiac afterload (4).
  
  A growing number of outpatient clinical programs have found that mindful exercise has been especially helpful with select hypertensive, dyslipidemic, and cardiac rehabilitation patients. Tai chi, restorative/therapeutic and viniyoga, NIA, and Feldenkrais are particularly well suited for outpatient phase III and IV cardiac rehab because of their ability to improve strength, coordination, and stress management skills while being relatively low-risk for inducing myocardial ischemia and musculoskeletal injury. This is because these particular mindful exercise programs are executed at a low tempo and use very low resistance movements while using breathwork and proprioceptive awareness to reduce tension and instill a relaxation response. These low-level mind-body programs day also be more appropriate for those patients for which conventional physical conditioning is contraindicated such as in patients with poor ventricular function and AICD emplacement. Patients with NYHA Class I to III heart failure may also be responsive to mind-body exercise programs such as tai chi, restorative and therapeutic yoga, and Alexander. Such programs reduce stress, improve muscular strength and balance, and generate a sense of well-being which is so important in patients with poor ventricular function. Most Iyengar yoga and Ashtanga yoga postures would be contraindicated for all classes of heart failure patients because the isometric nature of such exercise is capable of generating excessive pressure on the left heart. Inverted poses should be contraindicated for any patient with existing coronary disease but especially those with any class of heart failure.
  
  

Most recent treadmill ECG results
Exercise tolerance in METS
S-T segment changes
Heart rate - blood pressure response
Cardiac rhythm response
Ventricular function

Associated risk factors
Exercise history
CVD history (CABG, pMI, PTCA, angina)
Musculoskeletal health, especially spine, cervical and low back
CVD-related symptom history
Current medications

Chronic Conditions and examples of appropriate mindful exercise therapy:

Hypertension I & II restorative and low-level Iyengar yoga, TC
Hypertension III & IV restorative yoga, TCC, AT
Recent post MI restorative yoga, TC, TCC, IY, AT, VY
CHF I-III restorative, TC, AT
CHF IV restorative yoga, TCC, AT
MVP restorative yoga, VY,TC, TCC, NIA
PAT restorative yoga, TC, VY, TCC, NIA
NIDDM restorative & IY, NIA, TC, AT
Chronic anger TC, TCC, RY, IY, AT, Pilates, NIA
Anxiety (GAD) restorative yoga, TC, TCC, IY, AT, VY
Depression restorative yoga, NIA, TC, VY
Back pain/arthritis Pilates, AT, IY, VY key: TC, t'ai c'hi; TCC, t'ai c'hi chih; AT, Alexander Technique; NIA, neuromuscular integrative action; IY, Iyengar yoga; VY, viniyoga.

Conclusions
Hatha yoga continues to emerge as an effective non-pharmacologic complimentary approach to treating a variety of disorders. There is scientific evidence that hypertension, anxiety, depressive disorders, blood lipid disorders, pain, coronary disease, and poor self-esteem all favorably respond to many forms of hatha yoga (25). Regular participation in yoga exercise may also improve compliance because of its portability and relative low- intensity nature.

Many research studies have demonstrated that individuals can learn to control specific physiologic parameters with yoga. Despite all of the interest and perceived benefits of hatha yoga there still remains a great need for more peer-reviewed and adequately controlled research trials investigating the impact of hatha yoga on disease states, perceived stress, and health care costs. Although there is a considerable international body of research, much is statistically underpowered, lacks adequate controls, and/or is void of comparisons with conventional health enhancement models. The quantity and quality of yoga exercise research will surely escalate as Western graduate schools develop structured course work and students pursue study and investigational projects in this promising forms of mindful exercise. Likewise, It is not beyond reason that in the near future the fitness and health promotion industry will benefit from the inclusion of mind-body exercise guidelines and resources in respected exercise consensus publications that recommend appropriate quality and quantity of exercise for primary and secondary prevention purposes (1,2,5, & 6). It is conceivable that the alliance of conventional health promotion programming with mind-body approaches will further reduce health care utilization and the unnecessary burden of degenerative disease. Given the present and growing mandate for implementing integrated disease management programs to effectively reduce health care costs and inspire self-care, mind-body fitness programs will continue to grow as an integral element of health promotion and medicine.

References/Resources:
Primary References:
1. Lasater J Relax and Renew. Rodmell Press, 1995 2. Kraftsow G Yoga for Wellness: Healing with The Timeless Teachings of Viniyoga. Penguin Putman, Inc., 1999

Supportive Resources/References:
1. American College of Sports Medicine. Guidelines for Exercise Testing and Prescription. 5th edition. Williams and Wilkins;1995. 2. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation Programs. 3rd edition. Champaign IL:Human Kinetics;1999 3. Lehrer PM, Woolfold RL., eds. Principles and Practice of Stress Management. 2nd ed. New York:Guilford;1993:443-462. 4. DiCarlo LJ, Sparling PB, Hinson BT, et.al. Cardiovascular, metabolic, and perceptual responses to hatha yoga standing poses. Medicine Exercise Nutrition and Health. 1995;4:107-112. 5. American Heart Association: Exercise Standards: A Statement for Healthcare Professionals from The American Heart Association. Circulation.1995; 91:580-615. 6. Agency for Health Care Policy and Research (AHCPR). Cardiac Rehabilitation: Clinical Practice Guidelline Number 17. U.S. Department of Health and Human Services, AHCPR Publication No. 96-0672; 1995.

Other Research References:
7. Berger B. and Owen D. Mood Alteration with Yoga and Swimming: Aerobic Exercise May Not Be Necessary. Perceptual and Motor Skills, 1992;75:1331-1343. 8. Schell FJ, Allolio B, Schonecke OW. Physiological and psychological effects of hatha-yoga exercise in healthy women. Intern J of Psychosomatics. 1994;41:46-52. 9. Nespor K. Pain management and yoga. Intern J of Psychosomatics. 1991;38:76-81. 10. Linden W, Chambers I. Clinical effectiveness of non-drug treatment of hypertension: a meta-analysis. Annals of Behav Med. 1994;16:35-45. 11. Patel C. Yoga-Based Therapy. from Lehrer & Woolfolk: Principles and Practice of Stress Management. 2nd Edition. New York:Guilford Publishers;1993. 12. Broota A, Varma R, Singh A. Role of relaxation in hypertension. J of the Indian Acad Appl. Psych. 1995;21:29-36. 13. Joshi LN, Joshi VD, and Gokhale LV. Effect of short term Pranayama practice on breathing rate and ventilatory functions of the lung. Indian J of Physio and Pharmacology. 1992;36:105-108. 14. La Forge R. Exercise-associated mood alterations: a review of interactive neurobiologic mechanisms. Medicine Exercise Nutrition and Health. 1995;4:17-32. 15. Bahrke, M.S. & Morgan W.P. Anxiety reduction following exercise and meditation. Cognitive Therapy and Research. 1978;2:323-333. 16. Morgan, WP, Goldstone SE. eds. Exercise and Mental Health. Washington DC:Hemispheric Publishing;1987. 17. Brown DR. Exercise, fitness, and mental health. In: Bouchard C, Shepard RJ, Stephens T (eds.) Exercise, Fitness, and Health: A Consensus of Current Knowledge.Champaign,IL:Human Kinetics, 1990:606-626. 18. Khanam, AA. et. al. Study of pulmonary and autonomic functions of asthma patients after yoga training. Indian J Physiol Pharmacol. 1996;40:318-324. 19. Astin JA. Stress reduction through mindfulness meditation. Psychother Psychosom. 1997;66:97-106 20. Harrington A. (editor). The Placebo Effect: An Interdisciplinary Exploration. Harvard University Press, 1997. 21. Schmidt T et. al. Changes in cardiovascular risk factors and hormones during a comprehensive residential three month kriya yoga training program and vegetarian nutrition. Acta Physiol Scan Suppl 1997;640:158-162 22. Raju PS, et. al. Influence of intensive yoga training on physiologic changes in 6 adult women: a case report. J Alternative and Complementary Medicine. 1997. 3:291-295. 23. Telles S & Naveen KV. Yoga for rehabilitation: an overview. Indian J Med Sci. 1997, 51:123-127. 24. Luskin FM et. al. A review of mind-body therapies in the treatment of cardiovascular disease: Part I: Implications for the elderly. Alternative Therapies. 1998 4:46-61. 25. Monroe R, Ghosh AK, and Kalish D. Yoga Research Bibliography: Scientific Studies on Yoga and Meditation. Cambridge England:Yoga Biomedical Trust;1989. 26. Vedanthan PK, Kesavalu LN, Murthy KC et. al. Clinical study of yoga techniques in university students with asthma: a controlled study. Allergy Asthma Prox, 1998 Jan, 19:1, 3-9. 27. Austin J. Zen and The Brain. MIT Press, 1998.