Protective Role of Moolabandha While Practicing Bhastrika and Kapalabhati by Women Vulnerable to Bladder Dysfunction: A Preliminary Ultrasound Study.

AIM: Obstetrical trauma and chronic exposure to increased intraabdominal pressure (IIAP) are known to increase vulnerability toward stress urinary incontinence. Bhastrika and Kapalabhati being fast yogic breathing maneuvers (FYBM), their association with IIAP is likely. Therefore, a preliminary descriptive study was conducted using transabominal ultrasound mode, to find whether impact of FYBM reinforced by prevailing risk factors had any adverse effect on the bladder neck status and urethral mobility of female yogic practioners and whether simultaneous application of Moolabandha inhibited such impact. MATERIAL: Mindray DC N3 model of diagnostic ultrasound unit with M probe was used for assessment.
METHODS: This study included 15 heterogenous female yoga teachers having average age, years of practice, and body mass index as 42.7 years, 7.33 years, and 24.86 kg/m2, respectively. Retrovesical angle (RVA) and posterior displacement (PD) and inferior displacement (ID) of urthetrhra were assessed while performing Bhastrika and Kapalabhati maneuvers with and without applying Moolabandha. Data obtained were then used for descriptive analysis.
RESULTS: Analysis showed a mixed picture, i.e., negative impact as well as preservation of protective strain-levator reflex in certain variables while practicing FYBM. Complicated labor and practice of power yoga appeared to reinforce the impact of FYBM. The values of RVA as well as PD and ID dropped and were statistically significant when FYBM was performed with Moolabandha. Aging factor, uneventful vaginal labor, or obesity could not confirm as prevailing risk factors.
CONCLUSION: Moolbandha proved its protective behavior while practicing Bhastrika and Kapalabhati by vulnerable women. Copyright:

Introduction

Stress urinary incontinence (SUI) is a highly embarrasing health issue causing adverse effects on quality of life among women;[12] whereas, the documented factors to impose risk of SUI are aging,[2] parity,[3] obesity,[4] and exposure to increased intraabdominal pressure (IIAP).[5]

Chronic impact of IIAP negatively affects the bladder neck support and urethral mobility which are manifested by widening of retrovesical angle (RVA) and rotation of proximal urethra along with trigone in the posteroinferior direction, respectively.[678]

Levator ani provide dynamic support to the pelvic sling[9] via straining-levator reflex (SLR) which is jeopardized due to chronic exposure to IIAP.[10] Bhastrika and Kapalabhati are fast yogic breathing maneuvers (FYBM) and include forced expiration, hence likely to associate with IIAP. Therefore, it was hypothesized that practice of Bhastrika and Kapalabhati jeopardizes SLR when prevailing risk factors reinforce the negative effect (if any) of both FYBM.

In physiotherapy, a protective maneuver termed as “Knack” is recommended to inhibit impact of IIAP during daily functioning.[11] Moolabandha resembles knack since both involve strong contraction of pelvic floor muscles (PFMs).

Moolabandha is a recommended practice, while practicing Pranayama because it serves as a “root lock” and prevents leakage of “Prana” - the life energy through pelvic outlet.[12] However, during practice of Pranayama, many are observed to avoid application of Moolabandha in apprehension that it would affect their concentration on breathing. Whereas, Kapalabhati being a “Shudhikriya,” application of Moolabandha is not emphasized. Therapeutic application of Moolabandha for PFM training is recommended,[13] but studies on its protective role while practicing Bhastrika and Kapalabhati among women, who are already exposed to risk factors of bladder dysfunction, is not found in literature. Hence, this study was aimed.

IIAP causes negative impact on the bladder neck support and urethral mobility, which is manifested by widening of RVA and rotation of proximal urethra along with trigone, expressed as posterior displacement(PD) and inferiordisplacement(ID), respectively. Diagnostic ultrasound (DUS) is known to be the best, noninvasive option for such investigation.[6] Therefore, these variables were assessed on DUS.

Methods

A conveniuent sample of 15 individuals was selected from the Yoga Sadhana Mandir, Navi Mumbai. Selection criteria included women in reproductive age with regular menstrual cycle, minimum of 5 years of regular practice of yoga with yogic breathing maneuvers and without any history of chronic exposure to cough, constipation or heavy work/sports.

The study was conducted at a private radiology center in Navi Mumbai. After obtaining informed consent from each individual, basic anthropometric assessment was recorded.

A DUS unit mindray DC N3 model with M probe was used for the study and was operated by registered radiologist. The researcher gave verbal commands to each individual while performing FYBM and simultaneously guided the radiologist to record the readings at appropriate phases of breathing. Study was conducted in the supine position. A transabdominal method with 3.5–6 MHz curvilinear probe was used to study the movements of partly filled urinary bladder (approximately 30–50 cc). After placing the probe on the lower abdomen, the urethra, bladder neck, and superior edge of pubic symphysis were identified. Sagittal scanning was then performed in the midsagittal plane to measure RVA, PD, and ID during Bhastrika and Kapalabhati, performed with and without applying Moolabandha at a speed of 20 and 120 strokes per cycle, respectively. Three readings were recorded for each variable with a 10 s break in-between each maneuver.

The average value of each variable and percentage change in the same after applying Moolabandha was calculated. No change or reduction in the values after application of Moolabandha was considered as preserved SLR whereas a rise in values was considered as negative impact of FYBM. Age, duration of yoga practice, parity with number of deliveries, complicated labor, obesity, and practice of power yoga were considered as prevailing risk factors. Descriptive analysis was conducted using derived values.

Results

The average age, duration of yogic practices, and body mass index (BMI) ranged from 42.7 years, 7.33 years, and 24.86 kg/m2, respectively. Of 15 individuals, 11 had history of 1–4 vaginal deliveries; of which, 7 had uneventful labor and 4 had complicated labor (prolonged second stage/instrumentation), 2 were nulliparous, and 2 delivered with C section.

Kapalabhati appeared to exert higher impact than Bhastrika and application of Moolabandha showed reduction in percentage value of all the variables.

Resting RVA ranged between 122° and 169° (average 144.73°). During Bhastrika and Kapalabhati without Moolabandha, it increased by 3.36% and 5.8%, respectively. With application of Moolabandha, RVA decreased by 10.13% and 9.81% in Bhastrika and Kapalabhati, resepctively. A paired sampled t-test was conducted to compare the values between RVA without Moolabandha and RVA with oolabandha in Kapalabhati as well as Bhastrika [Table 1]. There were statistically significant differences observed in RVA in both Bhastrika as well as Kapalabhati with P < 0.005 in both, suggesting that the RVA reduces when Bhastrika and Kapalabhati are performed with moolbandha.

Table 1

Effect of Bhastrika and Kapalabhati on retrovesicular angle with and without Moolabandha

RVA	Bhastrika	Kapalabhati
RVA with Moolabandha (mean±SD)	−14.66±10.63	132.13±16.31
RVA without Moolabandha (mean±SD)	4.93±14.15	152.13±16.37
t=14	7.093	4.536
P	0.000	0.000

SD=Standard deviation, RVA=Retrovesical angle

PD during Bhastrika and Kapalabhati ranged between 0–2.4 cm and 0–2.3 cm, respectively, with Bhastrika and Kapalabhati showing 6.86% and 8.66% displacement, respectively, without Moolabandha. With application of Moolabandha, PD reversed toward baseline, in all the individuals in both the practices. A paired sampled t-test was conducted to compare the values of PD in Bhastrika and Kapalabhati, with and without moolabandh which was statistically significant with P < 0. 05 in both [Table 2].

Table 2

Effect of Bhastrika and Kapalabhati on posterior displacement of urethra with and without Moolabandha

PD of urethra	Bhastrika	Kapalabhati
PD with Moolabandha (mean±SD)	0.93±0.91	0.98±0.82
PD without Moolabandha (mean±SD)	0.30±0.47	0.3467±0.33
t=14	3.544	3.631
P	0.003	0.003

SD=Standard deviation, PD=Posterior disoplacement

The ID ranged between 0 and 2.5 cm in Bhastrika and 0–10.2 cm in Kapalabhati, performed without Moolabandha, showing 4% and 7.46% displacement, respectively. With incorporated Moolabandha, reversed toward baseline was observed in all individuals. A paired sampled t-test was conducted to compare the values between ID during Bhastrika and Kapalabhati without moolabandh and with Moolabandha [Table 3]. The reversal in Bhastrika was statistically significant (P < 0.05), whereas in Kapalabhati, it was not significant (P > 0.05).

Table 3

Effect of Bhastrika and Kapalabhati on inferior displacement of urethra with and without Moolabandha

ID of urethra	Bhastrika	Kapalabhati
ID with Moolabandha (mean±SD)	0.20±0.33	0.25±0.32
ID without Moolabandha (mean±SD)	0.60±0.84	1.12±2.57
t=14	2.537	1.461
P	0.024	0.166

SD=Standard deviation, ID=Inferior displacement

Among 6 continent individuals having 1–4 vaginal deliveries, the oldest (50 years) individual with single vaginal delivery showed total preservation of SLR in all the variables. Whereas, the only individual with highest number of vaginal deliveries (4) revealed preservation of SLR in RVA values during both FYBM.

Among 5 incontinent parous individuals, 4 had history of complicated vaginal labor and one was practicing power yoga. All the 5 individuals showed increased values in all the variables while practicing FYBM.

Among two nulliparous individuals, the older (50 years) individual with prevailing obesity (BMI 26.1 kg/m2) and highest duration of practice (18 years) showed preservation of SLR in all the variables during FYBM whereas the youngest (30 years) individual involved in power yoga showed increased values of PD and ID during both FYBM.

While practicing both the FYBM, an individual with history of delivery through planned C section showed increased value of RVA whereas, the another with history of emergency C section showed increased values of all the variables.

Discussion

As per Indian government law, the use of DUS has been restricted only to registered radiologists. Hence, taking into account the busy schedule of radiologists, we included a small sample size in this nonfunded project.

Transperineal mode is better than transabdominal mode[14] when DUS is used for investigation of bladder dysfunction. Since transperineal mode involved ethical issues,[15] we used transabdominal mode.

This study revealed a mixed picture with negative impact of Kapalabhati and Bhastrika without Moolabandha on RVA and postero-ID of urethra, as well as preservation of SLR and RVA. However, application of Moolabandha during Kapalabhati and Bhastrika significantly showed a lift in RVA as well as correction of postero-ID of urethra in all individuals. Duration of practice and known risk factors such as age, parity, and obesity could not confirm as vulnerable factors but history of complicated labor and practice of power yoga revealed vulnerability and accepted our hypothesis that Moolabandha serves as a protective maneuver while practing Bhastrika and Kapalabhati by female yoga practitioners.

Limitations of the study

This was an original study. However, it was conducted on a very small size and heterogenous group, in terms of parity and age.

Conclusion

This study revealed protective role of Moolabandha against bladder dysfunction while practicing Bhastrika and Kapalabhati maneuvers by female yoga practioners who are already exposed to risk factors such as complicated labor and practice of power yoga; although this was a preliminary descriptive study, it gave directions for further research in this regard to confirm our findings statistically and to identify other prevailing risk factors if any.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.