IAETSD JOURNAL FOR ADVANCED RESEARCH IN APPLIED SCIENCES ISSN NO: 2394-8442

EFFECT OF SURYANAMASKARA ON CONSTIPATION

A RANDOMIZED CONTROLLED TRIAL
Dr. Shivaram Gannamani 1, Dr. Shiva Prasad Shetty2, Dr. Prasanth Shetty3
1(Post Graduate, Division Of Yoga therapy, Department Of Post Graduate Studies, SDM College Of Naturopathy And Yogic Sciences, India)
2(Dean, Division of Yoga therapy, Department Of Post Graduate Studies, SDM College Of Naturopathy And Yogic Sciences, India)
3(Principal, Department Of Post Graduate Studies, SDM College Of Naturopathy and Yogic Sciences, India)

Abstract
BACKGROUND: Suryanamaskara The salutations to the Sun God is also a part of Indian traditional yogic practices. Clinically,
suryanamaskaras have also been reported to help in the prevention of digestive complaints like gastric ulcers.

OBJECTIVES: To evaluate the effects of suryanamaskara in individuals suffering from constipation on: Constipation Symptoms,
Constipation related Quality of Life

METHODS: A minimum of 100 subjects are screened as per diagnostic criteria and 60 were selected based on inclusion and
exclusion criteria. The assessment tools included patient assessment of constipation symptom (PAC-SYM) patient assessment of
constipation-quality of life questionnaire (PAC-QOL).

RESULTS: The reduction in total symptoms as well as scores in all clusters of PAC-SYM, when we compared both the groups with
unpaired t test, showed a highly significant changes (p<0.0001) in intervention group compared to control group. The reduction in
total scores as well as scores in all clusters of PAC-QOL, when we compared both the groups with unpaired t test, showed a highly
significant changes (p<0.0001) in intervention group compared to control group.

CONCLUSION: The study results concluded that 4 weeks of suryanamaskara practice has shown to be effective in reducing
constipation symptoms and constipation related quality of life.

Keywords- suryanamaskara, constipation PAC-QOL, PAC -SYM, quality of life.

INTRODUCTION
The word yoga, meaning unity or oneness, was derived from the Sanskrit word yuj which means to join.1It includes
ancient practices like postures, breathing techniques and meditation which is now gaining a lot of attention from healthcare
professionals.1 Suryanamaskara The salutations to the Sun God is also a part of Indian traditional yogic practices.2 Suryanamaskara is
known to be one of the best exercise in yogic practices which consists of mainly 12 exercises of different positions having its mainly
impact on the human body. It helps the practitioner to be socially acceptable, mentally relaxed, physically fit, emotionally balanced, and
spiritually awakened. Hereby, this word is binded from two words, one is Surya and other Namaskar. It means Surya which is a form
of fire and Namaskar, a form of respect. When a man does these postures, he will be able to live life as courageously as fire and hearty
like vinaya.3
The 12 steps of suryanamaskara consists of movements which stretch the spinal column and massage, tone and stimulate vital
organs through alternately flexing the body forwards and backwards.4 It has hence already been proved that suryanamaskaras has a
tremendous effect on all part of the digestive system like the pharynx, esophagus, stomach, intestines and liver in order to activate and
tone up the digestive system by alternatively stretching and compressing abdominal organs. Clinically, suryanamaskaras have also been
reported to help in the prevention of digestive complaints like gastric ulcers.5

Exercise is believed to shorten the transit time through the gastrointestinal tract and thus enhance evacuation of stool. but in
other way, lack of muscle tone as a result of inactivity decreases the facilitative function of the abdominal and pelvic floor musculature
in evacuating the stool. [6] Chronic constipation is one of the most important components of clinical gastroenterology practice. Chronic
constipation can affect from 2% to 27% of the population.

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It significantly interferes with their daily standards of living and quality of life and not only affects them physically but also
mentally and becomes troublesome for many patients. Constipation can be clinically identified based on its definition, either self-
reported or using the Rome criteria. [7]

Constipation leads to an increased number of medical visits resulting in an involvement of various diagnostic procedures,
associated medical problems and treatment using laxatives as well as herbal remedies. However, studies on the prevalence of
constipation conducted to date yield discordant results, with estimates between 2 percent and 34 percent. [8-18] In fact, nearly 15% of
the US population meet the criteria for chronic constipation (CC). Even though the word constipation gives rise to several
meanings, it differs between patients, cultures and regions.

Constipation is a condition of the digestive system where a person experiences hard feces that are difficult to eliminate; it may
be extremely painful, and in severe cases (fecal impaction) lead to symptoms of bowel obstruction. [19 20 21] Constipation is defined as
having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry, small in size, and difficult to
eliminate. Some people who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the
sensation of a full bowel. [22] Constipation occurs when the colon absorbs too much water or if the colon's muscle contractions are
slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools can become hard and dry. [23, 24]

However, there havent been scientific evidences published on the practice of suryanamaskaras for constipation, having a
strong clinical background for the role of asanas and exercises in the management of constipation, it is essential to have a standard
protocol for the same. Hence this study was planned to find out whether the practice of suryanamaskaras has any effects on
constipation.

METHODOLOGY
Source of Data:
The subjects are recruits from general population.

Method of Collection of Data:

The data is collected using standard questionnaires which have been tested for reliability and validity. Their use in the selected
population has also been found to be appropriate. The Pre and Post assessments is done using the following variables:
Patient Assessment of Constipation Symptom (PAC-SYM)
Patient Assessment of Constipation-Quality of Life Questionnaire (PAC-QoL)

Criteria for Diagnosis:

Rome 3 criteria for Chronic constipation 25
Symptom onset at least 6 months prior to diagnosis
Presence of symptoms for the last 3 months (see below)
Loose stools are rarely present without the use of laxatives.
Fewer than 3 bowel movements per week
Symptoms include 2 or more of the following during at least 25% of defecations:
Straining
Lumpy or hard stools
Sensation of incomplete evacuation
Sensation of anorectal obstruction or blockade
Manual manoeuvres to facilitate evacuation

Inclusion Criteria:
The following inclusion criteria would be the basis for selecting subjects:
Subjects aged between 17 30 years
Subjects fulfilling diagnostic criteria for constipation
Willing to participate in the trial by signing an informed consent form

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Exclusion Criteria:
Participants will be excluded if they have:
Constipation with risk factors.
Constipation associated with systemic complications like ulcerative colitis, chrons disease, hemorrhoids etc.
Has a medical condition which precludes dietary changes like anemia.
Declined to give consent for the trial.

Study Plan:

Design
A Randomized Controlled Trial

Sample Size
100 Subjects are screened as per diagnostic criteria. A minimum of 60 subjects are selected based on inclusion and exclusion criteria.
They are randomly allocated to either of the groups i.e. interventional or control group. Hence, a minimum of 30 subjects are recruited
for Suryanamaskara group (interventional) and 30 subjects to the control group.
Grouping
2 Groups-
Intervention / Suryanamaskara group (n= 30 subjects)
Control Group (n= 30 subjects)

Fig. 1 Illustration of Study Plan

Assessment of Results
Appropriate statistical tests are done to assess mean differences across the baseline (Pre) and endpoint (Post) based on the
quality of data. These tests are done using Statistical Analysis Software - Statistical Package for Social Sciences (SPSS).

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Outcome Variables:
Patient Assessment of Constipation Symptom (PAC-SYM)
The Patient Assessment of Constipation Symptom was developed to assess symptom frequency and severity of chronic
constipation. This 12-item self-report measure is divided into three symptom subscales (i.e. abdominal, rectal and stool). Items are
scored on a four-point Likert scale, with 4 indicating the worst symptom severity. A total score for the PAC-SYM can range from 0 to
48. No cut-off score has been reported.
Patient Assessment of Constipation-Quality of Life (PAC-QoL)
Patient Assessment of Constipation-Quality of Life is a self-reported questionnaire, was used to measure the quality of life of
patients. The PAC-QOL contains 28 items grouped into 4 subscales covering: Worries and concerns (11 items), Physical discomfort (4
items), Psychosocial discomfort (8 items), and Satisfaction (5 items). A 5-point Likert response scale, ranging from 0 (Not at all / None
of the time) to 4 (Extremely / All of the time), is used over a 2-week recall period. Here (lower scores=better QOL) 72

Data extraction
The assessments were collected on the first day (baseline data) and the end of 4 weeks (post data). The data was organized in
Microsoft Excel Sheets (version 2010).

Data Analysis
Data were analyzed using IBM SPSS 21.0.

Ethical Considerations:
Subjects who fulfilled the inclusion criteria were shown information sheet having details regarding the nature of study and
intervention to be used. Subjects were given enough time to go through the study details mentioned in the information sheet. They
were given the opportunity to ask any question and if they agree to participate in the study they were asked to sign the informed
consent form. All expressed their willingness to participate in the study by giving signed informed consent. Approval was obtained
from Institutional Ethical Committee, as all tests were essentially non-invasive in nature.

RESULTS
The present study was conducted to evaluate the effectiveness of Suryanamaskara in any of the outcome variables viz
Patient-Assessment of Constipation Symptoms (PAC-SYM) including internal domains Abdominal symptoms (4 items), Rectal
symptoms (3 items), Stool symptoms (5 items) and Patient-Assessment of Constipation Quality of Life questionnaire (PAC-QOL)
including internal domains Worries and concerns (11 items), Physical discomfort (4 items), Psychosocial discomfort (8 items),
Satisfaction (5 items) among constipation patients. Results were compared within group and between two groups, interventional and
control. Where in data was extracted at both baseline and post-intervention in both groups.

In PAC-SYM the results after applying independent t test showed there is a significant decrease in total symptoms scores in
post compared to pre within intervention group with 79.05%,( p=0.0001) and no significant reduction in total symptoms scores in
control group was only 3.39%, (p=0.2242).The reduction in total symptom scores when we compared both the groups with
independent t test, the t value is 16.3209 showed a highly significant changes (p<0.0001) in intervention group compared to control
group.

In PAC-SYM cluster the results after applying independent t test showed there is a significant decrease in abdominal
symptoms scores in post compared to pre within intervention group with 84.08%, (p=0.0001) and increase in abdominal symptoms
scores in control group was 4.80%, (p=0.3158). The reduction in abdominal symptoms scores when we compared both the groups
with independent t test the t value is 13.6246 showed a highly significant changes (p<0.0001) in intervention group compared to
control group.
In PAC-SYM cluster the results after applying independent t test showed there is a significant decrease in rectal symptom
scores in post compared to pre within intervention group with 83.64%, (p=0.0001) and there is a decrease in rectal symptom scores in
control group 1.66%, (p=0.8741). The reduction in rectal symptom scores when we compared both the groups with independent t test
the t value is 6.0972 showed a highly significant changes (p<0.0001) in intervention group compared to control group.

In PAC-SYM cluster the results after applying independent t test showed there is a significant decrease in stool symptom
scores in post compared to pre within intervention group with 73.35%, (p=0.0001) and there is a decrease in stool symptom scores in
control group 10.49%, (p=0.0053). The reduction in stool symptom scores when we compared both the groups with independent t
test the t value is 12.2118 showed a highly significant changes (p<0.0001) in intervention group compared to control group.

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In PAC-QOL the results after applying independent t test showed there is a significant decrease in total quality of life scores
in post compared to pre within intervention group with 73.43%, (p=0.0001) and there is an increase in total quality of life scores in
control group 6.09%, (p=0.0230). The reduction in total quality of life scores when we compared both the groups with independent t
test the t value is 20.9615 showed a highly significant changes (p<0.0001) in intervention group compared to control group.

In PAC-QOL cluster the results after applying independent t test showed there is a significant decrease in physical discomfort
scores in post compared to pre within intervention group with 77.65%, (p=0.0001) and there is a decrease in physical discomfort
scores in control group 1.87%, (p=0.6112). The reduction in physical discomfort scores when we compared both the groups with
independent t test the t value is 12.4261showed a highly significant changes (p<0.0001) in intervention group compared to control
group.

In PAC-QOL cluster the results after applying independent t test showed there is a significant decrease in psychological
discomfort scores in post compared to pre within intervention group with 73.22%, (p=0.0001) and there is an increase in psychological
discomfort scores in control group 6.84%, (p=0.0540). The reduction in psychological discomfort scores when we compared both the
groups with independent t test the t value is 16.1979 showed a highly significant changes (p<0.0001) in intervention group compared
to control group.

In PAC-QOL cluster the results after applying independent t test showed there is a significant decrease in Worries and
concerns scores in post compared to pre within intervention group with 72.90%, p=0.0001and there is an increase in Worries and
concerns scores in control group 9.59%, p=0.0103.The reduction in Worries and concerns scores when we compared both the groups
with independent t test the t value is 17.0197 showed a highly significant changes (p<0.0001) in intervention group compared to
control group.

In PAC-QOL cluster the results after applying independent t test showed there is a significant decrease in satisfaction scores
in post compared to pre within intervention group with 71.34%, p=0.0001and there is an increase in satisfaction scores in control
group 4.26%, p=0.3130. The reduction in satisfaction scores when we compared both the groups with independent t test the t value is
12.7931 showed a highly significant changes (p<0.0001) in intervention group compared to control group.

Table 1: Comparison of test and control groups with respect to total symptoms scores and its component and quality of life scores and
its component at pretest and posttest by independent test

Pre t value P Post t value P value Difference t P value

value value
Test Control Test Control Test Control
Total 29.60 31.43 -1.60 0.1132 6.20 3 30.37 -22.79 0.0001* 23.40 1.07 16.32 0.0001*
symptoms 5.32 3.27 .96 4.25 5.83 4.70
Abdominal 10.47 11.10 -1.02 0.3111 1.67 1 11.63 -21.81 0.0001* 8.80 2. -0.53 13.62 0.0001*
symptoms 2.36 2.44 .60 1.92 43 2.86
Rectal 5.50 2. 6.03 -0.87 0.3861 0.90 0 5.93 -10.81 0.0001* 4.60 2. 0.10 6.097 0.0001*
symptoms 32 2.41 .99 2.35 14 3.43
Stool 13.63 14.30 -0.95 0.3431 3.63 2 12.80 -13.62 0.0001* 10.00 1.50 12.21 0.0001*
symptoms 2.63 2.77 .33 2.86 2.67 2.73
Quality of 82.67 83.17 -0.26 0.7932 21.97 88.23 -19.03 0.0001* 60.70 -5.07 20.96 0.0001*
life 8.21 6.38 15.5 11.05 12.72 11.56
Physical 11.63 12.47 -1.62 0.1093 2.60 3 12.23 -13.47 0.0001* 9.03 2. 0.23 12.42 0.0001*
discomfort 1.85 2.11 .10 2.39 98 2.49
Psychologica 22.90 23.40 -0.71 0.4767 6.13 5 25.0 3. -15.47 0.0001* 16.77 -1.60 16.19 0.0001*
l symptoms 2.76 2.65 .38 96 4.59 4.18
Worries and 31.73 31.63 0.099 0.9214 8.60 6 34.67 -16.90 0.0001* 23.13 -3.03 17.01 0.0001*
concerns 4.60 3.07 .62 5.24 5.85 6.05
satisfaction 16.40 15.67 1.232 0.2226 4.70 3 16.33 -16.37 0.0001* 11.70 -0.67 12.79 0.0001*
1.85 2.68 .08 2.38 3.92 3.56

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Table 2: Comparison of pre and post with respect to total symptoms scores and its component and quality of life scores and its
component in test and control group by independent test.
Test group % of P value Control group % of P value
change change
Pre Post Pre Post
Total symptoms 29.60 5.32 6.20 3.96 79.05%# 0.0001* 31.43 3.27 30.37 4.25 3.39%# 0.2242
Abdominal 10.47 2.36 1.67 1.60 84.08%# 0.0001* 11.10 2.44 11.63 1.92 -4.80%# 0.3158
symptoms
Rectal 5.50 2.32 0.90 0.99 83.64%# 0.0001* 6.03 2.41 5.93 2.35 1.66%# 0.8741
symptoms
Stool symptoms 13.63 2.63 3.63 2.33 73.35%# 0.0001* 14.30 2.77 12.80 2.86 10.49%# 0.0053*
Quality of life 82.67 8.21 21.97 15. 73.43% 0.0001* 83.17 6.38 88.23 11.0 -6.09%# 0.0230*
54 5
Physical 11.63 1.85 2.60 3.10 77.65%# 0.0001* 12.47 2.11 12.23 2.39 1.87%# 0.6112
discomfort
Psychological 22.90 2.76 6.13 5.38 73.22%# 0.0001* 23.40 2.65 25.0 3.96 -6.84%# 0.0540*
symptoms
Worries and 31.73 4.60 8.60 6.62 72.90%# 0.0001* 31.63 3.07 34.67 5.24 -9.59%# 0.0103*
concerns
satisfaction 16.40 1.85 4.70 3.08 71.34%# 0.0001* 15.67 2.68 16.33 2.38 -4.26%# 0.3130

*P<0.05
DISCUSSION
The total symptoms of constipation are found to have a significant reduction in post data compared to pre data within the
intervention group (p=0.0001) with no significant reduction in control group (p=0.2242) when compared between the groups,
intervention group showed a significant change (p<0.0001) compared to control group.

In an earlier study done on IBS for 6 weeks showed similar results in reductions of IBS symptoms in Yoga group which
practiced reclining postures, standing postures, forward bends, supported inversions, backbends, and seated postures similar to that of
suryanamaskaras compared to control group which followed standard treatment for IBS.26This showed in the current study after
practicing suryanamaskara there was a significant reduction in total symptoms in intervention group compared to control group.

In a recent single-arm pilot study of yoga for 20 children ages 8 to 18 years with IBS or functional abdominal pain (FAP),
improvement in abdominal pain including worst pain, constipation, and nausea were noted.25In the present study there is reduction in
abdominal symptoms post data compared to pre data within intervention group(p=0.0001) with statistically significant reduction in
control group (p=0.3158).The results contribute to the literature showing a reduction in abdominal symptoms in constipation such as
stomach cramps, abdominal pain, discomfort in abdomen and bloating . Our results are also consistent with previous research
supporting the use of yoga to improve IBS, similarly in this current study even suryanamaskaras proved to reduce the abdominal
symptoms.

In the current study the rectal symptoms including rectal burning during and after a bowel movement, rectal bleeding and
tearing during or after a bowel movement showed a significant reduction in post compared to pre within intervention group
(p=0.0001) and in control group there was a decrease in rectal symptoms but not statistically significant.

In study done by Murali Krishnan on isha yoga which included suryanamaskara proved increased parasympathetic dominance
in test group compared to control group (p<0.01). 27 Sympathetic dominances can cause increase in rectal burning in which
parasympathetic signals tend to intensify the peristaltic waves and relax the internal anal sphincter, thus converting the intrinsic
myenteric defecation reflex from a weak effort into a powerful process of defecation that is effective in emptying the larger bowel all
the way from splenic flexure of the colon to anus28 this may have reduced the rectal symptoms in the current study.

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To measure quality of life in constipation patients PAC-QOL was used. Present study showed a significant improvement in
the intervention group (p=0.0001) and there was an improvement in total quality of life scores in control group also(p=0.0230) but not
so significant this may be because of the control group continued to do physical activates which might have resulted in improvement
in their quality of life. a similar study done on iyengar yoga and IBS had seen improvement in health related quality of life in IBS
patients (p =0.03).26

In quality of life related physical discomfort scores which included bloating to the point of bursting ,sense of heaviness and
urge to open bowel showed there is a significant decrease in physical discomfort scores in post compared to pre within intervention
group (p=0.0001) this could be due to contraction of abdominal muscle during suryanamaskara practice force the fecal contents of
colon downwards and at the same time causes the pelvic floor to relax downward and pulling outward on anal ring to evacuate the
feaces, in current study which may have decreased the feeling of heaviness and bloating, in a similar study done by Subhadra Evans et
al showed significance decrease in physical discomfort where Child Somatization Inventory (CSI) (1821)was used in which Items from
the abdominal symptoms subscale include abdominal pain, nausea, constipation, feeling bloated, heaviness .26

In quality of life related psychosocial discomfort scores showed there is a significant decrease in psychosocial discomfort
scores in post compared to pre within intervention group (p=0.0001), and also there is an increase in psychological discomfort scores
in control group (p=0.0540) but not so significant than intervention group. The practice of suryanamaskara improved the overall
wellbeing in patients Studies have shown that the practice of yoga reduces perceived stress and negative feelings, and that it improves
psychological symptoms by lowering the levels of anxiety and anger, in both adults and children.29

Similar to above results quality of life related Worries and concerns scores showed there is a significant decrease in Worries
and concerns scores in post compared to pre within intervention group (p=0.0001), and also there is an increase in Worries and
concerns scores in control group (p=0.0103) this may be due to lack of any type of intervention in the control group caused the
increase in worries and concerns.

In quality of life related satisfaction scores showed there is a significant increase in satisfaction scores in post compared to pre
within intervention group (p=0.0001) and decrease in satisfaction scores in control group (p=0.0540).This showed that after the
practice of suryanamaskara patients were satisfied by the treatment, regularity and how often they have bowel movement, with this
valid data it can be proven that suryanamaskara can be given as an adjacent treatment in treating constipation.

Strengths of the study

No documented adverse effects.
Subjects did not face any problems during intervention or while collecting data.
All the procedures were done in Ideal conditions.
Qualitative results were collected, without any faults.
No drop outs.

LIMITATIONS
An objective variable could have been added.
As the compliance to practice was self -reported it could have been over reported
Study could have been metacentric.
Study can be done with larger sample to generalize the study outcomes to a larger population.
Measures of bowel transit time and diet intervention are missing.
Duration of Intervention could have been longer.
No follow up assessments done to understand the long term benefits.
Assessments were limited to constipation symptoms and constipation related quality of life.

Directions for future research

Future studies must have objective variables to augment the reported benefits of this study.
Study can be done with larger sample to generalize the study outcomes to a larger population.

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CONCLUSION
The findings of the study suggest possible application of suryanamaskara as effective management in reducing rectal
symptoms, stool symptoms, abdominal symptoms and improving the quality of life in chronic constipation in intervention group as
compared to the control group.

suryanamaskara in patients suffering from constipation is a simple and feasible non pharmacological intervention to relieve
the symptoms and improve the quality of life however further studies may be required to standardize and establish possible
mechanisms behind these effects, hence with the present findings, suryanamaskara can be effectively employed in patients with
constipation.

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