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Contents lists available at ScienceDirect

Journal of Ayurveda and Integrative Medicine

journal homepage: http://elsevier.com/locate/jaim

Review Article

Health and therapeutic benefits of Shatkarma: A narrative review of

scientific studies
P.S. Swathi*, B.R. Raghavendra, Apar Avinash Saoji
Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), 19, Eknath Bhavan, Gavipuram Circle, KG Nagar,
Bengaluru, 560019, India

a r t i c l e i n f o a b s t r a c t

Article history: Shatkarma, also known as Shatkriya are a set of six yogic cleansing techniques described in the Hatha
Received 7 May 2020 Yoga texts. Several health benefits of these procedures are indicated in the traditional texts of Yoga.
Received in revised form However, there is no comprehensive literature about the scientific evidence on Shatkriya. Hence, we
20 October 2020
searched in PubMed, PubMed Central and Google Scholar databases to review relevant articles in English.
Accepted 24 November 2020
Available online xxx
The search yielded a total 723 references, published from 1976 to April 2020. Based on the inclusion and
exclusion criteria, 37 articles were included in this review. We found scientific studies on four out of six
cleansing techniques. The limited evidence on Shatkriya suggests positive effects on various physiological
Keywords:
Shatkarma
and clinical domains. The practice of dhauti was found to enhance respiratory functions and was useful in
Shatkriya digestive disorders. Nasal cleansing, neti was particularly found beneficial in managing the rhinosinusitis
Yoga in age groups ranging from children to adults. Although trataka practice was found to enhance cognition
Yogic cleansing technique and bring a state of relaxation, but there was no evidence supporting its role in eye disorders. Kapalabhati
Physiological effects practice appears to have a beneficial role in the activation of sympathetic nervous system, enhance
cognition, and improve overall metabolism. Further large-scale clinical trials with robust designs are
warranted to evaluate the effects of Shatkriya in health and disease.
© 2020 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences
and Technology and World Ayurveda Foundation. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction the subject matter. Thus, the current review was undertaken to
summarize the scientific evidence on the physiological and thera-
Cleansing practices are part of most indegenous health systems, peutic effects of the Shatkriya.
be it Yoga, Naturopathy, Ayurveda, or Chinese Medicine. In Yoga, six
cleansing practices are described in the Hatha Yoga tradition, which
are known to balance the constitution of an individual. These six
cleansing practices in Yoga are known as Shatkarma or Shatkriya, 1.1. Traditional references for Shatkriya
which are said to promote health and well-being by purifying the
whole body. Hatha Yoga Pradipika (ch: 2, v. 21 and 22) of Swat- There are four major texts of Hatha Yoga tradition viz. Hatha
marama recommends the practice Shatkriya prior to practice of Yoga Pradipika, Gheranda Samhita, Shiva Samhita and Hathar-
pranayama (yogic breath regulation). The Shatkriya techniques atnavali. Among them Gheranda samhita and Hatha Yoga Pradipika
include dhauti (internal cleansing), basti (yogic enema), neti (nasal describe the purification of the body, with reference to six variants
cleansing), trataka (concentrated gazing), nauli (abdominal of the cleansing procedures [1,2]. Gheranda Samhita has an elabo-
massaging) and kapalabhati (frontal sinus cleansing) [1]. Although rate description of the sub-types and benefits of the Shatkriya.
several health benefits of Shatkriya are narrated in HathaYoga texts, Hatharatnavali, which is the latest among the Hatha Yoga texts,
there is a lack of comprehensive literature on scientific studies in narrates eight variants of cleansing techniques [3]. However, the six
cleansing techniques described in the Hatha Yoga Pradipika of
Swami Swatmarama are most popular among the Yoga practi-
* Corresponding author.
tioners. The main objective of Shatkriya is to balance the three
E-mail: swathisanketh@gmail.com (P.S. Swathi). humours (tridosha) in the body, mucus (kapha), bile (pitta) and
Peer review under responsibility of Transdisciplinary University, Bangalore. wind (vata) [1].

https://doi.org/10.1016/j.jaim.2020.11.008
0975-9476/© 2020 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences and Technology and World Ayurveda Foundation. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: P.S. Swathi, B.R. Raghavendra and A.A. Saoji, Health and therapeutic benefits of Shatkarma: A narrative review of
scientific studies, J Ayurveda Integr Med, https://doi.org/10.1016/j.jaim.2020.11.008
P.S. Swathi, B.R. Raghavendra and A.A. Saoji Journal of Ayurveda and Integrative Medicine xxx (xxxx) xxx

Though there are a few similarities in the cleansing procedures intervention once in a week for 4 weeks demonstrated better scores
described in Yoga and Ayurveda (such as basti and vamana dhauti), in the Cleveland clinic constipation scale. The control group
the yogic cleansing methods are unique for multiple reasons. The showed no significant change during the follow-up period [6].
yogic cleansing is done by the practitioner himself under the
guidance of Yoga teacher and without administration of any 3.1.3. Effect of dhauti in chronic low back pain
medicine. A self as controlled study was conducted in 40 in-patients,
randomly assigned to receive laghu shankha prakshalana and back
2. Methodology pain yogic special technique on specific days. Assessments were
performed before and immediately after the sessions. Pain and
A comprehensive literature search in PubMed, PubMed Central, disability were assessed using Oswestry disability index, state
and Google Scholar databases was carried out for the keywords anxiety using the state subscale of Spieldberger’s state and trait
“shatkriya, shatkarma, dhauti. yogic stomach wash, basti, yogic anxiety inventory, spinal flexibility, and straight leg raising tests
enema, neti, yogic nasal cleansing, nasal irrigation, trataka, yogic using Leighton type goniometer and caliper type goniometer
visual concentration, nauli, yogic abdominal massage, kapalabhati, respectively. Both Yoga sessions were found to beneficial to the
yogic frontal sinus cleansing, high frequency Yoga breathing”. The patients, but the magnitude of change was higher following the
search yielded a total number of 665 references from the year 1976 laghu shankha prakshalana session. Thus, laghu shankha prak-
till April 2020 for the above-mentioned keywords. Experimental shalana practice was found to reduce pain, disability, anxiety, and
and quasi-experimental studies and case reports in English, with help to increase in flexibility [7].
yogic cleansing techniques as an intervention were included in the
review. The studies that had combination of Yoga practices were 3.1.4. A complication of dhauti
excluded. After applying the inclusion and exclusion criteria and Practice of dhauti is generally considered safe when it is done
removing the duplicates, a total of 37 studies were selected for the under the guidance of a teacher. One case study was found to report
final review. The studies are presented based on the cleansing the adverse effect of dhauti during the literature review. A case of
techniques. dental erosion diagnosed using the Tooth Wear Index was reported
by Meshramkar and Patil (2007) which they had attributed to the
3. Summary of scientific evidence on yogic cleansing regular practice of kunjala kriya for 12 years [8].
techniques Thus, from the limited evidence available on dhauti kriya, it was
found useful as a therapeutic modality in the management of res-
3.1. Dhauti piratory and digestive disorders. The practice should be done under
the guidance of a trained teacher, which may help to avoid possible
A literal meaning of dhauti is internal cleansing. Four major complications. Further large-scale clinical trials are required to
forms of dhauti kriya as described in the Gheranda Samhita viz. antar establish the usefulness of dhauti as therapeutic modality. We have
(internal), danta (teeth), hrid (cardiac) and moola shodhana (puri- summarized the studies on dhauti in Table 1.
fication of the anus) [1,2]. The most popular forms of dhauti include
vamana dhauti, also known as kunjala kriya, vastra dhauti and 3.2. Neti (yogic nasal cleansing)
shankha prakshalana. Kunjala kriya includes drinking warm saline
water and voluntarily inducing vomiting to clear the contents of The practice of Neti is advised in Hatha Yoga to clean the nasal
stomach. In vastra dhauti, the practitioner swallows a soft cotton passage. In classical reference of Hatha Yoga Pradipka only sutra neti
cloth of about 2 m length and 4 cm width and removes the same. is explained however in general four variations of Neti practiced,
The practice of shankha prakshalana includes drinking warm saline which includes jala (water), sutra (thread), dugdha (milk), and
water and passing it in the bowels by inducing peristalsis through ghritha (ghee) [1,9]. The most popular forms of Neti practice are jala
certain postures [1]. It aids in reducing ailments of the digestive and sutra neti. In Jala neti, saline warm water is passed from one
system like constipation, biliousness, indigestion, chronic gastritis, nostril to another using a specially designed pot. The classical
reflux acts. It even helps to reduce accessory organ ailments of practice of sutra neti involves inserting a thread in the nostril and
digestive systems like torpid liver, sluggish pancreas, urinary removing it from the mouth. In modern times instead of thread, a
elimination, renal complaints, and dyspeptic condition. Indirectly it sterile catheter is used. Neti removes mucus from nostrils, sinuses
strengthens the heart and respiratory systems like cough, asthma, which helps to allow the air easily without obstruction. This help in
tonsillitis and teeth problems. It even benefits in arthritis, diabetes, reducing allergic rhinitis, tonsillitis and to prevent cough, cold and
and loosening of weight [4]. tension headache due to eye strain.

3.1.1. Effects of dhauti on respiratory system 3.2.1. Use of Neti for rhino-sinusitis
A study was conducted to assess the effect of kunjala kriya on the A study done on 150 subjects with chronic sinusitis assigned
pulmonary functions in healthy volunteers. The authors found the them in 3 treatment groups: nasal irrigation with a bulb syringe or
practice to play a role in enhancing pulmonary functions along with jala neti, or reflexology massage. The follow-up duration was for 2
increased vagal tone. These findings were based on the increase in weeks. All three groups demonstrated improvement in rhinosinu-
slow vital capacity, forced inspiratory volume along with a reduc- sitis outcome measures [10]. More than 70 percent of the partici-
tion in expiratory reserve volume and respiratory rate. The findings pants wanted to continue practicing nasal irrigation even after
also indicate a possible increase in endurance of the respiratory completion of the study. The study also depicted that the im-
muscles, decreased airway resistance, better emptying of lungs, provements in the symptoms were better in male population.
which may play a role in restrictive lung disorders [5]. Smokers in the study did not show improvement in the symptoms.
Sinusitis is a common problem among children. Shoseyov et al.
3.1.2. Effect of dhauti on bowel health (1998) conducted a double blind RCT to illustrate the efficacy of
A recent randomized controlled study done on 60 healthy in- normal water verses jala neti in children with chronic sinusitis. The
dividuals, demonstrated beneficial effects of laghu shankha prak- outcome measures used were cough, nasal secretion and radio-
shalana in bowel health. Thirty volunteers who received the logical assessment tools. They found significant improvements in
2
P.S. Swathi, B.R. Raghavendra and A.A. Saoji Journal of Ayurveda and Integrative Medicine xxx (xxxx) xxx

Table 1
Evidence summary on Dhauti.

Author Sample size Study type and Duration of Variables studied Findings
Intervention

Kiran et al., 2019 [6] 60 (Experimental ¼ 30, RCT Cleveland Clinic Constipation Four sessions of laghu shanka
Control ¼ 30) Once a week for 4 weeks for study Score prakshalana reduced constipation
group & control group did not score
receive intervention
Balakrishnan et al., 2018 [5] 18 (Experienced ¼ 9, Comparative Study between Slow & forced vital capacity, Improved respiratory functions
naïve ¼ 9) naïve and experienced Inspiratory & expiratory reserve were observed after Kunjal kriya
practitioners. volume, Respiratory rate & tidal practice.
Single session volume
Haldavenkar et al., 2014 [7] 40 Self as control study Pain & disability, state anxiety, A single session of Laghu shanka
Single sessions of laghu shanka spine flexibility and straight leg prakshalana was found better
prakshalana and back pain raising than back pain specific yoga
specific yoga techniques were session in reducing disability,
compared after 3 days of training anxiety & improved spine
flexibility in patients with chronic
low back
Meshramkar et al., 2007 [8] 1 Single case report Tooth wear index of Smith & The regular practice of kunjal
Knight kriya for a prolonged time led to
dental erosion

four-weeks in the group which used jala neti, when compared to involving 107 nasopharyngeal carcinoma patients after irradiation.
normal saline. The effects were sustained for a follow-up period of The follow-up duration for the study was six months [18].
one month after the conclusion of the trial [11].
A case series was conducted to report effects of jala neti in 10 3.2.3. Complication of Sutra neti
cases of sinusitis among children (age range: 3e9 years). The au- There was a case of 67 year old man presenting with change of
thors found improvement in the disease-related Quality of life and voice, loss of sensation of smell, nose blockage and mouth
in symptom management [12]. breathing after regular practice of Sutra neti. He had to undergo a
An early study assessed the inflammatory markers in thirty controlled ablation for release of the nostrils. The investigators
symptomatic patients with active perennial allergic rhinitis. The suggested to avoid vigorous practice of sutra neti [19].
three interventions compared were nasal heated water particles at Thus, Neti, being one of the easiest cleansing procedures in Yoga,
43 degrees C for 20 min, heated molecular water vapor at 41
C for plays advantageous role in management of rhino-sinusitis. A case
20 min, and simple jala neti at 39
C solution for 15 min at weekly study also indicates beneficial effect of sutra neti on obstructive
intervals. Nasal washes were done before and immediately after the sleep apnea and snoring. The results indicate that the traditional
treatments, at 30 min, 2 h, 4 h, 6 h. Inflammatory mediators such as explanation from Hatha Yoga Pradipika stating neti can help to cure
histamine, prostaglandin D2, leukotriene C4 concentrations were disease above the throat appear to be supported with scientific
assessed using a competitive radioimmunoassay. Inflammatory evidence. The evidence based effects of neti kriya are summarized
mediators in nasal secretions decreased substantially after jala neti. in Table 2.
It reduced histamine for a period of 6 h, after a single 15 min
treatment, illustrating the beneficial effect of jala neti in reducing 3.3. Trataka (yogic visual concentration)
allergic response and inflammation [13].
A study (SNIFS Trial) assessing the efficacy of self-management The practice of trataka involves concentrated gazing on a small
tools for recurrent sinusitis compared jala neti with steam inhala- object (usually a candle flame). The classical explanation of the
tion. The investigators of the study followed 32 participants for a practice involves gazing at an object without blinking the eyes, till
period of six months. They concluded both interventions were tears roll out. The technique is said to reduce the eye disorders and
acceptable to the patients, but jala neti was found to be effective in to reduce the laziness [1]. The scientific studies on Trataka used
symptom management [14]. A large scale RCT involving 871 par- cognitive functions and vision as their outcome measures.
ticipants indicated that jala neti being better in managing symp-
toms of rhino-sinusitis and being acceptable to participants than 3.3.1. Effect of trataka on attention and cognition
steam inhalation [15]. A self as control study assessed effect of trataka on critical
A randomized control trial with seventy-six subjects followed flicker fusion (CFF). CFF is defined as the frequency at which a
patients with sinusits for a period of six months. The investigators flickering stimulus perceived to be continuous. Thirty subjects
found improved quality of life, reduced symptoms, and need for were recruited for the study who were conditioned for the prac-
medications in patients who performed jala neti daily for six- tice through five sessions on different days before the
months [16]. commencement of assessments. Subjects were assessed individ-
ually for CFF immediately before and after the trataka or control
3.2.2. Neti for post-irradiation rhinosinusitis in nasopharyngeal sessions. The trataka session involved eye exercise followed by
carcinoma gazing at the candle flame whereas control session had only eye
Sinusitis and nasopharyngeal irritation are common following exercise. The CFF was assessed with increasing and decreasing
radiotherapy for nasopharyngeal carcinoma. A five-year follow-up frequencies. The trataka group shown a significant increase in CFF,
study demonstrated that long term nasal irrigation helped in and there was a nonsignificant reduction in CFF following the
improving quality of life (QoL) of patients affected with nasopha- control session [21].
ryngeal carcinoma within a one year of intervention there was a Another study with similar sample size (n ¼ 30) and design
relief in nasal symptoms [17]. Similar observation of improved evaluated the cognitive performance using the adult version of the
quality of life and reduced symptoms were observed in a trial Stroop-color-word test. The results indicated improvement in
3
P.S. Swathi, B.R. Raghavendra and A.A. Saoji Journal of Ayurveda and Integrative Medicine xxx (xxxx) xxx

Table 2
Evidence summary of Neti.

Author Sample size Study type and duration of Variables studied Findings
Intervention

Tiwana et al., 2019 [19] 1 Single case report Nasal endoscopy Vigorous practice of sutra neti
led to velopharyngeal stenosis
requiring surgical intervention.
Leydon et al., 2017 [14] 32 Qualitative semi-structured Medication score, symptom Neti was found better than
interview study checklist steam inhalation in reducing
Six months symptoms of rhinosinusitis.
Little et al., 2016 [15] 871 (Usual care ¼ 210, Nasal RCT Rhinosinusitis Disability Index Neti was found better than
irrigation ¼ 219, Steam Six months (RSDI) steam inhalation in reducing
inhalation ¼ 232, symptoms of rhinosinusitis.
Combined ¼ 210)
Lin et al., 2015 [12] 10 Pre and Post study Sinus & Nasal Quality of Life Neti helped to reduce chronic
Daily for one month of nasal survey, Overall Nasal Quality of nasal symptoms and improved
irrigation Life quality of life
Luo et al., 2014 [17] 1134 (GroupA ¼ Nasal irrigator, Follow up study Sinus & Nasal Quality of Life Long term use of neti helped in
Group B ¼ homemade nasal Five years survey improvement of quality of life
irrigation connector combined in nasal sinusitis patients
with enemator, Group C used
nasal sprayer)
Liang et al., 2008 [18] 107 (Nasal irrigation ¼ 44, Non RCT Questionnaire and radiological The 6 months of follow up study
irrigation ¼ 63) Once daily upto six months of assessment of rhinosinusitis of neti after radiotherapy, neti
nasal irrigation seems to improve the quality of
life and symptoms.
Rabago et al., 2002 [16] 76 (Experimental ¼ 52, RCT Medical outcome survey short Neti helped in reduction of
Control ¼ 24) Daily hypertonic saline nasal form, Rhinosinusitis Disability symptoms and medication,
irrigation upto six months and Index, Single- Item- Sinus even improved in quality of life
control group didn’t receive Symptom Severity assessment in sinusitis patients.
intervention
Heatley et al., 2001 [10] 150 (Nasal irrigation with bulb RCT Rhinosinusitis outcome Neti was found equally effective
syringe ¼ 43, nasal irrigation Each group underwent 2 weeks measures, Daily medication use for the management of
with irrigation pot ¼ 39, & of intervention rhinosinusitis, when compared
reflexology massage ¼ 46) with reflexology massage and
nasal irrigation using bulb
syringe.
Shoseyov et al., 1998 [11] 30 (Hypertonic saline ¼ 15, Randomized double blind study Radiology score & nasal There was significant reduction
Normal saline ¼ 15) Four weeks of hypertonic saline secretion, cough or postnasal in nasal secretions, cough &
and nasal saline drip for rhinosinusitis postnasal drip in hypertonic
solution group than neti group
Georgitis; 1994 [13] 30 Self as control study Nasal secretions - histamine, Neti and large particle water
prostaglandin D2, leukotriene vapour reduced nasal
C4 histamines & leukotriene C4
indicative of reduced nasal
inflammation.
Ramalingam and 1 Single case report Self-assessment of symptoms Practice of sutra neti helped
Smith; 1990 [20] person to reduce snoring and
obstructive sleep apnea

selective attention, response inhibition, cognitive flexibility method and trataka. The investigators reported subjective im-
following trataka session [22]. provements in the vision without any change in objective assess-
A randomized controlled trial done in elderly population evalu- ment tools following both forms of eye exercises [25,26]. Table 3
ated the effect of trataka on cognitive function. There was improve- illustrates the studies on trataka. Although, traditional texts quote
ment in the performance in the cognitive tasks such as digit span, six- trataka can be used to treat eye disorders, but not many studies
letter cancellation test, and tail making test following a 26-day have evaluated the role of trataka in eye disorders. The limited
intervention compared to the baseline. This study indicates a evidence does not support role of trataka in eye disorders, thus
possible role of trataka in preventing cognitive decline in elderly [23]. there is scope for further scientific evaluation in the subject area
The studies also demonstrat enhanced cognitive functions and
3.3.2. Effect of trataka in autonomic functions autonomic relaxation immediately following the practice. Thus,
A study assessed the immediate effect of trataka on heart rate there is a need to explore long term effects of trataka in physio-
variability (HRV) and breathing rate following two sessions on two logical and clinical settings.
different days. The investigators found an increased in vagal tone
following trataka depicted by a decrease in heart rate and breath 3.4. Kapalabhati (yogic frontal brain cleansing)
rate, low frequency component of HRV and increase in high fre-
quency component. No changes were observed following the con- Kapalabhati is a combination of two syllables, kapala means
trol session [24]. forehead and bhati means shining. The practice of kapalabhati
involves breathing out at a rapid pace (~1e2 Hz) by flapping the
3.3.3. Clinical trials on trataka and eye disorders abdomen. Classical texts indicate beneficial role of Kapalabhati in
A study assessing outcomes of ametropia and presbyopia respiratory disorders [1] It is also known as high frequency Yoga
compared the effects of two forms of eye exercises viz. Bates breathing due to the nature of practice. Generally the practice of
4
P.S. Swathi, B.R. Raghavendra and A.A. Saoji Journal of Ayurveda and Integrative Medicine xxx (xxxx) xxx

Table 3
Evidence summary of Trataka.

Author & Year Sample size Study type and duration of Variables studied Findings
Intervention

Tiwari et al., 2018 [26] 48 Comparative study Snellen’s Chart Trataka and eye exercise did not
(Trataka yoga Eight weeks of either trataka or show any significant changes in
kriya ¼ 24, Eye eye exercise group refractive errors
exercise ¼ 24)
Raghavendra and Singh; 30 Self as control study Stroop colour-word test Improvement in selective
2016 [22] After 15 days of orientation attention, cognitive flexibility,
programme in trataka, and response inhibition was
immediate effect of 25 min found following trataka session
assessed for trataka & control
session
Talwadkar et al., 2014 [23] 60 RCT Digit span test, six letter Trataka session in elderly
(Trataka group ¼ 36, One month (26 days) of trataka cancellation test, trail making population shown significant
control group ¼ 24) or control group test increase in cognitive levels
compare to control group
Raghavendra and 30 Self as control study Heart rate variability (HRV) & Trataka group shown decrease
Ramamurthy; 2014 [24] After 15 days of orientation respiration rate in heart rate, breath rate, low
programme in trataka, frequency component of HRV
immediate effect of 25 min and increase in high frequency
assessed for trataka & control component of HRV
session
Gopinathan et al., 2012 [25] 66 RCT Signs and symptoms of Both Trataka and eye exercise
(Eye exercise ¼ 32, Once daily for three weeks of presbyopia, retinoscopy, improve subjective signs and
trataka yoga kriya ¼ 34) eye exercise or trataka autorefractometer, keratometer symptoms, but no change in
both groups on objective
assessments
Mallick and Kulkarni; 2010 30 Self as control study Critical Flicker fusion After the practice of trataka
[21] Five practice session of trataka there was a significant increase
(30 min) introduced before the in critical flicker fusion
immediate assessment. compare to eye exercise group

Kapalabhati is done prior to practice of pranayama (yogic Transcranial doppler was used to assess the cerebral blood flow
breathing practices). Some masters categorize the practice of changes during practice of kapalabhati. There was a reduction noted
kapalabhati as one of the pranayama itself. However, the practice in the end diastolic velocity and mean flow velocity indicating a
is classified as one of the Shatkriya as per the traditional Yoga decrease in cerebral blood flow. Such change could be due to
texts [27]. reduction of partial pressure of CO2 during the practice which in-
volves breathing at a high frequency [42].
3.4.1. Effect of kapalabhati on metabolism An RCT performed on 60 mild to moderate asthma patients
One of the earliest studies on kapalabhati showed a decrease in demonstrated 10 min of practice of kapalabhati can enhance the
blood urea with an increase in creatinine and tyrosine following forced vital capacity, forced expiratory volume in one second and
one minute of practice in twelve healthy subjects. These changes their ratio. These finding indicate a possible role of kapalabhati in
were attributed to a possible promotion of decarboxylation and management of bronchial asthma [43].
oxidation [28].
3.4.3. The complication of kapalabhati
3.4.2. Effect of kapalabhati on respiratory and cardiovascular A case report presented a 29-year-old healthy woman, who
changes developed the spontaneous pneumothorax caused due to extreme
Stancak and colleagues conducted a group of experiments to practice of kapalabhati. The investigators attributed such compli-
determine physiological changes associated with kapalabhati as cation to pushing the practice to physiological extreme limits [44].
early as in 1991. Their experiments demonstrated reduction in Thus, the studies on kapalabhati illustrate the beneficial effects
baroreflex sensitivity and vagal tone, associated with increase in of the technique in enhancing cognitive and respiratory functions
blood pressure and heart rate following kapalabhati. They could and leading to a state of physiological arousal. Such changes can be
also demonstrate slower brain waves in the EEG topography which used in clinical situations such as bronchial asthma. However, one
were attributed to the subjective relaxation in the participants should be careful not to strain while performing the practice of
[29e31]. kapalabhati, which may also lead to complications. The evidence
Series of studies were conducted by Telles et al. on the effects of summary on kapalabhati is summarized in Table 4.
kapalabhati. They found kapalabhati improves cognitive perfor-
mance and attention assessed through event related potentials 3.5. Basti (yogic enema)
[32], associated with decreased anxiety [33]. Similar positive out-
comes were found with motor performance [34] and finger dex- There are two forms of Basti described in Hatha Yoga, jala (wa-
terity [35] and spatial and working memory tasks [36] following ter) and sthala (dry). Both basti practices involve the cleansing of
Kapalabhati. They also observed sympathetic arousal [37,38], and the colon. Swami Swatmarama considers the practice of basti
metabolic activation [39], during kapalabhati however, the practice beneficial for balancing tridosha and dhatus and to purify mind and
does not cause increase in the prefrontal cerebral circulation [40]. senses [1]. According to sage Gherenda, basti reduces the disorders
A study conducted on effect of kapalabhati on cognitive func- of vata and is beneficial in urinary and digestive problems. It is also
tions demonstrated improvements in the cognitive tasks [41]. known to improve digestion [2].
5
P.S. Swathi, B.R. Raghavendra and A.A. Saoji Journal of Ayurveda and Integrative Medicine xxx (xxxx) xxx

Table 4
Evidence summary of Kapalabhati.

Author & Year Sample size Study type and duration of Variables studied Findings
Intervention

Gupta et al., 2019 [36] 15 Repeated measures study Corsi block-tapping task Improvement in memory scores
Single session of 18 min assessed following breath awareness,
for kapalabhati and breath kapalabhati did not show any
awareness on two separate days significant changes
and control group were sitting at
ease
Telles et al., 2019 [33] 61 Repeated measures study Six letter cancelation task & Kapalabhati practice increased
Single session of 18 min assessed Spielberger’s State Trait Anxiety attention with reduction in
for kapalabhati and breath Inventory eS anxiety levels
awareness on two separate days
and control group were sitting at
ease
Nivethitha et al., 2018 [42] 18 Repeated measures study Cerebrovascular haemodynamic During practice of 1 min of
Single session on three- different changes using Transcranial kapalabhati, decreased cerebral
yogic techniques were performed doppler blood flow was noted
for different duration
Raghavendra 60 (Kapalabhati ¼ 30 RCT Pulmonary functions using Practice of kapalabhati enhanced
et al., 2016 [43] and Deep Single session of 10 min for each Spirometry forced vital capacity, forced
breathing ¼ 30) group expiratory volume and thier ratio
in asthma patients
Telles et al., 2016 [40] 40 (Experimental ¼ 20, Two group-controlled trial Haemodynamic changes - Practice of kapalabhati does not
and Control ¼ 20) Single session of 18 min assessed functional near-infrared cause increase in the prefrontal
for kapalabhati and breath spectroscopy cerebral circulation
awareness on two separate days
and control group were sitting at
ease
Telles et al., 2015 [39] 67 (Experimental ¼ 47, RCT Metabolic & ventilatory changes - Metabolic activation was
and Control ¼ 20) Single session of 18 min assessed open circuit oxygen consumption observed after the practice of
for kapalabhati and breath analyser kapalabhati
awareness on two separate days
and control group were sitting at
ease
Telles et al., 2014 [34] 50 Repeated measures study Hand grip strength and Motor Breath awareness and kapalabhati
Single session of 15 min assessed speed improved arm & finger tapping,
for kapalabhati and breath kapalabhati alone enhanced hand
awareness on two separate days grip strength
Balaram; 2013 [41] 36 Repeated measures study Six letter cancellation task and The practice of kapalabhati did
Comparison made between digit letter substitution task not show any significant changes
Single sessions of kapalabhati for in performance in the six-letter
1 and 5-min on two separate days cancellation task and digit letter
substitution task
Telles et al., 2012 [35] 94 (Kapalabhati ¼ 47, RCT Finger Dexterity and Visual Improvement in finger dexterity
breath awareness ¼ 47) Single session of 10 min discrimination and visual discrimination
kapalabhati and breath awareness following kapalabhati when
for same period compared to breath awareness
Telles et al., 2011 [38] 38 Self as Control Study Heart rate variability The practice of kapalabhati shown
Single session of 15 min of a reduction in parasympathetic
kapalabhati and breath awareness modulation and increased
on alternate days sympathetic arousal
Joshi et al., 2009 [32] 30 (Kapalabhati ¼ 15, Comparative study Cognition & attention - P300 Kapalabhati and breath
and breath Single session of 1 min for each event-related potentials awareness, both practices shown
awareness ¼ 15) group improvement in selective
attention assessed through P300
Jhonson et al., 2004 [44] 1 Single case report Chest radiograph The case of spontaneous
pneumothorax was reported after
the practice of kapalabhati
Raghuraj et al., 1998 [37] 12 Self as Control Study Heart rate variability Kapalabhati practice shown an
Single session increase in low frequency power,
LF/HF ratio and a decrease in high
frequency power signifying
increased sympathetic activity
k et al., 1991 [31]
Stanca 17 Pre-Post Study Cardiovascular and respiratory The practice of kapalabhati shown
Single session of 5 min of changes a reduction in baroreflex
kapalabhati sensitivity and vagal tone,
associated with an increase in
blood pressure and heart rate.
k et al., 1991 [30]
Stanca 11 Pre-Post Study Electrical activity of the brain - During the practice of kapalabhati
Single session of 20 min of EEG topography initial 10 min, there was an
kapalabhati increase in alpha and beta waves,
in the last 15 min, there was an
increase in theta waves and
maintained during the resting
period after kapalabhati.

6
P.S. Swathi, B.R. Raghavendra and A.A. Saoji Journal of Ayurveda and Integrative Medicine xxx (xxxx) xxx

Table 4 (continued )

Author & Year Sample size Study type and duration of Variables studied Findings
Intervention
k et al., 1991 [29]
Stanca 24 Pre-Post Study Respiratory and cardiovascular Kapalabhati altered the
Single session of 15 min of rhythmicity’s respiratory frequency and
kapalabhati increased blood pressure
Desai & Gharote; 1990 [28] 12 Details about the design of the Serum urea, creatinine, and There was a significant reduction
study are not available tyrosine in blood urea, increase in
creatinine, and tyrosine following
1 min kapalabhati

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