Hypertension case.pptx

Case Presentation
Presented by
Dr. DEVANSHI GOEL
JR 1- MD (Naturopathy)

2
Table of contents
1. Preliminary data
2. Clinical presentation
3. History
4. General physical examination, Vital data
5. Systemic examination
6. CVS examination
7. Investigations
8. Introduction to CVS
9. Hypertension- intro, epidemiology, types etiology, pathophysiology, clinical manifestation,
complications, differential diagnosis
10. Introduction to the cystic lesion
11. Examination of the cervical spine
12. Naturopathy diagnosis
13. Naturopathic understanding of the case
14. Management through yoga and naturopathy

Preliminary data
Name: Mrs. Nisha Goel
Age: 50 years
Sex: female
Address: Shastri Nagar, Meerut
Occupation: Homemaker
Marital status: Married

Clinical Presentation
4
Source of History: Medicine OPD, CSSH, Meerut
Chief complaint: C/o pain in the occipital and parietal area for the past 4 months
K/c/o OA of both knees for the past 10 years
K/c/o Hypertension for the past 7 years

5
History of present illness:
The patient has complained of pain in the parietal and occipital regions for the past four months. Along with
nausea symptoms, pain is linked to anxiety and restlessness. Pain typically starts extremely severe in the
morning and then subsides during the day. Aggravates when seated alone or in a warm environment, and is
eased by taking antihypertensive medications, or simply relaxing in a windy, open area.
History of known cases:
For the past 10 years, the patient had osteoarthritis in both knees.
After a minor RTA (which caused an injury to the Lt knee) 26 years prior, the patient went to the doctor for the
first time complaining of knee pain. She began experiencing knee discomfort after that incident, but it didn't get
any worse until 2014. In 2014, she was diagnosed with OA in both knees, Lt knee > Rt knee. The hip joint, the
calf muscles, or occasionally the ankles are the areas where the discomfort radiates. Long strolls, standing still,
and stair climbing make it worse; a light oil massage and relaxation make it better. The patient is now not taking
any medication and is only relying on precautions.

For the past 7 years, the patient has been a known case of hypertension.
The patient first time visited the doctor with symptoms, which included discomfort in the occipital and parietal areas,
she experienced pain that often started quite severely in the morning and waned progressively over the day associated
with restlessness, anxiety, and nausea and hence got diagnosed with hypertension 7 years ago.
Recently she got diagnosed with Diabetes type 2 mellitus and hyperthyroidism.
History of past illness:
In 2008, the patient was identified as having an intradural extramedullary cystic lesion at C6-C7 (ventral to the cord).
The patient complained of neck pain for four to five months, with more recent pain lasting 15 days, radiating to both
upper limbs and partial loss of sensation on the right side. and received treatment with C5-C6-C7 laminectomy and
excision biopsy.
In 2012, the patient experienced the same symptoms once more. She underwent an MRI, revealing a thin-walled non-
enhancing intradural extramedullary cystic lesion at levels C6-C7 in the anterior spinal canal. and received treatment
with a 6-week course of medication that contained (mecobal od, nucoxia 90, and Dolonex dt)

Medical History
Prolomet XL- 50 mg – AC bf (beta blocker)
Amlodipine 2.5mg – HS (calcium channel blocker)
Atorvastatin 10 mg – OD (HMG co-A reductase inhibitor)
Surgical History
Excision biopsy and laminectomy of C5-C6-
C7 done under GA on 29/08/08
7

Gynecological History
Menarche: 14 years
Menopause: 47 years
Menstrual flow: 2-3 days
Obstetrics History
Gravida: 4
Parity: 4
Abortion: 0
Living: 4
G4 P4 A0 L4
8

Personal History
Diet: Vegetarian
Appetite: decreased
Thirst: decreased (4-5 glasses of water/day)
Micturition: reduced in frequency
Bowel: irregular in motion (sometimes)
Habit: 2 cups of tea/ day
Addiction: Nil
Sleep: Disturbed (due to restlessness)
Allergy: None
Exercise: yoga and exercises of knee
Family History
Father was hypertensive
Mother was hypertensive and diabetic
Sister is hypertensive and has OA of rt. knee
9

General Physical examination
General Condition: well built (overweight)
Pallor: present
Icterus: absent
Clubbing: absent
Cyanosis: absent
Pedal edema: present
Sacral edema: absent
Lymphadenopathy: non-palpable
Gait: Varus
Skin: dry skin
Nails: Cracked nails
Hairs: hair fall
Vital Data
Height: 152 cm
Weight: 62 kg
BMI: 26.8 kg/m2
B.P: 170/110 mmHg
Pulse rate: 98 bpm
RR: 21 cpm
SpO2: 97 %
Temp: Afebrile
10

Systemic Examination
GIT Examination
• Inspection – shape, and umbilicus normal
• Palpation – liver, and spleen normally placed
• Auscultation – normal bowel sounds
• Percussion – normal tympany sound
CNS Examination
• Patient is conscious
• Well-oriented to place, time, person
RS Examination
• Inspection – size, and shape symmetrical
• Palpation – movement of chest normal
• Percussion – resonating note heard
• Auscultation – normal vesicular sounds
heard
11
Douglas, G. et al. (2013) Macleod's clinical examination. 13th edition. Edinburgh: Mosby.
Mehta, J.K. et al. (2016) P.J. Mehta's practical medicine for Students & Practitioners. 21 st. Hari Bhavan, Mumbai:
National Book Depot.

Systemic Examination
CVS Examination • Peripheral examination:
1. JVP
2. Pulse
3. Blood pressure
• Central examination:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
12
Mehta, J.K. et al. (2016) P.J. Mehta's practical medicine for Students & Practitioners. 21 st. Hari Bhavan, Mumbai: National Book Depot.
Douglas, G. et al. (2013) Macleod's clinical examination. 13th edition. Edinburgh: Mosby.

Peripheral examination:
Examination Normal Case findings
1. JVP <4 cm Found at 3 cm
2. Pulse
rate
rhythm
60-100 bpm
Regular
98 bpm
irregular
3. Blood pressure <120/80 mmHg 170/110 mmHg

Inspection:
1. Precordium Normally smooth contoured No significant changes
2. Apex impulse Normally seen in left 5th ICS in mid
clavicular line
Seen in Lt. 5th ICS in anterior axillary
line
3. Other pulsations Normally not seen No significant finding
4. Dilated veins Normally no dilated veins seen over
the chest
No significant finding
5. Scars Normally not present Surgical scar present at the back of
the neck at C5-C8 level

Palpation:
1. Temperature Afebrile No significant changes
2. Tenderness Absent Absent
3. Apex beat Found in 5th ICS in mid clavicular line No significant changes
4. Left parasternal heave Normally absent Absent
5. Diastolic shock Found in pulmonary & aortic area Heard loud in aortic area
6. Thrills Normally absent Absent

Percussion:
Examination Normal Case finding
1. Upper border of heart Dull sound heard in 3rd lt.
ICS in parasternal line
No significant changes
2. Left border of heart Dull sound heard at apex
beat area
3. Right border of heart Dull sound heard in 3rd rt.
ICS in retrosternal line
4. To determine situs Liver dullness heard in rt
side and stomach tympany
at lt. Side

Auscultation:
1. Heart sounds
i. First heart sound (S1)
ii. Second heart sound (S2)
iii. Third heart sound (S3)
iv. Fourth heart sound (S4)
Heard, soft sound (LUB)
Heard as A2, P2 (DUBB)
Can be heard/ not heard
Normally not heard
Heard (loud sound)
A2 heard louder
Not heard
S4 heard, in tricuspid area
2. Murmurs Normally absent No significant finding
A P
E
T M

18
S1 S2 S2
S1 S1 S2 S1 S2
S4 S4 S4 S4
Systole
Systole
Systole Systole
Diastole Diastole Diastole Diastole
Diastole

Investigations
Thyroid Profile
19
Lipid Profile
Complete
Haemogram
HbA1c
Glycosylated
Hemoglobin
Cardio
C- reactive
protein Serum

27
Investigations done in the past

28
Investigations done in the past

Introduction to the cardiovascular system
29

30
Anatomy and Physiology of heart
• The cardiovascular system consists of blood vessels and the
heart. Blood is pumped into blood vessels by the heart.
Blood is transported throughout the body by blood vessels.
• The heart is a muscular organ that circulates blood
throughout the body. It is located, between the two lungs.
There are two atria and two ventricles among its four
chambers. The muscle in the ventricles is thicker than the
muscle in the atrium.
Katz AM. Physiology of the Heart. Lippincott Williams & Wilkins; 2010 Nov 9.

31
• Heart is made up of three layers of tissues:
1. Outer pericardium – The pericardium is the outer covering
of the heart.
2. Middle myocardium – The middle layer of the heart's wall,
known as the myocardium, is made up of cardiac muscle
fibers. The myocardium, which makes up the majority of the
heart, is what causes the heart to beat.
3. Inner endocardium – The heart wall's innermost layer is
known as the endocardium. It is a delicate, shiny membrane
that is thin and smooth.
Torrent-Guasp F, Kocica MJ, Corno AF, Komeda M, Carreras-Costa F, Flotats A, Cosin-Aguillar J, Wen H. Towards a new understanding of the heart structure and
function. European Journal of cardiothoracic surgery. 2005 Feb 1;27(2):191-201.

32
• The human heart has four valves.
1. Atrioventricular valves are the two valves that connect the atria
and ventricles.
2. The semilunar valves are the last two.
• Valves permit only one direction of blood flow through the heart.
• Mitral or bicuspid valves are additional names for the left
atrioventricular valve, two valvular cusps combine to make it.
• Tricuspid valve refers to the right atrioventricular valve, which is
made up of three cusps.
• The aortic valve and the pulmonary valve are semilunar valves.
• These two valves are known as semilunar valves because of their
half-moon shape.
• Three flaps make up semilunar valves.
Hinton RB, Yutzey KE. Heart valve structure and function in development and disease. Annual review of physiology. 2011 Mar 17;73:29-46.

Introduction to Hypertension
33
• According to the World health organization
Hypertension, also known as high or raised blood
pressure, is a condition in which the blood vessels
have persistently raised pressure. Blood is carried
from the heart to all parts of the body in the vessels.
Each time the heart beats, it pumps blood into the
vessels. Blood pressure is created by the force of
blood pushing against the walls of blood vessels
(arteries) as it is pumped by the heart. The higher the
pressure, the harder the heart has to pump.
Hypertension (1996) World Health Organization. World Health Organization. Available at: https://www.who.int/health-topics/hypertension.

Epidemiology
34
• Between 1990 and 2015, the rate of SBP of at least 110 to 115
mmHg increased from 73,119 to 81,373 per 100,000, and SBP
of 140 mmHg or higher increased from 17,307 to 20,526 per
100,000.
• The estimated annual death rate per 100,000 associated with
SBP of at least 110 to 115 mmHg increased from 135.6 to
145.2 and the rate for SBP of 140 mmHg or higher increased
from 97.9 to 106.3.
• The largest numbers of SBP-related deaths were caused by
ischemic heart disease (4.9 million; 54.5%), hemorrhagic
stroke (2.0 million; 58.3%), and ischemic stroke (1.5 million;
50.0%).
• Recent estimates have suggested that the number of patients
with hypertension could increase by 15 to 20%, reaching
close to 1.5 billion by 2025.
Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nature Reviews Nephrology. 2020 Apr;16(4):223-37.

Classification of hypertension according to the American Heart Association
35
Carey RM, Whelton PK, 2017 ACC/AHA Hypertension Guideline Writing Committee*. Prevention, detection, evaluation, and management of high blood pressure in adults:
synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Annals of internal medicine. 2018 Mar 6;168(5):351-8.

Types of hypertension
36
Primary Hypertension Secondary Hypertension
• Primary hypertension also known as essential
hypertension
• About 90-95% of hypertensives have this type.
• Cause of essential hypertension is unknown.
• Genetic or family history present.
• Lifestyle- inactivity, stress, obesity, tobacco, salt,
alcohol, unhealthy dietary habits
• Age- Above 40 usually
• Metabolic disorder
• Secondary hypertension is caused by an identified
cause
• Renal diseases – chronic renal failure,
glomerulonephritis
• Endocrine – hyperthyroidism
• Cardiovascular – constriction of the aorta
• Medications- oral contraceptive pills.
• Obstructive sleep apnea
Rimoldi SF, Scherrer U, Messerli FH. Secondary arterial hypertension: when, who, and how to screen? European heart journal. 2014 May 14;35(19):1245-54.
Vallee A, Safar ME, Blacher J. Essential hypertension: Definitions, hemodynamic, clinical and therapeutic review. Presse Medicale (Paris, France: 1983). 2019 Jan 18;48(1 Pt 1):19-28.

Non Modifiable factors
•Age – Our blood vessels naturally thicken and stiffen
over time. These changes increase the risk of high
blood pressure.
•Gender – Men are more likely than women to develop
high blood pressure throughout middle age. But in older
adults, women are more likely than men to develop
high blood pressure.
•Genetic factor (epigenesis)
•Ethnicity – High blood pressure is more common in
African American and Hispanic adults than in white or
Asian adults.
Modifiable factors
Lifestyle habits can increase the risk of high blood
pressure, including if you:
•Eat unhealthy foods often. This is especially true for
foods with too much sodium and not enough potassium.
•Drink too much alcohol or caffeine.
•Don’t get enough physical activity.
•Smoke or use illegal drugs such as cocaine.
•Don’t get enough good-quality sleep.
•Medications such as – Antidepressants,
decongestants, birth control pills, and (NSAIDs)
Etiology and risk factors
Kuneš J, Zicha J. The interaction of genetic and environmental factors in the etiology of hypertension. Physiological research. 2009;58(Suppl 2):S33-41.

Pathophysiology of hypertension
38
Saxena, T., Ali, A. O., & Saxena, M. (2018). Pathophysiology of essential hypertension: an update. Expert review of cardiovascular therapy, 16(12), 879–887.

Adua E. Decoding the mechanism of hypertension through multiomics profiling. Journal of Human Hypertension. 2022 Nov 3:1-2.

Clinical manifestations of hypertension
•severe headaches
•chest pain
•dizziness
•difficulty breathing
•nausea
•vomiting
•blurred vision or other vision changes
•anxiety
•confusion
•buzzing in the ears
•nosebleeds
•abnormal heart rhythm
40
Hypertension (1996) World Health Organization. Available at: https://www.who.int/health-topics/hypertension.

Complications of hypertension
Hypertensive changes in the heart
• Heart failure
• Stroke
• Left ventricular hypertrophy
Hypertensive changes in the brain
• Cerebral edema
• Hemiplegia
• Stroke
Hypertensive changes in vision
• Hypertensive retinopathy
41
Hypertensive changes in the kidney
• Kidney failure
Harsh Mohan - textbook of pathology, 6th edition (no date) Google Drive. Available at: https://docs.google.com/file/d/0BxvjJ4mG_bfYR3gxeGpRb1RvN3M/edit

Differential diagnosis of hypertension
Essential Hypertension
• Anxiety
• Stress
Secondary Hypertension
• Hyperaldosteronism
• coarctation of the aorta
• renal artery stenosis
• chronic kidney disease
• aortic valve disease
42
Iqbal, A. M., & Jamal, S. F. (2022). Essential Hypertension. In StatPearls. StatPearls Publishing.

Measures for Evaluation and investigation
• Blood workup including complete blood count
• ESR
• HbA1c
• thyroid profile
• blood cholesterol levels
43
Iqbal, A. M., & Jamal, S. F. (2022). Essential Hypertension. In StatPearls. StatPearls Publishing.

Introduction to Cystic lesion
44
• A cyst is a tiny tissue pocket that contains fluid, air, or other things. Cysts may be brought on by heredity,
inflammatory conditions, infections, or other problems. Even though they are typically harmless, complications
may require medical attention.
• The membrane sheath (theca) or dura mater tube that encases the spinal cord and cauda equina is known as the
thecal sac or Dural sac. The cerebrospinal fluid is contained in the thecal sac, which gives the spinal cord
nourishment and buoyancy.

Examination of the cervical neck
• Inspection – Posture
• Movement tests – Cervical AROM
Cervical PROM
Overpressure movements
• Palpation – Temperature
Tenderness
Trigger points
• Neurological assessment –

49
Naturopathy diagnosis
• Facial Diagnosis – Frontal encumbrance present
(central obesity)
• Iris Diagnosis – Sodium ring present in 7th zone
Nerve rings seen
Simon A, Worthen DM, Mitas JA. An evaluation of iridology. Jama. 1979 Sep 28;242(13):1385-9.

Naturopathy understanding
50
• Central obesity – Accumulation of morbid matter
• Raised BP – Lowered vitality
• Cystic lesion present? – Enervation
• Tridosha – Vatta and pitta dominant
• Guna – Rajasik and tamasik dominant
Schoendorfer N, Roytas D. Naturopathic diagnostic techniques. Clinical Naturopathy: An evidence-based guide to practice. 2010 May 4:19.

Aim of naturopathy management
51
• To Maintain Blood pressure
• To maintain weight according to the age
• To relieve anxiety
• To relieve knee discomfort
• To maintain Blood sugar levels and thyroid levels
• To prevent further complications
Schoendorfer N, Roytas D. Naturopathic diagnostic techniques. Clinical Naturopathy: An evidence-based guide to practice. 2010 May 4:19.

Management plan for Hypertension
Massage Hydrotherapy Mud therapy Diet therapy Chromo therapy
Yoga therapy

Manipulative therapy
Title and author Journal and year Intervention Conclusion
Givi M, et al.
Long-term effect of massage
therapy on blood pressure in
prehypertensive women.
Journal of Education and health
promotion
April 2018
A single-blind clinical trial
investigation including 50
prehypertensive women (18 to 60
years old) was done. Three times
a week for 10-15 minutes, the test
group of 25 patients received 10
sessions of Swedish massage on
the face, neck, shoulders, and
upper chest whereas the control
group of 25 patients simply
reclined in the same setting
without receiving any massage.
The results indicated that mean
SBP and DBP in the massage
group were significantly lower in
comparison with the control group
immediately after the intervention
(P < 0.001).

Nelson N. L. (2015). Massage therapy: understanding the mechanisms of action on blood pressure. A scoping review. Journal of the American Society of Hypertension: JASH, 9(10), 785–793.

Hydrotherapy
Joicy MS, et al.
Effect of Neutral Immersion Bath
with Epsom Salt on Hypertensive
Individuals.
Indian Journal of Integrative
Medicine.
2021 Nov
A randomized controlled trial
including 100 hypertensives (30 to
50 years). Group I given NIB with
Epsom salt was given, and Group
II was in supine rest. Subjects
underwent the intervention or
supine rest for about 20 minutes.
According to the study's findings,
NIB with Epsom salt on
hypertensive people results in
lower sympathetic tone and is
useful for evaluating cardio-renal
reflexes and baroreceptor-
mediated regulation of the kidney.
Additionally, when Epsom salt is
added to water, magnesium ions
separate from the salt molecules
to form magnesium ions and
sulfate ions, both of which are
readily absorbed by the skin and
release serotonin.

SNS activity
Neutral immersion bath with Epsom salt
Neutral temp. effect upon CNS
Effect of Epsom salt (MgSO4)
Effect of water
Mg ions Sulfate ions
Absorbed by the skin
Helps in arterial relaxation Serotonin
Vasodilation Reduces anxiety
BP
Blocks nociceptors Activates thermoreceptors
Buoyancy
BP
Activates vagal tone
PNS activity
BP

Mud therapy
Valsakumar, et al.
Immediate effect of cold spinal
mud pack therapy on autonomic
variables in primary hypertensive
individuals: a randomized trial.
Journal of Complementary &
integrative medicine
2021
A randomized controlled trial
including 100 hypertensives (30 to
50 years). Group 1 was given cold
spinal mud packs and Group 2
was given prone rest. After 20 min
of CSMP showed a statistically
significant reduction (p<0.01) in
mean values of Systolic BP,
Diastolic BP, and HRV
According to the study's findings,
CSMP reduces the sympathetic
tone and shifts the sympathovagal
balance in favor of
parasympathetic dominance,
contributing to a decrease in BP
and effective changes in
components of HRV.

58
Cold spinal mud pack
Mud has components like mg, k Relaxes vasoconstriction
Vasodilation SNS activity
PNS activity
Arterial pressure
BP
Gets absorb by skin

Yoga therapy
Wang, Y., et al.
Immediate effect of mind sound
resonance technique (MSRT - a
yoga-based relaxation
technique) on blood pressure,
heart rate, and state anxiety in
individuals with hypertension:
a pilot study.
Journal of complementary and
integrative medicine.
2018
A pilot study recruited 30
hypertensive patients (30-60
yrs). First, 15 participants
received MSRT intervention
on day 1 and SR intervention
on day 2, and later, 15
participants received SR on
day 1 and MSRT on day 2.
All the participants received
4-day MSRT training
sessions prior to the study.
MSRT intervention was found to
be an effective intervention to reduce
blood pressure, HR, and state anxiety
among individuals with HTN.
These findings encourage further
studies with larger sample size

Diet therapy
Title and author Journal and year Conclusion
Basu, A. et al.
Pomegranate juice: a heart-
healthy fruit juice.
Nutrition Review
2009
Based on an analysis of the juices' ability to reduce iron and
scavenge free radicals, pomegranate juice was found to have three
times the antioxidant capacity of red wine and green tea.
Ellagitannins and anthocyanins are the two main antioxidant
polyphenols found in pomegranate juice. Ellagitannins, which are
abundant in the peel, membranes, and piths of the fruit, make up
92% of the antioxidant activity in pomegranate juice.

Increased serum antioxidant capacity
decreased plasma lipids and lipid peroxidation
decreased oxidized-LDL uptake by macrophages
decreased intima-media thickness
enhanced biological actions of nitric oxide
decreased inflammation
decreased angiotensin-converting enzyme activity
and decreased systolic blood pressure.

Chromotherapy
Mahoklory SS, et al.
The Effects of Chromotherapy on
the Stress Level of Patients With
Hypertension.
Journal Berita Ilmu Keperawatan.
2022 Feb
This study used a one-group, pre-
and post-test design with one
control group in a quasi-
experimental setting.
Chromotherapy was administered
to the treatment group, but not to
the control group. The LED lights
used in this investigation are a
mix of green and blue. Five green
and blue light bulbs are positioned
crosswise in each gadget. A 50-
centimeter light transmission
device was used for the
intervention, which was set 210
cm above the participant's body
and left for 15 to 35 minutes.
Green and blue light
chromotherapy has been shown to
be an effective way to stimulate
the pituitary and pineal glands to
produce hormones like serotonin
and endorphin, which maintain
psychological health, balance
mood and feelings, repair
damaged cells, and give the body
the healing energy it needs.
Therefore, this study suggests that
hypertension patients use
chromotherapy to lessen stress
and lower blood pressure.

Magnetotherapy
Li R, et al.
Magnetic stimulation of carotid
sinus as a treatment for
hypertension.
The Clinical Journal of
Hypertension
2019 February
In a randomized, controlled,
cross‐over pilot study, 15 subjects
underwent randomization into
group A and group B. In group A,
participants were then assigned to
start with sham stimulation first.
In group B, participants were
started with 1 Hz stimulation. And
then reversed with treatments.
Magnetic stimulation was given
with magnetic stimulator through
circular coil over carotid sinus.
This study demonstrated that
MSCS treatment activates the
carotid baroreflex and can lower
the blood pressure and heart rate
in prehypertensive and
hypertensive patients.

Acupuncture
Li, J. et al.
The Mechanism of Acupuncture
in Treating Essential
Hypertension: A Narrative
Review.
International journal of
hypertension.
2019
Acupuncture has an antihypertensive effect when used as a
complementary therapy. The neuroendocrine system, RAAS,
vascular endothelium, oxidative stress, and other variables all have a
role in the mechanism of acupuncture for hypertension; there is also
cross-talk between various systems and various targets. The
antihypertensive action also alters the functional images, genes,
metabolism, etc. Acupuncture not only lowers blood pressure but
also protects target organs. Overall, acupuncture may be a useful
technique for managing hypertension based on the mechanistic
studies.

Fasting therapy
Al Attar, et al.
Mechanisms underlying the
effects of caloric restriction on
hypertension.
Biochemical pharmacology
2022 June
This study shows the effect of CR in reducing high blood pressure
by reversing vascular dysfunction is of unique importance,
especially with the absence of complete success of traditional anti-
hypertensive medication in controlling hypertension in some cases.

Yoga for Nerve enervation
Telles S, et al.
Yoga: Can it be integrated with
the treatment of neuropathic
pain?
Annals of neurosciences.
2019
yoga is believed to modulate the action of nitric oxide
release/endothelial function, endogenous endocannabinoids, and
opiates.

Naturopathy
Protocol
Days 9-10 am session 3-4 pm session
Monday Neutral spinal spray Cold hip bath and GH pack
Tuesday Neutral underwater massage Oil application to knee with IRR
Wednesday Full body massage Hot arm and foot bath and cold chest pack
Thursday Neutral immersion bath Mustard pack to knee
Friday Neutral circular jet General oil application with mud eye pack
Saturday Partial massage to hips and legs Full mud bath
Sunday Vibro massage none

Yoga regimen
S. No. Program Duration
1. Opening prayer 2 minutes
2. Sukshma vyayama (Loosening exercises) 6 minutes
Greeva sanchalana (neck movements)
Skandha chakra (shoulder rotation)
Kehuni naman (elbow flexion, extension)
Mushtika bandhana (hand clenching)
Janu naman (knee flexion, extension)
Padanguli naman & Goolf naman (toe & ankle – flexion, extension)
3. Asanas 20 minutes
Standing series Tadasana (mountain pose)
Vrikshasana (tree pose)
Virabhadrasana (warrior pose)
5 minutes
Supine series Utthanapadasana series (elevated legs-up pose)
Shavasana (corpse pose) 5 minutes
Prone series Bhujangasana (cobra pose)
Shalabhasana (locust pose)
Makarasana (crocodile pose)
5 minutes
Sitting series Chair yoga 5 minutes
4. Pranayama 15 minutes
Sheethli, sheetkari 5 minutes
Nadi shodhana 5 minutes
Bhramari 5 minutes
5. Relaxation technique 15 minutes
Deep relaxation technique (DRT)

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