The Newly Enrolled Hypertensive Who Wants Sirsasana
Ravi is 58, an office manager with hypertension diagnosed two years ago, on amlodipine 5 mg. His intake reading was 152/94 mmHg; BMI is 31 and he has been sedentary for a decade. He has joined your six-week beginner wellness batch - three 45-minute sessions a week, eight students, one mat each and four blocks, no wall ropes. He tells you his goals are to lose weight and to learn sirsasana, and that he has watched 'power yoga' videos online. He also mentions mild cervical spondylosis and that he sometimes feels dizzy when he stands up quickly. He has not seen his physician in eight months.
1. Sort Ravi's stated goals into what you will teach in weeks 1–3, what you will defer, and what you will decline outright. Give the reasoning behind each decision.
Read the worked answer
Decline outright (for now)
- Sirsasana and any sustained inversion: head-below-heart positions raise intracranial and intraocular pressure and challenge cerebral autoregulation; with a resting BP of 152/94 this is not a beginner practice. His cervical spondylosis adds a second, independent contraindication to axial loading of the neck.
- 'Power yoga' style continuous flow: sustained high-intensity work with breath-holding and rapid transitions is the pattern most likely to produce a pressure surge in an untrained, hypertensive beginner.
Defer
- Kapalabhati, bhastrika, and any kumbhaka.
- Deep forward folds held long with the head hanging, and any pose that provokes his dizziness.
Teach now
- Slow, held standing poses with support, gentle Surya Namaskara at walking pace with rests, supine and seated work, savasana, simple strength (chair-assisted squats, wall push-ups).
- Slow transitions: his postural dizziness may be amlodipine-related orthostatic drop; cue him to rise in stages and hold a wall.
Reframe the weight goal: yoga alone produces modest weight change. Offer it as one component alongside walking and diet, and say so honestly rather than implying the batch will deliver the outcome.
2. Write the breath-work component of his sessions for weeks 1–3, specifying practices, duration and what you monitor - and justify what you exclude.
Read the worked answer
Structure (5–8 minutes, seated on a chair or with the back to a wall, end of class)
- Minutes 1–2: natural breath awareness, hands on lower ribs; no counting.
- Minutes 3–5: Ujjayi with an extended exhale, roughly 4 in / 6 out, only if the ratio stays comfortable.
- Minutes 6–7: Anulom vilom without retention, equal counts to his comfort.
- Minute 8: 5 rounds bhramari, then silence.
Excluded and why
- Kumbhaka: retention raises intrathoracic pressure and produces swings in venous return and blood pressure; not appropriate while BP is above target and unmonitored.
- Bhastrika/kapalabhati: forceful breathing drives sympathetic activation and can precipitate dizziness, tinnitus or headache in a hypertensive beginner.
- Rapid breathing of any kind, and long breath-holds at the end of exhale.
Monitoring Watch for dizziness, headache, flushing, blurred vision, chest discomfort, or an inability to return to a calm breath within a minute. If any appear, stop the practice, sit quietly, and let him breathe normally. Record the session and the symptom in his file. He should not practice breath-work lying flat immediately after eating, and the room should not be cold or draughty for a beginner.
3. What referral and documentation action do you take before he starts, and what would make you stop a session mid-class?
Read the worked answer
Before he starts
- Send a short clearance letter to his physician: state that he is joining a beginner yoga programme, give the intake BP, list his medications, and ask for a target BP, any exercise restrictions and whether yoga is appropriate now. Note to him (in writing) that coming back with a physician's note is a condition of continuing the vigorous parts of the course.
- Flag the eight-month gap in medical review and the untreated reading as the reason - this is a wellness referral, not a diagnosis.
- Document: signed informed consent, intake including BP and symptoms, the referral letter, and the plan you gave him with the deferrals stated.
Stop the session if
- Chest pain or pressure, severe or sudden headache, blurred or double vision, confusion, fainting or near-fainting, one-sided weakness or slurred speech (emergency response, not a yoga adjustment).
- A repeat reading at or above 180/110, or any reading above the limit his physician sets.
- Marked breathlessness, palpitations that do not settle within a couple of minutes of rest.
After any such event, write a contemporaneous incident note - time, practice, signs, action taken, duration, outcome, who was informed - and do not resume the practice until he has been medically reviewed.