Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 54  |  Issue : 2  |  Page : 112-118

A review on the physiological and therapeutic effects of Śankhaprakṣhālana kriyā (yogic bowel cleansing)


1 Department of Yoga Science, University of Patanjali, Haridwar, Uttarakhand, India
2 Department of Psychology, University of Patanjali, Haridwar, Uttarakhand, India
3 Yog-Shatkarma Clinic and Research Centre, Patanjali Ayurveda Hospital, Haridwar, Uttarakhand, India

Date of Submission14-Jun-2022
Date of Decision21-Aug-2022
Date of Acceptance22-Aug-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Mr. Jaydeep Negi
Department of Yoga Science, University of Patanjali, Haridwar - 249 405, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ym.ym_75_22

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  Abstract 


Śankhaprakṣhālana (SP) kriyā is an integral component of ṣaṭkarmas (the six cleansing practices of Haṭha Yoga). It involves drinking lukewarm salt water in combination with dynamic yoga āsanas which leads to the cleansing of the entire alimentary canal. The objectives of this study are to systematically elucidate the practice of SP kriyā and to collate and review studies that highlight its immediate and long-term physiological and therapeutic effects. Keywords such as “shankha prakshalana, laghu shankha prakshalana, varisara dhauti, and yogic colon cleansing” were used for search in multiple research databases. A total of 12 studies with SP kriyā as the main intervention were included in this review. Eight studies have reported the immediate effects of SP. The practice of SP immediately benefits in primary hypertension and chronic low back pain. Clinical studies support its effective use as a colonoscopy preparation. There is no risk of electrolyte imbalance, blood pressure, and pulse rate changes in healthy individuals after SP. The technique of drinking saline along with dynamic āsanas plays a significant role in faster bowel cleansing. Other four studies have reported the long-term (1–2 months) effects of SP with variations in the frequency and duration of practice. SP is found beneficial in managing digestive issues such as constipation, migraine-associated abdominal discomfort, and irritable bowel syndrome. It is also an effective weight management practice for obese. Hence, the practice offers diverse health benefits. Further clinical trials are required to support the findings in clinical populations and to determine the effective frequency and total duration of the practice in the long term.

Keywords: Dhauti kriya, Hatha yoga, laghu shankha prakshalana, shankha prakshalana, shatkarma, yogic colon cleansing


How to cite this article:
Negi J, Bhardwaj AK, Kumar S. A review on the physiological and therapeutic effects of Śankhaprakṣhālana kriyā (yogic bowel cleansing). Yoga Mimamsa 2022;54:112-8

How to cite this URL:
Negi J, Bhardwaj AK, Kumar S. A review on the physiological and therapeutic effects of Śankhaprakṣhālana kriyā (yogic bowel cleansing). Yoga Mimamsa [serial online] 2022 [cited 2023 Feb 6];54:112-8. Available from: https://www.ym-kdham.in/text.asp?2022/54/2/112/363813




  Introduction Top


Haṭha Yoga, the most popular branch of modern-day yoga involves various practices of the physical body to achieve the ultimate goal of yoga, i.e., developing an attitude of complete detachment toward all events of life (nirliptaṁ)[1] and re-establishment of the seer in one's own essential nature (drṣtuḥ svarūpe-avasthānam).[2] In Gheraṇḍa Saṁhitā, which is the most elaborative text on Haṭha yogic practices, the foremost essential quality for achieving perfection in Haṭha Yoga is the purification of the body (śodhanam).[1] Six purification practices or ṣaṭkarma, i.e., dhauti (internal body cleansing), basti (yogic enema), neti (nasal cleansing), trāṭaka (focused gazing), nauli (abdominal massaging), and kapālbhāti (frontal head cleansing), have been extensively described for that purpose. The objective of these purification techniques is to balance the tridoṣa in the body, namely vāta (wind), pitta (bile), and kapha (mucus)[3] and prepare the yoga practitioner for higher practices of yoga-like āsana (steady body posture), prāṇāyāma (breath regulation), and dhyāna (meditation).

Vārisāra antar-dhauti (internal body cleansing with water) is one of the most important dhauti practices described in Gheraṇḍa Saṁhitā (1/17-18). This technique is said to be very secret as it purifies the body and bestows a divine body upon perfection.[1] It is commonly known as Śankhaprakṣhālana (SP) kriyā, which comprises two words: śankha, means “conch” representing the coiled and cavernous-shaped intestine and prakṣhālana means “to wash.” The practice of SP involves drinking lukewarm salt water in combination with dynamic yoga postures which leads to complete cleansing of the alimentary canal.

Although numerous health benefits of this practice are mentioned in the contemporary Haṭha Yoga texts, there is a lack of scientific literature based on evidence about this practice. The present review is carried out to systematically review the practice of SP kriyā and the available evidence on the immediate and long-term physiological and therapeutic effects of the practice.


  Review Methodology Top


To search for the published articles on online databases such as PubMed, PubMed Central, Cochrane Library, AYUSH Research Portal, and Google Scholar, the following keywords were used “shankh prakshalana, shankha prakshalana, laghu shankha prakshalana, varisara dhauti, yogic colon cleansing.” The results showed total of 202 references from the year 1980 to 2022. Experimental and quasi-experimental studies with SP or laghu SP kriyā as the primary intervention were included in the review. Studies involving a combination of other yoga practices along with SP kriyā were excluded from the review. A total of 12 studies (eight full-text articles, three abstracts, and one dissertation) were selected for review after the implementation of the inclusion and exclusion criteria and the removal of the duplicates. Authentic yoga books and articles were also referred.


  ŚAnkhaprakṣHāLana Kriyā Technique Top


The main action of SP is to allow a large quantity of water to pass from the mouth to the anus without being absorbed in the digestive tract. To achieve this, there are various ways of performing SP in Hatha Yoga. The most commonly practiced procedure of SP kriyā recommended by Bihar School of Yoga involves drinking 1–2 glasses of lukewarm saline water as quickly as possible, rather than intermittent sipping in full squat position and followed by a sequence of five dynamic āsanas, 8-10 times each: tādāsana (palm tree pose or upward stretch), tiryaka tādāsana (swaying palm tree pose or side stretch), kaṭichakrāsana (waist rotation or twist stretch), tiryaka bhujangāsana (twisting cobra pose or push up stretch) and udarakarṣṇāsana (abdominal stretch pose or squatting stretch). This is repeated 3–5 times until clear bowel movements start in the toilet. After completion, proper rest is taken in śavāsana (corpse pose).[1] To enhance the cleansing experience, Arya et al. have also introduced the concept of mindful bowel cleansing, in which a person is instructed to focus on the body, deep breathing, and contemplate on purification of the body while performing SP kriya.[4]

Based on the intensity of cleansing, there are two versions of SP kriyā: pūrṇa (complete) SP and laghu (short) SP (LSP) kriyā, both having a similar procedure. The pūrṇa SP involves a greater amount of solution intake and more sets of yoga poses. It demands strict precautions before, during, and after the practice related to diet, sleep, rest, exercise, and climate on the day of practice; and is generally recommended only twice a year due to its rigorous cleansing effect. However, the shorter version of SP does not require much time, precautions, and physical strain, and is mainly meant for encouraging the normal functioning of bowels. It is generally recommended once a week but it can be practiced daily in special cases.[5]

In all of the studies reviewed, LSP was practiced. Only two studies[6],[7] strictly followed the rules of LSP, i.e., performing only 3–4 cycles of āsanas and drinking only 6–8 glasses of water.[5] In other studies, the cycle of drinking water and āsanas were performed until bowel movements were clear.

Frequency and total duration of intervention

There are variations in the frequency and total duration of LSP in the reviewed studies. In two studies, LSP has been performed once a week for 1[7] and 2[8] months, respectively. Other studies have included – three sessions of LSP within a gap of 10 days;[9] two sessions of SP within a gap of 2 days;[10] SP within a gap of 5 days, then 4 SP once a week;[11] five sessions of SP within a gap of 10 days;[11] and SP within a gap of 2 days for 3 weeks.[11] Seven studies have included only one session of LSP.[4],[6],[12],[13],[14],[15],[16]

Use of different additives in water preparation

For the purpose of general cleansing, lukewarm (99°F–102°F) saltwater (0.9%–1% sodium chloride solution) is ideal and should be used.[6],[15] There are a few other solutions as well, like pure cold water, water and hīng (Ferula asafoetida Linn), water and garlic essence, water and onion essence, water and bhānga (Cannabis sativa), water and almond essence, water and lime, etc., mentioned by Swami Satyananda Saraswati.[17] However, the therapeutic use of these additives for SP is yet to be explored. SP with normal water and triphalā water has been successfully used in primary hypertensive patients.[10] Adding a twist of lemon also enhances the palatability of the solution.[4]

Rest period after emptying the bowel

Śavāsana is recommended immediately after emptying the bowel to relax the increased peristaltic movements and restores the balance in the whole body.[1] The period of rest varies in the studies reviewed. Of the nine studies, four studies did not mention the duration of rest given to the participants.[4],[8],[9],[15] In three studies, rest duration ranged from 5 to 45 min,[7],[14],[11] and in another two studies, a guided deep relaxation technique was practiced for 15 min.[6],[10]

Therapeutic benefits

Stimulation and washing of the whole alimentary canal relieve digestion-related issues such as acidity, flatulence, indigestion, and constipation.[17] Malshe (2018) hypothesized that SP washes out the sludge if formed in the gall bladder which may prevent the formation of gall bladder stones.[18] It also aids in dispelling intestinal worms from the gut.[18] SP is an essential prescription in yoga therapy protocols for various metabolic disorders such as diabetes mellitus, hypoglycemia, obesity, hypothyroidism, and various skin problems such as pimples, boils, and eczema.[5] A clean and healthy gut also leads to a calm and balanced mental state.[17]

Summary of studies on the immediate effects of Śankhaprakṣhālana kriyā

Effect of Śankhaprakṣhālana kriyā on physiological parameters

Four studies have assessed the immediate effects of SP on various physiological parameters. Kumar and Kulshrestha (2011) reported no significant immediate effect on body weight, temperature, pulse rate, and blood pressure (BP) following a session of SP.[14] Since SP involves drinking saline water (1.5–3 L) and it is a major concern that a high intake of sodium chloride might cause an electrolyte imbalance in the body. To explore this concern, a total intestinal perfusion study conducted by Arya et al. showed that the average salt intake was 18 g (range 13.5–22.5) with a total solution intake of 2 L (range 1.5–2.5). Sodium absorption was 30.9% (2.29 g) with a range of 3.5%–60.6%. None of the serum electrolyte values were found clinically significant.[13] In another study, Arya et al. found a significant increase in serum sodium and chloride levels and a significant decrease in bicarbonate and blood urea nitrogen immediately after SP. However, all these electrolyte changes were considered clinically insignificant.[4] The study also reported a significant reduction in body weight from baseline values (mean difference = −0.95, standard deviation [SD] = 3.14) in contrast to the study of Kumar and Kulshrestha (2010). Differences in weight change immediately after SP depend on the intensity or grade of gastrointestinal tract (GIT) cleansing.[19] Another study by Arya, Gupta and Arya (2010) has also confirmed clinically insignificant blood electrolyte changes in SP.[15]

Role of Śankhaprakṣhālana kriyā in hypertension

Mashyal et al. assessed the safety and immediate effect of SP in 32 patients with mild to moderate primary hypertension. SP with normal water and with triphalā (a mild herbal laxative) was given to the same participants on two different days. The results showed a significant lowering in systolic and diastolic BP and pulse rate immediately following both sessions. The number of visits for bowel clearance during the process was found significantly higher with triphalā water. Although no significant difference was found between both the techniques, the magnitude of reduction (BP and pulse rate) following triphalā water SP was higher. Thus, SP is not only safe for lowering BP in hypertensive patients but is found more beneficial than yogic breathing practices such as alternate nostril yogic breathing and abdominal breathing with biofeedback.[10]

Role of Śankhaprakṣhālana kriyā in chronic lower back pain

Haldavnekar et al. compared the immediate effect of SP kriyā and back pain-specific yoga asanas in 40 patients having mild-to-moderate chronic pain in the lumbar region. Patients were randomly assigned to perform each practice on two different days. Both practices were found beneficial in CLBP, but the changes were significantly higher following SP. SP was found safe and demonstrated a better reduction in pain, disability, and state anxiety, and also showed greater immediate improvements in spinal flexibility (extension, flexion, right and left lateral bending).[6] Long-term carryover effects of LSP in CLBP also need to be assessed.

Use of Śankhaprakṣhālana kriyā as colonoscopy preparation

SP kriyā has been effectively used for cleaning the colon before colonoscopy for clinical diagnostic purposes. Chouhan et al. reported no significant difference in the quality of bowel preparation between SP and polyethylene glycol solution (a commonly used method for colonoscopy preparation); and significantly fewer adverse events associated with SP.[12] Another study by Arya, Gupta and Arya (2010) demonstrated that Shudh™ colon cleanse (SCC), a standardized procedure of SP kriyā produces a significantly better quality of bowel preparation for colonoscopy than a contemporary bowel preparation solution.[15] The finding was further supported by a randomized controlled trial involving 133 patients referred for colonoscopy. The study showed that SCC was not inferior to Half Lytely colon prep (HCP), a contemporary bowel prep solution, in the quality of bowel preparation for colonoscopy. The average bowel preparation time for SCC (1.9 h) was significantly shorter than HCP (10.9 h), which allowed both preparation and procedure of the colonoscopy on the same day in case of SCC. The palatability of the solution and willingness to repeat the process were also rated significantly better for SCC.[4]

Significance of drinking technique and dynamic āsanas

Rapid drinking of saline in bolus form (rather than sipping slowly) along with the dynamic āsanas of SP plays a very significant role in the fast and effective cleaning of the bowels. Arya et al. assessed the effect of drinking lukewarm saline rapidly in bolus form without āsanas and with five dynamic āsanas of SP on the liquid gastric emptying pattern. The ultrasound findings showed that dynamic āsanas did not allow saline to accumulate in the gastric antrum. Drinking the solution rapidly in bolus form leads to fast gastric emptying, which was further enhanced by the dynamic āsanas.[16] In another study, Arya, Gupta and Arya (2010) observed two categories of bolus drinkers during the process of SP: drinkers who consumed 480 ml (n = 15) of saline in 1–2 min had their first bowel movement within an average of 25.8 min (SD = 4.83) and completed the process in an average 87.8 min, and others who consumed 240 ml (n = 12) in <1 min had their first bowel movement within 57.42 min (SD = 21.05) and took more average time 119.17 min to complete the process.[15] The evidence based immediate effects of SP are summarized in [Table 1].
Table 1: Evidence summary on the immediate effects of Śankhaprakṣhālana kriyā

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Summary of studies on the long-term effects (1–2 months) of Śankhaprakṣhālana kriyā

Significance of Śankhaprakṣhālana kriyā in digestive disorders

Regular cleansing of complete GIT helps in the management of various digestive disorders. Divyashree et al. found that administration of three sessions of SP each after 10 days of interval significantly reduces abdominal discomfort and disability caused by migraine and improves gastrointestinal functions and quality of life in migraineurs with abdominal discomfort. When compared to the baseline, 20th day, and 30th day of assessment, the average electrogastrogram recordings demonstrated a shift to normogastria (2 ± 4 cycle/min), which indicated improvement in peristalsis.[9] A randomized controlled study carried out on 60 healthy individuals showed better outcomes on the Cleveland clinic constipation scale following one session of SP once a week for 4 weeks.[7] Thus, the practice of SP once a week is found effective for improving bowel health in healthy individuals. SP has also benefitted in managing the symptoms of Irritable Bowel Syndrome (IBS). Singh et al. reported significant relief in all the symptoms of IBS such as diarrhea, vague abdominal pain, loss of appetite, and vomiting tendency and a significant reduction in the dependency on medicine after the intervention. SP was administered within 5 days of interval, then 4 SPs within 7 days of interval. After that, patients were advised SP weekly or once in 2 weeks as per their need.[11] However, these results need to be validated with proper clinical trials.

Effect of laghu Śankhaprakṣhālana on obesity

Gayathri (2019) reported a significant reduction in the anthropometric measurements (body weight, body mass index, and waist–hip ratio) and lipid profile following the SP kriyā once a week for 8 weeks in 40 obese adults.[8] Further, randomized controlled studies with a large sample need to be undertaken to support these findings.

Use of Śankhaprakṣhālana kriyā as an artificial kidney

In the early articles, Sigdell (1982 and 1984) hypothesized that SP kriyā could be used as an alternative to the artificial kidney.[20],[21] Based on the concept of gastrointestinal dialysis, the author compared SP kriyā with an alternative to the artificial kidney[22] and concluded that both techniques were basically the same. Singh et al. found no significant change in blood urea and creatinine levels in six patients with chronic renal failure following five sessions of SP with an interval of 10 days. However, in two early cases of renal failure, a significant reduction in blood urea level was observed after 3 weeks of SP every 3rd day with 5–6 L of saline.[11] This indicates a possible role of SP in blood purification, in addition to intestinal cleansing. Proper clinical trials are required to support the findings. The evidence based long-term effects of SP are summarized in [Table 2].
Table 2: Evidence summary on the long-term effects of Śankhaprakṣhālana kriyā

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Precautions and adverse effects

Beginners should always practice SP under the guidance of a qualified yoga teacher. Having a light meal or no solid food items the night before performing SP reduces the amount of fecal load and allows easy and fast expulsion of feces. One should also try to avoid eating anything (fasting for 6–8 h) before SP, which clears the small intestine of all nutrients and removes the “ileal break,”[23] thus allowing a large amount of saline to reach the colon without being absorbed from the upper parts of the intestines. Fasting also reduces the chances of vomiting during rapid bolus drinking of saline.[4] Performing āsanas at mild-to-moderate intensity with proper deep inhalation and exhalation helps in faster bowel movement and reduces tiredness during the process.[4] Sitting in a squatting pose in the toilet rather than sitting on a pedestal latrine may also aid in the complete and faster evacuation.[24] Do not force a bowel movement (which otherwise activates the sympathetic nervous system and closes the sphincters more tightly); it should be completely natural.[25] Although there are no special food restrictions or prescriptions following LSP, having a light meal like khicadī (cooked rice and lentil) with ghee after the practice is beneficial.[5] Of all the reviewed studies, only four studies mentioned khicadī as the next immediate meal.[7],[8],[11],[14] The practice involves performing a total of 120–200 dynamic āsanas (3–5 sets, 5 × 8 = 40 āsanas in each set) along with rapid drinking of warm salt water, therefore people having any medical condition must seek guidance from a trained yoga teacher before attempting SP.

In the reviewed studies, no serious adverse effects were reported. A few common adverse events such as mild nausea, vomiting, mild abdominal cramps, mild dizziness, and headache were reported during SP, which were only transient and did not hinder the session.[4],[15]


  Discussion and Conclusion Top


SP kriyā helps in attaining a disease-free clean internal body, which is the foremost requirement in the Haṭha Yoga tradition. We found 12 studies with SP as the main intervention in multiple online databases.

Eight studies have reported the immediate effect of a single session of SP. The studies indicate that there is no significant risk of weight change, fluid absorption or electrolyte imbalance, BP and pulse rate changes in healthy individuals after drinking a large volume of saline (approximately 1.5 to 3 L) in SP due to the fast transit of saline and less time for ionic exchange in the GIT. Voluntary vigorous stimulation and washing of visceral organs, followed by deep relaxation immediately activate the parasympathetic nervous system,[26] which alleviates the increased blood pressure and pulse rate in hypertensive patients. The sequential spinal movements (elongation, twisting, and lateral bending) in dynamic āsanas and complete expulsion of the fecal load from the intestines remove pranic blockages in the abdominal and lumbar regions, which immediately yield better spinal flexibility and pain reduction in CLBP. Three clinical studies have supported the effective use of SP as a colonoscopy preparation. The bolus form of drinking in quick succession and the set of five āsanas are the key practices which lead to faster gastric emptying and bowel movement. The use of different additives in SP water further enhances the cleansing experience (faster cleansing, better palatability of the solution, and safety in the case of hypertensive patients).

Four studies have reported long-term (1–2 months) effects of SP. The frequency and duration of the practice vary in all these studies. The studies reveal that regular practice of SP improves disturbed bowel motility (segmental and peristaltic contractions), irregularities of bowel habits (gastrocolic reflex), and digestive secretions,[27] which helps in the management of digestive issues such as constipation, migraine-associated abdominal discomfort, and IBS. Long-term repeated yoga-based GIT cleansing also enhances the digestive tract sensitivity and interoceptive awareness of the body,[17],[28] thus reducing the chance of overeating and obesity.[29],[30] Along with the fecal matter, SP also washes the bile acid pool to some extent, which reduces the breakdown and absorption of fat for the next few days of SP, resulting in weight reduction.[18] Hypothesis indicating the use of SP as an artificial kidney is yet to be explored with clinical trials. Studies showed that the practice of SP for 1–2 months is safe and does not cause any adverse effects.

From the available evidence, we found that SP not only cleanses the GIT but also brings about a conditioning effect on the autonomic and enteric nervous systems, which then manifests as an improvement in the health of the whole body. This review did not include studies, in which SP kriyā was a part of multicomponent comprehensive yoga therapy. The quality of evidence was also not assessed in this review. Further large-scale clinical trials are required to evaluate the therapeutic effectiveness of SP in clinical populations and to determine its effective frequency and total duration parameters in the long term so that the usefulness of SP kriyā can be established as a therapeutic modality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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