Upload 100 files

subfolder_0/A Cross-National Survey on Health Perceptions and Adopted Lifestyle-Related Behavior during the COVID-19 Pandemic.txt

@@ -0,0 +1,1550 @@
+Original Paper
+Health Perceptions and Adopted Lifestyle Behaviors During the
+COVID-19 Pandemic: Cross-National Survey
+Nandi Krishnamurthy Manjunath1, PhD; Vijaya Majumdar1, PhD; Antonietta Rozzi2, MA; Wang Huiru3, PhD; Avinash
+Mishra4, PhD; Keishin Kimura5; Raghuram Nagarathna1, MD; Hongasandra Ramarao Nagendra1, PhD
+1Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru, India
+2Sarva Yoga International, Sarzana SP, Italy
+3Shanghai Jiao Tong University, Shanghai, China
+4Vivekananda Yoga China, Shanghai, China
+5Japan Yoga Therapy Society, Yonago City, Japan
+Corresponding Author:
+Vijaya Majumdar, PhD
+Swami Vivekananda Yoga Anusandhana Samsthana University
+#19, Eknath Bhavan, Gavipuram Circle
+KG Naga
+Bengaluru, 560019
+India
+Phone: 91 08026995163
+Email: [email protected]
+Abstract
+Background: Social isolation measures are requisites to control viral spread during the COVID-19 pandemic. However, if these
+measures are implemented for a long period of time, they can result in adverse modification of people’s health perceptions and
+lifestyle behaviors.
+Objective: The aim of this cross-national survey was to address the lack of adequate real-time data on the public response to
+changes in lifestyle behavior during the crisis of the COVID-19 pandemic.
+Methods: A cross-national web-based survey was administered using Google Forms during the month of April 2020. The
+settings were China, Japan, Italy, and India. There were two primary outcomes: (1) response to the health scale, defined as
+perceived health status, a combined score of health-related survey items; and (2) adoption of healthy lifestyle choices, defined
+as the engagement of the respondent in any two of three healthy lifestyle choices (healthy eating habits, engagement in physical
+activity or exercise, and reduced substance use). Statistical associations were assessed with linear and logistic regression analyses.
+Results: We received 3371 responses; 1342 were from India (39.8%), 983 from China (29.2%), 669 from Italy (19.8%), and
+377 (11.2%) from Japan. A differential countrywise response was observed toward perceived health status; the highest scores
+were obtained for Indian respondents (9.43, SD 2.43), and the lowest were obtained for Japanese respondents (6.81, SD 3.44).
+Similarly, countrywise differences in the magnitude of the influence of perceptions on health status were observed; perception
+of interpersonal relationships was most pronounced in the comparatively old Italian and Japanese respondents (β=.68 and .60,
+respectively), and the fear response was most pronounced in Chinese respondents (β=.71). Overall, 78.4% of the respondents
+adopted at least two healthy lifestyle choices amid the COVID-19 pandemic. Unlike health status, the influence of perception of
+interpersonal relationships on the adoption of lifestyle choices was not unanimous, and it was absent in the Italian respondents
+(odds ratio 1.93, 95% CI 0.65-5.79). The influence of perceived health status was a significant predictor of lifestyle change across
+all the countries, most prominently by approximately 6-fold in China and Italy.
+Conclusions: The overall consistent positive influence of increased interpersonal relationships on health perceptions and adopted
+lifestyle behaviors during the pandemic is the key real-time finding of the survey. Favorable behavioral changes should be bolstered
+through regular virtual interpersonal interactions, particularly in countries with an overall middle-aged or older population. Further,
+controlling the fear response of the public through counseling could also help improve health perceptions and lifestyle behavior.
+However, the observed human behavior needs to be viewed within the purview of cultural disparities, self-perceptions, demographic
+variances, and the influence of countrywise phase variations of the pandemic. The observations derived from a short lockdown
+period are preliminary, and real insight could only be obtained from a longer follow-up.
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 1
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+(JMIR Form Res 2021;5(6):e23630) doi: 10.2196/23630
+KEYWORDS
+health behavior; self-report; cross-national survey; COVID-19; behavior; perception; lifestyle; nutrition; real-time
+Introduction
+The World Health Organization (WHO) declared the outbreak
+of COVID-19 a pandemic on March 11, 2020 [1]. As of March
+24, 2020, the most affected regions in the world were the
+Western Pacific region (China, the Republic of Korea, Japan,
+etc), with a total of 96,580 reported confirmed cases, and the
+European region (Italy, Spain, Germany, the United Kingdom,
+etc), which accounted for a total of 195,511 positive cases [2].
+There was a global panic due to the shifting of the COVID-19
+epicenters from China to Europe, mainly Italy, which reported
+the worst outcomes up to March 25, 2020 (69,176 reported cases
+and the maximum number of COVID-19 deaths of 6820) [2].
+Global disease outbreaks impact varied aspects of physical and
+mental health, even suicidality [3-5]. As observed in the
+infectious disease epidemic of severe acute respiratory syndrome
+(SARS) in 2003, exposure to new pathogens can manifest as a
+qualitatively distinct mental impact [6]. Social isolation
+measures 
+(large-scale 
+quarantines, 
+long-term 
+home
+confinements, and nationwide lockdowns) [7-11], although
+essential for controlling viral spread, go against the inherent
+human instinct of social relationships [12,13]. If these measures
+are implemented for a long duration, they can be detrimental
+to mental health, as observed in recent reports from China and
+Vietnam [14-17], and they are expected to result in modification
+of people’s lifestyle behaviors, such as increased adoption of
+unhealthy dietary habits and sedentary behavior. These changes
+can exacerbate the burden of the “pandemics” of behavioral and
+cardiovascular diseases that already prevail in modern societies
+[18,19]. The latest trends of re-emergences of such infectious
+disease outbreaks merit timely preparedness involving
+community engagement and focus on healthy lifestyle behaviors
+[20,21]. Although the mental impact of the COVID-19 pandemic
+is being addressed in a timely fashion [22,23], the associated
+real-time influences on people’s health perceptions and lifestyle
+choices remain underresearched [24,25]. Careful consideration
+of the demographic and cultural impact of tailored public health
+intervention strategies on human behavior is also greatly needed
+when designing such strategies. Here, we report the findings of
+a cross-national survey that aimed to generate rapid perspectives
+on the status of health-related perceptions and their influence
+on the likelihood of adoption of healthy lifestyle choices during
+the COVID-19 pandemic. The settings were China and Japan,
+two nations in the Western Pacific region that were greatly
+impacted by COVID-19; Italy, from the European region; and
+India, a highly populous South Asian country that was a
+potential threat region at the time of the survey [2,7-9,11].
+Methods
+Sampling and Data Collection
+Given the restricted mobility restrictions and confinement due
+to 
+the 
+COVID-19 
+lockdown, 
+we 
+conducted 
+a
+cross-sectional survey using a web-based platform. We
+disseminated the survey through the circulation of a Google
+Form via institutional websites and private social media
+networks, such as Facebook and WhatsApp. We also used the
+group email lists of a few social organizations, universities,
+academic institutions, and their interconnections to share the
+questionnaire links, which further facilitated the snowball
+sampling. The respondents were residents of China, Japan, Italy,
+and India who were aged 18 years or older. We anonymized
+the data to preserve and protect confidentiality. The study was
+approved by the institutional review boards and institutional
+ethics committees of the respective nations: Swami Vivekananda
+Yoga Anusandhana Samsthana (SVYASA), India; Sarva Yoga
+International, Italy; Shanghai Jiao Tong University, China; and
+Japan Yoga Therapy Society, Japan. Respondents were informed
+about the objectives of the survey and the anonymity of their
+responses. Informed consent was obtained through a declaration
+of the participants of their voluntary participation, the
+confidentiality of the data, and the use of the collected
+information for research purposes only. The survey period was
+April 3-28, 2020. Once submitted, the responses were directly
+used for the analysis, and revisions of the responses were not
+allowed.
+Questionnaire Structure
+We chose a short format for the questionnaire, with 19 questions
+to facilitate rapid administration. The first set of questions
+(Q1-Q5) were related to the respondents’ demographic details:
+age, gender, country of residence, working status, and the
+presence of any chronic illness or disability diagnosed by a
+physician. The next set (Q6-Q14) contained perception-related
+questions on self-rated physical and mental health, sleep quality,
+coping ability, energy status (a psychological state defined as
+an individual's potential to perform mental and physical activity
+[26,27]), coping flexibility, and perceptions related to
+interpersonal relationships as well as the fear of the pandemic.
+The questions were phrased as statements, with responses
+recorded on 3- or 5-point scales. For example, the respondents
+were requested to self-rate their mental and physical health
+status with the questions “How do you rate your physical health
+at present as” and “How do rate your mental health at present
+as” with answer modalities of (1) excellent, (2) very good, (3)
+good, (4) average, and (5) poor. These single-item self-health
+assessment questions are validated tools used in national surveys
+and epidemiological studies to assess health perceptions among
+individuals, strongly related to various morbidities, and
+mortality, and they have been validated across various ethnicities
+[28-33]. A further set of questions (Q15-Q19) focused on items
+related to the respondents’ recent lifestyle behavior choices:
+eating habits, engagement in physical activity or exercise, and
+substance use. Permitted responses for these behavior-related
+questions were either yes or no. For eating habits, the
+respondents provided self-rated scores for their time of eating;
+nourishment related to intake of vegetables and fibers; and daily
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 2
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+intake of “junk food” (described as packaged and processed
+sweets or salty snacks); the combined scores were dichotomized
+into “good” (score ≥3) and “poor” (score ≤2).
+Data Analysis
+An exploratory factor analysis using the principal axis factoring
+and varimax rotation suggested that three factors were present
+in the data. Items related to health perceptions were used to
+form a scale for perceived health status (the health scale); the
+scores were represented as mean (SD). For the remaining two
+factors, we could not form scales, as they scored Cronbach α
+values <.6; instead, we used the most relevant single item to
+represent the factor. The two primary outcomes of the study
+were the health scale and the adoption of healthy lifestyle
+choices. The health scale was derived as mentioned above;
+further health scale scores were categorized based on tertile
+distribution into low (poor), middle (average), and high (good)
+scores. Adoption of healthy lifestyle choices was defined as the
+engagement of the respondent in any two of three healthy
+lifestyle choices (eating habits, substance use, and exercise).
+Multivariate linear and logistic regression analyses were used
+to test the influence of the perceptions and the personal variables
+on the primary outcomes. Most of the items in the survey were
+recorded as 3-point responses. Hence, to achieve homogeneity
+in the analyses of the survey items, the 5-point Likert responses
+of the self-rated health items, excellent, very good, good,
+average, and poor, were collapsed into three categories: (1) very
+good/excellent, (2) good, and (3) average/poor. Analysis of
+variance was used to assess comparisons between continuous
+variables, and P<.05 was considered significant. Chi-square
+analysis was used for cross-country comparisons for categorical
+variables.
+Results
+The aim of this survey was to understand the cross-national
+psychosocial and behavioral impact of the lockdowns and social
+isolations imposed due to the COVID-19 pandemic. We received
+3370 responses: 1342 from India (39.8%), 983 from China
+(29.2%), 669 from Italy (19.8%), and 377 from Japan (11.2%).
+The demographic profiles of the respondents are presented in
+Table 1.
+Table 1. Countrywise representation of the personal characteristics of the survey participants.
+P valuea
+Italy (n=669)
+Japan (n=377)
+China (n=983)
+India (n=1342)
+Overall (N=3371)
+Variable
+<.001
+48.43 (13.65)
+53.49 (9.35)
+29.77 (11.98)
+29.42 (12.29)
+36.04 (15.54)
+Age (years), mean (SD)
+<.001
+Age group (years), n (%)
+31 (4.7)
+1 (0.3)
+490 (49.8)
+685 (51.0)
+1200 (35.6)
+18-24
+84 (12.5)
+4 (1.1)
+152 (15.5)
+267 (19.9)
+503 (14.9)
+25-34
+309 (46.2)
+217 (57.5)
+314 (32.0)
+330 (24.6)
+1176 (34.9)
+35-54
+169 (25.2)
+98 (26.0)
+21 (2.1)
+40 (3.0)
+330 (9.8)
+55-64
+76 (11.4)
+57 (15.1)
+6 (0.6)
+20 (1.5)
+162 (4.8)
+>65
+<.001
+506 (75.6)
+348 (92.0)
+802 (81.6)
+880 (65.6)
+2535 (75.2)
+Female gender, n (%)
+<.001
+395 (59.0)
+335 (89.0)
+406 (41.3)
+582 (43.4)
+1709 (50.7)
+Working, n (%)
+<.001
+314 (46.9)
+151 (40.0)
+84 (8.5)
+169 (12.6)
+647 (19.2)
+Has a chronic illness, n (%)
+aCross-country comparisons for categorical variables were conducted using chi-square analysis. Analysis of variance was conducted to assess comparisons
+among the continuous variable of age. A P value <.05 was considered significant.
+The mean age of the respondents was 36.04 years (SD 15.54)
+(Table 1); the average age of the Indian and Chinese respondents
+(29.42 years, SD 12.29, and 29.77 years, SD 11.98, respectively)
+was lower than that of the Japanese and Italian respondents
+(53.49 years, SD 9.35, and 48.43 years, SD 3.65, respectively).
+Overall, there was a higher representation of the female gender
+(2535/3371, 75.2%). Japan had the highest representation of
+women (348/377, 92.0%) and working people (335/377, 89.0%)
+(Table 1). Italy and Japan had the highest representations of
+respondents with a known status of chronic illness (314/669,
+46.9%, and 151/377, 40.0%, respectively).
+Table 2 shows the countrywise status of the perceptions of health
+and psychosocial factors reported in response to the ongoing
+outbreak of COVID-19. The health status score was highest for
+Indian respondents (9.43, SD 2.43) and lowest for Japanese
+respondents (6.81, SD 3.44). Overall, 846/3371 (25.1%) of the
+respondents had good health status; Japanese and Chinese
+respondents had the highest representation of low health status
+(236/377, 62.6%, and 562/983, 57.2%, respectively). Sleep
+quality was perceived well by the majority of Indians (917/1342,
+68.3%), and the majority of Japanese and Chinese respondents
+perceived their sleep quality as average/poor (264/377, 70%,
+and 554/983, 56.3%, respectively). Italian respondents had
+almost equal representations of good and average sleep qualities.
+Coping abilities during social isolation were perceived as good
+by 1264/3371 (37.5%) of the overall population, with the
+countrywise trend of India (672/1342, 50.1%) > Italy (283/669,
+42.3%) > Japan (131/377, 34.8%) > China (178/983, 18.1%).
+Fear response was almost equally distributed in positive or
+intermediate categories for most of the country respondents,
+except for Italians, among whom the intermediate or partial fear
+response was the most evident (469/669, 70.1%). Coping
+flexibility responses were very similar across all the countries
+except Japan, wherein the majority of respondents (317/377,
+84.1%) reported experiencing little challenging response to
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 3
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+sudden changes in living norms. Responses to interpersonal
+relationships followed the trend of India (733/1342, 54.6%) >
+Japan (183/377, 48.5%) > Italy (287/669, 42.9%) > China
+(337/983, 34.3%). Adopted lifestyle behavior yielded the trend
+of India (1129/1342, 83.9%) > Italy (361/669, 54.0%) > China
+(436/983, 44.4%) > Japan (137/377, 36.2%).
+Based on the regression analysis on the perceived health status,
+female respondents had a 0.14 lower score compared to male
+respondents (Table 3). Participants with a positive history of
+chronic illness and those who were not working also had lower
+health status scores, by 0.11 and 0.04, respectively, compared
+to their counterparts. Increased personal relationships and
+positive fear response were associated with increases in health
+status across all the countries, particularly Japan, which showed
+the highest value of β (.60). For Indian respondents, an increase
+in age was significantly associated with increase in health status
+by a score of 0.12.
+Increased interpersonal relationships was a significant predictor
+of adoption of health lifestyle choices across the respondents
+in all the countries except for Italy (adjusted OR 1.93, 95% CI
+0.65-5.79) (Table 4). Positive perception of fear was
+significantly associated with likelihood of adoption of healthy
+lifestyle choices only in Indian respondents (adjusted OR 2.41,
+95% CI 1.18-4.96). Perceived health status categories were
+significantly associated with the likelihood of adoption of
+healthy lifestyle choices across all the countries; most
+prominently, high health status increased adoption of healthy
+lifestyle choices by approximately 6-fold in China and Italy.
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 4
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+Table 2. Countrywise representation of perceptions and behavioral changes among the survey respondents related to the COVID-19 outbreak.
+P valuea
+Italy (n=669)
+Japan (n=377)
+China (n=983)
+India (n=1342)
+Overall
+(N=3371)
+Perception or behavior and response
+First factorb
+.01
+8.43 (2.56)
+6.81 (3.44)
+7.09 ( 2.92)
+9.43 (2.43)
+8.26 (3.36)
+Health status, mean (SD)
+150 (22.4)
+69 (18.3)
+71 (7.2)
+556 (41.4)
+846 (25.1)
+High, n (%)
+Medium, n (%)
+225 (33.6)
+72 (19.1)
+350 (35.6)
+413 (30.8)
+1062 (31.5)
+294 (43.9)
+236 (62.6)
+562 (57.2)
+413 (30.8)
+1463 (43.4)
+Low, n (%)
+<.001
+Self-rated physical health, n (%)
+173 (25.9)
+88 (23.3)
+467 (47.5)
+629 (46.9)
+1357 (40.2)
+Excellent/very good
+375 (56.0)
+135 (35.8)
+200 (20.3)
+573 (42.7)
+1283 (38.1)
+Good
+121 (18.1)
+154 (40.8)
+316 (32.1)
+140 (10.4)
+731 (21.7)
+Poor/average
+<.001
+Self-rated mental health, n (%)
+206 (30.8)
+93 (24.7)
+0 (0)
+645 (48.1)
+944 (28.0)
+Excellent/very good
+371 (55.4)
+122 (32.4)
+642 (65.3)
+535 (39.9)
+1670
+(49.5)
+Good
+92 (13.8)
+162 (43.0)
+341 (34.7)
+162 (12.1)
+757 (22.5)
+Poor/average
+<.001
+Self-rated sleep quality, n (%)
+328 (49.0)
+113 (29.9)
+429 (43.6)
+917 (68.3)
+1787 (53.0)
+Good
+240 (35.9)
+234 (62.1)
+477 (48.5)
+354 (26.4)
+1305
+(38.7)
+Average
+101 (15.1)
+30 (8.0)
+77 (7.8)
+71 (5.3)
+279
+(8.3)
+Poor
+<.001
+Self-rated coping abilities, n (%)
+283 (42.3)
+131 (34.8)
+178 (18.1)
+672 (50.1)
+1264 (37.5)
+Good
+298 (44.5)
+139 (36.8)
+516 (52.5)
+539 (40.1)
+1492 (44.3)
+Average
+88 (13.2)
+107 (28.5)
+289 (29.4)
+131 (9.8)
+615 (18.2)
+Poor
+Second factor , n (%)
+<.001
+Fear/anxiety related to COVID-19c
+125 (18.7)
+157 (41.6)
+470 (47.8)
+628 (46.8)
+1380 (40.9)
+Not at all (positive)
+469 (70.1)
+213 (56.5)
+485 (49.3)
+662 (49.3)
+1829 (54.3)
+Partially (intermediate)
+75 (11.2)
+7 (1.9)
+28 (2.8)
+52 (3.9)
+162 (4.8)
+Extremely (negative)
+<.001
+Self-perception of low energy
+261 (39.0)
+239 (63.4)
+282 (28.7)
+667 (49.7)
+1449 (43.0)
+Never
+390 (58.3)
+132 (35.0)
+672 (68.4)
+641 (47.8)
+1835 (54.5)
+Sometimes
+18 (2.7)
+6 (1.6)
+29 (3.0)
+34 (2.5)
+87 (2.6)
+All the time
+<.001
+Challenging response to sudden changes in living norms (coping flexibility)
+144 (21.5)
+44 (11.7)
+221 (22.5)
+436 (32.5)
+845 (25.1)
+Least/not at all/little
+309 (46.2)
+317 (84.1)
+411 (41.8)
+417 (31.1)
+1454 (43.1)
+Little
+216 (32.3)
+16 (4.2)
+351 (35.7)
+489 (36.4)
+1072 (31.8)
+Extremely/somewhat
+Third factor, n (%)
+<.001
+Interpersonal relationshipsc
+287 (42.9)
+183 (48.5)
+337 (34.3)
+733 (54.6)
+1540 (45.7)
+Increased
+310 (46.3)
+179 (47.5)
+550 (56.0)
+533 (39.7)
+1572 (46.6)
+Not changed
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 5
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+P valuea
+Italy (n=669)
+Japan (n=377)
+China (n=983)
+India (n=1342)
+Overall
+(N=3371)
+Perception or behavior and response
+72 (10.8)
+15 (4.0)
+96 (9.8)
+76 (5.7)
+259 (7.7)
+Reduced
+<.001
+Motivating influence of COVID-19 on lifestyle
+221 (33.0)
+132 (35.0)
+217 (22.1)
+605 (45.1)
+1175 (34.8)
+Completely
+360 (53.8)
+223 (59.2)
+695 (70.7)
+641 (47.8)
+1919 (57.0)
+Partially
+88 (13.2)
+22 (5.8)
+71 (7.2)
+96 (7.1)
+277 (8.2)
+Not at all
+<.001
+485 (72.5)
+283 (75.1)
+750 (76.3)
+1126 (83.9)
+2643 (78.4)
+Adoption of ≥2 healthy lifestyle choices
+<.001
+361 (54.0)
+137 (36.3)
+436 (44.4)
+867 (64.6)
+1801 (53.4)
+Adoption of healthy eating behavior
+<.001
+623 (93.1)
+355 (94.1)
+918 (93.4)
+1277 (95.2)
+3173 (94.1)
+Decreased dependency on and use
+of tobacco, alcohol, or any other
+substances
+<.001
+426 (63.7)
+272 (72.1)
+672 (68.4)
+910 (67.8)
+2280 (67.6)
+Increased engagement in exercise
+or similar activities
+aCross-country comparisons for categorical variables were conducted using chi-square analysis; all the P values were significant.
+bAn exploratory factor analysis using principal axis factoring and varimax rotation suggested that there were 3 factors present in the data. The first
+factor consisted of health-related perceptions; composite scores for perceived health were generated as summative scores of the included items.
+cFor the remaining 2 factors, scales could not be formed; rather, the single items that were thought to best summarize the respective factors were
+considered for further association analyses.
+Table 3.  Multivariate linear regression analysis (β coefficients, standard errors, and t and P values) of the association between health status, personal
+variables, and perceptions.
+Italy
+Japan
+China
+India
+Overall
+Predic-
+tors
+P
+t
+SE
+β
+P
+t
+SE
+β
+P
+t
+SE
+β
+P
+t
+SE
+β
+P
+t
+SE
+β
+Demographic variables
+.51
+–0.66
+0.02
+–.07
+0.12
+1.55
+0.02
+.08
+.07
+1.79
+0.01
+.07
+<.001
+3.74
+0.01
+.12
+<.001
+5.12
+0.01
+.14
+Age
+Gender (reference: male)
+.97
+–0.03
+0.52
+<.001
+0.77
+–0.30
+0.64
+.01
+.72
+–0.35
+0.23
+–.01
+<.001
+–3.24
+0.14
+–.09
+<.001
+–7.51
+0.12
+–.14
+Fe-
+male
+Working status (reference: working)
+.72
+–0.36
+0.55
+–.03
+0.48
+–0.71
+0.56
+–.04
+.59
+–0.54
+0.23
+–.02
+.75
+–0.32
+0.15
+–.01
+.04
+–2.04
+0.13
+–.04
+Not
+work-
+ing
+Chronic illness (reference: no)
+.34
+–0.96
+0.47
+–.09
+0.01
+–2.81
+0.35
+–.14
+.04
+–2.04
+0.31
+–.06
+<.001
+–6.12
+0.20
+–.16
+<.001
+–5.63
+0.15
+–.11
+Yes
+Perceptions
+Interpersonal relationships (reference: decreased)
+.03
+2.17
+0.68
+.27
+<.001
+4.86
+0.85
+.60
+<.001
+4.12
+0.31
+.21
+<.001
+6.48
+0.28
+.38
+<.001
+10.76
+0.21
+.37
+In-
+creased
+.12
+1.56
+0.66
+019
+0.01
+2.66
+0.84
+.33
+.28
+1.08
+0.29
+.05
+<.001
+3.71
+0.29
+.21
+<.001
+4.15
+0.21
+.14
+No
+change
+Fear response (reference: poor)
+<.001
+3.03
+1.02
+.50
+0.01
+2.72
+1.38
+.54
+<.001
+8.02
+0.52
+.71
+<.001
+8.69
+0.33
+.59
+<.001
+10.84
+0.30
+.54
+Posi-
+tive
+.08
+1.77
+0.97
+.30
+0.20
+1.30
+1.37
+.26
+<.001
+4.35
+0.51
+.38
+<.001
+5.22
+0.33
+.35
+<.001
+5.82
+0.30
+.29
+Fair
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 6
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+Table 4. Role of perceptions in the adoption of healthy lifestyle choices.
+Italy
+Japan
+China
+India
+Overall
+Perception
+Adjusted OR
+(95% CI)
+OR
+(95% CI)
+Adjusted OR
+(95% CI)
+OR
+(95% CI)
+Adjusted OR
+(95% CI)
+OR
+(95% CI)
+Adjusted OR
+(95% CI)
+OR
+(95% CI)
+AdjustedbOR
+(95% CI)
+ORa
+(95% CI)
+Health status (reference: low)
+6.22
+(1.90- 20.40)
+3.33
+(2.01-
+5.51)
+2.83
+(1.18-6.77)
+3.64
+(1.59-
+8.37)
+5.83
+(2.30-4.79)
+6.02
+(2.38-
+15.20)
+2.62
+(1.75-3.92)
+2.98
+(2.07-
+4.28)
+3.42
+(2.51-4.64)
+3.67
+(2.87-
+4.68)
+High
+2.46
+(1.03-5.83)
+2.10
+(1.42-
+3.12)
+1.06
+(0.54-2.08)
+1.33
+(0.72-
+2.45)
+2.43
+(1.72-3.45)
+2.61
+(1.85-
+3.69)
+1.57
+(1.07-2.31)
+1.76
+(1.24-
+2.50)
+2.00
+(1.59-2.50)
+2.09
+(1.72-
+2.54)
+Medium
+Interpersonal relationshipsc (reference: decreased)
+1.93
+(0.65-5.79)
+1.86
+(1.07-
+3.22)
+5.25
+(1.46-8.92)
+4.43
+(1.49-
+13.15)
+1.77
+(1.03-3.05)
+2.01
+(1.18-
+3.41)
+2.16
+(1.15-4.08)
+1.86
+(1.03-
+3.37)
+2.42
+(1.70-3.45)
+2.21
+(1.64-
+2.98)
+In-
+creased
+1.40
+(0.50-3.96)
+1.59
+(0.93-
+2.73)
+1.88
+(0.54-6.52)
+1.87
+(0.65-
+5.42)
+0.99
+(0.61-1.62)
+1.03
+(0.64-
+1.68)
+1.18
+(0.63-2.21)
+1.09
+(0.60-
+1.97)
+1.18
+(0.84-1.66)
+1.25
+(0.94-1.7)
+Not
+changed
+Fear responsec (reference: poor)
+2.20
+(0.41-11.71)
+1.62
+(0.86-
+3.04)
+4.85
+(0.73-32.19)
+1.84
+(0.34-
+9.99)
+2.18
+(0.96-4.94)
+2.38
+(1.06-
+5.33)
+2.41
+(1.18-4.96)
+2.72
+(1.38-
+5.36)
+2.50
+(1.54-4.05)
+2.43
+(1.69-
+3.50)
+Positive
+1.25
+(0.27-5.80)
+1.34
+(0.80-
+2.27)
+1.97
+(0.31-12.55)
+0.93
+(0.18-
+4.93)
+1.32
+(0.59-2.96)
+1.46
+(0.66-
+3.23)
+1.32
+(0.65-2.65)
+1.37
+(0.71-
+2.65)
+1.33
+(0.83-2.14)
+1.36
+(0.95-
+1.93)
+Fair
+aOR: odds ratio.
+bAdjusted for sex, age, work status, and history of chronic illness.
+cFactor represented by a single item that was thought to best represent the underlying notion.
+Discussion
+The aims of this short cross-national behavioral survey study
+were to generate rapid ideas regarding perspectives on health
+and lifestyle behavior and to provide initial insights into
+designing global but culturally tailored public health policies.
+Health Perceptions: Countrywise Status
+A differential countrywise response was observed toward
+perceived health status across the survey participants; Indians
+had a better representation of high health status (41.4%)
+compared to respondents from other countries (China, 7.2%,
+Japan, 18.2%, and Italy, 22.5%). Despite the inconsistencies in
+health perceptions, there was a consistent influence of social
+support measured by perceptions of interpersonal relationships
+and fear of perceived health status. However, there were
+countrywise differences in the magnitude of the impact of
+perceptions on health status; perception of interpersonal
+relationships was most pronounced in the comparatively older
+Italian and Japanese respondents (β=.68 and .60, respectively)
+and that of fear in the Chinese respondents (β=.71). These
+findings favor the implementation of regularized virtual
+interpersonal interactions toward combating the adverse health
+impact of the pandemic, particularly in countries with a higher
+proportion of older people [34]. Controlling the fear response
+through counseling would also aid the improvement of health
+outcomes in populations affected by pandemics. The findings
+of this survey related to the influence of gender on health
+perceptions (the health status score of female respondents was
+lower by 0.14 units compared to that of male respondents) are
+in line with the global trend of poorer health perception in
+women than in their male counterparts [35]. These real-time
+findings observed during the pandemic also relate with reports
+documented before the COVID-19 pandemic, with a generally
+higher prevalence of adverse mental health symptoms in women
+compared to men [36]. Overall, there seemed to be a differential
+influence of demographic variables on health perceptions across
+the global population during the pandemic.
+The comparatively high scores of the perceived health status in
+Indian respondents could be underlined by an early phase of
+the pandemic with slower progression in India during the survey
+period [11]. The younger age of the Indian respondents (mean
+age 29.42 years, SD 12.29) seemed to further facilitate
+interpersonal relationships (54.6%) during the lockdown, which
+also explains their better health status (β=.38) [34,37]. Younger
+age identity has been associated with well-being and better
+perceptions of health [38]. However, in this survey, an
+unexpectedly positive linear relationship was observed between
+increasing age and better perception of health status (β=.12) in
+young Indian respondents. This finding can be attributed to the
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 7
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+compounding effect of the COVID-19 pandemic on already
+existing emotional distress among young adults (related to their
+examinations, uncertainties, social relationships, etc) [39].
+Unfortunately, in line with previous reports [14,15], we could
+also observe a continued/posttraumatic impact of the pandemic
+in Chinese respondents, reflected in their comparatively low
+perception of health status (poor health status was reported by
+57.2% of these respondents). We believe the poor health
+perceptions in the Chinese respondents is due to the underlying
+influence of fear perceptions (β=.71). Further, since the country
+had successfully emerged from the first wave of the pandemic
+during the survey, and social norms had also almost returned
+to normal, with fewer imposed lockdowns, the moderate increase
+in interpersonal relationships (34.3%) may not be sufficient to
+facilitate health status.
+The observed low status of perceived health in the Japanese
+respondents (low health status, 62.6%) is in accord with a health
+paradox in that country, which is a tendency to perceive health
+poorly despite the advanced economy [40,41]. Although this
+influence is not direct, an indirect influence of the comparatively
+old, middle-aged demographic profile of the Japanese
+respondents along with the mediatory impact of chronic diseases
+on health status (β=–.14) could also underlie the lower health
+perceptions of the Japanese respondents [42]. The perception
+of poor sleep quality in the Japanese respondents also needs
+attention, as this finding is in line with reports of the suicidal
+tendencies in this country [43].
+On a positive note, amid the aggravated pandemic at the time
+of the survey, the majority of the Italian respondents who were
+middle-aged perceived only partial fear of the pandemic (70.1%
+response), and they reported better health perceptions (health
+status score 8.43, SD 2.56) than Japanese respondents (health
+status score 6.81, SD 3.44) and Chinese respondents (health
+status score 7.09, SD 2.92). Approximately 55% of the responses
+for self-rated physical and mental health were in the
+moderate/fair tier, which is in accord with the reported tendency
+of Italian people toward intermediate categories of health
+perception [44]. The lack of negative influence of middle age
+and chronic illness on health perception can be attributed to the
+highly efficient medical care and adequate access to social
+support provided in Italy during the lockdown (improved
+interpersonal relationships were reported by 42.9% of Italian
+respondents).
+Role of Perceptions in the Adoption of Lifestyle
+Choices: Countrywise Comparisons
+Despite the imposed social isolation and home confinement and
+the prevailing fear during the COVID-19 pandemic, we observed
+a positive behavioral response toward lifestyle. Overall, 78.4%
+of the respondents adopted at least 2 healthy lifestyle choices
+during the COVID-19 pandemic. The majority of the
+respondents (67.6%) reported increased engagement in physical
+activity or exercise as opposed to the expected sedentary
+behavior due to home confinement. This favorable although
+unexpected outcome can be attributed to the timely release of
+the advisory recommendations made by various global and
+government agencies, including the WHO, on home-based or
+other easy‐to‐perform exercises under physical restrictions
+[45,46]. One of the crucial affirmative responses observed in
+this survey was the overwhelming response toward substance
+use (94.1%), which is more justifiable by lack of availability
+[47] than motivational influence. Along similar lines, in a recent
+survey on the immediate response to COVID-19, a 3% reduction
+in smoking was reported in Italians, which was attributed to the
+fear of increased risk of respiratory distress or mortality [48].
+To this end, we suggest the implementation of internet-based
+and cost-effective behavioral therapies, particularly cognitive
+behavioral therapy, which may aid the successful alleviation of
+maladaptive coping tendencies, thereby reducing the risk of
+future health catastrophes in the post–COVID-19 era [49,50].
+Social connectedness is an important dimension that controls
+population health and healthy lifestyle behavior [51]. In this
+cross-national survey, perception of increased social support
+and capital, manifested through enhanced interactions among
+close friends and family members (measured as interpersonal
+relationships in the survey), seemed to fill the void of missing
+social connectedness and encouraged the adoption of healthy
+lifestyle choices (adjusted OR 2.42, 95% CI 1.70-3.45). The
+substantial representation of the adoption of healthy lifestyle
+choices in Chinese and Japanese respondents (~75%),
+irrespective of their overall poor health perceptions, could be
+related to reverse causality. In the Japanese respondents (who
+had an older, middle-aged demographic profile), their working
+status (OR 4.37, 95% CI 1.19-16.02) (Table S1, Multimedia
+Appendix 1) and interpersonal relationships (OR for the
+adoption of healthy lifestyle choices 5.25, 95% CI 1.46-18.92)
+also seemed to contribute significantly to the adoption of healthy
+lifestyle behavior.
+The influence of interpersonal relationships on the adoption of
+healthy lifestyle choices was not consistent across different
+countries and was absent in the Italian respondents. However,
+this finding aligns with the previously reported relationship
+between a healthy lifestyle and self-perceived health in the
+European population [52]. Perception of good health was a
+prominent predictor of adoption of a healthy lifestyle (adjusted
+OR 6.22, 95% CI 1.90-20.40) in the middle-aged Italian
+respondents, with a 36.6% proportion of older individuals (>55
+years). Even intermediate scores of health perceptions (health
+status) also significantly predicted the likelihood of the adoption
+of healthy lifestyle choices (OR 2.43, 95% CI 1.72-3.45) in the
+Chinese respondents compared to the respondents from other
+countries, explained by their demographic characteristic of
+younger age. These countrywise differential cultural influences
+of perceptions on health and health behaviors during pandemics
+indicate that endorsement of the same, such as family support
+and togetherness, should consider existing disparities, especially
+for western countries [13].
+The findings of this report, particularly those regarding varied
+health perceptions and their differential influence on the
+likelihood of adopting healthy lifestyle choices, should be
+considered within the purview of the survey period with
+countrywise phase variations of the pandemic. Chinese
+respondents displayed the continued impact of the pandemic,
+as they had already witnessed one phase of the pandemic [2].
+Younger Indian respondents scored better for their health- and
+behavior-related perceptions due to the stable and early phase
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 8
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+of the pandemic (as of April 22, there was a comparatively
+steady expansion of COVID-19 cases in India compared to other
+countries, with 18,985 confirmed cases [11]). However, the
+responses of Japanese and Italian respondents related to their
+older age; these countries were also witnessing rising waves of
+COVID-19 at the time of the survey [7,53]. Japan was under
+an extended state of national emergency, as the number of
+“untraceable” cases was soaring [7]. Italy was also under an
+extended period of lockdown and was one of the hardest-hit
+nations, with an apparent mortality rate of approximately 13%
+[53,54].
+The observed predominantly female participation in the survey
+indicates a lack of stringent sampling but also highlights the
+active involvement of women, who are considered to be at high
+risk of socioeconomic vulnerability toward disease outbreaks
+such as the COVID-19 pandemic. The positive response for
+self-care in women is also a sign of improving gender equity
+toward health awareness. The observed overwhelmingly female
+participation level (75.2%) could not be ascribed to the gender
+representation of countries such as India and China [55] but
+could be ascribed to the high readiness of the female population
+to interactively use the internet, in particular to research
+health-related information and programs, as observed in recent
+reports [56-58].
+The study is limited by the lack of inclusion of perceptions of
+preventive behaviors and did not compare the respondents’
+views on precautionary measures, such as the use of face masks
+[59]. In a recent cross-country comparison between Polish and
+Chinese respondents, higher use of face masks in Chinese
+respondents (Polish respondents, 35.0%; Chinese respondents,
+96.8%; P<.001) was found to be associated with better physical
+and mental impact of the COVID-19 pandemic [59]. Further,
+the observations of the adopted lifestyle choices presented here
+are derived from a short lockdown period during the COVID-19
+pandemic and are preliminary, influenced mostly by
+self-perception; demographic and cultural differences and
+realistic insight could only be obtained from a longer follow-up.
+Due to the self-reported nature of the observations, positive
+behavioral responses toward lifestyle are likely to be inflated.
+Good perceived health was associated with improved
+interpersonal relationships. Older respondents were least likely
+to report a positive relationship change, as observed in the
+responses of Italian and Japanese survey participants. However,
+there was a strong influence of improved interpersonal
+relationships on perceived health as well as adoption of healthy
+lifestyle choices in Japanese respondents. These findings
+indicate the potential of regularized virtual interpersonal
+interactions to attenuate the adverse psychosocial impact of
+such pandemics.
+In conclusion, the key finding of the survey is that the consistent
+positive influence of increased interpersonal relationships and
+good perceptions of health were found to have a significant
+influence on adopted lifestyle behaviors during the adverse time
+course of the COVID-19 pandemic. These favorable behavioral
+perceptions should be bolstered through enhanced health
+awareness, and regularized virtual interpersonal interactions,
+particularly in countries with an overall middle-aged or older
+population. Simultaneously, controlling the fear response
+through counseling would also help improve health outcomes
+in nations affected by pandemics. However, the observed human
+behavior has cultural influences, and it may not be globally
+generalizable.
+Data Availability Statement
+The data that support the findings of this study are available on
+request from the corresponding author.
+Acknowledgments
+The authors gratefully acknowledge the contributions of Dr Ravi Kulkarni and Dr Kousthubha for facilitating the data processing
+and providing technical support for preparing Google Forms, etc. There was no funding source for this study.
+Authors' Contributions
+MNK conceptualized the survey, performed the literature search, collected data from public sources, and contributed to the
+manuscript writing. VM wrote the manuscript and performed the literature search and statistical analyses. NR conceptualized the
+study and revised the manuscript. HR reviewed the manuscript. MNK and VM finalized the manuscript. The corresponding author
+had full access to all the data in the study and had final responsibility for the decision to submit for publication.
+Conflicts of Interest
+None declared.
+Multimedia Appendix 1
+Supplementary table.
+[DOCX File , 20 KB-Multimedia Appendix 1]
+References
+1.
+Listings of WHO’s response to COVID-19. World Health Organization. URL: https://www.who.int/news-room/detail/
+29-06-2020-covidtimeline [accessed 2021-05-10]
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 9
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+2.
+Srivastava N, Baxi P, Ratho R, Saxena S. Global trends in epidemiology of coronavirus disease 2019 (COVID-19). In:
+Saxena S, editor. Coronavirus Disease 2019 (COVID-19). Medical Virology: From Pathogenesis to Disease Control.
+Singapore: Springer; Apr 03, 2020.
+3.
+Leaune E, Samuel M, Oh H, Poulet E, Brunelin J. Suicidal behaviors and ideation during emerging viral disease outbreaks
+before the COVID-19 pandemic: a systematic rapid review. Prev Med 2020 Dec;141:106264 [FREE Full text] [doi:
+10.1016/j.ypmed.2020.106264] [Medline: 33017599]
+4.
+Yip PS, Cheung Y, Chau P, Law Y. The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS)
+and suicide among older adults in Hong Kong. Crisis 2010 Mar;31(2):86-92. [doi: 10.1027/0227-5910/a000015] [Medline:
+20418214]
+5.
+de Berker AO, Rutledge RB, Mathys C, Marshall L, Cross GF, Dolan RJ, et al. Computations of uncertainty mediate acute
+stress responses in humans. Nat Commun 2016 Mar 29;7(1):10996 [FREE Full text] [doi: 10.1038/ncomms10996] [Medline:
+27020312]
+6.
+Zheng W. Mental health and a novel coronavirus (2019-nCoV) in China. J Affect Disord 2020 May 15;269:201-202 [FREE
+Full text] [doi: 10.1016/j.jad.2020.03.041] [Medline: 32339137]
+7.
+Looi M. Covid-19: Japan prepares to extend state of emergency nationwide as "untraceable" cases soar. BMJ 2020 Apr
+16;369:m1543. [doi: 10.1136/bmj.m1543] [Medline: 32299811]
+8.
+Chen J, Lu H, Melino G, Boccia S, Piacentini M, Ricciardi W, et al. COVID-19 infection: the China and Italy perspectives.
+Cell Death Dis 2020 Jun 08;11(6):438 [FREE Full text] [doi: 10.1038/s41419-020-2603-0] [Medline: 32513951]
+9.
+Vaughan A. Italy in lockdown. New Sci 2020 Mar 14;245(3273):7 [FREE Full text] [doi: 10.1016/S0262-4079(20)30520-0]
+[Medline: 32372775]
+10.
+Signorelli C, Scognamiglio T, Odone A. COVID-19 in Italy: impact of containment measures and prevalence estimates of
+infection in the general population. Acta Biomed 2020 Apr 10;91(3-S):175-179 [FREE Full text] [doi:
+10.23750/abm.v91i3-S.9511] [Medline: 32275287]
+11.
+The Lancet. India under COVID-19 lockdown. Lancet 2020 Apr;395(10233):1315. [doi: 10.1016/s0140-6736(20)30938-7]
+12.
+Baumeister RF, Leary MR. The need to belong: desire for interpersonal attachments as a fundamental human motivation.
+Psychol Bull 1995 May;117(3):497-529. [Medline: 7777651]
+13.
+Bavel JJV, Baicker K, Boggio PS, Capraro V, Cichocka A, Cikara M, et al. Using social and behavioural science to support
+COVID-19 pandemic response. Nat Hum Behav 2020 May;4(5):460-471. [doi: 10.1038/s41562-020-0884-z] [Medline:
+32355299]
+14.
+Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the
+initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ
+Res Public Health 2020 Mar 06;17(5):1729 [FREE Full text] [doi: 10.3390/ijerph17051729] [Medline: 32155789]
+15.
+Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, et al. A longitudinal study on the mental health of general population
+during the COVID-19 epidemic in China. Brain Behav Immun 2020 Jul;87:40-48 [FREE Full text] [doi:
+10.1016/j.bbi.2020.04.028] [Medline: 32298802]
+16.
+Le HT, Lai AJX, Sun J, Hoang MT, Vu LG, Pham HQ, et al. Anxiety and depression among people under the nationwide
+partial lockdown in Vietnam. Front Public Health 2020 Oct 29;8:589359 [FREE Full text] [doi: 10.3389/fpubh.2020.589359]
+[Medline: 33194995]
+17.
+Le XTT, Dang AK, Toweh J, Nguyen QN, Le HT, Do TTT, et al. Evaluating the psychological impacts related to COVID-19
+of Vietnamese people under the first nationwide partial lockdown in Vietnam. Front Psychiatry 2020 Sep 2;11:824 [FREE
+Full text] [doi: 10.3389/fpsyt.2020.00824] [Medline: 32982807]
+18.
+Jeste DV, Lee EE, Cacioppo S. Battling the modern behavioral epidemic of loneliness: suggestions for research and
+interventions. JAMA Psychiatry 2020 Jun 01;77(6):553-554. [doi: 10.1001/jamapsychiatry.2020.0027] [Medline: 32129811]
+19.
+Mattioli AV, Ballerini Puviani M, Nasi M, Farinetti A. COVID-19 pandemic: the effects of quarantine on cardiovascular
+risk. Eur J Clin Nutr 2020 Jun 05;74(6):852-855 [FREE Full text] [doi: 10.1038/s41430-020-0646-z] [Medline: 32371988]
+20.
+Mukherjee S. Emerging infectious diseases: epidemiological perspective. Indian J Dermatol 2017;62(5):459-467 [FREE
+Full text] [doi: 10.4103/ijd.IJD_379_17] [Medline: 28979007]
+21.
+Lau JTF, Yang X, Tsui HY, Pang E, Wing YK. Positive mental health-related impacts of the SARS epidemic on the general
+public in Hong Kong and their associations with other negative impacts. J Infect 2006 Aug;53(2):114-124 [FREE Full text]
+[doi: 10.1016/j.jinf.2005.10.019] [Medline: 16343636]
+22.
+Xiang Y, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus
+outbreak is urgently needed. Lancet Psychiatry 2020 Mar;7(3):228-229. [doi: 10.1016/s2215-0366(20)30046-8]
+23.
+Rajkumar RP. COVID-19 and mental health: a review of the existing literature. Asian J Psychiatr 2020 Aug;52:102066
+[FREE Full text] [doi: 10.1016/j.ajp.2020.102066] [Medline: 32302935]
+24.
+Balanzá-Martínez V, Atienza-Carbonell B, Kapczinski F, De Boni RB. Lifestyle behaviours during the COVID-19 - time
+to connect. Acta Psychiatr Scand 2020 May;141(5):399-400 [FREE Full text] [doi: 10.1111/acps.13177] [Medline: 32324252]
+25.
+Tran BX, Ha GH, Nguyen LH, Vu GT, Hoang MT, Le HT, et al. Studies of novel coronavirus disease 19 (COVID-19)
+pandemic: a global analysis of literature. Int J Environ Res Public Health 2020 Jun 08;17(11):4095 [FREE Full text] [doi:
+10.3390/ijerph17114095] [Medline: 32521776]
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 10
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+26.
+Loy BD, Cameron MH, O'Connor PJ. Perceived fatigue and energy are independent unipolar states: supporting evidence.
+Med Hypotheses 2018 Apr;113:46-51 [FREE Full text] [doi: 10.1016/j.mehy.2018.02.014] [Medline: 29523293]
+27.
+Lerdal A. A concept analysis of energy. its meaning in the lives of three individuals with chronic illness. Scand J Caring
+Sci 1998;12(1):3-10. [doi: 10.1080/02839319850163075] [Medline: 9601440]
+28.
+Bowling A. Just one question: if one question works, why ask several? J Epidemiol Community Health 2005 May
+01;59(5):342-345 [FREE Full text] [doi: 10.1136/jech.2004.021204] [Medline: 15831678]
+29.
+Chandola T, Jenkinson C. Validating self-rated health in different ethnic groups. Ethn Health 2000 May;5(2):151-159. [doi:
+10.1080/713667451] [Medline: 10984833]
+30.
+Cislaghi B, Cislaghi C. Self-rated health as a valid indicator for health-equity analyses: evidence from the Italian health
+interview survey. BMC Public Health 2019 May 09;19(1):533 [FREE Full text] [doi: 10.1186/s12889-019-6839-5] [Medline:
+31072306]
+31.
+Cullati S, Mukhopadhyay S, Sieber S, Chakraborty A, Burton-Jeangros C. Is the single self-rated health item reliable in
+India? A construct validity study. BMJ Glob Health 2018 Nov 09;3(6):e000856 [FREE Full text] [doi:
+10.1136/bmjgh-2018-000856] [Medline: 30483411]
+32.
+Baćak V, Ólafsdóttir S. Gender and validity of self-rated health in nineteen European countries. Scand J Public Health
+2017 Aug;45(6):647-653. [doi: 10.1177/1403494817717405] [Medline: 28673121]
+33.
+Park JH, Lee KS. Self-rated health and its determinants in Japan and South Korea. Public Health 2013 Sep;127(9):834-843.
+[doi: 10.1016/j.puhe.2012.12.012] [Medline: 23790805]
+34.
+Goodwin R, Hou WK, Sun S, Ben-Ezra M. Quarantine, distress and interpersonal relationships during COVID-19. Gen
+Psychiatr 2020;33(6):e100385 [FREE Full text] [doi: 10.1136/gpsych-2020-100385] [Medline: 33163857]
+35.
+Boerma T, Hosseinpoor AR, Verdes E, Chatterji S. A global assessment of the gender gap in self-reported health with
+survey data from 59 countries. BMC Public Health 2016 Jul 30;16(1):675 [FREE Full text] [doi: 10.1186/s12889-016-3352-y]
+[Medline: 27475755]
+36.
+Lim GY, Tam WW, Lu Y, Ho CS, Zhang MW, Ho RC. Prevalence of depression in the community from 30 countries
+between 1994 and 2014. Sci Rep 2018 Feb 12;8(1):2861 [FREE Full text] [doi: 10.1038/s41598-018-21243-x] [Medline:
+29434331]
+37.
+Kalish Y, Luria G, Toker S, Westman M. Till stress do us part: on the interplay between perceived stress and communication
+network dynamics. J Appl Psychol 2015 Nov;100(6):1737-1751. [doi: 10.1037/apl0000023] [Medline: 25867166]
+38.
+Benyamini Y, Burns E. Views on aging: older adults' self-perceptions of age and of health. Eur J Ageing 2020
+Dec;17(4):477-487. [doi: 10.1007/s10433-019-00528-8] [Medline: 33381001]
+39.
+Shanahan L, Steinhoff A, Bechtiger L, Murray AL, Nivette A, Hepp U, et al. Emotional distress in young adults during the
+COVID-19 pandemic: evidence of risk and resilience from a longitudinal cohort study. Psychol. Med 2020 Jun 23:1-10.
+[doi: 10.1017/s003329172000241x]
+40.
+Kim M, Khang YH. Why do Japan and South Korea record very low levels of perceived health despite having very high
+life expectancies? Yonsei Med J 2019 Oct;60(10):998-1003 [FREE Full text] [doi: 10.3349/ymj.2019.60.10.998] [Medline:
+31538436]
+41.
+Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus
+(2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci 2020 Apr;74(4):281-282
+[FREE Full text] [doi: 10.1111/pcn.12988] [Medline: 32034840]
+42.
+Park J, Lee K. Self-rated health and its determinants in Japan and South Korea. Public Health 2013 Sep;127(9):834-843.
+[doi: 10.1016/j.puhe.2012.12.012] [Medline: 23790805]
+43.
+Radford MH. Transcultural issues in mood and anxiety disorders: a focus on Japan. CNS Spectr 2004 Jun 07;9(6 Suppl
+4):6-13. [doi: 10.1017/s1092852900025451] [Medline: 15181380]
+44.
+Hardy MA, Acciai F, Reyes AM. How health conditions translate into self-ratings: a comparative study of older adults
+across Europe. J Health Soc Behav 2014 Sep 19;55(3):320-341 [FREE Full text] [doi: 10.1177/0022146514541446]
+[Medline: 25138200]
+45.
+Dwyer MJ, Pasini M, De Dominicis S, Righi E. Physical activity: benefits and challenges during the COVID-19 pandemic.
+Scand J Med Sci Sports 2020 Jul 16;30(7):1291-1294 [FREE Full text] [doi: 10.1111/sms.13710] [Medline: 32542719]
+46.
+Mattioli AV, Ballerini Puviani M, Nasi M, Farinetti A. COVID-19 pandemic: the effects of quarantine on cardiovascular
+risk. Eur J Clin Nutr 2020 Jun 05;74(6):852-855 [FREE Full text] [doi: 10.1038/s41430-020-0646-z] [Medline: 32371988]
+47.
+Gupta R, Hussain A, Misra A. Diabetes and COVID-19: evidence, current status and unanswered research questions. Eur
+J Clin Nutr 2020 Jun 13;74(6):864-870 [FREE Full text] [doi: 10.1038/s41430-020-0652-1] [Medline: 32404898]
+48.
+Di Renzo L, Gualtieri P, Pivari F, Soldati L, Attinà A, Cinelli G, et al. Eating habits and lifestyle changes during COVID-19
+lockdown: an Italian survey. J Transl Med 2020 Jun 08;18(1):229 [FREE Full text] [doi: 10.1186/s12967-020-02399-5]
+[Medline: 32513197]
+49.
+Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of coronavirus disease 2019
+(COVID-19) beyond paranoia and panic. Ann Acad Med Singap 2020 Mar 31;49(3):155-160. [doi:
+10.47102/annals-acadmedsg.202043]
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 11
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+50.
+Zhang MW, Ho RC. Moodle: The cost effective solution for internet cognitive behavioral therapy (I-CBT) interventions.
+THC 2017 Feb 21;25(1):163-165. [doi: 10.3233/thc-161261]
+51.
+Martino J, Pegg J, Frates EP. The connection prescription: using the power of social interactions and the deep desire for
+connectedness to empower health and wellness. Am J Lifestyle Med 2017 Oct 07;11(6):466-475 [FREE Full text] [doi:
+10.1177/1559827615608788] [Medline: 30202372]
+52.
+de Groot LCPMG, Verheijden M, de Henauw S, Schroll M, van Staveren WA, SENECA Investigators. Lifestyle, nutritional
+status, health, and mortality in elderly people across Europe: a review of the longitudinal results of the SENECA study. J
+Gerontol A Biol Sci Med Sci 2004 Dec;59(12):1277-1284. [doi: 10.1093/gerona/59.12.1277] [Medline: 15699526]
+53.
+Torri E, Sbrogiò LG, Rosa ED, Cinquetti S, Francia F, Ferro A. Italian public health response to the COVID-19 pandemic:
+case report from the field, insights and challenges for the department of prevention. Int J Environ Res Public Health 2020
+May 22;17(10):3666 [FREE Full text] [doi: 10.3390/ijerph17103666] [Medline: 32456072]
+54.
+Ceylan Z. Estimation of COVID-19 prevalence in Italy, Spain, and France. Sci Total Environ 2020 Aug 10;729:138817
+[FREE Full text] [doi: 10.1016/j.scitotenv.2020.138817] [Medline: 32360907]
+55.
+Chao F, Gerland P, Cook AR, Alkema L. Systematic assessment of the sex ratio at birth for all countries and estimation of
+national imbalances and regional reference levels. Proc Natl Acad Sci U S A 2019 May 07;116(19):9303-9311 [FREE Full
+text] [doi: 10.1073/pnas.1812593116] [Medline: 30988199]
+56.
+Bali S, Dhatt R, Lal A, Jama A, Van Daalen K, Sridhar D, Gender and COVID-19 Working Group, Women in Global
+Health‚ and Gender and COVID-19 Working Group. Off the back burner: diverse and gender-inclusive decision-making
+for COVID-19 response and recovery. BMJ Glob Health 2020 May 07;5(5):e002595 [FREE Full text] [doi:
+10.1136/bmjgh-2020-002595] [Medline: 32385047]
+57.
+Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. The Lancet 2020 Mar;395(10227):846-848.
+[doi: 10.1016/s0140-6736(20)30526-2]
+58.
+Perrotta D, Grow A, Rampazzo F, Cimentada J, Del FE, Gil-Clavel S, et al. Behaviors and attitudes in response to the
+COVID-19 pandemic: insights from a cross-national Facebook survey. medRxiv. Preprint posted online on July 15, 2020.
+[FREE Full text] [doi: 10.1101/2020.05.09.20096388]
+59.
+Wang C, Chudzicka-Czupała A, Grabowski D, Pan R, Adamus K, Wan X, et al. The association between physical and
+mental health and face mask use during the COVID-19 pandemic: a comparison of two countries with different views and
+practices. Front Psychiatry 2020 Sep 9;11:569981 [FREE Full text] [doi: 10.3389/fpsyt.2020.569981] [Medline: 33033485]
+Abbreviations
+SARS: severe acute respiratory syndrome
+SVYASA: Swami Vivekananda Yoga Anusandhana Samsthana
+WHO: World Health Organization
+Edited by G Eysenbach; submitted 18.08.20; peer-reviewed by P Mathur, R Ho, A Videira-Silva; comments to author 26.10.20; revised
+version received 03.12.20; accepted 11.04.21; published 01.06.21
+Please cite as:
+Manjunath NK, Majumdar V, Rozzi A, Huiru W, Mishra A, Kimura K, Nagarathna R, Nagendra HR
+Health Perceptions and Adopted Lifestyle Behaviors During the COVID-19 Pandemic: Cross-National Survey
+JMIR Form Res 2021;5(6):e23630
+URL: https://formative.jmir.org/2021/6/e23630
+doi: 10.2196/23630
+PMID: 33900928
+©Nandi Krishnamurthy Manjunath, Vijaya Majumdar, Antonietta Rozzi, Wang Huiru, Avinash Mishra, Keishin Kimura, Raghuram
+Nagarathna, Hongasandra Ramarao Nagendra. Originally published in JMIR Formative Research (https://formative.jmir.org),
+01.06.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License
+(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
+provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information,
+a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 12
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX

subfolder_0/A Pilot Study on Evaluating Cardiovascular Functions during the Practice of Bahir Kumbhaka (External Breath Retention).txt

@@ -0,0 +1,349 @@
+Original Research Paper
+A pilot study on evaluating cardiovascular functions during the practice
+of Bahir Kumbhaka (external breath retention)
+L. Nivethitha*, A. Mooventhan, N.K. Manjunath
+Department of Research and Development, S-VYASA University, Bengaluru, Karnataka, India
+A R T I C L E 
+I N F O
+Article history:
+Received 21 October 2016
+Received in revised form 16 January 2017
+Accepted 17 January 2017
+Available online xxx
+Keywords:
+Cardiovascular functions
+Kumbhaka
+Pranayama
+A B S T R A C T
+Background: Breath is the dynamic bridge between body and mind and Pranayama (breathing techniques)
+is one of the most important yogic practices. There is a lack of scientific evidence on cardiovascular
+functions during the practice of pranayama techniques, especially Kumbhaka. Hence, this present study
+aims at evaluating the cardiovascular functions of healthy volunteers during the practice of Bahir
+Kumbhaka (BK) (external breath retention).
+Materials and methods: Nineteen healthy volunteers with the mean (standard deviation) age of 23.53
+(3.08) were recruited. All the subjects were asked to perform BK for the duration of 30 s (1 round) and
+repeat the same for 3-rounds with the rest period of 1 min between each round. Baseline, during and post
+assessments were taken before, during and immediately after the practice. Statistical analysis was
+performed using repeated measures of analysis of variance with the use of statistical package for the
+social sciences, version 16.
+Results: Result of this study showed a significant increase in systolic blood pressure (SBP) and rate
+pressure product (RPP) during the practice of BK which was revert back to normal after the practice; and a
+significant increase in diastolic blood pressure (DBP), mean arterial pressure (MAP) and double product
+(Do-P) during the practice of BK which did not revert back to normal even after the practice.
+Conclusion: The result of this pilot study suggests that the practice of BK increases the SBP, DBP, MAP, RPP
+and Do-P during the practice.
+© 2017 Elsevier Ltd. All rights reserved.
+1. Background
+Yoga is an ancient Indian science and the way of life, which
+includes the practice of specific posture (asana), regulated
+breathing (Pranayama) and meditation. Breath is the dynamic
+bridge between body and mind and Pranayama is an art of
+prolongation and control of breath which is one the most
+important yogic practices [1]. It consists of 4-important aspects
+like 1) Pooraka (inhalation), 2) Rechaka (exhalation), 3) Antar
+kumbhaka (internal breath retention), and 4) Bahir Kumbhaka
+(external breath retention) [2].
+Previous studies reported the effect of various pranayamas such
+as breath awareness, right nostril breathing, left nostril breathing
+[3], 
+alternate 
+nostril 
+breathing [3,4], 
+Kapalabhati, 
+Bhastrika,
+Kukkuriya, Savitri, Pranav [4] and Bhramari Pranayama [5] on
+cardiovascular variables before and after the practice. Only very
+few studies have reported the cardiovascular effect of particular
+pranayama technique during the practice [6].
+Though Kumbhaka (breath retention) is one of the important
+aspects of pranayama, it should only be practiced for as long as is
+comfortable and is not recommended for people with cardiovas-
+cular diseases (CVD) and high blood pressure (BP) [2]. The scientific
+reason for not recommending it to such people is less known and to
+the best of our knowledge there is no known study reported the
+cardiovascular 
+effect 
+of 
+Kumbhaka 
+practice 
+especially 
+Bahir
+(External) Kumbhaka (BK) either in healthy or people with CVD.
+Hence, this present pilot study aims at evaluating the cardiovas-
+cular effect of BK in healthy volunteers.
+2. Materials and methods
+2.1. Subjects
+Nineteen healthy volunteers with the mean (standard devia-
+tion) age of 23.53 (3.08) were recruited from a university, South
+India based on the following inclusion and exclusion criteria.
+Inclusion criteria: age = 18 years and above; gender = both male and
+female; subjects who are willing to participate in the study.
+Exclusion criteria: subject with the history of any systemic and
+* Corresponding author.
+E-mail address: [email protected] (L. Nivethitha).
+http://dx.doi.org/10.1016/j.aimed.2017.01.001
+2212-9588/© 2017 Elsevier Ltd. All rights reserved.
+Advances in Integrative Medicine xxx (2016) xxx–xxx
+G Model
+AIMED 105 No. of Pages 3
+Please cite this article in press as: L. Nivethitha, et al., A pilot study on evaluating cardiovascular functions during the practice of Bahir
+Kumbhaka (external breath retention), Adv Integr Med (2017), http://dx.doi.org/10.1016/j.aimed.2017.01.001
+Contents lists available at ScienceDirect
+Advances in Integrative Medicine
+journal homepage: www.elsevier.com/locate/aimed
+mental illness; regular use of medication for any diseases; chronic
+smoking or alcoholism; subject who is unable to perform BK. The
+study protocol was approved by the institutional ethical commit-
+tee and a written informed consent was obtained from each
+participant.
+2.2. Design of the study
+This is a single group repeated measure study, in which all the
+subjects were asked to perform BK. The baseline, during and post
+assessments were taken before, during and after the practice.
+2.3. Assessment
+Height: By using a standard measuring tape, height in cm of
+each subject was measured.
+Weight: By using a standard weighing machine, the weight in kg
+of each subject was measured.
+Body mass index (BMI): It has been derived by using height and
+weight in the formula of weight in kg divided by height in meter
+square [1].
+Cardiovascular variables:
+A beat to beat changes in the cardiovascular variables such as
+systolic blood pressure (SBP), diastolic blood pressure (DBP), mean
+arterial pressure (MAP), heart rate (HR), stroke volume (SV), left
+ventricular ejection time (LVET), cardiac output (CO), pulse interval
+(PI), and total peripheral resistant (TPR) were assessed in sitting
+position using non-invasive blood pressure monitoring system
+(Finapres 
+Continuous 
+Non-Invasive 
+Blood 
+Pressure 
+Systems,
+Netherlands). A finger cuff of suitable size was placed on the left
+middle finger, in between the interphalangeal joints. A Non-
+invasive blood pressure cuff was placed on the upper arm of the
+same hand at the level of the heart and the marker on the cuff was
+directly above the brachial artery. The hand was placed at the knee
+and flexed at the elbow. A brachial correction was also made for
+each subject before assessment. Assessments were taken at rest
+before starting of the pranayama (baseline), during and after each
+pranayama practice. Data were extracted in off-line and exported
+to Microsoft excel 2007.
+Assessments such as pulse pressure (PP), rate pressure product
+(RPP), and double product (Do-P) were derived by using following
+formulas. PP was calculated as (SP 
 DP); RPP as (HR  SP/100); and
+Do-P as (HR  MP/100) [7].
+2.4. Intervention
+Bahir Kumbhaka (BK) (External breath retention): Subjects were
+asked to perform breath holding/retention after exhalation [2] for
+the duration of 30-s. This is one round and it was repeated for 3-
+rounds with a rest (normal breath) period of 1-min between each
+round.
+2.5. Data analysis
+Statistical analysis was performed using repeated measures of
+analysis of variance and post hoc analysis with Bonferroni
+adjustment for multiple comparisons with the use of Statistical
+Package for the Social Sciences (SPSS) for Windows, Version 16.0.
+Chicago, SPSS Inc. p-value <0.05 was considered as significant.
+3. Results
+Demographic variables of the study group have been provided
+in Table 1. Results of this present study showed a significant
+increase in SBP and RPP during the practice of BK that revert back
+to normal after the practice; and a significant increase in DBP, MAP
+and Do-P during the practice of BK that did not revert back to
+normal even after the practice; and no such significant changes
+were observed in rest of the variables (Table 2).
+4. Discussion
+SBP, DBP, PP, and MAP are known as the best predictors of CVD
+risks [8]. Results of this present study showed a significant increase
+in SBP during the practice of BK and revert back to normal after the
+practice. It might attribute to the combined effect of increased level
+of CO due to increased level of HR and increased level of TPR during
+the practice of BK because SBP = CO  peripheral resistance (PR)
+[7].
+A significant increase in DBP, MAP during the practice of BK
+might attribute to the increase in TPR during the practice but these
+changes did not revert back to normal even after the practice and
+even though there was a reduction in TPR after the practice of BK.
+Hence, the mechanism behind the sustained effect of increased
+level of DBP and MAP even after the practice is unclear.
+The increase in RPP and Do-P might attribute to the increase in
+HR and BP. RPP and Do-P are the important indirect indicators of
+myocardial oxygen consumption and load on the heart [7]. A
+significant increase of these variables in this study indicates strain
+increasing effects of BK on the heart during the practice and
+relieved after the practice.
+Since Yoga is becoming popular throughout the world, people
+are 
+very 
+much 
+interested 
+in practicing 
+various 
+techniques
+especially the advanced techniques which include Kumbhaka
+practice within a short span of period. According to a Yogic text, the
+practice of advanced techniques should begin only after we
+become master over the basic techniques. And these advanced
+techniques has to be practiced gradually in order to get adopt the
+body and mind with the practice, to reach the final stage. If, it is not
+followed then that might lead to certain adverse effects [2]. This
+Table 1
+Demographic variables of the study group (n = 19).
+Variables 
+Study group (n = 19)
+Age (years) 
+23.53  3.08
+Gender 
+Males (n = 18) and female (n = 1)
+Height (m) 
+1.70  0.09
+Weight (kg) 
+60.42  8.60
+Body mass index (kg/m2) 
+20.90  2.30
+Table 2
+Cardiovascular changes while practicing Bahir Kumbhaka (n = 19) (RMANOVA).
+Variables 
+Baseline 
+During 
+Post
+SBP (mmHg) 
+115.93  14.35 
+129.22  18.53*
+119.53  12.75
+DBP (mmHg) 
+71.54  8.87 
+80.84  11.12*
+74.05  8.77*
+MAP (mmHg) 
+88.74  10.24 
+100.07  13.75*
+92.01  9.81*
+PP (mmHg) 
+44.39  8.23 
+48.38  9.86 
+45.48  7.30
+RPP (Units) 
+97.91  16.71 
+113.31  23.21*
+103.35  15.65
+Do P (Units) 
+74.97  12.29 
+87.72  17.27*
+79.67  12.69*
+HR (beats/mint) 
+84.61  10.82 
+87.94  13.68 
+86.82  11.92
+SV (l) 
+70.42  13.35 
+69.95  12.36 
+70.20  13.03
+LVET (ms) 
+267.86  17.03 
+259.49  20.82 
+261.90  18.86
+Cardiac output (l/mint) 
+5.89  1.24 
+6.07  1.40 
+6.00  1.15
+Pulse interval (ms) 
+730.50  98.08 
+712.26  133.55 
+716.63  116.19
+TPR (mmHg min/l) 
+1.04  0.29 
+1.11  0.31 
+1.02  0.27
+Note: All values are in mean  standard deviation. SBP = systolic blood pressure;
+DBP = diastolic blood pressure; MAP = mean arterial pressure; PP = pulse pressure;
+RPP = rate pressure product; Do-P: double product; HR = heart rate; SV = stroke
+volume; LVFT = left ventricular ejection time; TPR = total peripheral resistant.
+* p < 0.05.
+2 
+L. Nivethitha et al. / Advances in Integrative Medicine xxx (2016) xxx–xxx
+G Model
+AIMED 105 No. of Pages 3
+Please cite this article in press as: L. Nivethitha, et al., A pilot study on evaluating cardiovascular functions during the practice of Bahir
+Kumbhaka (external breath retention), Adv Integr Med (2017), http://dx.doi.org/10.1016/j.aimed.2017.01.001
+present study results also supporting the above mentioned
+concept by showing the increased level of SBP, DBP, MAP, RPP
+and Do-P during the practice of BK (one of the advanced aspects of
+pranayama) even in healthy volunteers. Hence, in order to avoid
+complications of high-BP, this kind of practices should not be
+recommended suddenly to the people with hypertension and other
+CVD. Care must be taken in administrating this breathing
+technique by mastering over the basic practices (slow/yogic
+breathing techniques) and then a gradual increase in the duration
+of practice to get adopt with the practice. Because, regular practice
+of slow inspiration and expiration for longer duration would help
+in training the stretch receptors of respiratory muscles, chest wall
+and walls of the alveoli to support the breath holding along with
+acclimatizing the central and peripheral chemoreceptors for both
+hypercapnoea and hypoxia.
+Breath holding time is one of the most important variables used
+to measure the respiratory function [9]. Longer the breath holding
+time, better the pulmonary function. Since, BK is one of the breath
+holding techniques that was shown to increase BP as well as RPP
+and Do-P (indirect measure of cardiac workload), regular practice
+of BK alone or along with other pranayama practices might be
+considered in cardio-respiratory training of healthy individuals to
+strengthen the system and to prevent the various cardio-
+respiratory problems.
+Strengths of this present study: First study evaluating the
+cardiovascular effect of BK during the practice itself; Beat to beat
+changes in the blood pressure was measured using standard
+advanced non-invasive blood pressure monitoring systems.
+Limitations of this study: Small sample size; subjects were
+healthy volunteers which is limiting the scope of this study in
+people with pathological conditions; autonomic function assess-
+ments such as heart rate variability, galvanic skin resistance, pulse
+plethesmogram; baroreflex sensitivity would have provided more
+information. Hence, further studies are required with larger
+sample size using all the above mentioned objective variables in
+both healthy and people with pathological conditions for the better
+understanding.
+5. Conclusion
+The result of this study suggests that the practice of BK
+increases the SBP, DBP, MAP, RPP and Do-P during the practice.
+Source of funding
+Nil.
+Conflict of interest
+None declared.
+References
+[1] A. Mooventhan, V. Khode, Effect of Bhramari pranayama and OM chanting on
+pulmonary function in healthy individuals: a prospective randomized control
+trial, Int. J. Yoga 7 (2014) 104–110.
+[2] S. Saraswati, Asana Pranayama Mudra Bandha, 4th rev. edition, Yoga
+Publications Trust, Munger, Bihar, India, 2008.
+[3] P. Raghuraj, S. Telles, Immediate effect of specific nostril manipulating yoga
+breathing practices on autonomic and respiratory variables, Appl.
+Psychophysiol. Biofeedback 33 (2008) 65–75.
+[4] V.K. Sharma, M. Trakroo, V. Subramaniam, M. Rajajeyakumar, A.B. Bhavanani, A.
+Sahai, Effect of fast and slow pranayama on perceived stress and cardiovascular
+parameters in young health-care students, Int. J. Yoga 6 (2013) 104–110.
+[5] T. Pramanik, B. Pudasaini, R. Prajapati, Immediate effect of a slow pace breathing
+exercise Bhramari Pranayama on blood pressure and heart rate, Nepal Med. Coll.
+J. 12 (2010) 154–157.
+[6] S. Telles, S.K. Sharma, A. Balkrishna, Blood pressure and heart rate variability
+during yoga-based alternate nostril breathing practice and breath awareness,
+Med. Sci. Monit. Basic Res. 20 (2014) 184–193.
+[7] A. Mooventhan, Immediate effect of ice bag application to head and spine on
+cardiovascular changes in healthy volunteers, Int. J. Health Allied Sci. 5 (2016)
+53–56.
+[8] H.D. Sesso, M.J. Stampfer, B. Rosner, C.H. Hennekens, J.M. Gaziano, J.E. Manson,
+et al., Systolic and diastolic blood pressure, pulse pressure, and mean arterial
+pressure as predictors of cardiovascular disease risk in men, Hypertension 36
+(2000) 801–807.
+[9] P.S. Karthik, M. Chandrasekhar, K. Ambareesha, C. Nikhil, Effect of pranayama
+and suryanamaskar on pulmonary functions in medical students, J. Clin. Diagn.
+Res. 8 (2014) BC04–BC06.
+L. Nivethitha et al. / Advances in Integrative Medicine xxx (2016) xxx–xxx 
+3
+G Model
+AIMED 105 No. of Pages 3
+Please cite this article in press as: L. Nivethitha, et al., A pilot study on evaluating cardiovascular functions during the practice of Bahir
+Kumbhaka (external breath retention), Adv Integr Med (2017), http://dx.doi.org/10.1016/j.aimed.2017.01.001

subfolder_0/A randomized controlled study on assessment of health status, depression, and anxiety in coal miners with copd.txt

@@ -0,0 +1,940 @@
+137
+© 2016 International Journal of Yoga | Published by Wolters Kluwer - Medknow
+A randomized controlled study on assessment of health 
+status, depression, and anxiety in coal miners with chronic 
+obstructive pulmonary disease following yoga training
+Rajashree Ranjita, Sumati Badhai, Alex Hankey, Hongasandra R Nagendra
+Division of Yoga and Life Science, Swami Vivekananda Yoga Anusandhana Samsthana Yoga University, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Rajashree Ranjita, 
+ 
+Swami Vivekananda Yoga Anusandhana Samsthana, No. 19, Eknath Bhavan, Gavipuram Circle, 
+ 
+Kempegowda Nagar, Bengaluru ‑ 560 019, Karnataka, India. 
+ 
+E‑mail: [email protected]
+increasingly affect the psychological well‑being of working 
+populations,[4] coal miners being more susceptible due to 
+highly risky and stressful working environments.[5] Prior 
+studies have documented association of depression and 
+anxiety among COPD patients[6‑9] more than non‑COPD 
+individuals.[10] Clinically significant symptoms of 
+depression were found in around half COPD patients[11,12] 
+while the prevalence of anxiety has been estimated at 
+INTRODUCTION
+Chronic obstructive pulmonary disease (COPD) is a 
+complex, treatment‑resistant disease with multiple 
+comorbidities, depression, and anxiety being the two of 
+the most important and least treated among them.[1] Other 
+than cigarette smoking, there is an increasing evidence 
+of occupational exposures as a major risk factor for 
+COPD[2,3] found the prevalence of COPD in nonsmoking 
+coal miners was 19% in a study. Depression and anxiety 
+Original Article
+Context: Psychological comorbidities are prevalent in coal miners with chronic obstructive pulmonary disease (COPD) and 
+contribute to the severity of the disease reducing their health status. Yoga has been shown to alleviate depression and anxiety 
+associated with other chronic diseases but in COPD not been fully investigated.
+Aim: This study aimed to evaluate the role of yoga on health status, depression, and anxiety in coal miners with COPD.
+Materials and Methods: This was a randomized trial with two study arms (yoga and control), which enrolled 81 coal miners, 
+ranging from 36 to 60 years with stage II and III stable COPD. Both groups were either on conventional treatment or combination 
+of conventional care with yoga program for 12 weeks.
+Results: Data were collected through standardized questionnaires; COPD Assessment Test, Beck Depression Inventory and 
+State and Trait Anxiety Inventory at the beginning and the end of the intervention. The yoga group showed statistically significant 
+(P < 0.001) improvements on all scales within the group, all significantly different (P < 0.001) from changes observed in the 
+controls. No significant prepost changes were observed in the control group (P > 0.05).
+Conclusion: Yoga program led to greater improvement in physical and mental health status than did conventional care. Yoga 
+seems to be a safe, feasible, and effective treatment for patients with COPD. There is a need to conduct more comprehensive, 
+high‑quality, evidence‑based studies to shed light on the current understanding of the efficacy of yoga in these chronic conditions 
+and identify unanswered questions.
+Key words: Anxiety; COPD assessment test; chronic obstructive pulmonary disease; depression; yoga.
+ABSTRACT
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.183714
+How to cite this article: Ranjita R, Badhai S, Hankey A, 
+Nagendra HR. A randomized controlled study on assessment of health 
+status, depression, and anxiety in coal miners with chronic obstructive 
+pulmonary disease following yoga training. Int J Yoga 2016;9:137-44.
+This is an open access article distributed under the terms of the Creative 
+Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows 
+others to remix, tweak, and build upon the work non‑commercially, as long as the 
+author is credited and the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Ranjita, et al.: Effect of yoga on depression, anxiety in COPD
+International Journal of Yoga • Vol. 9 • Jul-Dec-2016
+138
+40%.[13‑15] About one‑third of COPD sufferers is afflicted 
+by both.[16] The presence of these comorbid symptoms 
+significantly contributes to the impaired health status 
+in patients with COPD[17,18] irrespective of the degree of 
+airflow limitation.[19] Therefore, optimizing the health 
+status is an important goal in COPD management.[20] In a 
+systematic review, it has been reported that comprehensive 
+pulmonary rehabilitation benefits in a reduction in 
+short‑term depression and anxiety.[21] Limited evidence is 
+available on the effect of mindfulness‑based treatments 
+such as yoga for the management of depression and anxiety 
+in COPD patients.
+Yoga is a way of life, mainly has four primary 
+components: Physical postures to develop strength and 
+flexibility, breathing exercises to enhance respiratory 
+functioning, deep relaxation techniques to cultivate the 
+ability to release anxiety, and meditation/mindfulness 
+practices to promote emotion and stress regulation 
+skills.[22] Psychosomatic ailments arise due to a 
+disturbance in the mind.[23] The level of documented 
+evidence of yoga’s psychophysiological benefits for 
+depression and anxiety is progressively increasing.[24‑32] 
+Similarly, some research has been conducted on 
+yoga’s application to COPD[33‑37] but no study has been 
+published assessing the effect of yoga on coal miners, 
+for whom the condition is a major work‑related health 
+hazard. Hence, this study was aimed to evaluate the 
+effects of a 12 weeks program of the Integrated Approach 
+of Yoga Therapy (IAYT) on health status, depression, and 
+anxiety of COPD in coal miners compared to controls on 
+conventional care, based on the hypothesis that it would 
+improve the health status by decreasing depression and 
+anxiety symptoms. IAYT is a combination of breathing 
+practices, physical postures, pranayama, kriya, 
+meditation, relaxation techniques, and lectures.[22] Its 
+therapeutic applications as a supplementary therapy 
+for chronic health conditions in asthma,[38] cancer,[39] 
+diabetes,[40] schizophrenia,[41] and low back pain[42] are 
+well established.
+MATERIALS AND METHODS
+Participants
+Eighty‑one male nonsmoking coal miners with ages ranging 
+from 36 years to 60 years were recruited for the study. 
+They were all present coal miners of Rampur Colliery, 
+Odisha. A total of 279 coal miners were screened, of 
+whom 36 declined to sign the informed consent form. 
+Rest 243 underwent clinical examination, of these 162 met 
+any one of exclusion criteria and finally 81 registered for 
+the trial and were randomized into two groups, yoga and 
+waitlist controls. Figure 1 depicts the flow diagram of 
+the study, showing screening, enrollment, intervention, 
+assessments, and analysis.
+Inclusion criteria
+The inclusion criteria were as follows: Physician diagnosed 
+COPD with spirometric evidence of chronic airflow 
+limitation (forced expiratory volume in 1 s/forced vital 
+capacity, post bronchodilator <0.70), Global initiative for 
+Obstructive Lung Disease (GOLD) stage I and II COPD;[1]
+clinically stable for at least 3 months; literate to complete 
+the questionnaires.
+Exclusion criteria
+Exclusion criteria were: Prior experience of yoga; recent 
+COPD exacerbation; cognitive impairment; myocardial 
+infarction or recurrent angina within the previous 
+6 months; hospitalization within 3 months; and respiratory 
+tract infection within 1 month of enrollment.
+Informed consent
+The aim of the study was conveyed to those agreeing to 
+participate in the study; signed informed consent was 
+obtained from all participants prior to baseline assessment.
+Design
+This is a randomized, waitlist control, single‑blind clinical 
+trial in which 81 participants were assigned to two groups 
+(yoga and control) using a computer generated random 
+number table obtained from http://www.randomizer.org. 
+Numbered opaque envelopes were used to implement 
+the random allocation to conceal the sequence until 
+interventions were assigned.
+Study protocol
+At enrollment, medical, exposure histories, pulmonary 
+symptoms, and information about current pharmacological 
+treatments were obtained, and clinical examinations 
+performed by a specialist physician. Comorbid diagnoses 
+were established from clinical histories and examination 
+findings, supported by reviews of available medical 
+records. The yoga group practiced a set of integrated 
+yoga practices specially designed for COPD for 90 min 
+daily, 6 days/week for 12 weeks. Participants of control 
+group continued conventional therapy, completing all 
+assessments at the same times as the yoga group; they 
+were offered yoga at the end of the study. All participants 
+were asked to refrain from participating in any other yoga 
+classes during the study period.
+Blinding and masking
+Double blinding is not considered possible for yoga 
+interventions, where participants and trainer can 
+recognize group assignment. However, giving and scoring 
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Ranjita, et al.: Effect of yoga on depression, anxiety in COPD
+139
+International Journal of Yoga • Vol. 9 • Jul-Dec-2016
+the assessments were masked wherever feasible. The 
+statistician responsible for randomization, and subsequent 
+data analysis was not involved in administering the 
+intervention and was thus blind to the source of the data. 
+The clinical psychologist who administered and scored the 
+psychological questionnaires and the staff, who carried out 
+assessments, were blind to membership of the intervention 
+groups. Coded answer sheets were analyzed only after the 
+study’s completion.
+Study approval
+The study was approved by the Institution Ethics 
+Committee (Swami Vivekananda Yoga University, 
+Bangalore) through RES/IEC/28/2014 in accordance with 
+the Helsinki Declaration.
+Intervention
+The IAYT module was developed by Swami Vivekananda 
+Yoga Anusandhana Samasthana specifically for COPD. It 
+included simple and safe practices at physical, mental, 
+emotional, and intellectual levels. The yoga practice 
+protocol was designed in consultation with S‑VYASA’s 
+Medical Director. The daily schedule is detailed in 
+Table 1.
+Assessments
+Assessments were made on both groups before and after 
+the 12 weeks of intervention. The following questionnaires 
+were completed by all participants.
+COPD assessment test
+COPD Assessment Test (CAT) is a short questionnaire 
+developed for assessing and monitoring COPD in 
+routine clinical practice. It provides a valid, reliable, and 
+standardized measure of the impact of COPD on a patient’s 
+health and well‑being.[43,44] It consists of 8 items rated using 
+a Likert‑type scale of 0–5, providing a score out of 40, 
+higher scores representing the poorer quality of life (QoL). 
+Despite the small number of items, it covers a broad range 
+of effects on patients’ health. It takes less time to complete 
+than other health‑related QoL questionnaires.[45] CAT is 
+sensitive to changes in disease progression over time and 
+to the effectiveness of treatments.[46,47] Internal consistency 
+is excellent with Cronbach’s α =0.88 and test‑retest 
+reliability good in stable patients (ICCC = 0. 8).[43]
+Beck depression inventory
+All participants completed the Beck Depression 
+Inventory (BDI), 2nd edition.[48] BDI‑II is a self‑report 
+Total patients screened
+(n = 279)
+Declined informed consent 
+(n = 36)
+Underwent clinical examination
+(n = 243)
+Did not meet the inclusion
+criteria (n = 162)
+Random assignment (n = 81)
+Yoga group
+(n = 41)
+Control group
+(n = 40)
+Intervention 12
+weeks 
+Drop outs
+(n = 5)
+Drop outs
+(n = 4)
+Incomplete questionnaires
+(n = 1)
+Illness (n = 2)
+Out of station (n = 1)
+Reasons for
+drop out
+Incomplete questionnaires
+(n = 2)
+Illness (n = 1)
+Less attendance (n = 2)
+Final analysis
+Yoga (n = 36)
+Final analysis
+Control (n = 36)
+Figure 1: Flow of participants over study period
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Ranjita, et al.: Effect of yoga on depression, anxiety in COPD
+International Journal of Yoga • Vol. 9 • Jul-Dec-2016
+140
+questionnaire of 21 items scored from 0 to 3. It is 
+designed to assess depressive symptoms experienced 
+within the previous 2 weeks. It has high internal 
+consistency (Cronbach’s α =0.92); mean test‑retest 
+reliability is 0.72.[49] BDI‑II scores range from 0 to 63, 
+with categorical depression ratings of “minimal” (0–13), 
+“mild” (14–19), “moderate” (20–28), and “severe” 
+(29–63). BDI is considered a valid measure of depressed 
+mood for diverse populations.
+State trait anxiety inventory
+State and Trait Anxiety Inventory (STAI) is a reliable, 
+valid, and widely used measure of anxiety for clinical 
+practice and research, with a high degree of internal 
+consistency.[50] Cronbach’s α is 0.85 for the total scores.[51] 
+It includes separate measures of state anxiety and trait 
+anxiety each comprising 20 items rated on a 4 point 
+scale from 0 to 3 which range from 20, minimum, to 80, 
+maximum. Form S evaluates state anxiety, how subjects, 
+feel “at this moment;” while Form T assesses trait anxiety, 
+how the respondent feels “most of the time.” In India, 
+its reliability and validity are well established following 
+extensive use in adult populations. State anxiety reflects 
+subjective and transitory emotional states characterized 
+by consciously perceived feelings of nervousness, tension, 
+worries, and apprehension, and heightened autonomic 
+nervous system activity. In contrast, trait anxiety refers 
+to relatively stable individual differences in anxiety 
+proneness as a personality attribute that denotes general 
+tendency to respond with anxiety to perceived threats in 
+the environment.
+Data collection
+Clinical and demographic information were collected 
+using medical records and study‑specific forms. Adherence 
+and compliance were monitored through the use of daily 
+patient diaries and attendance records kept by the yoga 
+instructors. No make‑up sessions were provided for missed 
+classes. All participants were instructed to continue their 
+routine daily activities during the 12‑week intervention 
+period but were asked not to start a new yoga or exercise 
+regimen on their own during that time. A feedback form 
+was used to assess enjoyment and helpfulness of the 
+yoga intervention, and to ask whether participants would 
+recommend it to others.
+Table 1: Integrated approach of yoga therapy for 
+chronic obstructive pulmonary disease used in this study
+Name of the practices
+Duration (min)
+Breathing practices
+10
+Standing
+Hands in and out breathing
+1
+Hands stretch breathing
+1
+Ankle stretch breathing
+1
+Sitting
+Dog breathing
+1
+Rabbit breathing
+1
+Tiger breathing
+1
+Sasäìkäsana breathing (moon pose)
+1
+Prone
+Bhujaìgäsana breathing
+1
+Śalabhāsana breathing
+1
+Supine
+Straight leg raising breathing
+1
+Loosening practices
+10
+Forward and backward bending
+1
+Side bending
+1
+Twisting
+1
+Pawanmuktäsana kriyä (alternate leg)
+1×2
+Rocking and rolling
+1×2
+Surya Namaskära × 3 rounds
+1×3
+Yogäsanas (physical postures)
+20
+Standing
+Ardhakati cakräsana (lateral arc pose)
+2
+Pädahastäsana (forward bend pose)
+2
+Ardha cakräsana (half wheel pose)
+2
+Sitting
+Vakräsana (twisting posture)
+2
+Ardhamatsyendräsana (half spinal twist posture)
+2
+Paścimottānāsana (sleeping thunderbolt posture)
+2
+Prone
+Bhujaìgäsana (serpent pose)
+2
+Śalabhāsana (locust pose)
+2
+Supine
+Sarväìgäsana (shoulder stand pose)
+2
+Matsyäsana (fish pose)
+2
+Yogä chair breathing
+10
+Instant relaxation technique
+1
+Neck muscle relaxation with chair support
+1
+Neck movements in Vajräsana
+1
+Sasäìkäsana movement
+1
+Relaxation in Tadäsana
+1
+Neck movements in Tadäsana
+1
+Ardha cakräsana - Pädahastäsana
+1
+Quick relaxation technique
+3
+Präëäyäma
+10
+Kapälabhäti (frontal brain cleansing)
+2
+Vibhägiya präëäyäma (sectional breathing)
+2
+Näòéśodhana präëäyäma (alternate nostril 
+breathing)
+2
+Ujjayi präëäyäma (diaphragmatic breathing)
+2
+Bhrämaré präëäyäma (bee breathing)
+2
+Meditation
+10
+Nädänusandhäna (alternate day)
+10
+Om Meditation (alternate day)
+10
+DRT in Çaväsana (corpse pose)
+10
+Yogic counseling/lectures
+10
+Yoga philosophy and health, basis and applications 
+of yoga, Pancakoña viveka (five layers of existence), 
+COPD causes, complications and relation to 
+stress, Stress reaction and its management. Lifestyle 
+modification, diet and exercise, emotion and coping
+Table 1: Contd...
+Name of the practices
+Duration (min)
+Kriyä (once a week)
+90
+Theory on kriyä
+10
+Jala Neti
+20
+Sutra Neti
+20
+Vamana Dhouti
+25
+DRT
+15
+DRT = Deep relaxation technique, COPD = Chronic obstructive pulmonary disease
+Contd...
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Ranjita, et al.: Effect of yoga on depression, anxiety in COPD
+141
+International Journal of Yoga • Vol. 9 • Jul-Dec-2016
+Statistical analysis
+Data were analyzed using SPSS version 18.0 
+(IBM Corporation, USA). Within group changes and between 
+group treatment effects associated with participation in the 
+yoga intervention were evaluated using Chi‑square tests 
+for categorical data and paired t‑tests and independent 
+sample t‑tests for continuous data. P < 0.05 was considered 
+significant.
+RESULTS
+Descriptive features
+The study population initially consisted of 81 coal miners 
+with COPD. Five and four participants dropped out of 
+yoga and control group, respectively, for personal reasons 
+unrelated to the study, giving a final sample size of 72 (36 
+in each group). Total participants in GOLD stage II category 
+were 52.8% in yoga and 58.3% in controls, and in GOLD 
+stage III 47.2% in yoga and 41.7% in controls. Demographic 
+variables of patient’s average age, duration of employment 
+in coal mines, and duration of disease since diagnosis were 
+comparable as were initial test scores at baseline (all P > 
+0.05) [Table 2].
+COPD assessment test
+The practice of yoga for 12 weeks has significantly 
+lowered the CAT scores (P < 0.001) in the yoga group, 
+indicating better health status, whereas no significant 
+difference was observed in the control group (P = 0.294). 
+The results further revealed that the change occurred in 
+the yoga group was 23.05% and in the control group was 
+− 2.52%. Between‑group differences were statistically 
+significant (P < 0.001, independent t‑test) [Table 3].
+Beck depression inventory
+In both the groups, mean depression scores were reduced, 
+but the magnitude of change is statistically significant 
+and higher (P < 0.001, 25.53%) in the yoga group as 
+compared to the control group (P = 0.095, 3.23%). In 
+addition, significant group mean differences were observed 
+between yoga and control group’s post intervention scores 
+(P = 0.002) [Table 3].
+State and trait anxiety inventory
+The yoga group showed significantly lower scores in both 
+state and trait anxiety (P < 0.001), but controls showed no 
+significant change (P = 0.192 and P = 0.383, respectively). 
+State anxiety decreased by 15.98% in yoga and increased 
+by 1.98% in controls. A similar trend was observed in trait 
+anxiety also. It decreased by 13.35% in yoga and increased 
+by 1.46% in controls. Independent t‑tests gave statistically 
+significant differences between groups at posttest, P = 0.032 
+and P = 0.034, respectively. Overall anxiety score was 
+significantly reduced by 14.64% within the yoga group 
+(P < 0.001), whereas and there was slight increase by 1.71% 
+(P = 0.054) reported in the control group [Table 3].
+DISCUSSION
+To the best of our knowledge, this is the first 
+randomized‑controlled study investigating physical and 
+psychological health benefits associated with yoga practice 
+on coal miners with COPD. The study evaluated the impact 
+of yoga on their disease‑specific health status, depression, and 
+anxiety levels. Results suggested that IAYT practice facilitates 
+improvements in health status and reduces self‑reported 
+depression and anxiety levels after 12 weeks of practice.
+The results are consistent with previously reported 
+interventions based on yoga, which demonstrated positive, 
+beneficial effects on psychological and psychosocial 
+factors in diverse conditions such as diabetes,[40] cancer,[52] 
+CAD,[53] low back pain,[54] osteoarthritis of the knee,[55] and 
+pregnancy.[56,57] It is reported in a study that pranayama 
+(yogic breathing) mitigates posttraumatic stress disorder 
+and depression.[58] Another study on patients who 
+participated in education and stress management in 
+addition to exercise training during a 12‑week intervention 
+reported reductions in depression and anxiety.[59]
+A study reported that changes in depression and state and 
+trait anxiety did not significantly differ between the two 
+interventions (6 weeks of weekly yoga classes together 
+with exercise, compared to a 6 weeks weekly group 
+exercise) (GDS15, P = 0.749, STAI‑S, P = 0.595, STAI‑T, 
+P = 0.407).[60] Another study has similarly obtained unclear 
+effects following yoga intervention.[61]
+The pathophysiology of depression and anxiety among 
+COPD patient is complex and poorly understood. The 
+Table 2: Baseline characteristics of participants in both 
+yoga and control group
+Variables
+Mean±SD
+P (independent 
+sample t-test)
+Yoga 
+(n=36)
+Control 
+(n=36)
+Age
+53.69±5.66
+54.36±5.40
+0.611*
+Duration of employment 
+in coal mines
+28.36±4.62
+27.72±4.23
+0.543*
+Duration of disease 
+since diagnosis
+9.92±3.25
+10.69±2.54
+0.262*
+CAT
+20.69±5.53
+21.81±5.48
+0.395*
+BDI
+22.25±8.47
+24.14±9.21
+0.368*
+STAI (S)
+39.61±8.73 37.92±10.92
+0.469*
+STAI (T)
+41.06±7.82
+39.86±8.88
+0.547*
+STAI (total)
+80.67±16.06 77.78±19.27
+0.492*
+*Not significant. CAT = COPD assessment test, BDI = Beck depression inventory, 
+STAI = State-trait anxiety inventory, STAI (S) = State anxiety, STAI (T) = Trait anxiety, 
+SD = Standard deviation, COPD = Chronic obstructive pulmonary disease
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Ranjita, et al.: Effect of yoga on depression, anxiety in COPD
+International Journal of Yoga • Vol. 9 • Jul-Dec-2016
+142
+physical, emotional, and social impact of COPD may cause 
+a self‑perpetuating cycle that has a severe impact on a 
+patient’s physical and mental health status.[21] It has been 
+shown that high scores on perceived stress and anxiety 
+are related to increase in hypothalamic‑pituitary‑adrenal 
+(HPA) axis activity.[62] The effects of yoga in our results can 
+be explained by reduction in levels of psychophysiological 
+arousal via triggering neurohormonal mechanisms 
+that suppress sympathetic activity,[63,64] balance in the 
+autonomic nervous system responses,[65] alterations in 
+neuroendocrine arousal[66,67] through better regulation 
+of the HPA axis[68] resulting in reductions in stress and 
+anxiety.[32] Better psychological health resulting from stress 
+reduction might be due to relaxation techniques[69] which 
+contribute to the observed improvements in CAT scores in 
+our study. Thus, these psychological changes may explain 
+the physiological changes observed as better outcomes 
+seen in previous studies on integrated yoga in asthma.[38] 
+Yoga unites body, mind, and spirit; and enhances attention 
+by calming down the restless mind.[22] Thus, the deep 
+physiological rest that is achieved by the components of 
+pranayama, meditation, and other mindfulness practices 
+incorporated in the integrated yoga program could be 
+the major factors explaining observed benefits. Overall, 
+antidepressant effects of yoga programs can be attributed 
+to stress reduction.[70] Another study concluded the 
+practice of meditation strengthens the mental resolve 
+and hence decreases anxiety.[71] Yoga practices decrease 
+parasympathetic nervous system and GABAergic activity 
+that underlies stress‑related disorders which result in 
+amelioration of disease symptoms.[72] Reductions in 
+psychological hyper‑reactivity and emotional instability 
+achieved by yoga may be due to reduced efferent vagal 
+reactivity[73] already recognized as a main psychosomatic 
+factor in asthma,[74] might have similar physiology in 
+COPD also.
+This study is the first of its kind to conclude that integrated 
+yoga can act as an imperative line of therapy in the 
+management of COPD in coal miners. The novel aspects 
+of this study were (a) the randomized control design, 
+(b) good sample size, (c) incorporation of integrated yoga 
+approach, and (d) good compliance. A major constraint of 
+the study is the lack of an active control group. It would 
+have been valuable to include physiological measures of 
+stress such as Galvanic Skin Response and Heart Rate 
+Variability to overcome the subjectivity of self‑report 
+and to throw light on the mechanisms. In spite of the 
+aforementioned limitations, significant results were 
+manifested in a short time suggesting yoga therapy could 
+be a non‑pharmacological alternative for the management 
+of COPD. The current state of understanding necessitates 
+further assessment to evaluate benefits of yoga for COPD in 
+diverse populations, especially associated with depression 
+and anxiety followed over longer time periods. Robust 
+effectiveness and implementation studies are required 
+to determine whether yoga therapy can decrease medical 
+utilization. In addition, the findings of this study may 
+also provide evidence supporting the incorporation of 
+yoga into standardized pulmonary rehabilitation programs 
+as a practical adjunct to improve the management of 
+psychosocial symptoms associated with COPD.
+CONCLUSION
+In this study, 12 weeks of integrated yoga enhanced health 
+status and reduced depression and anxiety in coal miners 
+with COPD. Any system that can bring symptomatic relief 
+and improve different aspects of QoL of COPD patients 
+merits incorporation into standard COPD treatments. 
+Further research is warranted to confirm these preliminary 
+findings and facilitate implementation in clinical settings.
+Acknowledgment
+The authors would like to express gratitude Mr. Rajeev Lochan 
+and Soubhagyalaxmi Mohanty for assisting with manuscript 
+preparation. Thanks are due to Mr. Kunja Bihari Badhai, 
+senior yoga instructor for his experienced support and 
+advice. Also to Mr. Arjun Biswal for coordinating the 
+program. Special thanks to Dr. R Nagarathna, who offered 
+critical and thoughtful recommendations in the initial 
+development of the program and Dr. Balaram Pradhan, Ph.D. 
+for statistical analysis.
+Table 3: Change scores within yoga and control, and difference between groups with 95% CI
+Variables
+Yoga (n=36)
+Control (n=36)
+Between group
+Pre$
+Post$
+Pre$
+Post$
+Post 
+versus 
+post#
+P
+Group × 
+time 
+interaction
+P
+Mean±SD
+CI (LB-UB)
+Mean±SD
+CI (LB-UB)
+Mean±SD
+CI (LB-UB)
+Mean±SD
+CI (LB-UB)
+CAT
+20.69±5.53 18.82-22.56 15.92±6.51*** 13.71-18.12 21.81±5.48 19.95-23.66 22.36±5.65 20.45-24.27 0.001
+<0.001
+BDI II
+22.25±8.47 19.38-25.12 16.56±7.03*** 14.18-18.93 24.14±9.21 21.02-27.25 23.36±10.49 19.81-26.91 0.002
+<0.001
+STAI (S)
+39.61±8.73 36.66-42.56 33.28±9.92*** 29.92-36.63 37.92±10.92 34.22-41.61 38.67±10.92 34.97-42.36 0.032
+<0.001
+STAI (T)
+41.06±7.82 38.41-43.70 35.58±9.14*** 32.49-38.67 39.86±8.88 32.49-38.67 40.44±9.89 37.10-43.79 0.034
+<0.001
+STAI total 80.67±16.06 75.23-86.10 68.86±17.96*** 62.79-74.94 77.78±19.27 71.26-84.30 79.11±19.77 72.42-85.80 0.024
+<0.001
+$Paired t-test; #Independent t-test. BDI = Beck depression inventory, STAI = State-trait anxiety inventory, STAI (S) = State anxiety, STAI (T) = Trait anxiety, SD = Standard 
+deviation, CI = Confidence interval, LB = Lower bound, UB = Upper bound, CAT = COPD assessment test, COPD = Chronic obstructive pulmonary disease. 
+***Highly significant
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Ranjita, et al.: Effect of yoga on depression, anxiety in COPD
+143
+International Journal of Yoga • Vol. 9 • Jul-Dec-2016
+Financial support and sponsorship 
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+REFERENCES
+1.	
+GOLD. Global Strategy for the Diagnosis, Management and Prevention 
+of Chronic Obstructive Pulmonary Disease. Global Initiative for Chronic 
+Obstructive Lung Disease; 2015. Available from: http://www.goldcopd.org/
+uploads/users/files/GOLD_Report_2015.pdf. [Last accessed on 2015 Mar 09].
+2.	
+Hu Y, Chen B, Yin Z, Jia L, Zhou Y, Jin T. Increased risk of chronic obstructive 
+pulmonary diseases in coke oven workers: Interaction between occupational 
+exposure and smoking. Thorax 2006;61:290‑5.
+3.	
+Yasin M, Beatty B, Folz RJ. Depression, COPD and Coal Worker’s 
+Pneumoconiosis (CWP) are common among kentucky coal miners evaluated 
+for respiratory impairment. Am J Respir Crit Care Med 2015;191:A4683.
+4.	
+Fan LB, Blumenthal JA, Watkins LL, Sherwood A. Work and home stress: 
+Associations with anxiety and depression symptoms. Occup Med (Lond) 
+2015;65:110‑6.
+5.	
+Liu L, Wang L, Chen J. Prevalence and associated factors of depressive 
+symptoms among Chinese underground coal miners. Biomed Res Int 
+2014;2014:987305.
+6.	
+Laurin C, Lavoie KL, Bacon SL, Dupuis G, Lacoste G, Cartier A, et al. Sex 
+differences in the prevalence of psychiatric disorders and psychological 
+distress in patients with COPD. Chest 2007;132:148‑55.
+7.	
+Eisner MD, Blanc PD, Yelin EH, Katz PP, Sanchez G, Iribarren C, et al. 
+Influence of anxiety on health outcomes in COPD. Thorax 2010;65:229‑34.
+8.	
+Johansson R, Carlbring P, Heedman Å, Paxling B, Andersson G. Depression, 
+anxiety and their comorbidity in the Swedish general population: Point 
+prevalence and the effect on health‑related quality of life. PeerJ 2013;1:e98.
+9.	
+Giardino ND, Curtis JL, Andrei AC, Fan VS, Benditt JO, Lyubkin M, 
+et al. Anxiety is associated with diminished exercise performance and 
+quality of life in severe emphysema: A cross‑sectional study. Respir Res 
+2010;11:29.
+10.	 Felker B, Bush KR, Harel O, Shofer JB, Shores MM, Au DH. Added burden 
+of mental disorders on health status among patients with chronic obstructive 
+pulmonary disease. Prim Care Companion J Clin Psychiatry 2010;12. pii: 
+PCC.09m00858.
+11.	
+Yohannes AM, Baldwin RC, Connolly MJ. Depression and anxiety in elderly 
+outpatients with chronic obstructive pulmonary disease: Prevalence, and 
+validation of the BASDEC screening questionnaire. Int J Geriatr Psychiatry 
+2000;15:1090‑6.
+12.	 Lacasse Y, Rousseau L, Maltais F. Prevalence of depressive symptoms and 
+depression in patients with severe oxygen‑dependent chronic obstructive 
+pulmonary disease. J Cardiopulm Rehabil 2001;21:80‑6.
+13.	 Kunik ME, Roundy K, Veazey C, Souchek J, Richardson P, Wray NP, et al. 
+Surprisingly high prevalence of anxiety and depression in chronic breathing 
+disorders. Chest 2005;127:1205‑11.
+14.	 Yohannes AM, Willgoss TG, Baldwin RC, Connolly MJ. Depression and 
+anxiety in chronic heart failure and chronic obstructive pulmonary disease: 
+Prevalence, relevance, clinical implications and management principles. Int 
+J Geriatr Psychiatry 2010;25:1209‑21.
+15.	 Willgoss TG, Yohannes AM. Anxiety disorders in patients with COPD: A 
+systematic review. Respir Care 2013;58:858‑66.
+16.	 Panagioti M, Scott C, Blakemore A, Coventry PA. Overview of the prevalence, 
+impact, and management of depression and anxiety in chronic obstructive 
+pulmonary disease. Int J Chron Obstruct Pulmon Dis 2014;9:1289‑306.
+17.	 Ng TP, Niti M, Tan WC, Cao Z, Ong KC, Eng P. Depressive symptoms 
+and chronic obstructive pulmonary disease: Effect on mortality, hospital 
+readmission, symptom burden, functional status, and quality of life. Arch 
+Intern Med 2007;167:60‑7.
+18.	 Gudmundsson G, Gislason T, Janson C, Lindberg E, Hallin R, Ulrik CS, et al. 
+Risk factors for rehospitalisation in COPD: Role of health status, anxiety and 
+depression. Eur Respir J 2005;26:414‑9.
+19.	 Agusti A, Calverley PM, Celli B, Coxson HO, Edwards LD, Lomas DA, et al. 
+Characterisation of COPD heterogeneity in the ECLIPSE cohort. Respir Res 
+2010;11:122.
+20.	 Vestbo J, Hurd SS, Agustí AG, Jones PW, Vogelmeier C, Anzueto A, et al. 
+Global strategy for the diagnosis, management, and prevention of chronic 
+obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit 
+Care Med 2013;187:347‑65.
+21.	 Pumar MI, Gray CR, Walsh JR, Yang IA, Rolls TA, Ward DL. Anxiety and 
+depression‑Important psychological comorbidities of COPD. J Thorac Dis 
+2014;6:1615‑31.
+22.	 Nagarathna R, Nagendra HR. Integrated Approach of Yoga Therapy for Positive 
+Health. 2nd ed. Bangalore: Swami Vivekananda Yoga Prakashan; 2013.
+23.	 Rajesh SK, Ilavarasu JV, Srinivasan TM, Nagendra HR. Stress and 
+its expression according to contemporary science and ancient indian 
+wisdom: Perseverative cognition and the pañca kosas. Mens Sana Monogr 
+2014;12:139‑52.
+24.	 Shapiro D, Cook IA, Davydov DM, Ottaviani C, Leuchter AF, Abrams M. 
+Yoga as a complementary treatment of depression: Effects of traits and 
+moods on treatment outcome. Evid Based Complement Alternat Med 
+2007;4:493‑502.
+25.	 Davis K, Goodman SH, Leiferman J, Taylor M, Dimidjian S. A randomized 
+controlled trial of yoga for pregnant women with symptoms of depression 
+and anxiety. Complement Ther Clin Pract 2015;21:166‑72.
+26.	 Duan-Porter W, Coeytaux RR, McDuffie J, Goode A, Sharma P, Mennella H, 
+et al. Evidence map of yoga for depression, anxiety and post-traumatic stress 
+disorder. J Phys Act Health 2015. [Epub ahead of print].
+27.	 Doria S, de Vuono A, Sanlorenzo R, Irtelli F, Mencacci C. Anti‑anxiety 
+efficacy of Sudarshan Kriya Yoga in general anxiety disorder: A 
+multicomponent, yoga based, breath intervention program for patients 
+suffering from generalized anxiety disorder with or without comorbidities. J 
+Affect Disord 2015;184:310‑7.
+28.	 Jacquart J, Miller KM, Radossi A, Haime V, Macklin E, Gilburd D, et al. 
+The effectiveness of a community‑based, mind‑body group for symptoms of 
+depression and anxiety. Adv Mind Body Med 2014;28:6‑13.
+29.	 Forfylow AL. Integrating yoga with psychotherapy: A complimentary 
+treatment for anxiety and depression. Can J Couns Psychother 2011;45:132‑50.
+30.	 Uebelacker LA, Epstein‑Lubow G, Gaudiano BA, Tremont G, Battle CL, 
+Miller IW. Hatha yoga for depression: Critical review of the evidence for 
+efficacy, plausible mechanisms of action, and directions for future research. 
+J Psychiatr Pract 2010;16:22‑33.
+31.	 Telles S, Gaur V, Balkrishna A. Effect of a yoga practice session and a yoga 
+theory session on state anxiety. Percept Mot Skills 2009;109:924‑30.
+32.	 Hoge EA, Bui E, Marques L, Metcalf CA, Morris LK, Robinaugh DJ, et al. 
+Randomized controlled trial of mindfulness meditation for generalized 
+anxiety disorder: Effects on anxiety and stress reactivity. J Clin Psychiatry 
+2013;74:786‑92.
+33.	 Desveaux L, Lee A, Goldstein R, Brooks D. Yoga in the management 
+of chronic disease: A systematic review and meta‑analysis. Med Care 
+2015;53:653‑61.
+34.	 Donesky‑Cuenco D, Nguyen HQ, Paul S, Carrieri‑Kohlman V. Yoga therapy 
+decreases dyspnea‑related distress and improves functional performance in 
+people with chronic obstructive pulmonary disease: A pilot study. J Altern 
+Complement Med 2009;15:225‑34.
+35.	 Fulambarker A, Farooki B, Kheir F, Copur AS, Srinivasan L, Schultz S. Effect 
+of yoga in chronic obstructive pulmonary disease. Am J Ther 2012;19:96‑100.
+36.	 Santana MJ, S‑Parrilla J, Mirus J, Loadman M, Lien DC, Feeny D. An 
+assessment of the effects of Iyengar yoga practice on the health‑related quality 
+of life of patients with chronic respiratory diseases: A pilot study. Can Respir 
+J 2013;20:e17‑23.
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Ranjita, et al.: Effect of yoga on depression, anxiety in COPD
+International Journal of Yoga • Vol. 9 • Jul-Dec-2016
+144
+37.	 Soni R, Munish K, Singh K, Singh S. Study of the effect of yoga training 
+on diffusion capacity in chronic obstructive pulmonary disease patients: A 
+controlled trial. Int J Yoga 2012;5:123‑7.
+38.	 Nagarathna R, Nagendra HR. Yoga for bronchial asthma: A controlled study. 
+Br Med J (Clin Res Ed) 1985;291:1077‑9.
+39.	 Chandwani KD, Perkins G, Nagendra HR, Raghuram NV, Spelman A, 
+Nagarathna R, et al. Randomized, controlled trial of yoga in women with 
+breast cancer undergoing radiotherapy. J Clin Oncol 2014;32:1058‑65.
+40.	 McDermott KA, Rao MR, Nagarathna R, Murphy EJ, Burke A, Nagendra RH, 
+et al. A yoga intervention for type 2 diabetes risk reduction: A pilot randomized 
+controlled trial. BMC Complement Altern Med 2014;14:212.
+41.	 Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN. Yoga therapy as 
+an add‑on treatment in the management of patients with schizophrenia – A 
+randomized controlled trial. Acta Psychiatr Scand 2007;116:226‑32.
+42.	 Tekur P, Chametcha S, Hongasandra RN, Raghuram N. Effect of yoga on 
+quality of life of CLBP patients: A randomized control study. Int J Yoga 
+2010;3:10‑7.
+43.	 Jones PW, Harding G, Berry P, Wiklund I, Chen WH, Kline Leidy N. 
+Development and first validation of the COPD Assessment Test. Eur Respir 
+J 2009;34:648‑54.
+44.	 Jones PW, Brusselle G, Dal Negro RW, Ferrer M, Kardos P, Levy ML, et al. 
+Properties of the COPD assessment test in a cross‑sectional European study. 
+Eur Respir J 2011;38:29‑35.
+45.	 Ringbaek T, Martinez G, Lange P. A comparison of the assessment of quality of 
+life with CAT, CCQ, and SGRQ in COPD patients participating in pulmonary 
+rehabilitation. COPD 2012;9:12‑5.
+46.	 Mackay AJ, Donaldson GC, Patel AR, Jones PW, Hurst JR, Wedzicha JA. 
+Usefulness of the chronic obstructive pulmonary disease assessment test 
+to evaluate severity of COPD exacerbations. Am J Respir Crit Care Med 
+2012;185:1218‑24.
+47.	 Dodd JW, Hogg L, Nolan J, Jefford H, Grant A, Lord VM, et al. The COPD 
+assessment test (CAT): Response to pulmonary rehabilitation. A multicentre, 
+prospective study. Thorax 2011;66:425‑9.
+48.	 Beck AT, Steer RA, Brown GK. Manual for the beck depression inventory-II. 
+San Antonio, TX: Psychological Corporation; 1996.
+49.	 Dozois DJ, Covin R. The Beck Depression Inventory‑II (BDI‑II), Beck 
+Hopelessness Scale (BHS), and Beck Scale for Suicide Ideation (BSS). In: 
+Hersen M, Hilsenroth MJ, Segal DL, editors. Comprehensive Handbook of 
+Psychological Assessment. Personality Assessment and Psychopathology. 
+New York: John Wiley & Sons Inc.; 2004. p. 50‑69.
+50.	 Spielberger CD, Gorsuch RL, Lushene RE. The State‑Trait Anxiety Inventory 
+(Test Manual). Palo Alto, CA: Consulting Psychologists; 1970.
+51.	 Vitasari P, Wahab MN, Herawan T, Othman A, Sinnadurai SK. Re‑test of State 
+Trait Anxiety Inventory (STAI) among engineering students in Malaysia: 
+Reliability and validity tests. Procedia Soc Behav Sci 2011;15:3843‑8.
+52.	 Rao RM, Raghuram N, Nagendra HR, Usharani MR, Gopinath KS, Diwakar 
+RB, et al. Effects of an integrated yoga program on self‑reported depression 
+scores in breast cancer patients undergoing conventional treatment: A 
+randomized controlled trial. Indian J Palliat Care 2015;21:174‑81.
+53.	 Raghuram N, Parachuri VR, Swarnagowri MV, Babu S, Chaku R, Kulkarni R, 
+et al. Yoga based cardiac rehabilitation after coronary artery bypass surgery: 
+One-year results on LVEF, lipid profile and psychological states – A 
+randomized controlled study. Indian Heart J 2014;66:490-502.
+54.	 Tekur P, Nagarathna R, Chametcha S, Hankey A, Nagendra HR. A 
+comprehensive yoga programs improves pain, anxiety and depression in 
+chronic low back pain patients more than exercise: An RCT. Complement 
+Ther Med 2012;20:107‑18.
+55.	 Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effect of integrated yoga 
+therapy on pain, morning stiffness and anxiety in osteoarthritis of the knee 
+joint: A randomized control study. Int J Yoga 2012;5:28‑36.
+56.	 Satyapriya M, Nagarathna R, Padmalatha V, Nagendra HR. Effect of integrated 
+yoga on anxiety, depression & well being in normal pregnancy. Complement 
+Ther Clin Pract 2013;19:230‑6.
+57.	 Newham JJ, Wittkowski A, Hurley J, Aplin JD, Westwood M. Effects of 
+antenatal yoga on maternal anxiety and depression: A randomized controlled 
+trial. Depress Anxiety 2014;31:631‑40.
+58.	 Descilo T, Vedamurtachar A, Gerbarg PL, Nagaraja D, Gangadhar BN, 
+Damodaran B, et al. Effects of a yoga breath intervention alone and in 
+combination with an exposure therapy for post‑traumatic stress disorder and 
+depression in survivors of the 2004 South‑East Asia tsunami. Acta Psychiatr 
+Scand 2010;121:289‑300.
+59.	 de Godoy DV, de Godoy RF. A randomized controlled trial of the effect of 
+psychotherapy on anxiety and depression in chronic obstructive pulmonary 
+disease. Arch Phys Med Rehabil 2003;84:1154‑7.
+60.	 Chan W, Immink MA, Hillier S. Yoga and exercise for symptoms of depression 
+and anxiety in people with poststroke disability: A randomized, controlled 
+pilot trial. Altern Ther Health Med 2012;18:34‑43.
+61.	 Kirkwood G, Rampes H, Tuffrey V, Richardson J, Pilkington K. Yoga for 
+anxiety: A systematic review of the research evidence. Br J Sports Med 
+2005;39:884‑91.
+62.	 van Eck M, Berkhof H, Nicolson N, Sulon J. The effects of perceived stress, 
+traits, mood states, and stressful daily events on salivary cortisol. Psychosom 
+Med 1996;58:447‑58.
+63.	 Vempati RP, Telles S. Yoga‑based guided relaxation reduces sympathetic 
+activity judged from baseline levels. Psychol Rep 2002;90:487‑94.
+64.	 Ray US, Mukhopadhyaya S, Purkayastha SS, Asnani V, Tomer OS, Prashad R, 
+et al. Effect of yogic exercises on physical and mental health of young 
+fellowship course trainees. Indian J Physiol Pharmacol 2001;45:37‑53.
+65.	 Telles S, Nagarathna R, Nagendra HR, Desiraju T. Physiological changes 
+in sports teachers following 3 months of training in Yoga. Indian J Med Sci 
+1993;47:235‑8.
+66.	 Harte JL, Eifert GH, Smith R. The effects of running and meditation on 
+beta‑endorphin, corticotropin‑releasing hormone and cortisol in plasma, and 
+on mood. Biol Psychol 1995;40:251‑65.
+67.	 West J, Otte C, Geher K, Johnson J, Mohr DC. Effects of Hatha yoga and 
+African dance on perceived stress, affect, and salivary cortisol. Ann Behav 
+Med 2004;28:114‑8.
+68.	 Pascoe MC, Bauer IE. A systematic review of randomised control trials on the 
+effects of yoga on stress measures and mood. J Psychiatr Res 2015;68:270‑82.
+69.	 Manzoni GM, Pagnini F, Castelnuovo G, Molinari E. Relaxation training for 
+anxiety: A ten‑years systematic review with meta‑analysis. BMC Psychiatry 
+2008;8:41.
+70.	 Deberry S, Davis S, Reinhard KE. A comparison of meditation‑relaxation 
+and cognitive/behavioral techniques for reducing anxiety and depression in 
+a geriatric population. J Geriatr Psychiatry 1989;22:231‑47.
+71.	 Telles S, Nagarathna R, Nagendra HR. Autonomic changes while mentally 
+repeating two syllables – One meaningful and the other neutral. Indian J 
+Physiol Pharmacol 1998;42:57‑63.
+72.	 Streeter CC, Gerbarg PL, Saper RB, Ciraulo DA, Brown RP. Effects of yoga 
+on the autonomic nervous system, gamma‑aminobutyric‑acid, and allostasis 
+in epilepsy, depression, and post‑traumatic stress disorder. Med Hypotheses 
+2012;78:571‑9.
+73.	 Raghuraj P, Ramakrishnan AG, Nagendra HR, Telles S Effect of two selected 
+yogic breathing techniques of heart rate variability. Indian J Physiol Pharmacol 
+1998;42:467‑72.
+74.	 Nagendra HR, Nagarathna R. An integrated approach of yoga therapy 
+for bronchial asthma: A 3‑54‑month prospective study. J Asthma 
+1986;23:123‑37.
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]

subfolder_0/A review of the scientific studies on cyclic meditation.txt

@@ -0,0 +1,336 @@
+IJOY
+Online full text at
+http://www.ijoy.org.in
+Published by  Medknow Publications
+International 
+Journal of Yoga
+0973-6131
+Volume 2 | Issue 2 | Jul-Dec 2009
+C o n t e n t s
+}
+The power of Prana
+}
+A review of the scientific studies on cyclic meditation
+}
+Cardiovascular and metabolic effects of intensive Hatha Yoga training in middle-aged and older women from 
+northern Mexico
+}
+Effect of yogic education system and modern education system on memory
+}
+Motion analysis of sun salutation using magnetometer and accelerometer
+}
+Normative data for the digit-letter substitution task in school children
+}
+Effects of yoga on symptom management in breast cancer patients: A randomized controlled trial
+International Journal of Yoga 
+ y 
+ Vol. 2: 
+ y 
+ Jul-Dec-2009
+46
+A review of the scientifi
+ c studies on cyclic meditation
+Pailoor Subramanya, Shirley Telles
+Indian Council of Medical Research, Center for Advanced Research in Yoga and Neurophysiology, SVYASA, Bangalore, India
+Address for correspondence: Dr. Shirley Telles,
+Patanjali Yogpeeth, Maharishi Dayanand Gram, Bahadrabad, 
+Haridwar-249 402, Uttarakhand, India. 
+E-mail: [email protected]
+DOI: 10.4103/0973-6131.60043
+Review Article
+GENERAL
+Yoga is an ancient science, originating in India, which 
+has components of physical activity, instructed relaxation 
+and interoception.[1] Yoga includes diverse practices, 
+such as physical postures (asanas), regulated breathing 
+(pranayama), meditation and lectures on philosophical 
+aspects of yoga.[2-3] Meditation is the seventh of eight 
+steps prescribed to reach an ultimate stage of spiritual 
+emancipation (Patanjali, circa 900 B.C.).[4] While many 
+practitioners do learn meditation directly, others find it 
+easier to first pass through the other stages - learn yoga 
+postures (asanas) and regulated breathing (pranayamas). 
+It is postulated that when a novïce attempts to meditate 
+directly, there could be two responses based on the quality 
+of the mind viz., (i) a rajasic – active (personality) mind 
+would be restless all through the session and (ii) a tamasic 
+– a mind with inertia could fall asleep. This problem 
+of the mind is addressed in the Mandukya Upanishad. 
+Based on this a technique of ‘moving meditation’, which 
+combines the practice of yoga postures with guided 
+meditation was evolved, called cyclic meditation (CM), by 
+H.R. Nagendra, Ph.D., which has its’ origin in an ancient 
+Indian text, Mandukya Upanishad.[5] It is interesting to 
+note that CM does induce a quiet state of mind, which is 
+compatible with the description of meditation (dhyana 
+or effortless expansion), according to Patanjali. The 
+description states: ‘Tatra pratyayaikatanata dhyanam’ 
+(Patanjali’s Yoga Sutras, Chapter 3: Verse 2). This means 
+that the uninterrupted flow of the mind towards the object 
+chosen for meditation is dhyana.[4] Indeed, all meditations, 
+irrespective of the strategies involved are believed to help 
+reach this state. There are several strategies in meditation 
+which include breath awareness, awareness of internal 
+sensations, directing the attention to a mantra or a koan, 
+and keeping the eyes open with the gaze fixed on the object 
+of meditation. 
+The verse on which CM is based, states: ‘In a state of mental 
+inactivity awaken the mind; when agitated, calm it; between 
+these two states realize the possible abilities of the mind. 
+If the mind has reached states of perfect equilibrium do 
+not disturb it again’. The underlying idea is that, for most 
+persons, the mental state is routinely somewhere between 
+the extremes of being ‘inactive’ or of being ‘agitated’ and 
+hence to reach a balanced/relaxed state the most suitable 
+technique would be one which combines ‘awakening’ and 
+‘calming’ practices. 
+In CM, the period of practicing yoga postures constitutes 
+the ‘awakening’ practices, while periods of supine rest 
+comprise ‘calming practices’. An essential part of the 
+practice of CM is being aware of sensations arising in 
+the body.[6] This supports the idea that a combination 
+of stimulating and calming techniques practiced with 
+a background of relaxation and awareness (during CM) 
+may reduce psycho physiological arousal more than 
+resting in a supine posture for the same duration. The 
+practice of CM, includes yoga postures (asanas) which 
+involve muscle stretching and this has diverse benefits. 
+The effects, benefits and possible mechanisms underlying 
+CM are given below. 
+SCIENTIFIC STUDIES ON CM 
+The studies described below were all carried out at the 
+Swami Vivekananda Yoga Research Foundation, Bangalore, 
+India, where the technique was devised.
+Studies on autonomic and respiratory variables
+In a previous study, heart rate variability (HRV) was 
+studied in 42 male volunteers in CM and supine rest 
+(SR) sessions. The high frequency (HF) power of the 
+HRV increased during both CM and SR practice, which 
+is considered to suggest increased vagal tone.[7] However, 
+there was a marginally greater increase during CM (4.4 
+%) compared to during SR (1.0 %). In the same study the 
+low frequency (LF) power which is believed to correlate 
+with sympathetic activity was significantly less during 
+both CM (1.8 % decrease) and SR (0.3 % decrease). The 
+study showed parasympathetic dominance. The exact 
+mechanism underlying the effect of CM on the autonomic 
+nervous system is difficult to determine. The effect may be 
+47
+International Journal of Yoga 
+ y 
+ Vol. 2: 
+ y 
+ Jul-Dec-2009
+brought about by reduced cortical activity, which in turn 
+may modify the activity at the level of the hypothalamus.
+An earlier study on 35 male volunteers (between 20-
+46 yrs of age) showed a significant decrease in oxygen 
+consumption and increase in breath volume were 
+recorded after guided relaxation practiced for 10 minutes 
+compared to the equal duration of supine rest. During 
+guided relaxation the power of the LF component of the 
+heart-rate variability spectrum reduced, whereas the 
+power of the HF component increased, suggesting reduced 
+sympathetic activity.[8] However, another study on 40 male 
+volunteers (16 to 46 yrs) showed that Isometric relaxation 
+technique practiced for a minute showed a reduction in 
+the physiological signs of anxiety and stress.[9] 
+More recently, a study on 30 male volunteers (20 to 33 years) 
+showed a decrease in heart rate (HR), low frequency power 
+(LF power), LF/HF ratio, and an increase in the number of 
+pairs of Normal to Normal RR intervals differing by more 
+than 50 ms divided by total number of all NN intervals 
+(pNN50) following the practice of cyclic meditation (CM) 
+suggestive of a shift towards sympatho-vagal balance in 
+favor of parasympathetic dominance during sleep.[10] 
+Studies on applications in reducing occupational stress 
+levels
+In a subsequent study correlating CM and heart 
+rate variability, a two-day CM program decreased 
+occupational stress levels and baseline autonomic 
+arousal in 26 asymptomatic, male, middle managers,[11] 
+suggesting significant reduction in sympathetic activity. 
+The mechanisms underlying the decrease in occupational 
+stress levels may be related to decreased autonomic arousal 
+(sympathetic activation) as well as psychological factors, 
+though this remains a speculation.
+Studies on metabolism and oxygen consumed
+An earlier study on oxygen consumption showed that a 
+period of CM significantly reduced oxygen consumption 
+to a greater degree (32.1%) than a comparable period of 
+supine rest.[12] A recent study also showed that after the 
+practice of CM oxygen consumption decreased (19.3 %) 
+compared to following SR (4.8 %). Also, the change in 
+oxygen consumption suggested that after the practices (but 
+not during) there was a period of physiological relaxation 
+which was more after CM compared to SR.[13] 
+The energy expenditure (EE), respiratory exchange ratio 
+(RER) and heart rate (HR) of 50 male volunteers were 
+assessed before, during, and after the sessions of CM and 
+sessions of supine rest. CM reduced the energy expenditure 
+more than supine rest alone.[14] The studies cited above 
+were conducted using the self-as-control design. Reduction 
+in oxygen consumption due to CM practice could be related 
+to decreased oxygen consumption of the brain and the 
+skeletal muscles (which are probably more relaxed with 
+the practice of CM).
+Studies on attention and electrophysiology
+Earlier studies showed that despite the changes suggestive 
+of parasympathetic dominance following CM, there was a 
+decrease in the P300 peak latency and an increase in the 
+P300 peak amplitude when the P300 was obtained using 
+an auditory oddball paradigm.[15] The P300 component of 
+event-related brain potentials (ERPs) is generated when 
+persons attend to and discriminate stimuli which differ 
+in a single aspect. More recently, middle latency auditory 
+evoked potentials (0-100ms range) were examined in 47 
+male volunteers before and after the practice of CM which 
+has resulted in prolonged latencies of evoked potentials 
+generated within the cerebral cortex, supporting the idea 
+of cortical inhibition after CM.[16] The studies cited above 
+were conducted using the self-as-control design. The 
+mechanism by which CM may improve attention while 
+reducing sympathetic tone may be related to increased 
+proprioceptive input (during the practice of asanas) to the 
+Reticular Activating System (RAS), which in turn keeps 
+cortical areas receptive and active.[17] This is difficult to 
+understand as generally increased alertness and vigilance 
+is associated with an increase in sympathetic tone.
+Studies on performance in cancellation task
+In a previous study, the effect of CM practice on 
+performance in a letter cancellation task, was assessed 
+in 69 male volunteers (whose ages ranged from 18 to 
+48 years).[18] There was improved performance in the 
+task which required selective attention, concentration, 
+visual scanning abilities, and a repetitive motor response 
+following CM. The results were interpreted to suggest 
+that the improved performance after CM suggests that the 
+practice not only globally enhances performance but also 
+selectively reduces the probability of being distracted. 
+Again, it is difficult to understand how CM practice, 
+associated with reduced sympathetic activity, increases the 
+performance in an attention task. As described above this 
+may be via increased proprioceptive input to the reticular 
+activating system.
+Study on memory and anxiety
+In a recent study 57 male volunteers (group average age 
+± S.D., 26.6 ± 4.5 years) the immediate effect of CM 
+and SR were studied on memory and state anxiety. A 
+cyclical combination of yoga postures and supine rest 
+in CM improved memory scores immediately after the 
+practice and decreased state anxiety more than rest in a 
+classical yoga relaxation posture (shavasana).[19] Like the 
+Scientifi
+ c studies on CM
+International Journal of Yoga 
+ y 
+ Vol. 2: 
+ y 
+ Jul-Dec-2009
+48
+P300 event-related potential and the letter cancellation 
+task, performance in the memory task requires increased 
+alertness. The mechanism (as described above) remains 
+speculative.
+Study on polysomnography
+In a recent study, whole night polysomnography measures 
+and the self-rating of sleep were assessed on the night 
+following a day in which 30 male volunteers practiced 
+CM twice (approximately 22:30 minutes each time). This 
+was compared to another night when they had two, equal 
+duration sessions of supine rest (SR) on the preceding day. 
+The percentage of slow wave sleep (SWS) was significantly 
+more in the night following CM practice than the night 
+following SR;  percentage of rapid eye movement (REM) 
+sleep and the number of awakenings per hour were less. 
+The practice of CM during day time has been shown 
+to increase the percentage of slow wave sleep in the 
+subsequent night.[20] CM has a number of components 
+which may facilitate sleep such as increased physical 
+activity, muscle stretching, interoception, and guided 
+relaxation.
+CONCLUSION
+The practice of CM in general appears to bring about a 
+state of low physiological activation, as described above, 
+with reduced oxygen consumption and a shift in the 
+sympathovagal balance towards vagal dominance. A period 
+of CM practice significantly reduces oxygen consumption 
+and energy expenditure to a greater degree (32.1%) than 
+a comparable period of supine rest. The CM program has 
+also been shown to decrease occupational stress levels and 
+baseline autonomic arousal. There is also an improved 
+performance in a letter cancellation task which requires 
+selective attention, concentration, visual scanning abilities, 
+and a repetitive motor response following CM. Moreover, a 
+study of the P300 following CM suggested that participants 
+showed a better ability to discriminate auditory stimuli 
+of different pitches in a P300 auditory oddball task. The 
+prolonged latencies of evoked potentials, generated within 
+the cerebral cortex after the practice of CM, supported the 
+idea of cortical inhibition after CM. The practice of CM 
+during day time has been shown to increase the percentage 
+of slow wave sleep in the subsequent night. This 
+suggests that CM practice (i) reduces autonomic arousal, 
+(ii) improves attention, and (iii) improves quality of sleep. 
+ACKNOWLEDGMENT
+The authors gratefully acknowledge H.R. Nagendra, Ph.D. who 
+derived the cyclic meditation technique from ancient yoga texts. 
+REFERENCES
+1. 
+Vivekananda Kendra. Yoga the science of holistic living. Chennai: 
+Vivekananda Kendra Prakashan Trust; 2005.
+2. 
+Nagendra HR. Yoga its’ basis and applications. Bangalore: Swami 
+Vivekananda Yoga Prakashana; 2004. 
+3. 
+Saraswati Niranjanananda Swami. Prana, Pranayama, Pranavidya. Munger, 
+Bihar: Yoga publication trust, Bihar School of yoga; 1994.
+4. 
+Taimini IK. The science of yoga. Madras, India: The Theosophical Publishing 
+House; 1986.
+5. 
+Chinmayanada Swami. Mandukya Upanishad. Bombay, India: Sachin 
+Publishers; 1984. 
+6. 
+Nagendra HR, Nagarathna R. New perspectives in stress management. 
+Bangalore, India: Swami Vivekananda Yoga Prakashana; 1997.
+7. 
+Sarang P, Telles S. Effects of two yoga based relaxation techniques on heart 
+rate variability. Int J Stress Manag 2006;13:460-75. 
+8. 
+Vempati RP, Telles S. Yoga based guided relaxation reduces sympathetic 
+activity in subjects based on baseline levels. Psychol Rep 2002;90:487-94. 
+9. 
+Vempati RP, Telles S. Yoga based relaxation versus supine rest: A study of 
+oxygen consumption, breath rate and volume and autonomic measures. J 
+Indian Psychol 1999;17:46-52. 
+10. Patra S, Telles S. Heart rate variability during sleep following the practice 
+of cyclic meditation and supine rest. Appl Psychophysiol Biofeedback 2009; 
+In Press. 
+11. 
+Vempati RP, Telles S. Baseline occupational stress levels and physiological 
+responses to a two day stress management program. J Indian Psychol 
+2000;18:33-7. 
+12. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration 
+following two yoga relaxation techniques. Appl Psychophysiol Biofeedback 
+2000;25:221-7. 
+13. Sarang PS, Telles S. Oxygen consumption and respiration during and 
+after two yoga relaxation techniques. Appl Psychophysiol Biofeedback 
+2006;31:143-53.
+14. Sarang, SP, Telles S. Cyclic meditation: A moving meditation-reduces energy 
+expenditure more than supine rest. J Indian Psychol 2006;24:17-25.
+15. Sarang SP, Telles S. Changes in P300 following two yoga-based relaxation 
+techniques. Int J Neurosci 2006;116:1419-30.
+16. Subramanya P, Telles S. Changes in midlatency auditory evoked potentials 
+following two yoga-based relaxation techniques. Clin EEG Neurosci 
+2009;40:190-5. 
+17. Kandel ER, Schwartz JH, Jessell TM. Principles of neural science. 4th ed. 
+New York, USA: McGraw- Hill; 2000. 
+18. Sarang SP, Telles S. Immediate effect of two yoga based relaxation 
+techniques on performance in a letter-cancellation task. Percept Mot Skills 
+2007;105:379-85. 
+19. Subramanya P, Telles S. Effect of two yoga-based relaxation techniques on 
+memory scores and state anxiety. Biopsychosoc Med 2009;3:8.
+20. Patra S, Telles S. Positive impact of cyclic meditation on sleep. Med Sci 
+Monit 2009;15:CR375-81.
+Subramanya and Telles

subfolder_0/A self-rating scale to measure tridos.as in_unlocked.txt

@@ -0,0 +1,1111 @@
+Original Article
+	
+Ancient Science of Life / Oct-Dec 2013 / Vol 33 / Issue 2
+85
+A self-rating scale to measure tridos
+.as in 
+children
+S.P. Suchitra, H.R. Nagendra1
+Life Sciences, 1Vice Chancellor, Swami Vivekananda Yoga Anusandhana Samsthana, Yoga University, Bangalore
+INTRODUCTION
+A
+yurveda, the ancient life science is an aspect of Vedic lore 
+is broadly based on the principles of tridoṣas‑ vāta, pitta 
+and kapha. Tridoṣas are fundamental principles which maintain 
+bodily function (just as the sun, moon and air maintain the 
+universe, somatic functions are maintained by the dos
+.as).[1‑9]
+Western psychologists propose type and trait theories 
+for personality. Father of modern medicine, Hippocrates 
+ABSTRACT
+Background: Self  –  rating inventories to assess the 
+Prakr
+.ti (constitution) and personality have been developed 
+and validated for adults. To analyze the effect of personality 
+development programs on Prakr
+.ti of the children, standardized 
+scale is not available. Hence, present study was carried out to 
+develop and standardize Caraka Child Personality inventory (CCPI).
+Materials and Methods: The 77‑ item CCPI scale was developed 
+on the basis of translation of Sanskrit verses describing va
+-taja (a), 
+pittaja (b) and kaphaja prakr
+.ti (c) characteristics described in 
+Ayurveda texts and by taking the opinions of 5 Ayurveda experts 
+and psychologists. The scale was administered on children of the 
+age group 8-12 years in New Generation National public school, 
+Bangalore.
+Results: This inventory was named CCPI and showed excellent 
+internal consistency. The Cronbach’s alpha for A, B and C scales 
+were 0.54, 0.64 and 0.64 respectively. The Split ‑ Half reliability 
+scores for A, B and C subscales were 0.64. 0.60 and 0.66 
+respectively. Factor validity coefficient Scores on each item was 
+above 0.4. Scores on va
+-taja, pittaja and kaphaja scales were 
+inversely correlated. Test-retest reliability scores for A,B and C 
+scales were 0.87,0.88 and 0.89 respectively. The result of CCPI was 
+compared with a parent rating scale Ayurveda Child Personality 
+Inventory (ACPI). Subscales of CCPI correlated significantly 
+highly (above 0.80) with subscales of ACPI which was done for 
+the purpose of cross‑validation with respect to ACPI.
+Conclusions: The prakr
+.ti of the children can be measured 
+consistently by this scale. Correlations with ACPI pointed toward 
+concurrent validity.
+KEY WORDS: Tridosha, prakriti, va
+-ta, pitta, kapha, Ayurveda
+classifies individuals as choleric, melancholic, sanguine, and 
+phlegmatic based on the predominance of bodily humors. 
+This comes close to Ayurveda’s description of personalities 
+except for the description of vāta in the latter. Sheldon’s 
+Somato‑type classification ectomorphic, endomorphic, 
+mesomorphic types of personalities have been correlated 
+with Ayurveda prakṛti.[12] Other psychologists do not 
+consider wide‑ranging aspects of the personality.[10]
+Ayurveda classics[1‑9] propose a comprehensive analysis of 
+personality, encompassing physical‑physiological aspects 
+like color of the eyeball, texture of hair, appetite, sleep, 
+behavior, attitudes and interests, memory, intelligence, 
+mental stamina of an individual to come to a conclusion 
+about the tridoṣa state of the individual. The biological 
+qualities of tridoṣas also influence mental and behavioral 
+qualities. The texts suggest seven types of personality (vāta, 
+pitta, kapha, vāta–pitta, vāta–kapha, pitta–kapha, sama) 
+determined by predominance of a single, a pair, or all of 
+the doṣas.
+Ayurveda considers the balanced state (sama) of Tridoṣa 
+as health. Person with predominance of single and 
+double doṣas will certainly be vulnerable to diseases, as 
+vitiation of tridoṣas is the cause for the manifestation of 
+disease.[3] Accordingly, Ayurveda recommends specific 
+diet and daily regimen for different types of personalities 
+to maintain health.Studies have discussed the importance 
+of Ayurveda[11], tridoṣas.[12] A Statistical model of doṣa prakṛti 
+based on analysis of a questionnaire has been developed.[13]
+An analysis of the tridoṣa physiology, linking it to processes 
+of cellular physiology has been carried out. These studies 
+postulate the correspondence of functions of Vāta with 
+input/output  (homeostasis); Functions of Pitta with 
+Access this article online
+Quick Response Code:
+Website:
+www.ancientscienceoflife.org
+DOI:
+10.4103/0257-7941.139042 
+[Downloaded free from http://www.ancientscienceoflife.org on Wednesday, July 27, 2016, IP: 14.139.155.82]
+86 	
+Ancient Science of Life / Oct-Dec 2013 / Vol 33 / Issue 2
+Suchitra and Nagendra: Self rating scale to asses prakr
+.ti
+turnover (negative entropy production); and functions of 
+kapha with storage of the cellular functions.[14‑16] Similarly, a 
+genetic basis of tridoṣa constitution has been postulated.[17‑20] 
+A study comparing the Ayurveda personality concepts and 
+western psychology concepts is available.[21‑22] Ayurveda 
+tridoṣa theory and four elements of Buddhist medicine, 
+Chinese humorolgy has been compared.[23,24] Importance 
+of prakṛti in ageing has been discussed.[25] Effect of 
+isotonic exercise on different types of prakṛti has been 
+observed.[26] A difference in metabolism of different prakṛti 
+has been explained.[27] Left and right hemisphere chemical, 
+dominance has been observed with predominance of 
+doṣas.[28] Another study postulated  ADP‑induced maximal 
+platelet aggregation was highest among the vāta‑pitta 
+prakṛti individuals.[29] Relationship between vāta prakṛti 
+and Parkinson’s disease has been studied.[30] A scale to 
+measure tridoṣas in psychotic patients has been developed.[31] 
+Ayurveda Child Personality Inventory (ACPI), a parent 
+rating scale to measure tridoṣas in children has been 
+standardized.[32]  Chinese humorology and cosmology have 
+been compared showing that as humors control all the 
+activities of the body similarly in other form they control the 
+universe. [33] Scale to measure tridoṣas in psychotic patients 
+has been developed and standardized.[34] Ayurveda guṇa 
+inventory has been developed and standardized.[35]
+The scale has been developed based on Sanskrit verses 
+quoted in nine texts and content validitation of 10 
+Ayurveda experts and three psychologists had three 
+subscales ‑ vāta (number of items in scale‑46), pitta (number 
+of items in scale‑44), kapha (number of items in scale‑47). It 
+was associated with good Cronbach’s alpha (above 0.5) and 
+the Split‑Half scores for all subscales (above 0.6 except pitta 
+scale which was 0.39). Factor validity coefficient Scores on 
+each items was above 0.5.
+However, a simple self ‑ rating scale to assess the personality 
+of children, (as parents are often not available during 
+personality development camps etc) according to Āyurvedic 
+comprehensive concepts is not available.
+Aims of the present study were
+(i)	
+
+To develop a self‑rating scale Caraka child personality 
+inventory (CCPI)
+(ii)	 
+To measure tridoṣas in children and to compare with 
+criterion ACPI, parent rating scale to establish of 
+validity of the scale.
+MATERIALS AND METHODS
+Ethical clearance was approved by research board of 
+SVYASA  (Yoga University). The CCPI was developed 
+based on 522 characteristics from nine authoritative ancient 
+Ayurveda texts in Sanskrit describing characteristics typical 
+of vātaja, pittaja and kaphaja prakṛti. Item reduction was 
+carried out by deleting the repeated items, ambiguous 
+items, and by selecting those items specifically suitable for 
+children [Table 1].
+155 items were shortlisted out of 522 in the texts and, 
+translation in English, were presented to ten Ayurveda 
+experts. They were asked to judge the correctness of each 
+statement and to check (1) whether any of the item was 
+repeated or if any item should be added? (2) Whether the 
+features of vātaja, pittaja and kaphaja prakṛti selected for the 
+scale are correct and (3) if the items constructed represented 
+acceptable translation of the Sanskrit in the original texts. 
+147 items were retained. Out of which, some of items were 
+changed and refined [Table 2].[36]
+Based on the final list of statements from the Sanskrit texts, 
+77 questions of CCPI were framed by the researcher. The 
+scale was again presented to five Ayurveda experts and 
+one psychologist, who reviewed the format of this scale 
+and recommended a two point scoring (zero and one), 
+this was adopted in the final CCPI. Suggestions about the 
+Table 1: Texts and number of items
+Text
+Vāta prakr
+. ti
+Pitta prakr
+. ti
+Kapha prakr
+. ti
+a
+b
+c d a
+b
+c d a
+b
+c d
+Caraka Sam
+. hitā
+28 1 (27) 1 2 21
+0
+2 5 21 0 (21) 6 1
+Suśruta sam
+. hitā
+25 13 (12) 2 0 21 8 (14) 3 0 28 7 (21) 3 1
+As
+.t
+.ān
+. ga samgraha
+25 16 (9) 3 0 26 19 (7) 0 0 40 19 (21) 3 0
+As
+.t
+.ān
+. ga hṛdaya
+24 20 (4) 2 1 31 26 (5) 1 1 43 38 (5) 4 0
+Bhela Sam
+. hitā
+16 11 (5) 3 0 18 10 (8) 1 0 24 14 (0) 8 0
+Bhāvaprakāśa
+8
+7 (1)
+0 0 8
+8 (0) 0 0 6
+6 (0)
+0 0
+Harita Sam
+. hitā
+16
+7 (9)
+2 0 16 9 (7) 0 0 16
+9 (7)
+4 0
+Śārangadhara Sam
+. hitā
+6
+6 (0)
+0 0 5
+5 (0) 0 0 5
+4 (1)
+1 0
+Kāśyapa Sam
+. hitā
+28 28 (0) 0 0 21 21 (0) 0 0 21 21 (0) 0 0
+Number of initial items (Sanskrit) collected from Nine Ayurveda texts with number 
+of repeated, ambiguous items and items not concerned with children. a: Initial 
+number of items, b: Repeated (retained) number if items, c: Ambiguous items, 
+d: Items not concerned with children
+Table 2: Content validity by experts
+Experts
+Comment
+1 (RH)
+Agreed all questions except 3,4,5 questions
+2 (AH)
+Agreed all questions
+3 (SUG)
+Agreed all questions 4,5 questions
+4 (RA)
+Agreed for all items except 10,11 questions
+5 (SHK)
+Agreed for all items except 11,12 questions
+6 (AAJ)
+Suggested changes in the format of questions
+RH: Raju H, AH: Ahalya, SUG: Suguna, RA: Ramesh A, SHK: Shekahr K, AAJ: 
+Arati Jaggannath
+[Downloaded free from http://www.ancientscienceoflife.org on Wednesday, July 27, 2016, IP: 14.139.155.82]
+	
+Ancient Science of Life / Oct-Dec 2013 / Vol 33 / Issue 2
+87
+Suchitra and Nagendra: Self rating scale to asses prakr
+.ti
+phrasing of questions were incorporated. All questions 
+which were agreed upon by three to four Ayurveda experts 
+and psychologist, were retained.
+The final CCPI had 77 items ‑ 26 items for vātaja prakṛti 
+(A‑scale) 24 items for pittaja prakṛti (B‑scale) and 27 items 
+for kaphaja prakṛti (C‑scale) subscales. The questionnaire was 
+to be answered by the children (Appendix 2).
+Data collection and analysis
+Item difficulty level was analyzed by administering the 
+scale on 30 children on the age group 8‑12 years. Informed 
+consent of the children and parents was taken in prescribed 
+format (See Appendix‑3). For testing the internal consistency 
+and validity, the scale was administered on children who 
+were the students of New generation National Public school 
+in Bangalore, of both sexes between the age of 8 to 12 years 
+[Table 3].
+The final 77 item CCPI was administered on 200 children. 
+Ayurveda child personality inventory (ACPI), a parent 
+rating scale was administered on 30 parents of the children. 
+Comparison was done for the purpose of cross‑validation. 
+To assess Test‑retest reliability, CCPI was administered on 
+30 children, after an interval of 15 days.
+The Statistical Package for Social Sciences (SPSS‑16.0) was 
+used for data analysis. The data was analyzed for reliability. 
+The split‑half and Cronbach’s alpha tests were applied for 
+internal consistency analysis. Pearson’s correlation analysis 
+was done to check the degree of association between 
+vāta, pitta and kapha scores and Test and Retest reliability. 
+Principal component analysis (factor analysis) was done to 
+check the validity.
+RESULTS
+Content validity
+Amongst six experts, who served as judges all 77 questions 
+were agreed upon by four to five experts.[38]
+Item difficulty level
+This is defined as the presence of a said symptom expressed 
+as the percentage of children who score positive to that 
+item.[20‑22] The results obtained from the administration of 
+ACPI on parents of 60 children showed 136 items that had 
+a coefficient less than 0.9 (answered yes by the most) and 
+more than 0.3 (answered yes by the least number of subjects) 
+were retained.
+Internal consistency
+An analysis of the data collected from 200 children showed 
+the Cronbach’s alpha for V, P and K scales were 0.54, 0.64 
+and 0.64 respectively. The Split‑Half reliability for V, P and K 
+scale were 0.64, 0.60 and 0.66 respectively. This shows that 
+the three scales have acceptable internal consistency.[37,39]
+Test‑Retest reliability
+Scores on 30 Children revealed V, P and K scales have good 
+correlation, 0.87,0.88 and 0.89 respectively before and after 
+15 days of assessment.
+Correlations
+The subscales (Vāta, Pitta, Kapha) correlated significantly 
+(negatively) with each other [Table 4].
+Factor analysis
+Factor analytic co‑efficient obtained for each items in 
+the V‑scale, P‑scale, and K‑scale for total score was 
+more than 0.3. [Table 3].
+Correlation with ACPI –parent rating scale
+V, P, K subscales correlated significantly positively with V, 
+P, K scales of parent rating scale [Table 5].
+Table 3: Demographic data
+Sample
+Boys
+Girls
+Total
+Gender (boys)
+104
+96
+200
+Age range
+8‑12 years
+8‑12 years
+8‑12 years
+Mean±SD
+10.13±1.23
+10.0±1.18
+10.27±1.28
+Mean and standard deviation of demographics. Out of 200, children 104 were 
+boys, 96 were girls, aged around 8‑12 years. Mean age being 10.27. Studying in 
+3rd standard to 7th standard, mean education being 4.65. SD: Standard deviation
+Table 4: Correlation among subscales
+Scales
+Correlation
+Significance
+Vāta vs Pitta
+−0.31**
+P<0.01
+Vāta vs Kapha
+−0.49**
+P<0.01
+Pitta vs Kapha
+−0.66**
+P<0.01
+(**) r‑Pearson correlation values and significance of correlation between subscales 
+which is at 99% confidence level. Pitta highly negatively correlating with Kapha, 
+Vāta having less correlation with Pitta
+Table 5: Correlation with ACPI
+Vp vs Vc
+r=0.89**
+Pp vs Pc 
+r=0.85**
+Kp vs Kc 
+r=0.90**
+Pearson correlation (r) of each subscales of CCPI with subscales of parent rating 
+scale ACPI (**P<0.01). Vāta, Pitta, Kapha subscales of CCPI correlated highly 
+positively with Vāta, Pitta, Kapha subscales of ACPI (Parent rating scale)
+[Downloaded free from http://www.ancientscienceoflife.org on Wednesday, July 27, 2016, IP: 14.139.155.82]
+88 	
+Ancient Science of Life / Oct-Dec 2013 / Vol 33 / Issue 2
+Suchitra and Nagendra: Self rating scale to asses prakr
+.ti
+DISCUSSION
+The present study has described the development and 
+initial standardization of 77 items, self‑ rating, the CCPI 
+as an instrument to assess the personality (prakṛti) of the 
+children.
+The reliability of subscales was substantiated by Cronbach’s 
+Alpha co‑efficient ranged from 0.54 to 0.64 and Split‑half 
+analysis ranging from 0.60 to 0.66. This provided the 
+evidence of homogeneity of items.[40]
+For the ACPI (a parent rating scale to assess the prakṛti of 
+the children of the age group 6‑12 years), Cronach’s alpha 
+ranged from 0.55 to 0.84, spilt‑half coefficient ranged from 
+0.39 to 0.84. The construct validity of items of subscales was 
+supported by Factor –analysis which was done to check the 
+association of the items with subscales. Factor loadings for 
+Vāta scale ranged from 0.41‑0.7, for pitta scale 0.47 ‑0.72, for 
+kapha scale 0.41‑0.76 Appendix‑1.While of ACPI, 0.55‑0.86, 
+0.55‑0.78, 0.46‑0.77 respectively for vāta, pitta and kapha 
+scales. This proved to be a good correlation of items with 
+respective subscales.
+Correlation between vātaja, pittaja and kaphaja scale 
+scores was negative, suggesting discriminative validity. 
+Values ranging from 0.31 to 0.66, significance at 99% 
+confidence for all correlations. Although of ACPI was 
+0.16 to 0.82, significance for vāta‑ pitta correlation was at 
+95% confidence.
+Correlation with parent rating scale provided evidence 
+of concurrent validity. Classical texts of Ayurveda state 
+that when vāta and kapha (cold) increases, pitta decreases., 
+similarly when vāta decreases kapha increases.
+Applying the inventory to children, further helped to 
+measure the prakṛti of the children. Among selected 
+sample 27% were vāta‑pitta, 27%were pitta‑kapha, 
+33% were vāta‑kapha, 9% were kapha, 2%were sama, 2% were 
+pitta [Table 6].
+Changes in scores were observed between boys and 
+girls [Table 7]. Most girls scored high in kapha, vāta‑kapha 
+and pitta‑kapha prakṛti scales. Similarly Boys scored high in 
+pitta, vāta‑pitta prakṛti scales. Boys score was high in Pitta 
+indicating high aggressiveness and Girls scores were high 
+in Kapha indicating higher patience.
+Subscales of CCPI correlated highly (‘r’above 0.8), positively 
+with subscales of ACPI, parent rating scale  [Table  5], 
+suggesting criterion related validity.
+The difference in the results of self‑rating and parent‑rating 
+scales, may be because of discrepancy in types of prakṛti 
+of children, which was different in parent rating scale 
+study and self‑rating study, as both inventories were 
+administered in different schools, and variance in 
+ 
+race was observed [Ayurveda texts claim that prakṛti can be 
+influenced by race/ethnicity].[3]
+The Strength of the study is that it is the first attempt to 
+develop a consistent, self –rating scale to measure prakṛti of 
+the children. Knowing one’s prakṛti is the first step towards 
+maintaining one’s health.[1‑9] A  balanced state of three 
+doṣas is considered as health.[4] A tool as developed in this 
+study will be useful in assessing the clinical significance of 
+prakṛti based regimen in prevention of somatic and mental 
+illnesses.
+Though published scales are available to assess the 
+prakṛti of an individual,[11] they have been designed 
+for adultswhereas children require a different mode of 
+questioning. Hence, CCPI can be potentially used to 
+identify the predominant doṣas in children, and thus will 
+help to plan suitable regimens at an early age to maintain 
+health of the children.
+A study has revealed significant effect of Yoga on 
+tridoṣas.[32] And treatment modalities are different for 
+Table 7: Mean differences between Boys and Girls
+Sample
+Vāta
+Pitta
+Kapha
+Boys
+11.3
+11.8*
+11.8
+Girls
+11.2
+10.0
+13.6*
+Mean scores of Boys and Girls in each subscales. Showing high scores on kapha 
+in girls (13.6, for boys it is 11.8), high scores on pitta in Boys (11.8, for girls it is 
+10.0). Changes were significant P<0.05 (One sample t‑test). *P<0.001
+Table 6: Mean dos
+.a scores for three different diagnostic groups
+Doṣa→
+Diagnosis↓
+Vātaja
+Pittaja
+kaphaja
+Vāta‑pitta (n=17)
+14.3
+13.8
+7.0
+Pitta‑kapha
+7.1
+13.5
+14.9
+Vāta‑Kapha
+13.6
+7.0
+14.4
+Kapha
+7.0
+7.1
+20.8
+Pitta
+7.0
+20.7
+7.2
+Sama
+11.4
+11.5
+12
+Distribution of different categories of prakṛti children (who particularly scored high 
+in one or two subscales) sample scores in each subscales.Children scoring high 
+in Vāta‑Pitta scored 14.3 and 13.8 in respective Vāta‑Pitta scales., who scored 
+high in Pitta‑Kapha scored 13.5 amd 14.9 in respective scales and who scored 
+high in Vāta‑kapha scored 13.6 and 14.4 in respective scales. And who were 
+predominant in single dosahs, scored 20.8 (kapha prakṛti) ,20.7 (Pitta prakṛti) in 
+respective scales. Who were of sama prakṛti scored 11.4,11.5,12 in vāta, pitta, 
+kapha scales respectively
+[Downloaded free from http://www.ancientscienceoflife.org on Wednesday, July 27, 2016, IP: 14.139.155.82]
+	
+Ancient Science of Life / Oct-Dec 2013 / Vol 33 / Issue 2
+89
+Suchitra and Nagendra: Self rating scale to asses prakr
+.ti
+different prakṛti.[1‑9] Thus, the study is a initial step towards 
+positive health.
+Limitations of the study: Though CCPI is a consistent, 
+valid instrument, it has not addressed the  norms of the 
+scale. Further studies are needed to confirm whether the 
+items used in the inventory are sensitive enough to assess 
+prakr
+.ti with predominance of a particular doṣa. Studies 
+should be done on more number of samples and norms 
+should be established.
+CONCLUSIONS
+A CCPI is a consistent and valid instrument. Its reliability 
+to assess the prakṛti should be further studied. Tridoṣa 
+measure may point out to diet and regimen plans 
+management to prevent the disease and maintain the 
+health of the children.
+ACKNOWLEDGMENT
+We thank, Dr.Kishore, Dr. Aarti Jagannathan, Dr.Uma and 
+Āyurveda experts in Hubli, Bengaluru Ayurveda College, for their 
+support and participation in the study.
+REFERENCES
+1.	
+Tripati R. Ashtanga sangraha: Hindi commentary. Second edition. 
+New Delhi: Choukamba publications; 2001.
+2.	
+Tripati B. Ashtanga Hradaya: Hindi commentary. Second edition. 
+New Delhi: Choukamba publications; 1997.
+3.	
+Panday  GS. Caraka samhita: Hindi commentary. Fifth edition. 
+New Delhi: Choukamba publications; 1997.
+4.	
+Shastry KA. Sushruta Samhita: Hindi vyakhya. Fifteenth edition. 
+New Delhi: Choukamba publications; 2002.
+5.	
+Brahmashankaramishra. Bhavaprakash: Hindi Vyakhya. Tenth 
+edition. Varanasi: Chaukamba smaskrita bhavan; 2002.
+6.	
+Pandit Parashram shastri. Sharangadhara samhita: Samskrita vyakhya. 
+Sixth edition. Varanasi: Chaukamba Orientalia; 2005.
+7.	
+Krishnamurthy KH. Bhavaprakasha: English commentary. First edition. 
+Varanasi: Chaukamba Vishwabharati; 2000.
+8.	
+Pandit Hariprasad Tripati. Harita samhita: Hindi vyakhya. First edition. 
+Varanasi: Chaukamba Krishnadas Academy; 2005.
+9	
+Vidya Lakshmipati Shastri. Yogaratnakara: Hindi commentary. Re print 
+edition. Varanasi: Chaukamba Prakashana; 2007.
+10.	 Walter Misched. Introduction to Personality. New York: Holt. Rinehart 
+and Winston Inc.; 1971
+11.	 Concon AA.Tridosha and Three Original Energies; Am J Chin Med 
+1980 Winter;8:391.
+12.	 Rizzo‑Sierra CV. Ayurvedic genomics, constitutional psychology, and 
+endocrinology: The missing connection. J Altern Complement Med 
+2011 May;17:465‑8. Epub 2011 May 12.
+13.	 Joshi RR. A biostatistical approach to Ayurveda: Quantifying the 
+tridosa. Journal of Alternative and Complementary Medicine 
+2005;11:221‑225.
+14.	 Hankey A. The scientific value of Ayurveda. J Altern Complement Med 
+2005 Apr;11:221‑5.
+15.	 Hankey A. A test of the systems analysis underlying the scientific 
+theory of Ayurveda Tridosa. Journal of Alternative and Complementary 
+Medicine 2005;11:385‑390.
+16.	 Hankey  A. Establishing the Scientific Validity of Tridosha 
+part  1: Doshas, Subdoshas and Dosha Prakritis. Anc Sci Life. 
+2010 Jan;29:6‑18.
+17.	 Patwardhan B., Joshi K., Chopra A. Classification of Human Population 
+Based on HLA Gene Polymorphism and the Concept of Prakriti in 
+Ayurveda. Journal of Alternative and Complementary Medicine 
+2005;11:349 ‑353.
+18.	 Patwardhan B., Bodeker G. Ayurvedic genomics: Establishing a genetic 
+basis for mind‑body typologies. J Altern Complement Med 2008 Jun; 
+14:571‑6.
+19.	 Prasher B, Negi S, Aggarwal S, Mandal AK, Sethi TP, Deshmukh SR, 
+et al. Whole genome expression and biochemical correlates of 
+extreme constitutional types defined in Ayurveda. J Transl Med 
+2008 Sep 9;6:48.
+20.	 Mishra L, Singh BB, Dagenais S: Healthcare and disease management 
+in Ayurveda. Altern Ther Health Med 2001 Mar;7:44‑50.
+21.	 Aggarwal  S, Negi  S, Jha  P, Singh  PK, Stobdan  T, Pasha  MA, et 
+al. EGLN1 involvement in high‑altitude adaptation revealed 
+through genetic analysis of extreme constitution types defined 
+in Ayurveda. Proc Natl Acad Sci U S A 2010 Nov 2;107:18961‑6. 
+Epub 2010 Oct 18.
+22.	 Dube KC, Kumar A, Dube S: Personality types in Ayurveda. Am J Chin 
+Med 1983;11:25‑34.
+23.	 Dube KC: Nosology and therapy of mental illness in Ayurveda. Comp 
+Med East West 1979 Fall; 6:209‑28.
+24.	 Scharfetter C: Ayurveda; Schweiz Med Wochenschr. 1976 Apr 
+24;106:565‑72.
+25.	 Tripathi  PK, Patwardhan  K, Singh G: The basic cardiovascular 
+responses to postural changes, exercise, and cold pressor test: Do they 
+vary in accordance with the dual constitutional types of ayurveda? 
+Evid Based Complement Alternat Med 2011;2011:251850. Epub 
+2010 Aug 30.
+26.	 Ghodke Y, Joshi K, Patwardhan B: Traditional Medicine to Modern 
+Pharmacogenomics: Ayurveda Prakriti Type and CYP2C19 Gene 
+Polymorphism Associated with the Metabolic Variability. Evid Based 
+Complement Alternat Med 2009 Dec 16. [Epub ahead of print].
+27.	 Kurup  RK, Kurup PA: Hypothalamic digoxin, hemispheric 
+chemical dominance, and the tridosha theory. Int J Neurosci 
+2003 May;113:657‑81.
+28.	 Trawick  M. An Ayurvedic theory of cancer. Med Anthropol 
+1991 Jun;13:121‑36.
+29.	 Purvya MC, Meena MS. A review on role of prakriti in aging. Ayu 
+2011 Jan;32:20‑4.
+30.	 Manyam  BV,  Kumar  A. Ayurvedic constitution  (prakruti) 
+identifies risk factor of developing Parkinson’s disease. J Altern 
+Complement Med  2013 Jul;19:644‑9. doi: 10.1089/acm. 2011.0809. 
+Epub 2013 Mar 07.
+31.	 Supriya Bhalerao,  Tejashree Deshpande,  Urmila Thatte. Prakriti 
+(Ayurvedic concept of constitution) and variations in platelet 
+aggregation: BMC Complementary and Alternative Medicine 2012.
+32.	 Endo J, Nakamura T. Comparative studies of the tridosha theory in 
+Ayurveda and the theory of the four deranged elements in Buddhist 
+medicine. Kagakushi Kenkyu 1995;34:1‑9.
+33.	 Mahdihassan  S. A  comparative study of Chinese cosmology 
+cum‑humorology with eight elements. Am J Chin Med 
+1990;18:181‑4.
+34.	 Suchitra SP, Devika HS, Gangadhar BN, Nagarathna R, Nagendra HR, 
+Kulkarni  R. Measuring the tridosha symptoms of unmāda 
+(psychosis): A preliminary study; J Altern Complement Med. 
+2010 Apr;16:457‑62.
+35.	 Suchitra SP, Nagendra HR. Development and initial standardization 
+of Ayurveda Child Personality Inventory: International Conference on 
+Non‑communicable diseases. 2012 Februvary.
+36.	 Frank S. Freeman.Theory and Practice of Psychological Testing. Third 
+edition. New Delhi: Surjeet publications; 2006.
+37.	 Rutherford B. Cattell R.Hand book for the children’s personality 
+questionnaire (CPQ). Illinois. Indian economy edition; Institute of 
+Personality and Ability testing. 1999.
+38.	 AK Singh. Tests, Measurements and Research methods in Behavioral 
+[Downloaded free from http://www.ancientscienceoflife.org on Wednesday, July 27, 2016, IP: 14.139.155.82]
+90 	
+Ancient Science of Life / Oct-Dec 2013 / Vol 33 / Issue 2
+Suchitra and Nagendra: Self rating scale to asses prakr
+.ti
+sciences. Fifth edition. Patna: Bharati Bhavan publishers and 
+distributers; 2006.
+39.	 Anastasi A., Urbina S. Psychological testing. 7th Edition. Pearson 
+Education; 2005.
+40. Nunnaly JC. Psychometric theory. (2nd ed.). New York: Mc‑grow‑hill; 
+1978.
+Address for correspondence:
+S.P
+. Suchitra, 
+Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), Eknath 
+Bhavan, No.19, Gavipuram Circle, Kempegowda Nagar,  
+Bangalore - 560 019, India. 
+E-mail: [email protected]
+How to cite this article: Suchitra SP, Nagendra HR. A self-rating scale 
+to measure tridos
+.as in children. Ancient Sci Life 2013;33:85-91.
+Source of Support: Nil. Conflict of Interest: None declared.
+Table 1: Factor analytic coefficients of each item
+Vāta
+Loadings
+Pitta
+Loadings
+Kapha
+Loadings
+v1
+0.665
+p1
+0.698
+k1
+0.616
+v2
+0.575
+p2
+0.727
+k2
+0.618
+v3
+0.566
+p3
+0.574
+k3
+0.679
+v4
+0.553
+p4
+0.607
+k4
+0.646
+v5
+0.580
+p5
+0.837
+k5
+0.510
+v6
+0.608
+p6
+0.673
+k6
+0.567
+v7
+0.614
+p7
+0.520
+k7
+0.414
+v8
+0.417
+p8
+0.447
+k8
+0.612
+v9
+0.490
+p9
+0.528
+k9
+0.764
+v10
+0.578
+p10
+0.423
+k10
+0.693
+v11
+0.443
+p11
+0.617
+k11
+0.536
+v12
+0.631
+p12
+0.555
+k12
+0.628
+v13
+0.540
+p13
+0.590
+k13
+0.521
+v14
+0.550
+p14
+0.565
+k14
+0.625
+v15
+0.453
+p15
+0.559
+k15
+0.529
+v16
+0.589
+p16
+0.586
+k16
+0.764
+v17
+0.548
+p17
+0.615
+k17
+0.600
+v18
+0.569
+p18
+0.740
+k18
+0.602
+v19
+0.580
+p19
+0.704
+k19
+0.646
+v20
+0.476
+p20
+0.781
+k20
+0.605
+v21
+0.651
+p21
+0.644
+k21
+0.581
+v22
+0.573
+p22
+0.638
+k22
+0.582
+v23
+0.713
+p23
+0.471
+k23
+0.608
+v24
+0.587
+p24
+0.491
+k24
+0.596
+v25
+0.540
+k25
+0.680
+v26
+0.635
+k26
+0.421
+k27
+0.579
+Factor loadings‑correlations of each item with respective subsales
+APPENDIX‑1
+APPENDIX ‑2
+Caraka child personality inventory
+For children
+Instructions: There is no right or wrong answer. Select the 
+appropriate answer suitable to you and give explanation where 
+necessary
+A‑scale
+1
+I get skin problems easily
+Yes/No
+2
+I am thin
+Yes/No
+3
+Green lines (veins) are visible over 
+my arm than others
+Yes/No
+4
+My hair is rough and split
+Yes/No
+5
+Usually I hear some sound in my 
+knee while walking
+Yes/No
+6
+My nails grow faster than others
+Yes/No
+7
+Time taken by me to button my 
+cloth usually is
+_____
+8
+I eat food fast
+Yes/No
+9
+I eat _____ and _____ for 
+my breakfast (tell how much 
+also) (e.g.: 2 idlis, 2 dosa etc.)
+10
+I get tired easily during exercise
+Yes/No
+11
+I usually wake‑up in between sleep
+Yes/No
+12
+I usually talk in low pitch
+Yes/No
+13
+I can understand, what teacher 
+teaches faster than others
+Yes/No
+14
+I usually forget the issues faster 
+than others
+Yes/No
+15
+I have some plans for this year
+Yes/No 
+16
+Sometimes I like my relatives, 
+sometimes not
+Yes/No
+17
+If a classmate doesn’t behave 
+properly with me
+I will be silent/I will also 
+behave badly with him
+18
+When my parents ask me to stop 
+watching television do, I do it 
+immediately
+Yes/No
+19
+If my brother/sister/friend are 
+praised in front of me
+I beat them/I will 
+become concerned 
+unhappy/I am not much
+20
+I usually finish my home‑work, 
+before playing
+Yes/No
+contd...
+[Downloaded free from http://www.ancientscienceoflife.org on Wednesday, July 27, 2016, IP: 14.139.155.82]
+	
+Ancient Science of Life / Oct-Dec 2013 / Vol 33 / Issue 2
+91
+Suchitra and Nagendra: Self rating scale to asses prakr
+.ti
+APPENDIX ‑3
+Format of Informed consent
+I have been informed completely about the scale which is 
+about to measure the personality of My Son/Daughter……
+………………….I am agreeing completely for the analysis 
+of His/Her personality.
+Signature of the parent/Guardian
+Appendix ‑2: Contd...
+21
+I usually don’t think much about 
+person who have helped me
+Yes/No
+22
+I usually don’t like to make new 
+friends
+Yes/No
+23
+I like hard chapatti, bread much
+Yes/No
+24
+I like hot drinks much
+Yes/No
+25
+I can give stage performance easily
+Yes/No
+26
+I bite my teeth when not allowed 
+to do what I like to do
+Yes/No
+B‑scale
+1
+I get body pain after heavy exercise
+Yes/No
+2
+My body color is‑brown
+Yes/No
+3
+I usually have bad – breath
+Yes/No
+4
+Color of my eyes is brown
+Yes/No
+5
+Color of my nails is pink
+Yes/No
+6
+Color of my lips is pink
+Yes/No
+7
+I have small, brown eye‑lashes
+Yes/No
+8
+Color of my hair is brown
+Yes/No
+9
+I feel hungry in every
+______hours
+10
+Time taken for taking bath by me is
+______
+11
+I eat _____ and _____ for 
+lunch (tell how much also) 
+(e.g.,‑2 chapatis, one bowl rice etc.)
+12
+I drinks more water than others
+Yes/No
+13
+I sweat a lot compared to others
+Yes/No
+14
+I go for urine often
+Yes/No
+15
+I usually get prizes in sports
+Yes/No
+16
+I usually get head‑ache, eye‑pain if 
+I read for longer duration
+Yes/No
+17
+I change my decisions easily
+Yes/No
+18
+I can learn new subjects easily
+Yes/No
+19
+I usually get ______ grade in tests
+Yes/No
+20
+I usually admit my mistakes
+Yes/No
+21
+When my sister/brother/friend are 
+paid more attention in front of me
+I get angry/I want to 
+behave such a way, 
+parents pay attention 
+to me
+22
+My health gets upset when I eat 
+excessive sour taste foods
+Yes/No
+23
+I like cold drinks a lot
+Yes/No
+24
+My anger comes down quickly
+Yes/No
+C‑scale
+1
+I get leg and arm pain often
+Yes/No
+2
+I am liked by some friends/all friends
+3
+My body color is bright white
+Yes/No
+Appendix ‑2: Contd...
+4
+My eyes are big
+Yes/No
+5
+My hair is curly and thick
+Yes/No
+6
+My chest is wider comparatively
+Yes/No
+7
+My forehead is bigger
+Yes/No
+8
+My eye‑brows are big
+Yes/No
+9
+I usually take _____ minutes to 
+wear a dress
+10
+I eat food slowly
+Yes/No
+11
+I sweat less than others
+Yes/No
+12
+I will not get tired after exercise 
+for longer time
+Yes/No
+13
+I can wait, if food is delayed 
+sometimes
+Yes/No
+14
+I usually sleep good for longer time
+Yes/No
+15
+When my brother/sister/cousin 
+quarrels with me
+I also want to quarrel/I 
+want to keep quite
+16
+I usually talk in loud voice
+Yes/No
+17
+I usually get adjusted to new 
+school easily
+Yes/No
+18
+I usually can remember issues 
+happened years back as it is
+Yes/No
+19
+When my friend/classmate helps me
+I feel very thankful/I 
+want to remember for 
+always
+20
+I remember the scolding of my 
+parents a lot
+Yes/No
+21
+I want to give money to the beggars
+Yes/N
+22
+I like spicy foods
+Yes/No
+23
+I like to share my things with my 
+brother/sister
+Yes/No
+24
+I can withstand/tolerate pain
+Yes/No
+25
+I want to become ______ in my life
+26
+I like to serve my guests
+Yes/No
+27
+If my parents give money to me I 
+want to spend on:
+____
+contd...
+[Downloaded free from http://www.ancientscienceoflife.org on Wednesday, July 27, 2016, IP: 14.139.155.82]

subfolder_0/AUTONOMIC CHANGES WHILE MENTALLY REPEATING TWO SYLLABLES.txt

@@ -0,0 +1,21 @@
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 

subfolder_0/AWARENESS OF COMPUTER¬USE RELATED HEALTH RISKS IN SOFTWARE COMPANIES IN BANGALORE.txt

@@ -0,0 +1,71 @@
+ 
+Indian J Med Sci Vol. 58 No.5, May 2004  
+ 
+AWARENESS OF COMPUTERUSE RELATED HEALTH RISKS IN SOFTWARE 
+COMPANIES IN BANGALORE 
+ 
+SHIRLEY TELLES, RAJENDRA DEGINAL & LOKESH HUTCHAPPA 
+ 
+Sir,  
+There are important physiological, biochemical, somatic and psychological indicators of stress 
+related to work where human computer interaction occurs '. Prevention is the best management 
+of computer-related ailments since it is more effective, lasts longer, and costs less." Among 
+software development organizations worldwide, several are in India, in Bangalore city." Hence 
+this study evaluated the awareness of computer-use related health risks in software companies in 
+Bangalore.  
+ 
+Forty-three software companies in Bangalore were contacted. Twenty companies participated 
+and the manager for human resource development (HRD) filled in a questionnaire.  
+ 
+The questions were: (1) Are you aware that using a computer for over 5 hours a day can cause 
+health problems (yes/no)?; (2) If your answer was 'yes', what was the source of your 
+information? (books/ newspapers/ television/ experience of yourself or others/ other source 
+(specify)); (3) Name three health problems which you think are the most likely to occur; (4) In 
+your company are you using any lifestyle modification strategy? (yes/no); (5) If your answer was 
+'yes', what strategy does the company use? (6) If your answer to Question (4) was 'no', which of 
+the following was the most important reason for not using any strategy? (time constraints/ lack of 
+belief in such strategies/ poor response/ financial constraints/ lack of infrastructure/ no access to 
+a trained person/ any other reason (specify)).  
+ 
+In fifteen companies the number of software engineers was between 100 and 500 and five 
+companies had between 500 and 1000 employees. Seventeen out of twenty HRD managers were 
+aware of the health risks. Eleven had got the information from newspapers, five from the 
+employees' experience, and one from a television program. When asked about the three most 
+likely complaints, fifteen out of seventeen mentioned (i) visual strain, (ii) back pain, and (iii) 
+other musculoskeletal pains. Two mentioned 'psychological strain' and 'weight gain' as other 
+likely hazards. Two others did not know the likely problems. Ten out of seventeen were using 
+some lifestyle modification strategy, while seven were not. The following strategies were used: 
+indoor and outdoor games, yoga including meditation, health checkups, health advice, 
+recreational facilities, and a 'rooftop cafeteria'. The use of these strategies was optional. In the 
+case of the seven companies where no strategy was used, five of them gave the reason that they 
+had 'no access to a trained person to administer the strategy' and for two of them 'time 
+constraints' were the limiting factor.  
+ 
+Hence HRD managers in most software companies are aware of health risks of prolonged 
+computer use and which complaints are most probable. However the management strategies did 
+not seem adequate. In view of the increasing number of software companies across India this 
+topic requires attention.  
+ 
+ 
+ 
+ 
+ 
+ACKNOWLEDGMENT  
+ 
+The project was funded by a grant from the Central Council of Research in Yoga and 
+Naturopathy (CCRYN), Ministry of Health & Family Welfare, Govt. of India.  
+ 
+SHIRLEY TELLES, RAJENDRA DEGINAL & LOKESH HUTCHAPPA  
+Vivekananda Yoga Research Foundation, Bangalore, India E-mail: [email protected]  
+ 
+REFERENCES  
+ 
+1. Smith MJ, Conway FT, Karsh B10 Occupational stress in human computer interaction. Ind 
+Health. 1999;37:157-73.  
+2. Bawa J. Computers and your health. 1996.  
+Celestial Arts: Berkeley,CA.  
+3. Killcrece G., Kossakowski K-P, Ruefle R. et al.  
+Organizational models for computer security incident response teams (CSIRTs). Handbook 
+Carnegie-Mellon University(CMU)/Software Engineering Institute-2003-HB-001-15213-
+3890. 2003. SEI: Pittsburgh, PA.  
+ 

subfolder_0/Add-on Effect of Hot Sand Fomentation to Yoga on Pain, Disability, and Quality of Life in Chronic Neck Pain Patients.txt

@@ -0,0 +1,696 @@
+ 
+Current Problems in Diagnostic RadiologyIIMB Management ReviewJournal of Cardiac FailureJournal of Exotic Pet MedicineBiology of
+Blood and Marrow TransplantationSeminars in Spine SurgerySeminars in Arthritis & RheumatismCurrent Problems in Pediatric and
+Adolescent Helath CareSolid State Electronics Letters
+Accepted Manuscript
+Add-on effect of hot sand fomentation to yoga on pain, disability, and
+quality of life in chronic neck pain patients
+B. Nandini , A. Mooventhan Senior Medical Officer ,
+NK. Manjunath Professor
+PII:
+S1550-8307(17)30363-4
+DOI:
+10.1016/j.explore.2018.01.002
+Reference:
+JSCH 2294
+To appear in:
+The End-to-end Journal
+Received date:
+11 October 2017
+Revised date:
+5 January 2018
+Accepted date:
+5 January 2018
+Please
+cite
+this
+article
+as:
+B. Nandini ,
+A. Mooventhan Senior Medical Officer ,
+NK. Manjunath Professor , Add-on effect of hot sand fomentation to yoga on pain, disability, and quality
+of life in chronic neck pain patients , The End-to-end Journal (2018), doi: 10.1016/j.explore.2018.01.002
+This is a PDF file of an unedited manuscript that has been accepted for publication. As a service
+to our customers we are providing this early version of the manuscript. The manuscript will undergo
+copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
+note that during the production process errors may be discovered which could affect the content, and
+all legal disclaimers that apply to the journal pertain.
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+Highlights: 
+ Addition of hot sand fomentation (HSF) to yoga provides a better reduction in pain 
+and disability in patients with non-specific neck pain than yoga alone. 
+ All the subjects were actively participated in intervention 
+ No adverse effects were reported throughout the study period. 
+ Intervention is feasible, easy, safe and cost-effective  
+  
+ 
+ 
+ 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+Add-on effect of hot sand fomentation to yoga on pain, disability, and quality of life in 
+chronic neck pain patients        
+Running Title: Hot sand fomentation for neck pain 
+B. Nandini,1 A. Mooventhan,2 NK. Manjunath3  
+ 
+1Department of Yoga and Naturopathy, The School of Yoga and Naturopathic medicine, S-
+VYASA University, Bengaluru, Karnataka, India 
+2Senior Medical Officer, Department of Yoga, Center for Integrative Medicine and Research 
+(CIMR), All India Institute of Medical Sciences (AIIMS), New Delhi, India 
+3Professor, Division of Yoga and Life Sciences, & Head, Department of Research and 
+Development, S-VYASA University, Bengaluru, Karnataka, India 
+Number of Tables: 03 
+Number of Figures: 0 
+Word Count: 
+Abstract 
+: 250 
+Manuscript 
+: 2895 
+Corresponding contributor:  
+Dr. A. Mooventhan,  
+Senior Medical Officer, Department of Yoga, Center for Integrative Medicine and Research 
+(CIMR), All India Institute of Medical Sciences (AIIMS), New Delhi, India. 
+Mobile: +91 9844457496  
+E-mail: [email protected] 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+Add-on effect of hot sand fomentation to yoga on pain, disability and quality of life in 
+chronic neck pain patients    
+ABSTRACT: 
+Background: Neck pain is one of the commonest complaints and an important public health 
+problem across the globe. Yoga has reported to be useful for neck pain and hot sand has 
+reported to be useful for chronic rheumatism. The present study was conducted to evaluate 
+the add-on effect of hot sand fomentation (HSF) to yoga on pain, disability, quality of sleep 
+(QOS) and quality of life (QOL) of the patients with non-specific neck pain.      
+Materials and Methods: A total of 60 subjects with non-specific or common neck pain were 
+recruited and randomly divided into either study group or control group. Both the groups 
+have received yoga and sesame seed oil (Sesamum Indicum L.) application. In addition to 
+yoga and sesame seed oil, study group received HSF for 15-minutes per day for 5-days. 
+Assessments were taken prior to and after the intervention. 
+Results: Results of the study showed a significant reduction in the scores of visual analogue 
+scale for pain, neck disability index (NDI), The Pittsburgh Sleep Quality Index (PSQI), and a 
+significant increase in physical function, physical health, emotional problem, pain, and 
+general health both in study and control groups. However, reductions in pain and NDI along 
+with improvement in social functions were better in the study group as compared with control 
+group.  
+Conclusion: Results of this study suggest that addition of HSF to yoga provides a better 
+reduction in pain and disability along with improvement in the social functioning of the 
+patients with non-specific neck pain than yoga alone.  
+Keywords: Chronic pain; Fomentation; Naturopathy; Neck pain; Yoga  
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+BACKGROUND: 
+Back pain and neck pain are the major musculoskeletal problems in modern society causing 
+considerable costs in health care.[1] Non-specific[2] or common neck pain[3]  is defined as the 
+pain with a postural or mechanical basis[2] caused by altered neck mechanics, advanced age-
+related changes, additional load on the neck, occupational hazards as in computer 
+professionals or call center workers, faulty sleeping habits and sudden violent jerking injuries 
+to the neck as in whiplash injury and not due to any organic lesions.[3] It is an important public 
+health problem across the globe.[4] About two-thirds of people will experience neck pain at 
+some time with women being affected more than men.[2] The prevalence of neck pain has been 
+reported to be up-to 20% of the working populations worldwide[4] in which common neck pain 
+accounts for more than 80%.[3] It is often associated with marked disability[5] and sickness 
+absenteeism[3,5] that could disrupt a nation’s economy apart from disrupting the personal and 
+professional life of a patient.[3] Most patients with chronic neck pain were reported to use 
+alternative or complementary methods for their pain relief. Yoga (physical postures, breathing 
+exercises, meditation, and relaxation) was reported to be a safe and effective complementary 
+therapy for pain relief including chronic neck pain.[4] In a hydrotherapy textbook, the sand bath 
+was reported to be useful in cases of chronic rheumatism. It also reported that the local 
+applications of the sand bath may be made by heating the sand in an oven and heaping it about 
+the desired part as a hot sand application or fomentation.[6] Hot sand fomentation (HSF) is 
+commonly employed in various naturopathic hospitals for pain management. There are 
+various studies reporting the effect of a combination of exercise plus infrared, exercise plus 
+pillow; exercises plus manipulation; hot or cold packs plus massage; and heat combined with 
+other physical treatment for chronic neck pain management.[2] Though yoga was reported to 
+be useful for neck pain[4] and hot sand is reported to be useful for chronic rheumatism,[6] to the 
+best of our knowledge there is no known study reporting the combined effect of yoga and HSF 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+in patients with non-specific neck pain. Thus, the present study was conducted to evaluate the 
+add-on effect of HSF to yoga on pain, disability, quality of sleep (QOS) and quality of life 
+(QOL) in patients with non-specific neck pain. 
+ MATERIALS AND METHODS 
+Study Design: 
+This is a parallel group randomized controlled study. All the subjects were randomly (1:1 
+ratio) divided into either study group (n=30) or control group (n=30). The study group 
+received HSF for 15-minutes a day for the period of 5-days along with yoga and sesame seed 
+oil application while the control group received yoga and sesame seed oil application alone 
+for the same period. Assessments were taken prior to and after the intervention. 
+Subjects: 
+A total of 60 subjects with non-specific or common neck pain age range from 24 to 56 years 
+were recruited from a holistic health centre in South India, based on the following inclusion 
+and exclusion criteria. Inclusion criteria: Subjects with the age range of 20-60 years with 
+non-specific or common neck pain due to ligament strain, sprain of the neck muscles or 
+spasm (myalgia), cervical spondylosis without any neurological impairment and who were 
+willing to participate in the study were included in the study. Exclusion criteria: Subjects 
+with uncommon neck pains due to organic causes such as congenital conditions like wry neck 
+also known as torticollis (a twisted and tilted neck), inflammatory conditions like rheumatoid 
+arthritis, metabolic disorders like osteoporosis, neoplastic conditions, infective conditions like 
+tuberculosis, and posttraumatic conditions with ligament or bone injuries; subjects with the 
+history of mental illness; and those who underwent yoga and other naturopathy treatments for 
+the past 1 month were excluded from the study. The study was conducted in Anvesana 
+research laboratories that include an inpatient holistic healthcare centre, S-VYASA 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+University, Bengaluru, India. The study protocol was approved by the institutional ethics 
+committee (RES/IEC-SVYASA/106/2017) and a written informed consent was obtained 
+from each subject.  
+Interventions:  
+Both Study and Control Groups: Practice of Yoga (Loosening practices, asanas, pranayama, 
+relaxation and meditation techniques and lecture on yoga philosophy), low fat and low salt 
+vegetarian diet and application of sesame seed oil (also called as Gingelly oil) [the oil that is 
+derived from the seeds of plant species Sesamum Indicum L., a herbaceous annual belonging 
+to the Pedaliaceae family. It has been reported to have anti-inflammatory effect. The main 
+constituents of sesame seed oil include fatty acids (palmitic acid, palmitoleic acid, stearic 
+acid, oleic acid, linoleic acid, linolenic acid, and eicosanoic acid), lignans, and antioxidants, 
+such as ??-tocopherol.][7] were common for both study group and control group (Table 1).   
+Study Group: Along with yoga and sesame seed oil application, study group subjects have 
+received HSF that consists of approximately 250 gm. of sand devoid of thorns, shells and 
+pebbles heated up to tolerable temperature (39-40oC) using a pan placed on the stove. The 
+procedure of the preparation of HSF is as follows: As soon as the sand in the vessel was 
+properly heated it was poured at the centre of the double layer cotton cloth of dimensions 15 x 
+15 cm to tie it as a bolus. A strong thick thread was used to tie up the upper portion of the 
+bolus to avoid the outflow of the sand from small openings during the treatment procedure. 
+The free end of the cloth is then folded and tied to form a handle. Then the fomentation was 
+given by means of keeping it over (5 seconds) and taking it away from the painful region (2 
+seconds) which was continued for the duration of 15 minutes a day in the evening between 
+5:00 pm and 6:00 pm for the period of 5 consecutive days. In order to maintain the 
+temperature, the HSF bag was replaced by a new HSF bag every 5 minutes. Thus, we used 3 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+HSF bags to complete one session. The intervention was given by two (1 male and 1 female) 
+institutionally qualified therapists.      
+Control Group: Control group subjects were under their normal routine and did not receive 
+HSF for the same period.  
+Assessments: 
+The primary (visual analog scale for pain and neck disability index) and secondary outcome 
+[quality of sleep (QOS), and quality of life (QOL)] measures were taken before and after the 
+intervention as mentioned below: 
+Visual analog scale (VAS) for pain: It was used to evaluate subject’s intensity of pain on a 
+scale of 0 to 10, where 0 indicates no pain and 10 indicates worst pain. Subjects were advised 
+to mark on the scale to indicate their pain intensity before and after the intervention.[8] 
+Cronbach’s alpha = 0.95[9] 
+Neck Disability Index (NDI): It is a measurement tool used to measure 10 dimensions of 
+neck-specific disability, namely pain intensity, personal care, lifting, reading, headache, 
+concentration, work, driving, sleeping, and recreation. Each dimension is assessed with 1 
+item, measured on a 6-point scale from 0 (no disability) to 5 (full disability). The sum score 
+out of all 10 items is multiplied by 2 to obtain a score out of 100%. The score 0-20,  21-40, 
+41-60, 61-80, and 80-100 represents the normal, mild, moderate, severe and complete or 
+exaggerated disability. Cronbach’s alpha = 0.864. [10,11] 
+The Pittsburgh Sleep Quality Index (PSQI): It consists of seven components in 9-items 
+sleep questionnaire, which was used to evaluate subject’s QOS. The total score 0-4 indicates 
+good sleep quality, 5-10 indicate poor sleep quality, and >10 indicates the sleep disorder. 
+Cronbach’s alpha = 0.83.[12,13] 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+Short Form-36 Version 2 (SF-36 V2) Health Survey: 
+It consists of 36-items questionnaire, which measures the health in eight dimensions. For 
+each dimension, item scores were noted, averaged, and transformed into a scale of 0-100 
+where 0 indicates worst possible health and 100 indicates best possible health.[13,14] 
+Cronbach’s alpha = 0.85[15]  
+Sample size: 
+A total of 60 subjects with non-specific or common neck pain age range from 24 to 56 years 
+were recruited. The sample size was not calculated based on any previous study or pilot study 
+which is one of the limitations of the study.  
+Randomization: 
+All the subjects were randomly divided into either study group or control group using 
+computerized randomization available at http://www.randomization.com/. A simple 
+randomization procedure was performed for 60 subjects with 1:1 ratio to get a sample size of 
+(n=30) in each group. Random allocation of the intervention was kept in opaque sealed 
+envelopes until interventions were assigned. The randomization was performed by one of the 
+authors who did not involve in any part of the investigation.  
+Blinding: 
+It was not possible for us to blind the subjects from the intervention. However, the 
+investigator was kept blind to the study group and control group. 
+Data Analysis: Statistical analysis of within-group was performed using Wilcoxon signed 
+rank test and between groups analysis was performed using Mann Whitney-U-test with the use 
+of Statistical Package for the Social Sciences (SPSS) for Windows, Version 16.0. Chicago, 
+SPSS Inc. 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+RESULT 
+The details of the demographic variables of the study and control groups have been given in 
+table 2. Baseline characteristics were comparable and no significant differences were observed 
+between the groups in all the variables except pain and SF-36 health survey’s physical health 
+and energy scales. Results of the study showed a significant reduction in the scores of pain, 
+NDI, and social function in the study group compared to the control group. Within-group 
+analysis showed a significant reduction in VAS score for pain, NDI, PSQI and a significant 
+increase in physical function, physical health, emotional problem, pain, and general health 
+both in study and control groups, while a significant increase in energy level and social 
+functioning was observed only in study group unlike control group and no such significant 
+change was observed in emotional well being both in study and control groups (Table 3). The 
+compliance of the participants to the therapies was good due to voluntary participation and 
+there were no dropouts and none of the subjects reported any adverse effects during the study 
+period.  
+DISCUSSION 
+Research shows that spinal pain has become the largest category of medical claims, placing a 
+major burden on individuals and health care system. Yoga is quite commonly used as a 
+complementary therapy for spinal pain including neck pain.[1] Self-assessment questionnaires 
+are widely used to assess the outcome of medical management and interventions.[11] In the 
+present study, we used self-assessment questionnaires such as VAS for pain, NDI, PSQI and 
+SF-36 Healthy survey to assess the add-on effect of HSF on neck pain and disability, QOS and 
+QOL of patients with non-specific neck pain.  
+Results of this study showed a significant increase in the energy level and social functioning 
+only in the study group while no such significant changes were observed in the control group. 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+Moreover, the significant reduction in VAS score for pain and NDI score and the significant 
+increase in social functions were better in the study group compared with control group. It 
+suggests that the improvement in pain, neck disability, general energy level and the social 
+functioning of the people with the neck pain were better in the subjects who received HSF 
+along with yoga rather than the subjects who received yoga alone. It should be noted that 
+there was a significant baseline difference in pain between the groups and that might have 
+influenced the significant difference in the post-test analysis as well. However, the reduction 
+in the pain (mean score) was better in the study group (from 7.81 to 2.63; Difference = 5.18) 
+compared with control group (from 7.33 to 5.79; Difference = 1.54). Similarly, though there 
+was a significant baseline difference in SF-36 health survey’s energy level scale in between 
+groups, within group analysis showed a significant improvement in energy level in the 
+subjects those who received yoga plus HSF rather than the subjects those who received yoga 
+alone. This suggests that HSF might have additional effect in reducing pain and in improving 
+energy level of the patients with neck pain.  
+The better reduction in pain and neck disability in the study group compared with the control 
+group might attribute to the pain reducing and muscle relaxing effect of HSF. Improvement 
+in the energy level and social functioning of the study group unlike the control group might 
+attribute to the better reduction of pain and neck disability in the study group compared with 
+the control group. As mentioned in a previous study,[3] the tension that is associated with 
+stress is stored mainly in the neck muscles, diaphragm and the nervous system. Stress is 
+reported to produce spasm by interfering with coordination of different muscle groups 
+involved in the functioning of the neck. Thus, if these areas are relaxed, stress can get 
+reduced or if the stress reduced, these areas can be relaxed and these help in minimizing the 
+impact of stress in people with neck pain. In a previous study, yoga has been found to be an 
+effective tool in reducing stress levels that might have helped in reducing the pain and 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+disability by reducing the tension over the neck muscles indirectly.[3] According to a 
+hydrotherapy text, hot applications were reported to be effective in reducing pain and muscle 
+tension directly.[6] This explains the reason, why there was a better reduction in pain and 
+disability in the study group compared with control group. 
+Within group analysis of the present study showed a significant reduction in the scores of 
+VAS for pain, NDI, and PSQI and a significant increase SF-36 health survey especially in 
+physical function, physical health, emotional problem, pain, and general health both in study 
+and control groups. It suggests that practice of yoga with or without HSF was effective in 
+improving the problems that are associated with chronic neck pain such as neck pain, 
+disability, QOS and QOL.   
+The previous study on one of the advanced guided yoga relaxation techniques called “mind 
+sound resonance technique (MSRT)” was reported to add significant complimentary benefits 
+to conventional physiotherapy by reducing pain, tenderness, disability and providing 
+improved flexibility in patients with common neck pain.[3] Regular yoga practice has shown 
+to produce a significant reduction in time to fall asleep, decreased sleep disturbance during 
+night time, better sleep quality, decreased use of medications for sleep and improve overall 
+QOS[16] and also felt more rested and energetic in the morning.[17] Previous studies on yoga 
+practices showed improvement in pain, neck-related disabilities and health-related QOL in 
+patients with chronic non-specific neck pain.[18-20] And, sustained yoga practice seems to be 
+the most important predictor of long-term effectiveness in neck patients. A systematic review 
+has reported that the yoga can decrease pain and increase functional ability in patients with 
+spinal pain including neck pain.[1] Thus, the findings of the present study are consistent with 
+the reports of the previous studies.  
+Non-specific neck pain has reported to be associated with anxiety, depression[2] stress and 
+tension.[3] Yoga is fast advancing as an effective therapeutic tool in physical, psychological 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+and psychosomatic disorders. And the practice of yoga was found to be effective in reducing 
+stress, anxiety, pain[3] (by down regulating the hypothalamic pituitary adrenal axis and the 
+sympathetic nervous system)[4] and disability.[3,4] Moreover, yoga has shown to influence the 
+functional status of neck muscles of patients with neck pain[19] and reported to be an effective 
+method for treating neck pain by improving strength, flexibility and endurance that is a basic 
+goal of most rehabilitation programs for neck pain.[1] Thus, the reduction in pain and 
+disability and the improvement in QOS and QOL after yoga with or without HSF might 
+attribute to the effect of yoga on stress, anxiety, modulation of the hypothalamic pituitary 
+adrenal axis and the sympathetic nervous activity.  
+A qualitative study reported that the chronic neck pain patients those who have participated in 
+yoga intervention have changed on five dimensions of human experience: 1) Physically, most 
+participants cited renewed body awareness, both during yoga practice and in daily lives, 2) 
+Cognitively, participants reported increased perceived control over their health, 3) 
+Emotionally, they noted greater acceptance of their pain and life burdens, 4) Behaviourally, 
+they described enhanced use of active coping strategies, and 5) Socially, they reported 
+renewed participation in an active life.[21] In a previous study, intake of the vegetarian diet 
+has shown to be effective in reducing pain, tenderness, inflammatory markers and in 
+improving physical functioning of patients with rheumatoid arthritis.[22] Thus, the vegetarian 
+diet provided in the present study might also have attributed to the reduction in pain and 
+improvement in the health-related problems of neck pain.   
+Strength of the study: This is the first study evaluating the add-on effects of HSF to yoga in 
+patients with non-specific neck pain, the standard study design was adopted, and no adverse 
+effects were reported by the subjects throughout the study period. Limitations of the study: 
+Small sample size, short-term intervention, and lack of objective variables and assessments 
+such as stress, anxiety, muscle tension, flexibility, sleep architecture. Hence, long-term 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+studies are required with larger sample size and above-mentioned variables for the better 
+understanding of the effect and its underlying mechanisms.   
+CONCLUSION 
+Result of this study suggests that yoga with or without HSF is effective in reducing pain, 
+disability, and in improving QOS and QOL of patients with non-specific neck pain. However, 
+an addition of HSF to yoga provides a better reduction in pain and disability along with 
+improvement in the social functioning of the patients with non-specific neck pain than yoga 
+alone.  
+SOURCE OF FUNDING: Nil,  
+CONFLICT OF INTEREST: None declared 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+REFERENCES: 
+1. Crow EM, Jeannot E, Trewhela A. Effectiveness of Iyengar yoga in treating spinal 
+(back and neck) pain: A systematic review. Int J Yoga. 2015;8(1):3-14. doi: 
+10.4103/0973-6131.146046. 
+2. Binder AI. Neck pain. BMJ Clin Evid. 2008;2008. pii: 1103. 
+3. Yogitha B, Nagarathna R, John E, Nagendra H. Complimentary effect of yogic sound 
+resonance relaxation technique in patients with common neck pain. Int J Yoga. 
+2010;3(1):18-25. doi: 10.4103/0973-6131.66774. 
+4. Kim SD. Effects of yoga on chronic neck pain: a systematic review of randomized 
+controlled trials. J Phys Ther Sci. 2016;28(7):2171-4. doi: 10.1589/jpts.28.2171. 
+5. Cramer H, Lauche R, Langhorst J, Dobos GJ, Michalsen A. Validation of the German 
+version of the Neck Disability Index (NDI). BMC Musculoskelet Disord. 2014;15:91. 
+doi: 10.1186/1471-2474-15-91. 
+6. Kellogg JH. Rational Hydrotherapy. 2nd ed. Pune: National Institute of Naturopathy; 
+2005. 
+7. Hsu DZ, Liu CT, Chu PY, Li YH, Periasamy S, Liu MY. Sesame oil attenuates 
+ovalbumin-induced pulmonary edema and bronchial neutrophilic inflammation in 
+mice. Biomed Res Int. 2013;2013:905670. doi: 10.1155/2013/905670. 
+8. Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;2:175-84. 
+9. Knop C, Oeser M, Bastian L, Lange U, Zdichavsky M, Blauth M. Development and 
+validation of the Visual Analogue Scale (VAS) Spine Score. Unfallchirurg. 
+2001;104(6):488-97. 
+10. Vernon H, Mior S. The Neck Disability Index: A study of reliability and validity. J 
+Manipulative Physiol Ther. 1991;14:409-415 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+11. McCarthy MJ, Grevitt MP, Silcocks P, Hobbs G. The reliability of the Vernon and 
+Mior neck disability index, and its validity compared with the short form-36 health 
+survey questionnaire. Eur Spine J. 2007;16:2111-7. 
+12. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh 
+Sleep Quality Index: A new instrument for psychiatric practice and research. 
+Psychiatry Res 1989;28:193-213. 
+13. Mooventhan A, Nivethitha L. Effects of acupuncture and massage on pain, quality of 
+sleep and health related quality of life in patient with systemic lupus erythematosus. J 
+Ayurveda Integr Med 2014;5:186-9. doi: 10.4103/0975-9476.140484. 
+14. Jenkinson C, Stewart-Brown S, Petersen S, Paice C. Assessment of the SF-36 version 
+2 in the United Kingdom. J Epidemiol Community Health 1999;53:46-50. 
+15. Brazier JE, Harper R, Jones NM, O'Cathain A, Thomas KJ, Usherwood T, et al. 
+Validating the SF-36 health survey questionnaire: new outcome measure for primary 
+care. BMJ. 1992;305(6846):160-4. 
+16. Manjunath NK, Telles S. Influence of Yoga and Ayurveda on self-rated sleep in a 
+geriatric population. Indian J Med Res. 2005;121:683-90. 
+17. Bankar MA, Chaudhari SK, Chaudhari KD. Impact of long term Yoga practice on 
+sleep quality and quality of life in the elderly. J Ayurveda Integr Med. 2013;4:28-32. 
+doi: 10.4103/0975-9476.109548. 
+18. Cramer H, Lauche R, Hohmann C, Langhorst J, Dobos G. Yoga for chronic neck 
+pain: a 12-month follow-up. Pain Med. 2013;14:541-8. doi: 10.1111/pme.12053. 
+19. Cramer H, Lauche R, Hohmann C, Lüdtke R, Haller H, Michalsen A, et al. 
+Randomized-controlled trial comparing yoga and home-based exercise for chronic 
+neck pain. Clin J Pain. 2013;29:216-23. doi: 10.1097/AJP.0b013e318251026c. 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+20. Michalsen A, Traitteur H, Lüdtke R, Brunnhuber S, Meier L, Jeitler M, et al. Yoga for 
+chronic neck pain: a pilot randomized controlled clinical trial. J Pain. 2012;13:1122-
+30. doi: 10.1016/j.jpain.2012.08.004. 
+21. Cramer H, Lauche R, Haller H, Langhorst J, Dobos G, Berger B. "I'm more in 
+balance": a qualitative study of yoga for patients with chronic neck pain. J Altern 
+Complement Med. 2013;19:536-42. doi: 10.1089/acm.2011.0885. 
+22. Kjeldsen-Kragh J, Haugen M, Borchgrevink CF, Laerum E, Eek M, Mowinkel P, et 
+al. Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis. 
+Lancet. 1991;338:899-902. 
+ 
+ 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+TABLES: 
+Table 1: Detailed daily activities to study group and control group  
+Time 
+Schedule 
+5:30 am 
+OM meditation 
+6:00 am 
+Practice of asana (postures) 
+7:30 am 
+Breakfast  
+8:00 am 
+Bhagavat Geetha chanting followed by lecture on Yoga 
+9:00 am 
+Discussion with the ward doctors and assessment of vitals  
+10:00 am 
+Pranayama (breathing exercise) practices  
+11:00 am 
+Sukshma Vyayama (loosening exercise) 
+12:00 pm 
+Lecture on Yoga philosophy 
+1:00 pm 
+Lunch break  
+3:00 pm 
+Cyclic meditation 
+4:00 pm 
+Loosening exercise followed by asana 
+5:00 pm 
+Sesame oil application (for both the groups) followed by hot sand 
+fomentation (only for study group)  
+6:00 pm 
+Bhajan (Singing of sacred scriptures) 
+6:30 pm 
+Relaxation techniques  
+7:30 pm 
+Dinner  
+8:30-9:00 pm 
+Happy Assembly (interactions among the patients) 
+ 
+ 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+Table 2: Demographic variables of the study group (n = 30) and control group (n = 30) 
+Variable 
+Study group (n = 30) 
+Control group (n = 30) 
+p value 
+Age (Years) 
+32.70±6.04 
+35.27±8.28 
+0.202¶ 
+Gender 
+Female 14/Male 16 
+Female 13/Male 17 
+- 
+Height (cm) 
+159.53±3.56 
+160.52±4.57 
+0.395¶ 
+Weight (kg) 
+62.77±6.72 
+64.27±8.22 
+0.327¶ 
+BMI (kg/m2) 
+24.66±2.40 
+24.66±2.38 
+0.842¶ 
+Note: BMI = Body mass index. ¶ = Mann-Whitney U Test. 
+ 
+ 
+ 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+19 
+ 
+Table 3: Baseline and post-test assessments of study group and control group   
+Variables Assessment Sample 
+size (n) 
+Study group with 
+within group 
+analysis  
+(Wilcoxon signed 
+ranks test) 
+Control group 
+with within 
+group analysis  
+(Wilcoxon 
+signed ranks test) 
+Between 
+groups 
+analysis 
+(Mann-
+Whitney 
+U 
+Test)  
+p value 
+VAS 
+Baseline 
+29 
+7.81±1.08 
+7.33±0.83 
+0.019 
+Post test 
+29 
+2.63±0.98 
+5.79±1.18 
+<0.001 
+ 
+p<0.001 
+p<0.001 
+ 
+NDI 
+Baseline 
+30 
+34.47±7.31 
+34.80±6.34 
+0.846 
+Post test 
+30 
+11.20±5.37 
+23.73±7.10 
+<0.001 
+ 
+p<0.001 
+p<0.001 
+ 
+PSQI 
+Baseline 
+30 
+14.90±7.53 
+11.93±6.41 
+0.84 
+Post test 
+30 
+6.97±3.00 
+8.93±5.33 
+0.268 
+ 
+p<0.001 
+p<0.001 
+ 
+SF-36 Health Survey 
+PF 
+Baseline 
+30 
+45.00±20.97 
+54.17±18.29 
+0.154 
+Post test 
+30 
+71.00±20.02 
+66.17±18.08 
+0.201 
+ 
+p<0.001 
+p<0.001 
+ 
+PH 
+Baseline 
+30 
+20.00±27.39 
+35.83±31.27 
+0.023 
+Post test 
+30 
+59.17±41.25 
+59.17±34.42 
+0.819 
+ 
+p<0.001 
+p=0.002 
+ 
+ACCEPTED MANUSCRIPT
+ACCEPTED MANUSCRIPT
+20 
+ 
+EP 
+Baseline 
+30 
+27.78±30.43 
+27.78±31.66 
+0.826 
+Post test 
+30 
+64.44±43.71 
+51.67 ±35.11 
+0.204 
+ 
+p=0.001 
+p=0.003 
+ 
+Energy 
+Baseline 
+30 
+44.58±10.42 
+53.17±10.54 
+0.004 
+Post test 
+30 
+58.25±12.85 
+56.50±11.38 
+0.581 
+ 
+p<0.001 
+p=0.188 
+ 
+EW 
+Baseline 
+30 
+65.33±12.66 
+64.53±11.49 
+0.840 
+Post test 
+30 
+66.33±12.66 
+67.87±12.32 
+0.800 
+ 
+p=0.628 
+p=0.091 
+ 
+SF 
+Baseline 
+30 
+42.50±17.47 
+40.00±12.88 
+0.742 
+Post test 
+30 
+64.08±13.20 
+55.25±17.58 
+0.035 
+ 
+p<0.001 
+p=0.091 
+ 
+Pain 
+Baseline 
+30 
+40.75±17.47 
+39.83±16.58 
+0.745 
+Post test 
+30 
+69.00±16.95 
+49.92±17.09 
+<0.001 
+ 
+p<0.001 
+p=0.011 
+ 
+GH 
+Baseline 
+30 
+48.58±13.39 
+43.58±14.35 
+0.399 
+Post test 
+30 
+62.17 ±12.30 
+56.17±12.01 
+0.054 
+ 
+p<0.001 
+p<0.001 
+ 
+Note: All the values are in Mean ± Standard deviation. VAS= Visual analogue scale; NDI= 
+Neck disability index; PSQI= Pittsburgh sleep quality index; SF = Short form; PH= Physical 
+functioning; PH= Physical Health; EP= Emotional problem; EW= Emotional wellbeing; SF= 
+Social functioning; GH= General Health 
+ 
+ 

subfolder_0/Anxiolytic effects of a yoga program in early breast cancer patients undergoing conventional treatment_a randomized controlled trial..txt

@@ -0,0 +1,944 @@
+Complementary Therapies in Medicine (2009) 17, 1—8
+available at www.sciencedirect.com
+journal homepage: www.elsevierhealth.com/journals/ctim
+Anxiolytic effects of a yoga program in early breast
+cancer patients undergoing conventional treatment:
+A randomized controlled trial
+M. Raghavendra Rao a,∗, Nagarathna Raghuram b, H.R. Nagendra b,
+K.S. Gopinath a, B.S. Srinath a, Ravi B. Diwakar a, Shekar Patil a,
+S. Ramesh Bilimagga a, Nalini Rao a, S. Varambally c
+a Departments of CAM, Surgical Oncology, Medical Oncology and Radiation Oncology,
+Bangalore Institute of Oncology, Bangalore, India
+b Department of Yoga Research, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, India
+c Department of Psychiatry, NIMHANS, Bangalore, India
+Available online 14 October 2008
+KEYWORDS
+Yoga;
+Anxiety;
+Cancer;
+STAI;
+CAM;
+Relaxation
+Summary
+Objectives: This study compares the anxiolytic effects of a yoga program and supportive therapy
+in breast cancer outpatients undergoing conventional treatment at a cancer centre.
+Methods: Ninety-eight stage II and III breast cancer outpatients were randomly assigned to
+receive yoga (n = 45) or brief supportive therapy (n = 53) prior to their primary treatment i.e.,
+surgery. Only those subjects who received surgery followed by adjuvant radiotherapy and six
+cycles of chemotherapy were chosen for analysis following intervention (yoga, n = 18, control,
+n = 20). Intervention consisted of yoga sessions lasting 60 min daily while the control group was
+imparted supportive therapy during their hospital visits as a part of routine care. Assessments
+included Speilberger’s State Trait Anxiety Inventory and symptom checklist. Assessments were
+done at baseline, after surgery, before, during, and after radiotherapy and chemotherapy.
+Results: A GLM-repeated measures ANOVA showed overall decrease in both self-reported state
+anxiety (p < 0.001) and trait anxiety (p = 0.005) in yoga group as compared to controls. There
+was a positive correlation between anxiety states and traits with symptom severity and distress
+during conventional treatment intervals.
+Conclusion: The results suggest that yoga can be used for managing treatment-related symptoms
+and anxiety in breast cancer outpatients.
+© 2008 Published by Elsevier Ltd.
+ Sources of support: Central Council for Research in Yoga and Naturopathy, Ministry of Health and Family Welfare, Govt. of India.
+∗Corresponding author at: Departments of CAM, Bangalore Institute of Oncology, No8, P Kalinga Rao Rd, Sampangiramnagar, Bangalore,
+India. Tel.: +91 80 40206000; fax: +91 80 22222146.
+E-mail address: [email protected] (M.R. Rao).
+0965-2299/$ — see front matter © 2008 Published by Elsevier Ltd.
+doi:10.1016/j.ctim.2008.05.005
+2
+M.R. Rao et al.
+Background
+Anxiety and depression are the commonest psychiatric prob-
+lems encountered in cancer patients. Fear and anxiety
+associated with diagnosis of cancer, invasive treatment
+procedures, sexual dysfunction secondary to surgery and
+radiation, and aversive reactions to chemotherapy are
+among the common treatment-related side effects observed
+in cancer patients. Clinical descriptions have noted can-
+cer patient’s fears of the treatment (e.g., being ‘‘burned’’
+or ‘‘equating radiotherapy with electric current’’), causing
+sterility, sickness or vomiting and vast individual differences
+in their psychological reactions, which usually predisposes to
+anxiety.1—5 Apart from treatment-related anxiety the diag-
+nosis of cancer itself is anxiety provoking.
+Psychiatric disorders in cancer patients are often missed
+or untreated.6 Patients with breast cancer undergoing radi-
+ation treatment also report anxiety and depression before,
+during and after the treatment.7 The prevalence of anxi-
+ety and depression in cancer patients undergoing radiation
+treatment was 64% and 50%, respectively.1
+Earlier studies have shown that anxiety increases psy-
+chological distress and side effects following conventional
+treatment.8,9 This treatment-related distress is predictive
+of poorer treatment outcome, poor treatment compliance,
+greater pain, longer hospital stays, more postoperative
+complications and immune suppression.10,11 This has been
+attributed in part to subjects increased attentiveness to
+their somatic symptoms12 and development of aversive con-
+ditioned responses induced by anxiety.13 Therefore, there is
+a need to reduce anxiety in these patients.
+The literature on psychosocial treatment for breast can-
+cer patients provides uniform evidence for an improvement
+in mood, coping, adjustment, vigour, and decrease in dis-
+tressful symptoms using a variety of behavioural approaches
+including alternative medicine approaches such as yoga.14—21
+Yoga as a complementary and mind body therapy is being
+practiced increasingly across the world. It is an ancient
+Indian science that has been used for therapeutic ben-
+efit in numerous health care concerns in which mental
+stress was believed to play a role.22 This could be partic-
+ularly useful in cancer patients who perceive cancer as a
+threat.
+Results from earlier studies provide preliminary sup-
+port for anxiolytic effects of yoga interventions in cancer
+patients. Positive effects have been seen on a variety of out-
+comes, including sleep quality, mood, stress, cancer-related
+distress, cancer-related symptoms, and overall quality of
+life, as well as functional and physiological measures.23
+Further, results from cancer trials are bolstered by stud-
+ies conducted with non-cancer populations, which have
+demonstrated positive effects on similar outcomes (e.g.,
+improvements in mood and fatigue). These studies were
+typically more methodologically rigorous than those con-
+ducted with cancer populations and often included active
+control groups (e.g., relaxation,24 exercise,25 and wait listed
+controls26) lending further support to the results.27
+An earlier uncontrolled study with cancer patients in
+India also reported mood-enhancing effects with yoga
+intervention.28 Being diagnosed with cancer is in itself
+anxiety-provoking, and we hypothesize that yoga inter-
+vention may be effective for reducing general anxiety
+associated with the having cancer and those related to can-
+cer treatment.
+In this study, we compared the effects of a 24-week
+‘‘Integrated yoga program’’ with ‘‘Brief supportive ther-
+apy’’ control intervention in early operable breast cancer
+patients undergoing surgery, radiotherapy, and chemother-
+apy.
+Methods
+This is a single centre randomized controlled trial which
+recruited 98 recently diagnosed women with stage II and III
+operable breast cancers. The institutional ethics committee
+of the recruiting cancer centre approved the study. Patients
+were included if they met the following criteria: (i) women
+with recently diagnosed operable breast cancer, (ii) age
+between 30 and 70 years, (iii) Zubrod’s performance status
+0—2 (ambulatory >50% of time), (iv) high school education,
+(v) willingness to participate, and (vi) treatment plan with
+surgery followed by adjuvant radiotherapy and chemother-
+apy. Patients were excluded if they had (i) a concurrent
+medical condition likely to interfere with the treatment, (ii)
+any major psychiatric, neurological illness or autoimmune
+disorders, and (iii) secondary malignancy. The details of the
+study were explained to the participants and their informed
+consent was obtained in writing.
+Assessments were done prior to their surgery, fol-
+lowing surgery, during and following radiotherapy and
+chemotherapy.
+All
+participants
+in
+the
+study
+received
+the same dose of radiation (50 cGy over 6 weeks) and
+prescribed standard chemotherapy schedules (cyclophos-
+phamide, methotrexate, fluorouracil or fluorouracil, adri-
+amycin and cyclophosphamide—
+–six cycles). Subjects in both
+groups (control 45%, yoga 39%) received anxiolytic med-
+ications during their chemotherapy to prevent aversive
+responses (alprazolam 0.5 mg once daily for 1 week following
+chemotherapy infusion). The subjects received anxiolytics
+as a co-medication for only one to two cycles of chemother-
+apy. However, co-medication was given only to prevent
+aversive responses such as chemotherapy induced nausea
+and vomiting following chemotherapy.
+Measures
+Before randomization demographic information, medical
+history, clinical data, intake of medications, investigative
+notes and conventional treatment regimen were ascertained
+from all consenting participants. Participants completed the
+state trait anxiety inventory (STAI) that consists of a sep-
+arate self-report scale for measuring two distinct anxiety
+concepts: state anxiety and trait anxiety.29
+The A trait scale asks subjects to describe how they
+generally feel, an attempt to tap individual differences in
+‘‘anxiety proneness’’ where as the A-state scale asks the
+subjects to indicate how they feel at a particular moment in
+time. Subjects are asked to rate on a 4-point scale (almost
+never/not at all to almost always/very much) whether or
+not each statement best describes their feelings. Because
+the state measure is regarded similar to mood measures that
+have expectedly low test—retest reliabilities, comparison of
+internal consistencies between the state and trait measure
+Anxiolytic effects of a yoga program in early breast cancer patients
+3
+is more appropriate. Coefficient alpha values for the state
+measure range from 0.86 to 0.92 and those for trait measure
+are equally high.
+The subjective symptom checklist was developed dur-
+ing the pilot phase to assess treatment-related side effects,
+problems with sexuality and image, and relevant psycho-
+logical and somatic symptoms related to breast cancer.
+The checklist consisted of 31 such items each evaluated
+on two dimensions; severity graded from no to very severe
+(0—4) and distress from not at all to very much (0—4).
+These scales measured the total number of symptoms expe-
+rienced, total/mean severity and distress scores and were
+evaluated previously in a similar breast cancer population.30
+The patients from both groups were briefed together by
+investigators on filling the questionnaire. These self-report
+questionnaires were filled by patients themselves at assess-
+ment intervals.
+Randomization
+A person who had no part in the trial randomly allocated
+consenting participants (n = 98) to either yoga (n = 45) or
+supportive therapy groups (n = 53). Participants were ran-
+domized at the initial visit before starting any conventional
+treatment. Following randomization participants underwent
+surgery followed by radiotherapy (RT) and chemotherapy
+(CT) or any other treatment schedule as shown in Table 1.
+There were 12 dropouts in yoga and 17 dropouts in control
+group, respectively following surgery. Another 15 subjects
+and 13 subjects in yoga and control arm who did not receive
+the above treatment sequence were not considered for anal-
+ysis (see Fig. 1: trial profile).
+Sample size
+Earlier studies have reported very large effect size (>1) for
+anxiety scores with yoga intervention.31 We therefore used
+a conservative estimate of effect size/standardised differ-
+ence = 1 for our study. The sample size needed in our study
+based on formula32 is 17 subjects in each arm with p at
+0.05 and 80% power. There were 18 subjects in yoga and
+20 subjects in control group who contributed data to the
+study.
+Interventions
+The intervention group received an integrated yoga program
+and the control group received supportive therapy sessions,
+both imparted individually. Yoga practices consisted of a set
+of asanas (postures), breathing exercises, pranayama (vol-
+untarily regulated nostril breathing), meditation and yogic
+relaxation techniques with imagery. The details of these
+practices are described elsewhere.33 These practices were
+based on principles of attention diversion, awareness and
+relaxation to cope with stressful experiences. The subjects
+were given booklets, audiotapes with instructions on these
+practices for home practice using the instructors voice so
+that a familiar voice could be heard on the cassette.
+The subjects underwent four in-person sessions during
+their pre- and postoperative period and were asked to
+undergo three in-person sessions/week for 6 weeks dur-
+Figure 1
+Trial profile.
+ing their adjuvant radiotherapy treatment in the hospital
+with self-practice as homework on the remaining days. Dur-
+ing chemotherapy, subjects underwent in person sessions
+during their hospital visits for chemotherapy administration
+(once in 21 days) and were imparted in-person sessions by
+their trainer once in 10 days. The instructor monitored their
+homework on a day-to-day basis through telephone calls and
+house visits. Participants were also encouraged to maintain a
+daily log listing the yoga practices done, use of audiovisual
+aids, duration of practice, experience of distressful symp-
+toms, intake of medication and diet history. There were two
+instructors, one being a physician in naturopathy and yoga
+and the other a trained and certified therapist in yoga from
+the yoga institute. They together supervised and imparted
+the yoga and supportive therapy intervention with help from
+trained social workers and counsellors at the hospital.
+The control intervention consisted of brief supportive
+therapy with education as a component that is routinely
+offered to patients as a part of their care in this centre.
+We chose to have this as a control intervention mainly to
+control for the non-specific effects of the yoga program
+that may be associated with factors such as attention, sup-
+port and a sense of control. Subjects and their caretakers
+underwent counselling by a trained social worker (once in
+10 days, 15 min sessions) during their hospital visits for
+adjuvant radiotherapy/chemotherapy. Subjects in the sup-
+portive therapy group also completed daily logs or dairies
+on treatment-related symptoms, medication and diet dur-
+ing their chemotherapy cycles. The subjects were also given
+homework based on education component and were also
+4
+M.R. Rao et al.
+Table 1
+Demographic characteristics of the initially randomized sample (n = 98)
+All subjects
+Yoga group
+Control group
+n
+(%)
+n
+(%)
+n
+(%)
+Stage of breast cancer
+II
+47
+47.9
+24
+53.3
+23
+43.4
+III
+51
+52.1
+21
+46.7
+30
+Grade of breast cancer
+I
+1
+1
+1
+2.2
+0
+0
+II
+11
+11.2
+6
+13.3
+5
+9.4
+III
+86
+87.8
+38
+84.4
+48
+90.6
+Menopausal status
+Pre
+44
+44.9
+27
+60
+17
+32.1
+Post
+50
+51.1
+15
+33.3
+35
+66
+Peri
+2
+2
+2
+4.4
+0
+0
+Post-hysterectomy
+2
+2
+1
+2.2
+1
+1.9
+Histopathology type
+IDC
+75
+76.5
+38
+84.4
+37
+69.8
+ILC
+14
+14.3
+5
+11.2
+9
+17
+IPC
+6
+6.1
+2
+4.4
+4
+7.5
+IDC-P
+3
+3.1
+0
+0
+3
+5.6
+Treatment regimen
+S + RT + CT6
+49
+50
+22
+48.9
+27
+50.9
+S + CT6
+7
+7.1
+4
+8.9
+3
+5.6
+S + CT3 + RT + CT3
+28
+28.6
+12
+26.7
+16
+30.2
+S + RT
+10
+10.2
+5
+11.1
+5
+9.4
+S + CT6 + RT
+4
+4.1
+2
+4.4
+2
+3.8
+Stressful life events past 2 years
+Yes
+27
+28
+10
+22.2
+17
+32.1
+No
+71
+72
+35
+77.8
+36
+67.9
+Control group = Supportive Therapy, IDC—Infiltrating Ductal Carcinoma, ILC��Infiltarting Lobular Carcinoma, IPC—Infiltrating Papillary
+Carcinoma, IDC-P—Infiltrating Ductal Carcinoma-Papillary type, S—Surgery, RT—Radiotherapy, CT—Chemotherapy.
+followed up with telephone calls and house visits. While
+the goals of yoga intervention were stress reduction and
+appraisal changes, the goals of supportive therapy were edu-
+cation, reinforcing social support and coping preparation.
+Statistical methods
+Data were analyzed using Statistical Package for Social Sci-
+ences version 10.0. We used a per protocol analysis in this
+study analyzing only those subjects who underwent surgery
+followed by radiotherapy and six cycles of chemotherapy
+(in this order) for the study as heterogeneity in treat-
+ment modalities and sequence could have confounded the
+results. A GLM-repeated measures ANOVA was done with
+the within-subjects factor being time/assessments at six
+levels and between-subjects factor being groups at two
+levels (yoga and supportive therapy). Both within-subjects
+and between-subjects effect and group by time interac-
+tion effects were assessed. Post hoc tests were done using
+Bonferroni correction for changes at different time points
+between groups. Intention to treat analysis was also done on
+the initially randomized sample (n = 98) with baseline mea-
+sure and post-measure (post-CT) for all subjects. Baseline
+value was carried forward for subjects who did not have
+a post-measure (including those who received other treat-
+ment schedules and study drop outs). Pearson correlation
+analysis was used to study the bivariate relationships of
+anxiety state and trait scores with treatment-related symp-
+tom severity and distress at various conventional treatment
+intervals (post-surgery/mid-RT/mid-CT).
+Results
+The subjects in our study were recruited and followed-up
+between January 1999 and June 2004. The groups were
+comparable with respect to socio-demographic and medical
+characteristics (see Table 1). Subjects in both groups (con-
+trol 45%, yoga 39%) received anxiolytic medications during
+their chemotherapy to prevent aversive responses (alprazo-
+lam 0.5 mg once daily for 1 week following chemotherapy
+infusion). The subjects received anxiolytics as a comedica-
+tion for only one to two cycles of chemotherapy.
+Anxiety state
+A repeated measures analysis of variance was done on
+anxiety state scores. Sphericity was assumed with Hyun
+Anxiolytic effects of a yoga program in early breast cancer patients
+5
+feldt э at 0.6. Though group by time interaction effects
+were not significant, the between-subjects effect was sig-
+nificant F (1, 35) = 10.8, p = 0.002. Post hoc tests using
+Bonferroni correction showed significant decrease in anxiety
+states in yoga group as compared to control at post-surgery
+(mean change ± S.E., p value, 95% CI), (4.3 ± 1.96, p = 0.04,
+0.2—8.3), mid-RT (5.7 ± 2.2, p = 0.01, 1.3—10.2), post-RT
+(5.5 ± 2.1, p = 0.01, 1.3—9.7), mid-CT (8.9 ± 2.2, p < 0.001,
+4.3—13.3), and post-CT (8.9 ± 2.6, p = 0.002, 3.6—14.2) (see
+Table 2). However, intention to treat analysis done on the
+initially randomized sample showed a significant change
+between groups on state measure following intervention
+(4.7 ± 2.1, p = 0.05, 1.1—6.4) (Table 3).
+Anxiety trait
+A repeated measures analysis of variance was done on anx-
+iety trait scores. Sphericity was assumed with Hyun feldt
+э at 0.75. Though group by time interaction effects was
+not significant, the between-subjects effect was significant
+F (1, 35) = 8.2, p = 0.007. Post hoc tests using Bonferroni
+correction showed significant decrease in anxiety trait in
+the yoga group as compared to controls at post-surgery
+(mean change ± S.E., p value, 95% CI), (6.9 ± 2.4, p = 0.007,
+2—11.8), post-RT (5.8 ± 2.1, p = 0.01, 1.5—10.1), and post-
+CT (8.2 ± 2.8, p = 0.005, 2.6—13.8) (see Table 2). However,
+intention to treat analysis done on the initially randomized
+sample did not show any significant change between groups
+on trait measure following intervention (Table 3).
+Symptom distress
+A repeated measures analysis of variance was done on
+symptom distress scores. Sphericity was assumed with Hyun
+feldt э at 1. Group by time interaction effects was sig-
+nificant and between subjects effect was significant F (1,
+35) = 14.5, p = 0.001. Post hoc tests using Bonferroni cor-
+rection showed significant decrease in symptom distress
+in yoga group as compared to controls at post-surgery
+(mean change ± S.E., p value, 95% CI), (6.4 ± 2.3, p = 0.009,
+1.7—11.1), mid-RT (10.1 ± 2.8, p = 0.001, 4.3—15.8), post-
+RT (4.8 ± 1.7, p = 0.009, 1.4—8.2), mid-CT (16.3 ± 3.5,
+p < 0.001,
+9.3—23.3),
+and
+post-CT
+(7.7 ± 2.9,
+p = 0.01,
+1.6—13.7) (Table 2).
+There was a significant bivariate relationship between
+anxiety states and traits with severity and distress of
+treatment-related symptoms during various stages of con-
+ventional treatment (see Table 4).
+Discussion
+We compared the effects of a 24-week yoga program
+with supportive therapy in 38 recently diagnosed breast
+cancer outpatients undergoing surgery, radiotherapy, and
+chemotherapy. The results suggest an overall decrease in
+both anxiety state (reactive anxiety) and trait with time in
+both the groups. Yoga intervention reduced anxiety state
+scores by 0.5% following surgery, 4.9% and 6% during and fol-
+lowing radiotherapy and 8.5% and 11.6% during and following
+chemotherapy from their respective baseline means than
+Table 2
+Comparison of scores for anxiety state, trait and symptom distress at various stages of conventional treatment using GLM-repeated measures ANOVA
+Outcome measures
+Pre-surgerya
+Post-surgerya
+During radiotherapya
+Post-RT
+During chemotherapya
+Post-CT
+Pre-RT
+Mid-RT
+Pre-CT
+Mid-CT
+STAI-anxiety state
+Yoga, mean (S.D.)
+43.9 ± 11
+34 ± 3.2*
+34 ± 3.2
+29.3 ± 3.6*
+29.1 ± 3.6*
+29.1 ± 3.6
+29.3 ± 3.3***
+24.1 ± 3.1***
+Control, mean (S.D.)
+48.7 ± 11.6
+38.3 ± 7.4
+38.3 ± 7.4
+35.3 ± 8.2
+34.3 ± 8.2
+34.3 ± 7.8
+38.2 ± 8.5
+33.1 ± 10.5
+STAI-anxiety trait
+Yoga, mean (S.D.)
+42.1 ± 8.8
+33.4 ± 3.9***
+33.4 ± 3.9
+—
+30.1 ± 3.9**
+35.7 ± 7.8
+—
+26.7 ± 3.9***
+Control, mean (S.D.)
+46.8 ± 10.9
+40.6 ± 9.2
+40.6 ± 9.2
+—
+35.7 ± 7.8
+35.7 ± 7.8
+—
+34.9 ± 10.8
+Symptom distress
+Yoga, mean (S.D.)
+13.9 ± 9.5
+9.2 ± 8.3***
+9.2 ± 8.3
+10.1 ± 6.5***
+5.4 ± 5.6***
+31.8 ± 4.7
+15.3 ± 9.7***
+5.1 ± 6.5*
+Control, mean (S.D.)
+15.8 ± 8.5
+15.3 ± 5.7
+34.4 ± 8.7
+19.8 ± 10.1
+10.1 ± 4.7
+37.6 ± 7.8
+31.6 ± 11.1
+12.8 ± 10.7
+*p values < 0.05, **p values < 0.01, ***p values < 0.001, for post hoc tests comparing groups at different time points using Bonferroni correction. y = yoga, c = control/supportive therapy
+group.
+a Y (n = 18), C (n = 20).
+6
+M.R. Rao et al.
+Table 3
+Comparison of scores between yoga and control
+groups at baseline and following intervention on intention
+to treat analysis using RMANOVA in the initially randomized
+sample (n = 98)
+Measures
+Baseline
+(mean ± S.D.)
+Post-intervention
+(mean ± S.D.)
+Anxiety state
+Yoga (n = 45)
+47.7 ± 11.1
+37.8 ± 11.6*
+Control (n = 53)
+51.1 ± 10.9
+45.9 ± 14.2
+Anxiety trait
+Yoga (n = 45)
+45.7 ± 10.8
+37.9 ± 13.8
+Control (n = 53)
+48.5 ± 10.3
+41.5 ± 12.3
+y = yoga, c = control/supportive therapy group.
+* p < 0.05 for post hoc tests comparing groups at different time
+points using Bonferroni correction.
+the control group. There was also a corresponding decrease
+in anxiety trait scores by 7% following surgery, 8.1% follow-
+ing radiotherapy, and 10.4% following chemotherapy from
+their baseline means as compared to controls. However,
+the decrease was less on intention to treat analysis. Our
+results are bolstered by other studies in non-cancer popula-
+tions using yoga intervention that have clearly demonstrated
+both change in state and trait anxiety following 10 days to
+6 months of intervention.31,34—38
+In all these studies the effect size for reduction in anxiety
+by yoga were large (>0.8), where as in our study the effect
+size (Cohen’s f) for anxiety state was 0.33 and trait was
+0.24. Another randomized controlled trial in cancer patients
+using the anxiety subscale of the Profile of Moods Scale
+also reported large effect size with MBSR intervention.39,40
+High effect sizes seen with the above intervention could be
+due to absence of an effective control intervention. It can
+be argued that a modest effect size (<0.5) seen with our
+intervention could be due to the fact that we controlled
+for education, support and attention in these subjects that
+could have reduced the effects of our intervention. Another
+reason could also be for the fact that patients were followed
+over a long period and repeat measurements could have
+reduced the effect size of our intervention. Nevertheless,
+our finding that yoga helped reduce treatment-related dis-
+Table 4
+Pearson correlation (r values) between anxiety
+scores and treatment-related symptoms (severity and dis-
+tress) at various conventional treatment intervals
+Symptom severity
+Symptom distress
+r (95% CI)
+r (95% CI)
+Post-surgery
+Anxiety state
+0.66 (0.62—1.1)
+0.65 (0.34—0.84)
+Anxiety trait
+0.68 (0.77—1.3)
+0.69 (0.66—1.2)
+During radiotherapy
+Anxiety state
+0.73 (0.62—0.98)
+0.73 (0.5—0.79)
+Anxiety trait
+0.60 (0.62—1.15)
+0.58 (0.67—1.15)
+During chemotherapy
+Anxiety state
+0.58 (0.27—0.57)
+0.64 (0.26—0.70)
+Anxiety trait
+0.49 (0.31—1.1)
+0.50 (0.41—1.1)
+tress and severity at various treatment follow-up intervals
+support the anxiolytic effects of our intervention.
+Overall, the results suggest that anxiolytic effects of
+yoga program could be attributed to stress reduction rather
+than mere social support and education in conformity with
+earlier studies.41,42 Scores on anxiety state and trait corre-
+lated directly with symptom severity and distress at various
+stages of conventional treatment further supporting the
+idea that reductions in anxiety could contribute to decre-
+ments in treatment-related distress and outcomes.43 Earlier
+studies also show that state and distressful symptoms can
+also change an individual’s personality trait44 and hence
+trait changes can also be seen with our intervention. Ear-
+lier studies have shown that though distressful symptoms
+do influence traits, they are independent of each other and
+changes could be actually related to test retest issues and
+the inadequacy of the trait scale itself and not related to
+change in distressful symptoms. However, trait changes were
+not significant on intention to treat analysis and the results
+must therefore be viewed with caution. We have shown ear-
+lier that yoga has been helpful in reducing aversive reactions
+to chemotherapy such as nausea and vomiting.33 A reduction
+in symptom distress and subjective severity is an important
+benefit to be gained via stress reduction techniques such as
+yoga.
+We chose to have individual yoga therapy and supportive
+counselling sessions as compared to group therapy as being
+in a group could have confounded the benefits conferred
+by our interventions.45 Moreover, these individual sessions
+also helped to understand the specific needs and concerns
+of participants and monitor individual progress in practice.
+Finally, none of the patients in our study reported any mus-
+culoskeletal complaints or any other adverse event that may
+be related to yoga practice indicating that the yoga module
+developed for cancer patients was safe.
+We have also demonstrated that this yoga intervention
+package could be used in a cancer centre along with the
+routine treatment without any need for additional expen-
+sive infrastructure. This would be feasible and cost effective
+especially in a developing country where supportive services
+for cancer patients are rarely available and access to care
+is not affordable for the majority of the cancer population.
+One of the major limitations in our study is the inequality
+in contact duration of interventions. Supportive therapy
+interventions were used only with an intention of negating
+the confounding variables such as instructor—patient inter-
+action, education, and attention.46 However, inequality in
+contact duration of this intervention could have affected
+its effectiveness as successes of such interventions depend
+mainly on contact duration and content. Similar support-
+ive sessions have been used successfully as a control
+comparison
+group
+to
+evaluate
+psychotherapeutic
+interventions46,47
+and have been effective in control-
+ling chemotherapy related side effects.48 Secondly; it was
+not possible to mask the yoga intervention from the study
+participants. Blinding in yoga studies is a topic of intense
+discussion in yoga research. As yet there has been no perfect
+method for blinding yoga therapy from the participants
+because of the nature of the therapy itself, which involves
+the patients being asked to perform asanas as well as a
+spiritual component that includes the knowledge that they
+are performing yoga.
+Anxiolytic effects of a yoga program in early breast cancer patients
+7
+Conclusions
+In summary, our yoga-based intervention was effective in
+reducing reactive anxiety and trait anxiety in early breast
+cancer patients undergoing conventional cancer treatment.
+This was probably facilitated through stress reduction and
+helping the cancer patients to cope better with their illness
+at various stages of their conventional treatment. Future
+studies should explore the putative neurophysiologic mech-
+anisms underlying the anxiolytic effects conferred by yoga
+intervention.
+Acknowledgements
+We are thankful to Dr Jayashree, Mrs. Anupama for imparting
+the yoga intervention. We are thankful to Dr. B.N. Gangad-
+har, Prof and Head, Department of Psychiatry for editing this
+manuscript. We are thankful to Central Council for Research
+in Yoga and Naturopathy, Ministry of Health and Family Wel-
+fare, Govt. of India for funding this study.
+References
+1. Chaturvedi SK, Prabha Chandra S, Channabasavanna SM, Anan-
+tha N, Reddy BKM, Sharma Sanjeev. Levels of anxiety and
+depression in depression in patients receiving radiotherapy in
+India. Psychooncology 1996;5:343—6.
+2. Rotman M, Rogow L, Deleon G, Heskel N. Supportive therapy in
+radiation oncology. Cancer 1977;39:744—50.
+3. Smith LL, McNamara JJ. Social work services for radiation ther-
+apy patients and their families. Hosp Community Psychiatry
+1977;28:752—4.
+4. Welch DA. Assessment of nausea and vomiting in cancer
+patients undergoing external beam radiotherapy. Cancer Nurs
+1980:365—71.
+5. Yonke G. Emotional response to radiotherapy. Hosp Top
+1967;45:107—8.
+6. Derogatis LR, Morrow GR, Fetting J. The prevalence of psychi-
+atric disorders among cancer patients. JAMA 1983;239:751—7.
+7. Wengstrom Y
+, Haggmark C, Strander H, Forsberg C. Perceived
+symptoms and quality of life in women with breast cancer
+receiving radiation therapy. Eur J Oncol Nurs 2000;4:78—88.
+8. Tross S, Hendon J, Korzun A, Kornblith AB, Cella DF
+, Holland
+JF
+, et al. Psychological symptoms and disease-free and over-
+all survival in women with stage II breast cancer. Cancer and
+leukemia group B. J Natl Can Inst 1996;88:661—7.
+9. Walker LG, Heys SD, Ogston K. Psychological factors predict
+response to neo-adjuvant chemotherapy in women with locally
+advanced breast cancer. Psychooncology 1997;6:242—3.
+10. Johnston
+M.
+Anxiety
+in
+surgical
+patients.
+Psychol
+Med
+1980;10:142—52.
+11. Mathews A, Ridgeway V. Personality and surgical recovery. Br J
+Clin Psychol 1981;20:243—60.
+12. Chaturvedi SK, Bhandari S. Somatization and illness behaviour.
+J Psychosom Res 1989;33:147—53.
+13. Burish TG, Tope DM. Psychological techniques for controlling
+the adverse side effects of cancer chemotherapy: find-
+ings from a decade of research. J Pain Symptom Manage
+1992;7:287—301.
+14. Blake-Mortimer J, Gore-Felton C, Kimerling R, Turner-Cobb JM,
+Spiegel D. Improving the quality and quantity of life among
+patients with cancer: a review of the effectiveness of group
+psychotherapy. Eur J Cancer 1999;35:1581—6.
+15. Bottomley A. Where are we now? Evaluating two decades of
+group interventions with adult cancer patients. J Psychiatr
+Ment Health Nurs 1997;4:251—65.
+16. Anderson BL. Psychological interventions for cancer patients
+to enhance quality of life. J Consult Clin Psychol 1992;60:
+552—68.
+17. Cunningham AJ. Adjuvant psychological therapy for cancer
+patients: putting it on the same footing as adjunctive medical
+therapies. Psychooncology 2000;9:367—71.
+18. Fawzy FI. Psychosocial interventions for patients with can-
+cer: what works and what doesn’t. Eur J Cancer 1999;35:
+1559—64.
+19. Meyer TJ, Mark MM. Effects of psychosocial interventions with
+adult cancer patients: a meta-analysis of randomized experi-
+ments. Health Psychol 1995;14:101—8.
+20. Owen JE, Klapow JC, Hicken B, Tucker DC. Psychosocial inter-
+ventions for cancer: review and analysis using a three-tiered
+outcomes model. Psychooncology 2001;10:218—30.
+21. Targ EF
+, Levine EG. The efficacy of a mind—body—spirit group
+for women with breast cancer: a randomized controlled trial.
+Gen Hosp Psychiatry 2002;24:238—48.
+22. Khalsa SB. Yoga as a therapeutic intervention: a bibliometric
+analysis of published research studies. Indian J Physiol Phar-
+macol 2004;48:269—85.
+23. Bower
+JE,
+Alison
+Woolery
+MA,
+Sternleib
+B,
+Garet
+D.
+Yoga for cancer patients and survivors. Cancer Control
+2005;12(3):165—71.
+24. Wood C. Mood change and perceptions of vitality: a comparison
+of the effects of relaxation, visualization and yoga. J R Soc Med
+1993;86:254—8.
+25. Netz Y
+, Lidor R. Mood alterations in mindful vs. aerobic exercise
+modes. J Psychol 2003;137:405—19.
+26. Woolery A, Myers H, Sternleib B. A yoga intervention for young
+adults with elevated symptoms of depression. Altern Ther
+Health Med 2004;10:60—3.
+27. Patrick DL, Ferketich SL, Frame PS. National Institute of
+Healths State-of-the-Science Conference Statement: symptom
+management in cancer: pain, depression and fatigue. J Natl
+Cancer Inst 2003;95:1110—7.
+28. Joseph CD. Psychological supportive therapy for cancer
+patients. Ind J Cancer 1983;20:268—70.
+29. Spielberger CD, Gorsuch RL, Lushene RE. Test manual for the
+state trait anxiety inventory. Paolo Alto, CA: Consult Psychol-
+ogists Press; 1970.
+30. Bhaskaran SA. Behavioral management of patients with can-
+cer. Bangalore: National Institute of Mental Health and
+Neurosciences; 1996.
+31. Malathi A, Damodaran A. Stress due to exams in med-
+ical students—
+–role of yoga. Indian J Physiol Pharmacol
+1999;43:218—24.
+32. Whitley E, Ball J. Statistics review 4: sample size calculations.
+Crit Care 2002;6:335—41.
+33. Raghavendra RM, Nagarathna R, Nagendra HR et al. Effects of
+an integrated yoga program on chemotherapy induced nau-
+sea and emesis in breast cancer patients. Eur J Cancer Care
+2007;16:462—74.
+34. Bijlani RL. Influence of yoga on brain and behaviour: facts and
+speculations. Indian J Physiol Pharmacol 2004;48:1—5.
+35. Kabat-Zinn J, Massion AO, Kristeller J, et al. Effectiveness of
+a meditation-based stress reduction program in the treatment
+of anxiety disorders. Am J Psychiatry 1992;149:936—43.
+36. Khalsa SB, Cope S. Effects of a yoga lifestyle intervention on
+performance-related characteristics of musicians: a prelimi-
+nary study. Med Sci Monit 2006;12:325—31.
+37. Taneja I, Deepak KK, Poojary G, Acharya IN, Pandey RM,
+Sharma MP
+. Yogic versus conventional treatment in diarrhea-
+predominant irritable bowel syndrome: a randomized control
+study. Appl Psychophysiol Biofeedback 2004;29:19—33.
+8
+M.R. Rao et al.
+38. Woolery A, Myers H, Sternlieb B, Zeltzer L. A yoga intervention
+for young adults with elevated symptoms of depression. Altern
+Ther Health Med 2004;10:60—3.
+39. Carlson LE, Speca M, Patel DK, Goodey E. Mindfulness-based
+stress reduction in relation to quality of life, mood, symp-
+toms of stress, and immune parameters in breast and prostate
+cancer out patients. Psychosom Med 2003;65:571—81.
+40. Speca M, Carlson LE, Goodey E, Angen M. A randomized wait list
+controlled trial: the effect of a mindfulness meditation-based
+stress reduction program on mood and symptoms of stress in
+cancer outpatients. Psychosom Med 2000;62:613—22.
+41. Deberry S, Davis S, Reinhard KE. A comparison of meditation-
+relaxation and cognitive/behavioral techniques for reducing
+anxiety and depression in a geriatric population. J Geriatr Psy-
+chiatry 1989;22:231—47.
+42. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psy-
+chosocial treatment on survival of patients with metastatic
+breast cancer. Lancet 1989;2:888—91.
+43. Carey MP
+, Burish TG. Anxiety as a predictor of behavioral ther-
+apy outcome for cancer chemotherapy patients. J Consult Clin
+Psychol 1985;53:860—5.
+44. Fishbain DA, Cole B, Cutler RB, Lewis J, Rosomoff HI, Rosomoff
+RS. Chronic pain and the measurement of personality: do states
+influence traits? Pain Med 2006;7:509—29.
+45. Reissman
+F
+.
+The
+helper
+therapy
+principle.
+Soc
+Work
+1965;10:27—32.
+46. Telch CF
+, Telch MJ. Group coping skills instruction and sup-
+portive group therapy for cancer patients: a comparison of
+strategies. J Consult Clin Psychol 1986;54:802—8.
+47. Greer S, Moorey S, Baruch JD, et al. Adjuvant psychological
+therapy for patients with cancer—
+–a prospective randomized
+trial. Br Med J 1992;304:675—80.
+48. Burish TG, Snyder SI, Jenkins RA. Preparing patients for can-
+cer chemotherapy: effect of coping preparation and relaxation
+interventions. J Consult Clin Psychol 1991;59:518—25.

subfolder_0/Application of integrated yoga therapy to increase imitation skills in children with autism.txt

@@ -0,0 +1,552 @@
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+26
+Motor imitation is a complex developmental phenomenon 
+that serves important cognitive and social functions. At 
+a social level, it represents earliest forms of reciprocal 
+interactions between infant and the mother.
+There is a growing body of literature demonstrating that 
+children with autism have specific deficits in imitating 
+action on objects, body movements, vocalization, 
+gesture, functional objectives and facial expression. Most 
+researchers recognize imitation as a central deficit in 
+children with autism[3,4] and a lack of imitative play is one 
+of the diagnostic criteria for the disability.[5]
+Imitation is defined as the reproduction of a model’s 
+action in topography and function for the new actions 
+only. Charmil and Baren-Cohen,[6] Dawson and Adams[7] 
+and De Myer[8] were among the first to investigate 
+imitation skills in autism. In their experiment, 12 children 
+with autism and early childhood schizophrenia were 
+intROductiOn
+The ability to understand another person’s action and, if 
+needed, imitate that action is a core component of human 
+social behavior. Imitation skills can be observed as early 
+as infancy. In typical infants, imitation emerges early in 
+development and plays a crucial role in the development 
+of cognitive, social, communication and other behaviors 
+such as language, play and joint attention.[1]
+Early imitation is a non-verbal means of information 
+processing. In normal development, the baby is not taught 
+imitation as such; only in the second half of the year 
+parents begin to teach imitation like waving bye-bye, etc. 
+Typical children with autism spectrum disorder (ASD) fail 
+to demonstrate these skills. The more social the imitation 
+is, the harder it is to master. In the order of difficulty, 
+spontaneous object use is least difficult, motor object 
+imitation difficult and body imitation most difficult.[2]
+Background/Aim: Children with autism exhibit significant deficits in imitation skills, which impede the acquisition of more complex 
+behavior and socialization. Imitation is often targeted early in intervention plans and continues to be addressed throughout the 
+child’s treatment. The use of integrated approach to yoga therapy (IAYT) as a complementary therapy for children diagnosed 
+with autism spectrum disorder (ASD) is rarely reported and little is known on the effectiveness of such therapies. This study 
+investigated IAYT as a treatment method with children with ASD to increase imitative skills. 
+Materials and Methods: Parents and six children with ASD participated in a 10-month program of 5-weekly sessions and 
+regular practice at home. Pre, mid and post treatment assessments included observers and parent ratings of children’s imitation 
+skills in tasks related to imitation skills such as gross motor actions, vocalization, complex imitation, oral facial movements 
+and imitating breathing exercises. 
+Results: Improvement in children’s imitation skills especially pointing to body, postural and oral facial movements. Parents 
+reported change in the play pattern of these children with toys, peers and objects at home.
+Conclusions: This study indicates that IAYT may offer benefits as an effective tool to increase imitation, cognitive skills and 
+social-communicative behaviors in children with ASD. In addition, children exhibited increased skills in eye contact, sitting 
+tolerance, non-verbal communication and receptive skills to verbal commands related to spatial relationship.
+Key words: Autism, Yoga, Imitation
+ABSTRACT
+Application of integrated yoga therapy to increase imitation 
+skills in children with autism spectrum disorder
+Shantha Radhakrishna
+Sri. Ganapathi Sachchidananda (SGS) Vagdevi Centre for the Rehabilitation of Communication Impaired, Bangalore, Karnataka, India
+Address for correspondence: Shantha Radhakrishna,
+Sri. Ganapathi Sachchidananda (SGS) Vagdevi Centre for the Rehabilitation of Communication Impaired, 
+ 
+3rd C Main, 7th Cross, Girinagar II Phase, Bangalore - 560 085, Karnataka, India.
+E-mail: [email protected]
+DOI: 10.4103/0973-6131.66775
+Original Article
+www.ijoy.org.in
+27
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+compared to a controlled group of children with mental 
+retardation. The groups were evaluated on a variety of 
+body movements and object manipulation. Children with 
+autism exhibited significantly less imitation skill and 
+had particular difficulty with gestural imitation. Many 
+studies supported these findings. Heimann, Ullstadius, 
+Danigren and Gilberg[9] also found that motor tasks were 
+the least frequently imitated categories in children with 
+autism. Many more studies confirmed the above findings 
+of a relative deficit in motor imitation in children with 
+autism.[10]
+Imitation research on children with autism has focused 
+primarily on the form of imitation (i.e. gestural, object, facial, 
+vocal). Cognitive developmental research on imitation 
+in autism generally used Piagetian models of sensory 
+motor development and compared children with autism 
+to mental age matched peers on a series of sensory motor 
+tasks. In behavioral research of imitation in children with 
+autism, emphasis is often placed on factors influencing skill 
+acquisition including teaching factors such as presentation 
+mode and model type. Independent variables evaluated in 
+behavioral analytic literature typically include response 
+class generalization and peer modeling. De Myer’s[8]
+initial research generated many studies supportive of the 
+general findings of imitation deficits in autism. Findings 
+of deficits in imitation skills have significant implications 
+for the intervention approaches given the critical nature of 
+imitation to one’s ability to learn from the environment.
+Treatment for autism based on either behavioral or 
+cognitive developmental models emphasizes on developing 
+imitation skills in young children with autism. The 
+methods and treatments used remain to be empirically 
+validated.
+Many behavioral treatment approaches focusing on 
+imitation are in use in treating children with autism. In 
+discrete trial training (DTT), a target behavior or skill is 
+broken into component parts and repeatedly practiced 
+with prompting and fading the prompting until the skills 
+are mastered.
+The applied behavioral analysis (ABA) also includes 
+teaching imitation skills in a “command/prompt method” 
+where a teacher provides a prompt or command for the 
+autistic student to initiate and if the student achieves 
+the desired behavior, there are rewards and if not, there 
+are repeats of the command/prompt and a repeat for the 
+student to produce the expected behavior. The desired 
+behavior is then reinforced and the student can repeat the 
+expected behavior in the classroom.
+There are many behavioral treatment approaches such as 
+language training behavior, natural language procedure, 
+incidental teaching, pivotal learning and errorless 
+learning. All these basic procedures use ABA principles 
+such as stimulus control, prompts, modeling, shaping 
+and reinforcement to teach imitation skills. All these 
+procedures consider imitation skills to be essential to new 
+learning. Imitation skills are typically among the first to 
+be taught in many of these programs because they are 
+often considered being pre-requisite abilities for learning 
+other skills, e.g. motor imitation (clapping, running, 
+walking on toes and jumping). Once basic imitation skills 
+are established, they can be used as building blocks for 
+complex tasks.
+A pilot study by Radhakrishna[11] suggests that integrated 
+approach to yoga therapy (IAYT) can specifically increase 
+imitation skills, an essential pre-requisite for learning. It 
+also demonstrated changes in non-verbal communication, 
+self-esteem, emotional bonding, focus, tolerance to touch, 
+proximity and sharing of attention.
+The study reported here started with the premise that as 
+clinicians, we need to develop intervention approaches that 
+are derived from a number of theoretical understandings 
+of autism.
+The IAYT approach is based on the philosophy that the 
+child is perfect and whole, and that the child and therapist 
+are both unlimited in their abilities to teach. Supporting 
+these beliefs is empirically sound therapy based on yoga 
+philosophy and practice to help the child to reach his/her 
+highest potential for a quality life.
+mateRials and methOds
+subject selection
+This study adopted a case study approach. The IAYT 
+program was publicized through workshops conducted at 
+various national institutes and centers and schools for ASD 
+children. Six children admitted to SGS Vagdevi Integrated 
+School were matched for age, sex, IQ and socioeconomic/
+educational background of parents. Children who were 
+already diagnosed with ASD by leading institutions of 
+Bangalore, India, were selected for the study. Diagnosis 
+was cross-validated by the author using DSM-IV-TR[5] 
+criteria. The Childhood Rating Scale[12] was also used to 
+determine autism severity. All the children demonstrated 
+mild to moderate range of autism.
+Data are given in Table 1.
+Table 1: Demographic data
+No.
+Age
+Sex
+IQ
+SEB
+EB
+6
+8–14 years
+M/F = 5/1
+70 and above
+Middle class
+Graduates
+SEB = Socio-economic background (minimum Rs. 8000); EB = Educational 
+background (graduate mothers)
+ASDIM
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+28
+Written consent to participate in the study was obtained 
+from the parents.
+imitation test battery
+The tasks given in Table 2 were developed for this study 
+based on previous pilot study experience by the researcher 
+who is a speech-language/yoga therapist by profession.
+assessment procedure
+Special educators and parents contributed to a range of 
+data collection procedure through questionnaire and 
+observers’ comments and interviews. Assessment was 
+conducted at 3 points. Pre (1–12 sessions), mid (60th, 80th 
+and 100th sessions) and post (180th, 181st and 182nd 
+sessions).
+child assessment measures
+Perceived outcomes of IAYT for the child were measured 
+at the mid and end points of the program. Parents 
+completed a short questionnaire to see whether IAYT 
+has made any change on the five targeted areas of 
+behavior. A simple 3-point rating scale was used (based 
+on researcher’s pilot study[11]) to obtain information on 
+the level of benefit (0 = rarely imitates, 1 = occasionally 
+imitates, 2 = consistently imitates). Three trained 
+observers completed the assessment. Responses were 
+scored on a 3-point scale; a “2” was recorded if the child 
+produced exact imitation, a “1” was recorded if the child 
+produced an occasional imitation and a “0” was recorded 
+if the child rarely imitates or imitation absent. Inter-rater 
+reliability was established prior to scoring and maintained 
+throughout the study.
+yoga intervention
+Yoga therapy was then introduced five times a week 45 
+minutes daily for 10 months. Mother accompanied the 
+child during all these sessions. These sessions took place 
+in an open green, serene spiritual atmosphere overlooking 
+an ashram and temple. Children used their own mats and 
+marked their own boundary of operation. Yoga asanas 
+(postures) and pranayama (breathing exercises) adopted in 
+this study were specially selected to address issues related 
+to imitation difficulties with ASDs.
+Exercises adopted during IAYT are listed in Table 3.
+The sequence consisted of “warm-up asanas, strengthening 
+asanas, release of tension asanas, calming asanas and 
+breathing asanas”. Yogasanas selected initially were 
+physically less demanding. During warm-up asanas, if 
+the child did not imitate the therapist, the attending adult 
+physically guided the child to complete the task. The child 
+slowly learned that she/he is expected to imitate the model. 
+It also provided a motor plan to complete more asanas.
+Results and discussiOn
+First the children’s baseline data are described in 
+relation to imitation skills. Second, changes in various 
+parameters at mid and post therapy phase are discussed. 
+In the third section, changes in the related behavior, 
+namely communication, social relationships and 
+behavioral perseveration, are elaborated. The initial 
+interviews with parents and staff carried out to gain 
+an insight into the current imitation behavior are 
+summarized.
+Relative absence of imitation was not of immediate 
+concern to parents as their knowledge of the importance of 
+imitation and its impact on development was limited. From 
+the parents’ perceptive, lack of any form of communication, 
+not playing with other children, hyperactivity was 
+something they found particularly difficult to cope with.
+The baseline, mid and post therapy data are summarized 
+in Figure 1.
+summary of imitation behaviors 
+At the start of the study, children in this sample
+• never imitate gross motor actions (could not imitate 
+the model’s actions of pointing to body parts)
+• rarely imitate vocalization
+• never imitate two phase complex movements
+• rarely imitate oral facial movements
+• never imitate adult breathing in and out model
+Table 2: Target imitation skills
+Imitating  
+gross motor 
+actions
+Imitating 
+vocalization
+Complex 
+imitation
+Imitating 
+oral facial 
+movements
+Breathing 
+exercises
+Running
+Walking
+Jumping
+Walking on  
+toes
+Imitating  
+sounds (A, E,  
+U, OM)
+Imitating words
+Imitating  
+phrases
+Simple 
+asanas
+Imitating 
+sequence 
+actions
+Lips, tongue 
+and jaw 
+exercises
+Blowing 
+exercises
+In and out 
+breathing
+Sectional 
+breathing 
+Table 3: Yoga intervention
+Warm-up 
+asanas 
+Strengthening 
+asanas
+Release 
+of tension 
+asanas
+Calming 
+asanas
+Breathing 
+asanas
+Jogging
+Bending 
+exercises
+Twisting
+Trikonasana
+Parshavakonasana
+Veerabhadrasana
+Neck 
+exercises
+Back 
+bending 
+exercises
+Relaxation 
+exercises
+Sukhasana
+Shavasana
+Blowing 
+exercises 
+in and out 
+breathing
+sectional 
+breathing
+Radhakrishna
+29
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+All the six children performed poorly in imitating 
+breathing exercises. They could not perform even simple 
+blowing exercises. This may be directly related to their 
+poor vocalization and expressive speech. They had 
+difficulty imitating two or more sequence imitations, 
+initiate vocalization and imitating gross motor actions. 
+Children were clumsy with their movements, were poorly 
+coordinated and could not run, jump, hop and walk 
+on toes. Four out of six children occasionally imitated 
+oral facial movements like protruding, elevating tongue 
+and puckering lips. Generally, this supports previous 
+research findings that children underperformed on various 
+imitation tasks such as gross motor actions, vocalization, 
+complex imitation, oral facial imitation and imitating 
+breathing exercises.[10] Complex motor tasks were the 
+least frequently imitated category compared to oral facial 
+movement imitation. Children had more difficulty on 
+tasks with multiple components than task involving one 
+action. Attempts by the therapist to involve the child to 
+sit in vajrasana (folding both legs backward and sitting 
+on the heel) initially resulted in the child losing interest 
+in therapy program and running away. No attempts were 
+made to force the children on the therapy mat, but slowly 
+they joined the group voluntarily.
+During the mid assessment period, there was a significant 
+change in imitating gross motor actions, oral facial movements 
+and performing breathing exercises, but little change was seen 
+in imitating complex imitation and vocalization.
+During last few sessions, significant changes in the 
+imitation skills related to all the five parameters and 
+also changes in communication, functional object use, 
+language, play and joint attention were seen. Pattern of 
+eye contacts steadily improved. Children started focusing 
+on the yoga therapist as she gave counts with drumbeat. 
+Initially, mothers manually guided the children to imitate 
+the movement. Slowly, manual manipulation decreased 
+and children started imitating complex motor movements 
+spontaneously. It is possible that a gentle touch or 
+pressure gave them a different experience and they started 
+perceiving changing dynamics and became interested in 
+therapy. Consequently, children started to display early 
+shared attention behaviors such as looking at the peers, 
+making eye contact with the therapist and offering no 
+resistance to the therapist.
+In addition to these behaviors, an increase in facial 
+expression (pain and pleasure), vocalizations and gazing 
+at peers suggested an emerging understanding that sharing 
+an activity could be an enjoyable experience.
+As the therapy progressed, increase in imitation skills 
+was noticed in imitating familiar and learnt movement. 
+Children started looking at peer model, resulting in 
+higher levels of generalization and maintenance of learnt 
+imitation behavior. This supports the study by Carr and 
+Darey[13] using different types of models (peer and adult) 
+and suggesting that peer model would help in better 
+generalization and maintenance of the learnt skill. Close 
+physical proximity of the mother and prompting of a 
+specific behavior by the mother may be a contributing 
+factor for higher generalization.
+All the six children started to indicate their preferences 
+for asana, e.g. Shavasana, Parvathasana. They progressed 
+from the early resistance to passive tolerance to active 
+participation and enjoying the therapy sessions. Over 
+the course of yoga therapy, children started to trust, 
+share, initiate and reciprocate and thus the barrier to 
+communication of carrying the label of being “autistic” 
+is broken. By the end of 183rd session, all six children 
+engaged in 30–45 minutes of yoga therapy. During this 
+period, they all displayed increased intention to remain 
+in close proximity with the therapist and participated in 
+performing most of the asanas and breathing exercises.
+ASDIM
+Figure 1: Graphic representation of observed improvement in selected imitation behavioral traits
+0.18
+0.17
+0.17
+0.5
+0.15
+0.9
+0.7
+0.6
+1
+0.8
+1.8
+1.6
+1.4
+1.9
+1.5
+0
+0.2
+0.4
+0.6
+0.8
+1
+1.2
+1.4
+1.6
+1.8
+2
+Parameter used for Imitation behavioural assessment
+Average rating of responsiveness
+on a scale 0 to 2
+Imitating gross
+motor actions
+Imitating
+vocalization
+Complex imitation
+Imitating oral facial
+movements
+Imitating breathing
+exercises
+Pre
+Post
+Mid
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+30
+All the six children showed increased vocal imitation skills 
+by imitating vowels “a, e, i, o, u” and “OM”. This increased 
+vocal imitation may be due to the verbal behavior approach 
+adopted by the yoga therapist who is also a Speech-
+Language-Pathologist (SLP). Verbal behavior approach to 
+teaching language to children with autism emphasizes 
+teaching language units in its functional components 
+such as manding (to alter one’s environment), tacting 
+(to respond to sensory stimuli) and intraverbals (verbal 
+behavior in response to another person’s verbal behavior). 
+Imitation was used throughout the teaching of mands, tacts 
+and intraverbals. Changes in social interaction were seen. 
+Children started greeting the therapist with “namasthe” 
+(with folded hands) and verbalized “om shanthi” (let there 
+be peace) at the end of the therapy session.
+Children engaged in increased play interaction during yoga 
+therapy sessions. Children who display increased imitation 
+skills during yoga therapy transferred these responses into 
+play situation whenever they engaged in symbolic play. 
+Final interviews with parents and staff were carried out 
+to assess whether the child’s imitation skill has changed 
+over the course of the study. Parents reported that their 
+children indicated basic needs using gestures, interacting 
+with other children during play situation and increased 
+sitting tolerance for an activity.
+To conclude, this is the first scientific study in India 
+investigating the effect of IAYT to increase imitation skills 
+and also related language, social and cognitive skills. 
+This study aimed to investigate IAYT as a family-oriented 
+treatment alongside any conventional treatment received 
+by the children. The pilot study provides initial evidence 
+of the benefits of IAYT in alleviating the behavioral 
+symptoms of children diagnosed with ASD, confirmed 
+through parents’ and teachers’ report and children’s own 
+behavior. Future directions in IAYT research would be 
+well served by larger studies that involve teachers as well 
+as parents, followed by follow-up studies. Rigorously 
+controlled clinical trials on larger and more homogeneous 
+population would be needed to provide the necessary 
+rigor to assess the relative effect of IAYT as an alternative 
+or complementary treatment to increase imitation skills 
+in children with ASD. However, the indications are that 
+IAYT may offer families an effective management tool for 
+family-oriented treatment of childhood ASD.
+acknOWledGments
+The author gratefully acknowledges the contribution of parents of the 
+participants of the study and staff of Sri Ganapathi Sachchidananda 
+(SGS) Vagdevi Centre for the Rehabilitation of Communication 
+Impaired. The author also thanks Dr. Nagendra and Dr. Nagarathna 
+of Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA) 
+for their input on Integrated Yoga Therapy (IYT).
+RefeRences
+1. 
+Rogers S, Pennington B. A theoretical approach to the deficits in infantile 
+autism. Dev Psychol 1991;3:137-62.
+2. 
+Siegel B. The world of the autistic child, Oxford; Oxford University 
+ 
+Press: 1991.  
+3. 
+Smith IM, Bryson SE. Imitation and action in autism: A critical review. 
+Psychol Bull 1994;116:259-73.
+4. 
+Williams JH, Whiten A, Suddendorf T, Perrett DI. Imitation, mirror neurons 
+and autism. Neurosci Biobehav Rev 2001;25:287-95.
+5. 
+American Psychiatric Association, Diagnostic and statistical manual of 
+mental disorders. 4, text revision. Washington, DC: American Psychiatric 
+ 
+Association 2000. 
+6. 
+Charman T, Swettenham J, Baron-Cohen S, Cox A, Baird G, Drew A. Infants 
+with autism: An investigation of empathy, pretend play, joint attention, and 
+imitation. Dev Psychol 1994;33:781-9.
+7. 
+Dawson G, Adams A. Imitation and social responsiveness in autistic children. 
+J Abnorm Child Psychol 1984;12:209-26.
+8. 
+DeMeyer MK, Alpern GD, Barton S, DeMyer WE, Churchill DW, Hingtgen 
+JN, et al. Imitation in autistic, early schizophrenic, and non-psychotic 
+subnormal children. J Autism Child Schizophr 1972;2:264-87.
+9. 
+Heimann M, Ullstadius E, Danigren SO, Gilberg C. Imitation in autism. A 
+preliminary research ote. Behav Neurol 1992;5:219-27.
+10. Stone WL, Ousley OY, Littleford CD. Motor imitation in young children with 
+autism: What’s the object? J Abnorm Child Psychol 1994;25:475-85.
+11. 
+Radhakrishna S. Using Yoga Therapy (YT) to increase communication, 
+social and cognitive skills in children with autistic spectrum disorders. 
+Available from: http://www.integralpsychology.in/texts/nsip/nsip-abstracts/
+shantharadhakrishna.html. [Last cited on 2007].  
+12. Schopler E, Reichler RJ, DeVellis RF, Daly K. Toward objective classification 
+of childhood autism: Childhood Autism Rating Scale (CARS). J Autism Dev 
+Disord 1980;10:91-103.
+13. Carr EG, Darcy M. Setting generality of peer modeling in children with 
+autism. J Autism Dev Disord 1990;20:45-59.
+Radhakrishna
+Staying in touch with the journal
+1) 
+Table of Contents (TOC) email alert 
+ 
+Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to 
+www.ijoy.org.in/signup.asp.
+2) 
+RSS feeds 
+ 
+Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal’s website. 
+You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. 
+RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add 
+www.ijoy.org.in/rssfeed.asp as one of the feeds.

subfolder_0/Association between a guided meditation practice, sleep and psychological well-being in type 2 diabetes mellitus patients.txt

@@ -0,0 +1,231 @@
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Journal of Complementary and Integrative Medicine. 2018; 20150026
+Short Communication
+Mathew P Varghese1 / RagavendrasamyBalakrishnan1 / SubramanyaPailoor1,2
+Association between a guided meditation
+practice,sleep and psychological well-being in
+type2 diabetes mellitus patients
+1 S-VYASA University, 19, Gavipuram Circle, K G Nagar, Bangalore, India, E-mail: [email protected],
+[email protected]
+2 Department of Yoga, Central University of Kerala, Kasaragod, Kerala, India, E-mail: [email protected]
+Abstract:
+Background: Type 2 diabetes mellitus [T2DM] is one of the leading causes for mortality. This study examined
+the role of an self-awareness based guided meditation practice, Cyclic Meditation [CM] on perceived stress,
+anxiety, depression, sleep and quality of life in T2DM patients.
+Design: A single arm pre-post design was used for the study.
+Setting: The study was conducted in an auditorium for general public diagnosed with T2DM in Ernakulam,
+Kerala, India.
+Subjects: Subjects were 30 T2DM patients, both male and female of age 50.12 ± 11.15 years and BMI 25.14
+± 4.37 Kg/m2 and not having a history of hospitalisation were randomly recruited for the study following
+advertisements in national dailies.
+Intervention: Participants completed a supervised CM programs in the evenings, 5 days a week for 4 weeks,
+in addition to their regular medication.
+Measures: Perceived stress, anxiety and depression were assessed with Perceived Stress Scale, State Anxiety
+Inventory and Beck’s depression inventory, respectively. Sleep and quality of life were assessed with Pittsburgh
+Sleep Quality Index and WHO-Quality of Life – BREF respectively.
+Analysis: Changes in the outcome measures from baseline to 4 weeks were compared using paired “t” test.
+Results: After 4 weeks, the quality of life and sleep scores increased 7.1% [p = 0.001] and 32.7% [p = 0.001],
+respectively. The perceived stress, anxiety and depression reduced 26.1% [p = 0.001], 16.01% [p = 0.003] and
+37.63% [p = 0.006] as compared to their baseline reports. The CM practice also reduced daytime dysfunction.
+Conclusions: A guided self-awareness based meditation program was safe and effective in improving depres-
+sion, anxiety, perceived stress and enhance sleep and quality of life in T2DM patients, which could be helpful
+in reducing the future complications of T2DM. Mind management is essential along with medical management
+to achieve better clinical results.
+Keywords: cyclic meditation, depression, quality of life, sleep, type 2 diabetes mellitus
+DOI: 10.1515/jcim-2015-0026
+Received: May 7, 2015; Accepted: May 11, 2018
+Introduction
+India with a type 2 diabetes mellitus (T2DM) prevalence rate of 7.1% [1], is increasing proportionately to de-
+clare it an epidemic [2]. Psychological stress plays a vital role in the incidence and development of T2DM [3].
+Persistent stress causes release of stress hormones leading to loss of immune specificity, and a state of chronic
+low grade inflammation resulting in metabolic disorders and aging [4, 5]. T2DM is understood to be a state
+of chronic low grade inflammation, which over a period of time causes complications like atherosclerosis [6],
+coronary artery disease [7], nephropathy [8] and obesity [9]. It has been noted that complications cause more
+mortality than T2DM itself [10], demanding huge financial burden over the individual and also over the nation
+[11].
+Recent studies have given immense importance to understand the significance of relaxation. The role of
+introspection and self-awareness has been given considerable importance in classical yoga literatures. To facil-
+itate this process, a technique called cyclic meditation (CM) was evolved. CM, is a “moving meditation” which
+RagavendrasamyBalakrishnan is the corresponding author.
+© 2018 Walter de Gruyter GmbH, Berlin/Boston.
+1
+Brought to you by | Göteborg University - University of Gothenburg
+Authenticated
+Download Date | 7/20/18 1:14 PM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+Varghese et al.
+DE GRUYTER
+integrates the yoga practices along with guided meditation technique derived from Mandukya Upanishad [12],
+developed by Nagendra HR. The verse on which the CM is based states that “awaken the mind in states of
+mental inactivity; calm it when agitated; realise the possibilities of the mind in between these two mental states
+and when the mind reaches the state of equilibrium do not disturb it”. The idea of the technique is to achieve
+a state of equilibrium/relaxation through combination of alternating phases of stimulation and relaxation [13]
+(refer to supplement material 1). Unlike other meditation practices, whose practice involves either focussing
+or defocussing [14], CM involves a judicial combination of focussing followed by defocussing encouraging an
+individuals’ attention and enhancing autonomic balance [15]. Earlier studies have shown CM to enhance sleep
+quality, quality of life, and attention with better heart rate variability [15]. The present study was designed
+to understand the role of awareness based meditation practices, CM - in addressing depression, anxiety and
+quality of life in T2DM population.
+The pilot work was carried out following the approval from the Institutional Ethical Committee. Thirty pa-
+tients both male and female, diagnosed with T2DM since 6.97 ± 1.2 years, with mean 50.12 ± 11.15 years of
+age, and BMI 25.14 ± 4.37 Kg/m [2] and not having a history of hospitalisation in the past 6 months were re-
+cruited following advertisements issued in national dailies. A total of 70 patients were screened, and 33 patients
+matching the inclusion criteria were recruited for the study. A written informed consent was obtained from the
+recruits following their expression of interest to participate in the study. The study did not attract any financial
+binding with the subjects. The practice involved 23 min of pre-recorded cyclic meditation practice every day for
+5 days in a week for 1 month practiced under supervision of experts. Recorded tapes containing instructions
+were given to avoid the instructor bias.
+Observations were made during the start and end of the month long intervention. Paired samples “t” test
+was performed following normal distribution of data. Pittsburgh Sleep Quality Index revealed a significant
+improvement in the global score (p ≤0.001), subjective sleep quality (p = 0.05), sleep latency (p = 0.001), sleep
+duration (p = 0.017), sleep disturbance (p = 0.032), and daytime dysfunction (p = 0.029) suggestive of overall
+improvement in quality of sleep. Quality of life as measured through WHO – Quality of Life had shown sig-
+nificant improvements (p = 0.001). Also, a significant reduction was observed in state anxiety (p = 0.003), and
+depression scores (p = 0.006) as reported by the state trait anxiety inventory and beck’s depression inventory-
+II, respectively. Interestingly the subjective perception of stress was observed to be significantly reduced (p =
+0.001) as understood from the perceived stress scale [Table 1].
+Table 1: ap ≤0.05, bp ≤0.01, cp ≤0.001, Paired Sample “t” test. Comparing day 30 values with respective day 1 values
+(Mean ± SD) following cyclic meditation intervention.
+Assessments
+Pre
+Post
+p Value
+(Mean ± SD)
+(Mean ± SD)
+BDI-II
+11.96 ± 8.96
+7.46 ± 5.12b
+p ≤0.01
+PSS
+17.85 ± 6.39
+13.19 ± 5.42c
+p ≤0.001
+STAI (state)
+40.58 ± 8.84
+34.08 ± 9.04b
+p ≤0.01
+WHOQOL domains
+Physical health
+24.92 ± 3.16
+26.88 ± 3.80c
+p ≤0.001
+Psychological
+20.08 ± 3.11
+22.12 ± 3.23c
+p ≤0.001
+Social & personal
+relationships
+11.00 ± 1.98
+11.35 ± 2.17
+Environment
+27.85 ± 4.65
+29.88 ± 3.09a
+p ≤0.05
+Global score
+83.85 ± 10.34
+90.23 ± 9.88c
+p ≤0.001
+PSQI
+Subjective sleep
+quality
+0.88 ± 0.65
+0.62 ± 0.70a
+p ≤0.05
+Sleep latency
+0.92 ± 1.05
+0.35 ± 0.75c
+p ≤0.001
+Sleep duration
+1.92 ± 0.89
+1.58 ± 0.90a
+p ≤0.05
+Habitual sleep
+efficiency
+0.85 ± 1.19
+0.50 ± 0.99
+p = 0.059
+Sleep disturbance
+1.08 ± 0.69
+0.81 ± 0.57a
+p ≤0.05
+Use of sleep
+medication
+0.23 ± 0.82
+0.31 ± 0.88
+p = 0.538
+Daytime dysfunction
+0.81 ± 0.63
+0.50 ± 0.58a
+p ≤0.05
+Global score
+6.69 ± 3.83
+4.50 ± 3.23c
+p ≤0.001
+Earlier study on CM conducted on healthy volunteers showed a 32.1% reduction in Oxygen consumption
+inducing a state of enhanced physiological rest [16]. And, evoked potentials recorded from the cerebral cortex
+of healthy volunteers following CM showed prolonged latencies [17]. Whereas, cognitive evoked potentials
+2
+Brought to you by | Göteborg University - University of Gothenburg
+Authenticated
+Download Date | 7/20/18 1:14 PM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Varghese et al.
+suggested reduced latency and enhanced amplitude [18] suggesting a possible cortical inhibition following
+CM. Hence, we speculate from the study that, CM practice reduces the perception of stress and thereby it
+reduces state anxiety; enhances quality of sleep and quality of life in T2DM patients.
+The strength of the study is that we have demonstrated that CM improves the quality of sleep, life, and
+reduces the risk for depression in patients with T2DM which can be incorporated into clinical setting along
+with routine treatments. However, the limitation of this study is that the results needs to be validated with an
+identical group of patients who are under conventional treatment. Further studies are warranted to understand
+the probable mechanisms towards alleviation of associated complications and determining the effectiveness of
+using CM in the prevention of T2DM in the high risk group.
+Summarising the findings, CM in general appears to promote vagal predominance, decrease perceived
+stress and promotes sleep, mental well-being and quality of life. These findings suggest the necessity for mind
+management apart from the medical management in T2DM.
+Author contributions: All the authors have accepted responsibility for the entire content of this submitted
+manuscript and approved submission.
+Research funding: None declared.
+Employment or leadership: None declared.
+Honorarium: None declared.
+Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis,
+and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
+References
+[1] Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87:4–14.
+[2] Seidell JC. Obesity, insulin resistance and diabetes-a worldwide epidemic. Br J Nutr. 2000;83.
+[3] McEwen BS. Protective and damaging effects of stress mediators. New Eng J Med. 1998;338:171–9.
+[4] Bauer ME. Chronic stress and immunosenescence: a review. Neuroimmunomodulation. 2008;15:241–50.
+[5] Cannizzo ES, Clement CC, Sahu R, Follo C, Santambrogio L. Oxidative stress, inflamm-aging and immunosenescence. J Proteomics.
+2011;74:2313–23.
+[6] Duncan BB, Schmidt MI, Pankow JS, Ballantyne CM, Couper D, Vigo A, et al. Low-grade systemic inflammation and the development of
+type 2 diabetes the atherosclerosis risk in communities study. Diabetes. 2003;52:1799–805.
+[7] Danesh J, Whincup P
+, Walker M, Lennon L, Thomson A, Appleby P
+, et al. Low grade inflammation and coronary heart disease: prospective
+study and updated meta-analyses. Br Med J. 2000;321:199–204.
+[8] Sela S, Shurtz-Swirski R, Cohen-Mazor M, Mazor R, Chezar J, Shapiro G, et al. Primed peripheral polymorphonuclear leukocyte: a culprit
+underlying chronic low-grade inflammation and systemic oxidative stress in chronic kidney disease. J Am Soc Nephrol. 2005;16:2431–38.
+[9] Bastard JP
+, Maachi M, Lagathu C, Kim MJ, Caron M, Vidal H, et al. Recent advances in the relationship between obesity, inflammation, and
+insulin resistance. Eur Cytokine Netw. 2006;17:4–12.
+[10] Garcia MJ, McNamara PM, Gordon T, Kannell WB. Morbidity and mortality in diabetics in the Framingham population: sixteen year
+follow-up study. Diabetes. 1974;23:105–11.
+[11] Stratton IM, Amanda IA, Andrew WN, David RM, Susan EM, Carole AC, et al. Association of glycaemia with macrovascular and microvas-
+cular complications of type 2 diabetes (UKPDS 35): prospective observational study. Br Med J. 2000;321:405–12.
+[12] Chinmayanada S. Mandukya Upanishad. Bombay, India: Sachin Publishers; 1984.
+[13] Nagendra HR, Nagarathna R. New perspectives in stress management. Bangalore, India: Swami Vivekananda Yoga Prakashana; 1997.
+[14] Lutz A, Slagter HA, Dunne JD, Davidson RJ. Attention regulation and monitoring in meditation. Trends Cogn Sci. 2008;12:163–9.
+[15] Subramanya P
+, Telles S. A review of the scientific studies on cyclic meditation. Int J Yoga. 2009;2:46.
+[16] Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration following two yoga relaxation techniques. Appl Psychophysiol-
+ogy Biofeedback. 2000;25:221–7.
+[17] Subramanya P
+, Telles S. Changes in midlatency auditory evoked potentials following two yoga-based relaxation techniques. Clin EEG
+Neurosci. 2009;40:190–5.
+[18] Sarang SP
+, Telles S. Changes in P300 following two yoga-based relaxation techniques. Int J Neurosci. 2006;116:1419–30.
+3
+Brought to you by | Göteborg University - University of Gothenburg
+Authenticated
+Download Date | 7/20/18 1:14 PM

subfolder_0/BASELINE OCCUPATIONAL STRESS LEVELS AND PHYSIOLOGICAL RESPONSES.txt

@@ -0,0 +1,33 @@
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 

subfolder_0/BREATHING THROUGH A PARTICULAR NOSTRIL CAN ALTER METABOLISM AND AUTONOMIC.txt

@@ -0,0 +1,14 @@
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 

subfolder_0/Brainstem auditory evoked potentials in two mditative mental states.txt

@@ -0,0 +1,473 @@
+37
+International Journal of Yoga  Vol. 3  Jul-Dec-2010
+have been studies of short and midlatency auditory-evoked 
+potentials during meditation. The studies on midlatency 
+auditory-evoked potentials have most often shown changes 
+in a component called the Na-wave, a negative wave 
+occurring between 14 and 19 msec. The changes have been 
+in the form of an increase in amplitude,[8] suggesting the 
+requirement of more neurons. A decrease in latency has 
+also been reported,[9] suggesting a decrease in time taken 
+to transmit sensory information.
+Studies on short latency auditory-evoked potentials have 
+not shown such clear changes.[2] In that study, brainstem 
+auditory evoked potentials (BAEP) were measured in five 
+advanced practitioners of transcendental meditation (TM) 
+to determine whether such responses would reflect an 
+increase in perceptual acuity to auditory stimuli following 
+meditation. The BAEP provide an objective physiological 
+index of auditory function at a subcortical level. Repeated 
+INTRODUCTION
+The functions of the brain in meditation have been 
+studied using different techniques. These include the 
+electroencephalogram (EEG),[1] evoked potentials,[2] 
+regional cerebral glucose utilization as well as, more 
+recently, functional magnetic resonance imaging.[3] Among 
+these methods, a specific technique is selected for each 
+experiment as each of them have different spatial and 
+temporal resolutions.[4]
+Evoked potentials are used in meditation studies because a 
+correlation between different evoked potential components 
+and underlying neural generators is reasonably well 
+worked out.[5] Apart from this, it appears that the cerebral 
+cortex is actively involved in meditation.[6] Hence, one 
+may expect corticoefferent gating with changes occurring 
+at the subcortical relay centers.[7] For these reasons, there 
+Context: Practicing mental repetition of “OM” has been shown to cause significant changes in the middle latency auditory-
+evoked potentials, which suggests that it facilitates the neural activity at the mesencephalic or diencephalic levels.
+Aims: The aim of the study was to study the brainstem auditory-evoked potentials (BAEP) in two meditation states based on 
+consciousness, viz. dharana, and dhyana.
+Materials and Methods: Thirty subjects were selected, with ages ranging from 20 to 55 years (M=29.1; ±SD=6.5 years) who 
+had a minimum of 6 months experience in meditating “OM”. Each subject was assessed in four sessions, i.e. two meditation 
+and two control sessions. The two control sessions were: (i) ekagrata, i.e. single-topic lecture on meditation and (ii) cancalata, 
+i.e. non-targeted thinking. The two meditation sessions were: (i) dharana, i.e. focusing on the symbol “OM” and (ii) dhyana, 
+i.e. effortless single-thought state “OM”. All four sessions were recorded on four different days and consisted of three states, 
+i.e. pre, during and post.
+Results: The present results showed that the wave V peak latency significantly increased in cancalata, ekagrata and dharana, 
+but no change occurred during the dhyana session.
+Conclusions: These results suggested that information transmission along the auditory pathway is delayed during cancalata, 
+ekagrata and dharana, but there is no change during dhyana. It may be said that auditory information transmission was delayed 
+at the inferior collicular level as the wave V corresponds to the tectum.
+Key words: Brainstem auditory-evoked potential; cancalata; dharana; dhyana; ekagrata. 
+ABSTRACT
+Brainstem auditory-evoked potentials in two meditative 
+mental states
+Sanjay Kumar, Nagendra HR, Naveen KV, Manjunath NK, Shirley Telles
+Department of Yoga Research, Indian Council of Medical Research Center for Advanced Research in Yoga and Neurophysiology, SVYASA, 
+Bangalore, India
+Address for correspondence: Dr. Shirley Telles,
+Patanjali Yogpeeth, Maharishi Dayanand Gram, Bahadrabad, 
+Haridwar - 249 402, Uttarakhand, India. 
+E-mail: [email protected]
+DOI: 10.4103/0973-6131.72628
+Original Article
+www.ijoy.org.in
+[Downloaded from http://www.ijoy.org.in on Friday, March 04, 2011, IP: 117.211.90.10]
+International Journal of Yoga  Vol. 3  Jul-Dec-2010
+38
+measures of the BAEP of TM practitioners were taken 
+before and after a period of meditation and were compared 
+with those of age-matched controls. Peak latencies as well 
+as interwave latencies between major BAEP components 
+were evaluated. No pre–post meditation differences for 
+experimental subjects were observed at low-stimulus 
+intensities (0–35 dB). At moderate intensities (40–50 
+dB), the latency of the inferior collicular wave (wave 
+V) increased following meditation. However, at higher 
+stimulus intensities (55–70 dB), the latency of this wave 
+was slightly decreased. Comparison of the slopes and 
+intercepts of stimulus intensity–latency functions indicate 
+a possible effect of meditation on brainstem activity.[2] 
+This study on short latency auditory-evoked potentials 
+in TM meditation practitioners demonstrated that short 
+latency auditory-evoked potential varies with stimulus 
+characteristics.
+More recently, we have attempted to understand meditation 
+based on descriptions from an ancient yoga text. This is 
+Patanjali’s yoga sutras (circa 900 BC).[10] Based on this 
+description, meditation has been considered as two states, 
+namely dharana, which is characterized by focusing on 
+the object of meditation and dhyana, which is a defocused 
+state of mental expansiveness. With this background, 
+the present study was undertaken to determine whether 
+short latency auditory-evoked potentials would change in 
+normal subjects in meditation considered as both dharana 
+and dhyana sessions on separate days.
+MATERIALS AND METHODS
+Subjects
+Thirty subjects were selected in the age range between 20 
+and 55 years (group mean±SD, 29.1±6.5 years) recruited 
+from a residential setup, Swami Vivekananda Yoga 
+Research Foundation, Bangalore, in south India. This age 
+range was selected as short latency does not vary within 
+this age range in healthy individuals.[11] Only male subjects 
+were selected because it has been demonstrated that short 
+latency auditory-evoked potentials vary with the phases of 
+the menstrual cycle.[12] All of them had normal health based 
+on a routine case history and a clinical examination. Also, 
+all of them had experience of practicing meditation for at 
+least 30 min per day, 4 days in a week, for a minimum of 1 
+year. Their meditation practice was based on self-reporting 
+of the meditators as well as (where possible) consultations 
+with the meditation teacher (guru).
+To assess the quality of the practice, visual analogue scale 
+(VAS) was used at the end of each session.
+All of them expressed their willingness to participate in the 
+experiment. The project was approved by the Institution’s 
+Ethics Committee. The study protocol was explained to the 
+subjects and their signed informed consent was obtained.
+Apart from their prior experience of “OM” meditation, 
+they had undergone a 2-month orientation program in 
+“OM” meditation under the guidance of an experienced 
+meditation teacher.
+The condition to exclude subjects were any health disorder, 
+especially psychiatric or neurological disorders, auditory 
+deficits assessed by checking the auditory threshold of 
+each ear separately and any medication that alters the 
+functions of the nervous system. None of the subjects had 
+to be excluded for these reasons.
+The order of the four sessions (i.e. two meditation sessions 
+and two non-meditation control sessions) was randomized 
+for each subject using a standard random number table.[13] 
+This was done to prevent the influence of being exposed 
+to the laboratory for the first time for example, from 
+influencing the results among other reasons.
+Design
+Each subject was assessed in four sessions, i.e. two 
+meditation and two control sessions, to record BAEP
+. The 
+two control sessions were: (i) ekagrata, i.e. single-topic 
+lecture on meditation and (ii) cancalata, i.e. non-targeted 
+thinking. The two meditation sessions were: (i) dharana, 
+i.e. focusing on the symbol “OM” and (ii) dhyana, i.e. 
+effortless single-thought state “OM.” All four sessions 
+consisted of three states, i.e. “pre” (5 min), “during” (20 
+min) and “post” (5 min).
+The assessments were made on four different days, not 
+necessarily on consecutive days, but at the same time of 
+the day (i.e., the self-as-control design). The allocation of 
+the subjects to the four sessions was randomized using a 
+standard random number table.[13] This was done to prevent 
+the influence of being exposed to the laboratory for the 
+first time from influencing the results.
+Assessments
+BAEP were recorded using the Nicolet Bravo system 
+(Nicolet Biomedicals, Madison, WI, USA). The amplifier 
+settings were as follows: low-frequency filter 100 Hz, 
+high-frequency filter 3 KHz, sensitivity 50 µV
+, number of 
+sweeps averaged 1,500, sweep width 10 ms, delay 0 ms. 
+Binaural click stimuli, of alternating polarity, with 11.1 Hz 
+frequency and 100 µS duration, were delivered through 
+acoustically shielded earphones (Amplivox, Oxfordshire, 
+UK). The stimulus intensity was kept at 80 dB nHL. The 
+rejection level was expressed as a percentage of the full-
+scale range of the analog-to-digital converter. This level 
+was set at 90%. Silver chloride (Ag/AgCl) disc electrodes 
+were placed on the scalp using a conductive water-soluble 
+Kumar, et al.
+[Downloaded from http://www.ijoy.org.in on Friday, March 04, 2011, IP: 117.211.90.10]
+39
+International Journal of Yoga  Vol. 3  Jul-Dec-2010
+paste. The active electrode was at Cz according to the 
+International 10–20 system[14] referenced to linked ear 
+lobes, with the ground electrode on the forehead (FPz). All 
+electrode impedances were kept below 5 KΩ throughout 
+the session.
+Interventions
+Throughout all sessions, the subjects kept their eyes closed 
+and followed pre-recorded instructions. The instructions 
+emphasized carrying out the practice slowly, with 
+awareness and relaxation. The meditators who participated 
+in the study underwent 1 month of orientation sessions, 
+where they practiced two phases that formed a continuum 
+in meditation (dharana and dhyana) as two separate states 
+and two control states, i.e. cancalata or non-focused 
+thinking and ekagrata or focusing without meditation and 
+on more than one thought.
+These states are described in the traditional texts, i.e. the 
+Patanjali’s Yoga Sutras and Bhagavad Gita, stating that 
+when awake and in the absence of a specific task, the mind 
+is very distractible (cancalata), and has to be taken through 
+the stages of “streamlining the thoughts” (concentration 
+or ekagrata) before moving on to the states of meditation. 
+These are: one-pointed concentration or dharana and a 
+defocused, effortless single-thought state or dhyana.
+In the cancalata session, the 20-min period consisted of 
+“non-targeted thinking,” during which the subjects were 
+asked to allow their thoughts to wander freely as they 
+listened to a compiled audio CD consisting of brief periods 
+of conversation and talks on multiple topics recorded from 
+a local radio station transmission. In the ekagrata session, 
+the 20-min period consisted of focusing on a single topic, 
+which was listening to a lecture on meditation, with 
+multiple, yet associated, thoughts. In the dharana session, 
+the 20-min period consisted of focusing on the symbol 
+“OM.” During this session, they were asked to focus on the 
+meaning of the syllable, OM, which is used as a symbol for 
+the entire universe because OM is considered to represent 
+“that which sustains everything.”[15] In the dhyana session, 
+the 20 min of the practice consisted of meditation with 
+effortless absorption in the single-thought state of the 
+object of meditation, i.e. “OM.”
+For the two meditation sessions and the two control 
+sessions, subjects were given guided instructions through 
+separate recorded instructions for each session.
+Data extraction
+For the BAEP
+, the peak latencies and peak amplitudes of 
+all seven waves were calculated. Peak latency (msec) is 
+defined as the time from stimulus onset to the point of 
+maximum positive amplitude within the latency window. 
+Peak amplitude (V) is defined as the voltage difference 
+between a pre-stimulus baseline and the largest positive 
+going peak within a given latency window.
+Data analysis
+Statistical analysis was performed using SPSS (Version 
+10.0). The peak latencies and peak amplitudes of all seven 
+waves were analyzed using repeated-measures analyses of 
+variance (ANOVAs) and post hoc analyses with Bonferroni 
+adjustment were performed to compare “pre” data with 
+“during” and “post.”
+The repeated measures ANOVAs were performed with two 
+“within–subject” factors, i.e. Factor 1: Sessions; with four 
+levels, viz. cancalata, ekagrata, dharana and dhyana, and 
+Factor 2: States; with six levels, viz. pre, during (D1 to D4) 
+and post. These repeated measures ANOVAs were carried 
+out for the peak latency and peak amplitude of all levels.
+This was followed by a post hoc analysis with Bonferroni 
+adjustment for multiple comparisons between the mean 
+values of different states (pre, during 1 to during 4 and post).
+RESULTS
+The peak latency of wave V showed a significant difference 
+between Sessions (F=3.894, for df=2.678, 77.651, 
+P<0.015, Huynh-Feldt epsilon=0.893) and between States 
+(F=11.713, for df=4.181, 121.256, P<0.001, Huynh-Feldt 
+epsilon=0.836).
+Post hoc analysis with Bonferroni adjustment for each 
+session (cancalata, ekagrata, dharana and dhyana) 
+separately showed a significant increase in the latency of 
+wave V during the cancalata session (pre versus during, i.e. 
+D2; P=0.042), ekagrata session (pre versus during, i.e. D2; 
+P=0.009, pre versus during, i.e. D3; P=0.026, pre versus 
+during, i.e. D4; P=0.005 and pre versus post P=0.001) and 
+following the dharana session (pre versus post; P=0.018).
+The amplitude of wave V also showed a significant 
+difference between Sessions (F=6.515, for df=2.692, 
+78.060, P<0.001, Huynh-Feldt epsilon=0.897) and 
+between States (F=8.574, for df=4.292, 124.456, P<0.001, 
+Huynh-Feldt epsilon=0.858).
+Post hoc analysis with Bonferroni adjustment for each 
+session (cancalata, ekagrata, dharana and dhyana) 
+separately showed no significant change in the peak 
+amplitude of wave V (P>0.05). Also, there were no 
+significant change in the other waves (P>0.05).
+Hence, the changes in wave V peak latency alone are 
+presented in Table 1.
+Evoked potentials in meditation
+[Downloaded from http://www.ijoy.org.in on Friday, March 04, 2011, IP: 117.211.90.10]
+International Journal of Yoga  Vol. 3  Jul-Dec-2010
+40
+Kumar, et al.
+DISCUSSION
+In the present study, normal healthy volunteers who 
+were experienced in practicing meditation on the syllable 
+“OM” were assessed in two meditation (i.e., dharana 
+and dhyana) and two control sessions (i.e., cancalata 
+and ekagrata sessions). BAEP were recorded throughout 
+all four sessions. There was a significant increase in the 
+wave V peak latency during the cancalata, ekagrata and 
+dharana sessions but there was no change during the 
+dhyana session.
+In the literature, there is only one previous study of short 
+latency auditory-evoked potentials in TM practitioners. 
+In this study, at moderate stimulus intensities (40–50 dB), 
+the wave V latency increased following meditation.[2] In 
+contrast, at higher stimulus intensities, the wave V latency 
+was slightly decreased by a comparison of the slopes and 
+intercepts of stimulus intensity–latency functions. The 
+authors suggested a possible effect of TM on brainstem 
+activity. In the present study, there was no attempt to 
+vary the stimulus intensity, which was kept at the 80 dB 
+normal hearing level. This would fit in the category of a 
+higher-intensity stimulus based on the categorization in 
+the study.[2] In contrast to that study, even at this high-
+stimulus intensity, the latency of wave V did not decrease 
+during either of the two meditation sessions (dharana and 
+dhyana). In contrast, an increase in wave V peak latency 
+was found in the cancalata, ekagrata and dharana sessions. 
+No such increase was obtained in the dhyana session. An 
+increase in the latency of an evoked potential component 
+is taken to suggest that sensory information processing at 
+the level of the underlying neural generator is delayed.[16] 
+This suggests that in the cancalata, ekagrata and dharana 
+mental states, sensory processing at the midbrain level 
+was delayed. Another feature of the present study is that 
+a difference is seen in the nature of the results in the two 
+meditation sessions.
+In the introduction, it was already mentioned that dharana 
+and dhyana states have been described in an ancient yoga 
+text, namely Patanjali’s yoga sutras. In this text, dharana 
+literary means “fixing the mind on a specific object” 
+(Patanjali’s yoga sutras Chapter 3 verse 1). The mind 
+could be fixed on any point and. as long as disturbances 
+from any corner are warded off, this mental state is called 
+dharana. When dharana becomes effortless, it takes the 
+form of dhyana, which is defined as the uninterrupted 
+spontaneous flow of the mind toward the chosen object.
+In contrast to this, the two control sessions, i.e. cancalata 
+and ekagrata are described in another ancient text, the 
+Bhagavad Gita.[17] The cancalata state is characterized by 
+constant shifting of thoughts from one object to another. 
+The ekagrata state is quite different from this and is 
+similar to concentration. When haphazard thoughts are 
+streamlined in a single direction, it is called ekagrata.
+Hence, irrespective of whether meditators were in a state 
+of random thinking (cancalata), channelized thought 
+in concentration (ekagrata) or in a state of channelized 
+thought as in meditation (dharana), there was a delay in 
+sensory information processing, as mentioned above at 
+the mid-brain (possibly the inferior colliculus) level. In 
+contrast, when the mental state was characterized by a 
+lack of effort in dhyana, no such change occurred.
+Further studies are required to understand whether neural 
+relay centers further along the auditory pathway would 
+also change differently in dharana and dhyana states. The 
+limitations of the present study are: (i) the fact that there 
+was no attempt to vary stimulus intensities and hence the 
+earlier findings of McEvoy, Frumkin and Harkins,[2] could 
+not be examined, (ii) ekagrata, dharana and cancalata 
+sessions were not different and cannot be ruled out as 
+the VAS is essentially a subjective measure; no objective 
+measure was taken. Only those subjects who achieved 75% 
+of their ideal practice based of their subjective rating were 
+included in the study. Again, the possibility that the sound 
+stimulus influences all four practices cannot be ruled out. 
+This is another limitation of the study.
+Despite these limitations, the present study does 
+demonstrate a difference between the dharana and dhyana 
+states of meditation based on BAEP
+.[15,17,18]
+REFERENCES
+1.	
+Banquet JP. Spectral analysis of the EEG in meditation. Electroencephalogr 
+Clin Neurophysiol 1973;35:143-51.
+2.	
+McEvoy TM, Frumkin LR, Harkins SW. Effects of meditation on brainstem 
+auditory evoked potentials. Int J Neurosci 1980;10:165-70.
+3.	
+Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, 
+Table 1: Latency of wave V brainstem auditory-evoked potentials (BAEP) in four sessions
+Sessions
+States
+Pre
+During 1
+During 2
+During 3
+During 4
+Post
+Cancalata
+5.78±0.18
+5.82±0.18
+5.84**±0.17
+5.84±0.20
+5.84±0.18
+5.82±0.17
+Ekagrata
+5.76±0.19
+5.83±0.18
+5.83**±0.18
+5.83*±0.17
+5.87±0.19
+5.85***±0.18
+Dharana
+5.75±0.20
+5.80±0.19
+5.80±0.19
+5.78±0.21
+5.80±0.21
+5.82**±0.18
+Dhyana
+5.79±0.18
+5.81±0.19
+5.82±0.19
+5.81±0.18
+5.81±0.20
+5.82±0.18
+*P<0.05, **P<0.01, ***P<0.001; RM ANOVA with Bonferroni adjustment compared state with pre.
+[Downloaded from http://www.ijoy.org.in on Friday, March 04, 2011, IP: 117.211.90.10]
+41
+International Journal of Yoga  Vol. 3  Jul-Dec-2010
+et al. Meditation experience is associated with increased cortical thickness. 
+Neuroreport 2005;28:1893-7.
+4.	
+Mishra UK, Kalita J. Clinical neurophysiology. New Delhi: B.I. Churchill 
+Livingstore; 2001.
+5.	
+Woods DL, Clayworth CC. Click spatial position influences middle latency 
+auditory evoked potentials (MAEPs) in humans. Clin Electroencephalogr 
+1985;60:122-9.
+6.	
+Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, 
+et al. Meditation experience is associated with increased cortical thickness. 
+Neuroreport 2005;28:1893-7.
+7.	
+Napadow V, Dhond R, Conti G, Makris N, Brown EN, Barbieri R. Brain 
+correlates of autonomic modulation: Combining heart rate variability with 
+fMRI. Neuroimage 2008;42:169-77.
+8.	
+Telles S, Nagarathna R, Nagendra HR. Alterations in auditory middle latency 
+evoked potentials during meditation on a meaningful symbol–“OM”. Int J 
+Neurosci 1994;76:87-93.
+9.	
+Telles S, Naveen KV. Changes in middle latency auditory evoked potentials 
+during meditation. Psychol Rep 2004;94:398-400.
+10.	 Taimini IK. The Science of Yoga. Madras, India: The Theosophical 
+Publishing House; 1961.
+11.	
+Lauter JL, Oyler RF, Lord-Maes J. Amplitude stability of auditory brainstem 
+responses in two groups of children compared with adults. Br J Audiol 
+1993;27:263-71.
+12.	 Yadav A, Tandon OP, Vaney N. Auditory evoked responses during different 
+phases of menstrual cycle. Indian J Physiol Pharmacol 2002;46:449-56.
+13.	 ZAR JH. Biostatistical analysis. 4th ed. Delhi, India: Person Education 
+(Singapore) Pvt. Ltd; 2005.
+14.	 Jasper HH. The ten-twenty electrode system of the International federation. 
+Electroencephalogr Clin Neurophysiol 1958;10:371-5.
+15.	 Chinmayananda S. Mandukya Upanisad. Bombay: Sachin publishers; 1984.
+16.	 Subramanya P, Telles S. Changes in middle latency auditory evoked 
+potentials following two yoga based relaxation techniques. Clinical 
+EEG and Neuroscience 2009;40:190-95.
+17.	 Bhakttivedanta Swami Prabhupada AC. Bhagavad Gita: as it is. Mumbai: 
+The Bhaktivedanta Book Trust; 1998.
+18.	 Telles S, Desiraju T. Recording of auditory middle latency evoked potentials 
+during the practice of meditation with the syllable ‘OM’. Indian J Med Res 
+1993;98:237-9.
+Evoked potentials in meditation
+Author Help: Online submission of the manuscripts
+Articles can be submitted online from http://www.journalonweb.com. For online submission, the articles should be prepared in two files (first 
+page file and article file). Images should be submitted separately.
+1) 	 First Page File: 
+	
+Prepare the title page, covering letter, acknowledgement etc. using a word processor program. All information related to your identity 
+should be included here. Use text/rtf/doc/pdf files. Do not zip the files.
+2)	
+Article File: 
+	
+The main text of the article, beginning with the Abstract to References (including tables) should be in this file. Do not include any information 
+(such as acknowledgement, your names in page headers etc.) in this file. Use text/rtf/doc/pdf files. Do not zip the files. Limit the file size 
+to 1 MB. Do not incorporate images in the file. If file size is large, graphs can be submitted separately as images, without their being 
+incorporated in the article file. This will reduce the size of the file.
+3)	
+Images: 
+	
+Submit good quality color images. Each image should be less than 4096 kb (4 MB) in size. The size of the image can be reduced by 
+decreasing the actual height and width of the images (keep up to about 6 inches and up to about 1800 x 1200 pixels). JPEG is the most 
+suitable file format. The image quality should be good enough to judge the scientific value of the image. For the purpose of printing, always 
+retain a good quality, high resolution image. This high resolution image should be sent to the editorial office at the time of sending a revised 
+article.
+4)	
+Legends: 
+	
+Legends for the figures/images should be included at the end of the article file.
+[Downloaded from http://www.ijoy.org.in on Friday, March 04, 2011, IP: 117.211.90.10]

subfolder_0/CLINICAL STUDY OF YOGA TECHNIQUES IN UNIVERSITY STUDENTS WITH ASTHMA A CONTROLLED TRIAL.txt

@@ -0,0 +1,6 @@
+ 
+ 
+ 
+ 
+ 
+ 

subfolder_0/CYCLIC MEDITATION A MOVING MEDITATION REDUCES ENERGY EXPENDITURE MORE THAN SUPINE REST.txt

@@ -0,0 +1,25 @@
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 

subfolder_0/Cancer Prevention and rehabilitation through yoga.txt

@@ -0,0 +1,152 @@
+© 2018 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+1
+Cancer is one of the leading causes of death worldwide, 
+with an incidence of 14 million new cases per year, with 
+about 1 million diagnosed in India. The prevalence of 
+cancer has increased over the past decade and is expected 
+to rise by 8% in the next 5  years. Regular screening, 
+early detection, and improved therapies have increased 
+the 10‑year survival from 61% to 77% in the past decade. 
+However, advancements in cancer treatment have not 
+changed mortality rates.
+While cancer prevention is being debated and developed 
+in many health‑care facilities, there is no doubt a 
+strong component is in following some basic lifestyle 
+modifications.
+Cancer cells are not powerful invaders as viruses from 
+outside. They are born in our own bodies, say a thousand 
+in a billion cells which are created every day in our 
+bodies. However, our immune system takes care of them 
+recognizing them as enemies as it does with outside germs. 
+It is well known that stress is an immune suppression 
+factor and highly stressed lifestyle can bring confusion in 
+the immune system to recognize cancer as an enemy. On 
+the contrary, it thinks that they are good friends and does 
+not destroy them. This aspect is known as Viparyaya, a 
+state of mind in which reality is perceived wrongly  (an 
+example of perceiving a rope as snake or a post as 
+ghost). Unless this Viparyaya is corrected, the root cause 
+of cancer will not be vanquished. This is possible by 
+de‑stressing mind‑body through the practice of relaxation 
+techniques such as asanas, breath slowing Pranayama, and 
+mind‑calming meditation methods. Furthermore, proper 
+diet, exercise, avoiding smoking, use of tobacco in various 
+forms, psychedelic drug addictions, and uncontrolled 
+consumption of alcohol surely will help in the prevention 
+of cancer. This is where the role of Yoga practices take 
+importance. It is said in the Gita that he who eats sparingly, 
+who sleeps just adequately and who is skillful in action, for 
+such a person Yoga becomes a “killer of duhkha  (distress 
+or misery)”  (Bhagavad Gita 6:17).[1] A positive attitude in 
+work arena and to act stress‑free is an important factor in 
+maintaining high level of immunity. We know, for example, 
+many students report sick during examination time. This is 
+because of the stress that is experienced by them and their 
+inappropriate response to stress.
+It is presently recommended that overeating and eating 
+too often in a day could be causes of reduced immunity. 
+There are a few individuals who eat only twice a day 
+and skip all solid foods 1  day a month. Cancer cells are 
+known to proliferate deriving energy from the food we 
+eat; by skipping solid foods once a month, we could 
+arrest the proliferation and even eliminate production of 
+Cancer: Prevention and Rehabilitation through Yoga
+Editorial
+cancerous cells. More work is needed to substantiate these 
+statements; however, there is some basic understanding 
+of cancer cell activity which is important in cancer 
+prevention.
+We at Vivekananda Yoga Anusandhana Samsthana have 
+developed yoga module for cancer‑based on traditional 
+Yoga texts and research evidence. We have carried out 
+collaborative research studies on Breast Cancer with 
+MD Anderson Cancer Centre in Texas, USA. Consistent 
+improvements have been reported in anxiety, symptom 
+severity, distress, nausea and vomiting, and affect and 
+global QOL14 as well as beneficial effects on natural 
+killer cell counts and radiation‑induced DNA damage.[2‑5] 
+However, safety and efficacy of yoga has to considered 
+carefully in cancer care. Yoga should be practiced under 
+the guidance of trained yoga therapist.
+Addressing the root cause and using holistic healing 
+methods along with conventional methods would be the 
+best solution for cancer prevention and management. 
+Along with yoga, other Indian systems of medicines have 
+also shown beneficial effects in cancer care. Hence there 
+is a need for Integrating AYUSH in Palliative Care. Every 
+alternate year, we conduct an international conference on 
+Frontiers in Yoga Research and its Applications. This 
+year we have selected a theme “Integrative Oncology: 
+Future of Cancer Care.” The 22nd  INCOFYRA  –  2018 
+will make an effort to integrate Ayurveda, Naturopathy, 
+Yoga, Unani, Siddha, Homeopathy, and Modern Medicine 
+by bringing prominent researchers and doctors from all 
+these fields under one platform to evolve better cancer 
+care.
+HR Nagendra
+Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, 
+Karnataka, India 
+E‑mail: [email protected]
+References
+1.	
+Swarupananda 
+S. 
+Srimad 
+Bhagavad 
+Gita. 
+Kolkatta: 
+Advitashrama; 2016.
+2.	
+Rao MR, Raghuram N, Nagendra HR, Gopinath KS, Srinath BS, 
+Diwakar  RB, et  al. Anxiolytic effects of a yoga program in 
+early breast cancer patients undergoing conventional treatment: 
+A 
+randomized 
+controlled 
+trial. 
+Complement 
+Ther 
+Med 
+2009;17:1‑8.
+3.	
+Vadiraja  HS, Raghavendra  RM, Nagarathna  R, Nagendra  HR, 
+Rekha  M, Vanitha  N, et  al. Effects of a yoga program on 
+cortisol rhythm and mood states in early breast cancer patients 
+undergoing adjuvant radiotherapy: A randomized controlled trial. 
+Integr Cancer Ther 2009;8:37‑46.
+4.	
+Raghavendra RM, Nagarathna R, Nagendra HR, Gopinath KS, 
+Srinath  BS, Ravi  BD, et  al. Effects of an integrated 
+yoga 
+programme 
+on 
+chemotherapy‑induced 
+nausea 
+and 
+Nagendra: Yoga and Cancer
+2
+International Journal of Yoga | Volume 11 | Issue 1 | January‑April 2018
+emesis in breast cancer patients. Eur J Cancer Care  (Engl) 
+2007;16:462‑74.
+5.	
+Chandwani  KD, Perkins  G, Nagendra  HR, Raghuram  NV, 
+Spelman  A, Nagarathna  R, et  al. Randomized, controlled trial 
+of yoga in women with breast cancer undergoing radiotherapy. 
+J Clin Oncol 2014;32:1058‑65.
+How to cite this article: Nagendra HR. Cancer: Prevention and 
+rehabilitation through yoga. Int J Yoga 2018;11:1-2.
+Received: December, 2017. Accepted: December, 2017.
+This is an open access article distributed under the terms of the Creative Commons 
+Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, 
+and build upon the work non‑commercially, as long as the author is credited and the new 
+creations are licensed under the identical terms.
+Access this article online
+Quick Response Code:
+Website:
+www.ijoy.org.in
+DOI:
+10.4103/ijoy.IJOY_71_17
+© 2018. This work is published under
+https://creativecommons.org/licenses/by-nc-sa/4.0/ (the “License”).
+Notwithstanding the ProQuest Terms and Conditions, you may use this content
+in accordance with the terms of the License.

subfolder_0/Challenges faced in diabetes risk prediction among an indigenous South Asian population in India using the Indian Diabetes Risk Score.txt

@@ -0,0 +1,363 @@
+Themed Paper e Original Research
+Challenges faced in diabetes risk prediction among
+an indigenous South Asian population in India
+using the Indian Diabetes Risk Score
+V. Vijayakumar*, M. Balakundi, K.G. Metri
+Department of Yoga and Lifesciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA University),
+Bengaluru, India
+a r t i c l e i n f o
+Article history:
+Received 16 November 2017
+Received in revised form
+14 June 2018
+Accepted 7 September 2018
+Available online xxx
+Keywords:
+Diabetes risk
+Diabetes prevalence
+IDRS
+Indigenous
+South Asian ethnicity
+a b s t r a c t
+Objectives: Indigenous populations around the world have a higher health disparity and an
+increased risk of diabetes. Scientific literature on the prevalence of diabetes in India is not
+available, and the current work is a pilot study to explore the risk of diabetes in one such
+indigenous population in India.
+Study design: This is a cross-sectional survey and screening study.
+Methods: The study took place in a remote tribal hamlet of Machuru in South India. A door-
+to-door survey was conducted in the hamlet with a population of 555. The Indian Diabetes
+Risk Score (IDRS) questionnaire was completed by 160 individuals older than 25 years.
+Capillary blood glucose levels were measured to compare the glycaemic status with the
+predicted IDRS.
+Results: Of 160 adults who completed the questionnaire, 37 were at high risk (23.13%) as per
+the IDRS, 52 at medium risk (32.5%) and 71 at low risk (44.38%). None of the respondents
+knew their family history of diabetes owing to the lack of awareness about the condition.
+Interestingly, the villagers had a sedentary lifestyle owing to their unique family dynamics
+but a healthy diet. Five participants were diagnosed with diabetes, and 18 were diagnosed
+with impaired fasting glucose or prediabetes.
+Conclusions: The IDRS might not be an accurate measure to understand the risk of diabetes
+in this particular population owing to their unique family dynamics and a lack of aware-
+ness about diabetes. The best possible way to assess the diabetes risk might be through
+blood examination.
+© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
+* Corresponding author.
+E-mail address: [email protected] (V. Vijayakumar).
+Available online at www.sciencedirect.com
+Public Health
+journal homepage: www.elsevier.com/puhe
+p u b l i c h e a l t h x x x ( 2 0 1 8 ) 1 e4
+https://doi.org/10.1016/j.puhe.2018.09.012
+0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
+Please cite this article in press as: Vijayakumar V, et al., Challenges faced in diabetes risk prediction among an indigenous South Asian
+population in India using the Indian Diabetes Risk Score, Public Health (2018), https://doi.org/10.1016/j.puhe.2018.09.012
+Introduction
+The prevalence of diabetes is increasing worldwide, especially
+in the South Asian ethnic population.1 An increase in the
+prevalence of diabetes is observed both in rural and urban
+India.2 Indigenous populations are the natives of a country,
+with ‘defined territory and ethnic distinctiveness’ as the two
+distinguishing features.3 In India, indigenous groups are
+classified by the government as ‘scheduled tribes’.4 Health
+disparities between indigenous and non-indigenous pop-
+ulations are universal.5 In the case of diabetes, the prevalence
+and related mortality are 3e4 times higher in indigenous
+populations than in non-indigenous populations, and this has
+been extensively studied in various countries.6 Most of the
+accessible information, such as the scientific articles or pub-
+lished reports, on indigenous populations is from Western
+countries, particularly the US, Canada, New Zealand, the UK
+and Australia.6,7 With more than 705 individual ethnic groups
+and an indigenous population of more than 104 million in
+India,8 such structured published scientific literature on the
+tribal or indigenous population is very limited;7 in particular,
+there are no available scientific literature on the prevalence of
+diabetes.
+Diabetes risk assessment questionnaires are cost-effective
+tools for assessing the risk of diabetes. Several risk assess-
+ment tools have been developed using a combination of de-
+mographic, clinical and biochemical information.9 Every
+country has tailor-made questionnaires constructed based on
+the sociocultural factors and risk factors associated with the
+particular population. The Indian Diabetes Risk Score (IDRS) is
+one such tool to assess the risk of diabetes in the Indian
+population.10 IDRS consists of four questions, namely, on age,
+family history, physical activity and waist circumference. In
+general, indigenous populations are at an increased risk of
+diabetes when compared with non-indigenous populations.
+The present study aims at assessing the risk of diabetes in a
+remote tribal population in a southern state of India, using the
+IDRS questionnaire and evaluating the suitability of the IDRS
+questionnaire as an appropriate risk assessment tool.
+Methods
+Study design
+The present study is a cross-sectional study, assessing the
+current diabetes risk of the given population through survey
+and capillary blood screening. The presented data were
+collected as part of a health camp.
+Door-to-door surveys were conducted in a remote tribal
+hamlet of Machuru in South India as part of a health camp.
+The team went to every individual house to get the details of
+the family members. The total population of the hamlet was
+555. The IDRS questionnaire was completed by 160 individuals
+who were older than 25 years. The research team included
+members who could speak the local language, in addition to a
+member of the local community. Capillary blood glucose
+levels were measured using a standardised digital glucometer
+(Accu-Chek, Roche Diagnostics, Germany) after 8e12 h of
+overnight fasting to compare the current glycaemic status
+with their IDRS.
+Results
+The population of the hamlet was 555. In total, 160 adults
+older than 25 years were surveyed initially using the IDRS, and
+capillary glucose levels were measured in 103 individuals. The
+remaining 57 individuals did not give consent for the finger
+prick test.
+Among 160 adults, 37 were at high risk (23.13%) as per the
+IDRS, 52 at medium risk (32.5%) and 71 at low risk (44.38%; see
+Table 1). Five participants were diagnosed with diabetes, and
+18 were diagnosed with impaired fasting glucose (IFG) or
+prediabetes, according to the American Diabetes Association
+criteria (see Table 2). There was no significant difference in
+mean glucose levels or IDRS between the genders (P > 0.05).
+The risk prediction of the IDRS was not substantial in the
+current population. Amongst the 18 individuals with IFG, the
+IDRS recognised 12 to be at moderate risk and six at low risk of
+diabetes. Among the five individuals with diabetes, IDRS recog-
+nised four to be at moderate risk and one at high risk of diabetes.
+Discussion
+Exploring the lifestyle of a remote tribal indigenous popula-
+tion was a unique experience for the research team. The
+family dynamics of the population are very unique, in that
+there is only one earning member of the family (predomi-
+nantly a man younger than 30 years) and the rest of the family
+members who are older than 30 years become dependants
+and subsequently lead sedentary lives.
+None of the 160 adults who answered the IDRS question-
+naire knew whether their parents had diabetes. And, for the
+question on the ‘family history’ of diabetes, every single
+participant said that their parents were not diagnosed with
+diabetes as they had never checked their blood glucose levels
+before. It is noteworthy that the awareness about diabetes as a
+health condition is very minimal in the current population,
+let alone the previous generations. Family history scored ‘0’
+for all the subjects as none of them knew the diabetic status of
+their parents as no blood test was carried out to detect dia-
+betes. This indicates that diabetes awareness and screening
+programmes should also be conducted in the remote areas of
+Table 1 e Indian Diabetes Risk Score (IDRS) across both
+genders.
+Male (n ¼ 68)
+Female (n ¼ 92)
+Age in years (mean ± SD)
+34 ± 2.83
+46 ± 4.24
+IDRS risk (n)
+High risk
+10
+27
+Medium risk
+24
+28
+Low risk
+34
+37
+IDRS
+High risk
+55 ± 13
+56 ± 12
+(Mean ± SD)
+Medium risk
+40 ± 4.7
+38 ± 4.4
+Low risk
+29 ± 7.1
+32 ± 12
+SD, standard deviation.
+p u b l i c h e a l t h x x x ( 2 0 1 8 ) 1 e4
+2
+Please cite this article in press as: Vijayakumar V, et al., Challenges faced in diabetes risk prediction among an indigenous South Asian
+population in India using the Indian Diabetes Risk Score, Public Health (2018), https://doi.org/10.1016/j.puhe.2018.09.012
+the country to curb the increasing prevalence of diabetes in
+India.
+Age was found to be the major risk factor for diabetes in
+this study, followed by the lack of physical activity and
+abdominal obesity. In the current indigenous population,
+abdominal obesity was not prevalent and contributed only
+minimally to the risk score.
+The prevalence of diabetes and prediabetes in this particular
+indigenous population is much lower at 3.24% and 3.42% when
+compared with the national prevalence of 8.7% and 4.6%,
+respectively.11 This is contradictory to the findings from the
+indigenous populations of other countries, where the preva-
+lence of diabetes was 3e4 times higher, on average, than non-
+indigenous populations.6 The possible reasons could be that
+urbanisation has not reached this particular indigenous com-
+munity as much as in the developed countries. Health disparity
+in indigenous populations is attributed more to lifestyle factors
+than genetic factors.3 Despite a sedentary lifestyle above the
+age of 30 years, there are a few factors that are protective
+against diabetes in this study population. For example, whole-
+grain consumption helps to reduce the risk of diabetes,12,13 and
+this particular indigenous population still consumes whole
+grains and has not even heard about or used refined products
+for cooking. Locally grown vegetables are used in abundance
+and become a part of their daily diet which is possibly an added
+advantage as fruit and vegetable consumption is inversely
+associated with diabetes.14 Basic amenities such as electricity
+have still not reached these indigenous community dwellings.
+This could be seen as a blessing in disguise as they go to bed
+early and get up before sunrise, maintaining an optimal circa-
+dian rhythm, possibly keeping them healthy and protected
+against a metabolic disorder such as diabetes.15,16 Similar to
+most diabetes risk assessment questionnaires around the
+world, lifestyle risk factors such as diet and sleep are not
+included in the IDRS. The Finnish Diabetes Risk Score ques-
+tionnaire, which includes a question on diet, is found to be
+better than theIDRS in diagnostic accuracy and clinicalutility.17
+The addition of questions on diet and sleep in the diabetes risk
+assessment
+questionnaire
+might,
+thus,
+be
+beneficial
+in
+increasing the diagnostic accuracy of type 2 diabetes.
+The main strength of the study is that it has been con-
+ducted on a remote indigenous tribal population whose dia-
+betic status is not widely studied in India, as even accessibility
+by road is still limited in these areas.
+Limitations
+Diagnosis of type 2 diabetes was performed using capillary
+glucose levels and not venous blood glucose levels. Owing to
+the funding constraints and lack of resources at the remote
+tribal location, it was not possible to measure the plasma
+glucose levels, and the capillary blood glucose tests were
+performed using a glucometer. Screened individuals were
+older than 25 years, and there are higher chances that other
+types of diabetes such as type 1 diabetes or latent autoim-
+mune diabetes of adulthood might have gone unnoticed. The
+data reported were from a remote indigenous community in a
+southern state of India. The data might not be considered as a
+representative sample to explain the diabetic status of all the
+indigenous populations across the country.
+Conclusions
+The best way to assess the diabetes risk in this population
+might be through blood glucose measurements, rather than
+analysing the diabetes risk scores. The IDRS might not be an
+appropriate measure to detect the risk of diabetes in the given
+tribal population. The IDRS has definitely been of great benefit
+in the early type 2 diabetes risk prediction in a developing
+country such as India, similar to all other risk prediction
+questionnaires. Adding a few key lifestyle risk factors to the
+current available risk prediction tools could make them more
+precise. It might not be appropriate to generalise the findings
+obtained from this particular population to all the indigenous
+tribes in India, and further large-scale studies including other
+parameters such as glycated haemoglobin A1c and the oral
+glucose tolerance test would give a much better understand-
+ing about the diabetes prevalence in the indigenous pop-
+ulations of India.
+Author statements
+Ethical approval
+Ethical approval was not applied for the study as the data
+presented here are a part of a health camp, and this was not
+performed exclusively as a research study.
+Funding
+This research is funded by the JagMohan Maheswari trust, a
+not-for-profit organisation working on the welfare of indige-
+nous tribal populations. However, they did not have any in-
+fluence on the outcome of the study or designing the
+methodology.
+Competing interests
+The authors declare no conflict of interest.
+r e f e r e n c e s
+1. Vijayakumar V, Mavathur R, Sharma MN. Ethnic disparity and
+increased prevalence of type 2 diabetes among South Asians:
+aetiology and future implications for diabetes prevention and
+management. Curr Diabetes Rev 2017;14(6):518e22.
+Table 2 e Fasting capillary blood glucose measurement
+(n ¼ 103).
+Range
+Fasting glucose (mg/dL)
+[mean ± SD]
+Male
+Female
+Normal range
+88.79 ± 16.82
+87.69 ± 19.29
+Prediabetes range
+107.17 ± 12.58
+110 ± 14.96
+Diabetes range
+275 ± 19.52
+225.33 ± 18.31
+SD, standard deviation.
+p u b l i c h e a l t h x x x ( 2 0 1 8 ) 1 e4
+3
+Please cite this article in press as: Vijayakumar V, et al., Challenges faced in diabetes risk prediction among an indigenous South Asian
+population in India using the Indian Diabetes Risk Score, Public Health (2018), https://doi.org/10.1016/j.puhe.2018.09.012
+2. Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V,
+Unnikrishnan R, et al. Prevalence of diabetes and prediabetes
+(impaired fasting glucose and/or impaired glucose tolerance)
+in urban and rural India: phase I results of the Indian Council
+of Medical ResearcheIndia DIABetes (ICMReINDIAB) study.
+Diabetologia 2011;54(12):3022e7.
+3. Durie MH. The health of Indigenous peoples: depends on
+genetics, politics, and socioeconomic factors. BMJ Br Med J
+2003;326(7388):510.
+4. Subramanian SV, Smith GD, Subramanyam M. Indigenous
+health and socioeconomic status in India. PLoS Med
+2006;3(10):e421.
+5. Stephens C, Nettleton C, Porter J, Willis R, Clark S. Indigenous
+peoples' healthdwhy are they behind everyone, everywhere?
+Lancet 2005;366(9479):10e3.
+6. Si D, Bailie R, Wang Z, Weeramanthri T. Comparison of
+diabetes management in five countries for general and
+indigenous populations: an internet-based review. BMC Health
+Serv Res 2010;10(1):169.
+7. Valeggia CR, Snodgrass JJ. Health of indigenous peoples. Annu
+Rev Anthropol 2015;44:117e35.
+8. Ministry of Tribal Affairs. Scheduled tribes in India as revealed in
+census 2011 (RGI report). New Delhi: India Ministry of Tribal
+Affairs; 2017. Available: https://tribal.nic.in/writereaddata/
+AnnualReport/
+ScheduledTribesinIndiaasRevealedinCensus2011.pdf.
+9. Glu
+¨ mer C, Vistisen D, Borch-Johnsen K, Colagiuri S. Risk
+scores for type 2 diabetes can be applied in some populations
+but not all. Diabetes Care 2006;29(2):410e4.
+10. Mohan V, Deepa R, Deepa M, Somannavar S, Datta M. A
+simplified Indian Diabetes Risk Score for screening for
+undiagnosed diabetic subjects. J Assoc Phys India
+2005;53:759e63.
+11. Ogurtsova K, da Rocha Fernandes JD, Huang Y,
+Linnenkamp U, Guariguata L, Cho NH, et al. IDF Diabetes
+Atlas: global estimates for the prevalence of diabetes for 2015
+and 2040. Diabetes Res Clin Pract 2017;128:40e50.
+12. Aune D, Norat T, Romundstad P, Vatten LJ. Whole grain and
+refined grain consumption and the risk of type 2 diabetes: a
+systematic review and doseeresponse meta-analysis of
+cohort studies. Eur J Epidemiol 2013;28(11):845e58.
+13. Cho SS, Qi L, Fahey GC, Klurfeld DM. Consumption of cereal
+fiber, mixtures of whole grains and bran, and whole grains
+and risk reduction in type 2 diabetes, obesity, and
+cardiovascular disease. Am J Clin Nutr 2013. ajcn-067629.
+14. Jannasch F, Kr€
+oger J, Schulze MB. Dietary patterns and type 2
+diabetes: a systematic literature review and meta-analysis of
+prospective studies. J Nutr 2017;147(6):1174e82.
+15. Sridhar GR, Gumpeny L. Sleep, obesity and diabetes: the
+circadian rhythm. Adv Diabetes Nov Insights 2016:197.
+16. Tan E, Scott EM. Circadian rhythms, insulin action, and
+glucose homeostasis. Curr Opin Clin Nutr Metab Care
+2014;17(4):343e8.
+17. Pawar SD, Naik JD, Prabhu P, Jatti GM, Jadhav SB, Radhe BK.
+Comparative evaluation of Indian Diabetes Risk Score and
+Finnish Diabetes Risk Score for predicting risk of diabetes
+mellitus type II: a teaching hospital-based survey in
+Maharashtra. J Fam Med Prim Care 2017;6(1):120.
+p u b l i c h e a l t h x x x ( 2 0 1 8 ) 1 e4
+4
+Please cite this article in press as: Vijayakumar V, et al., Challenges faced in diabetes risk prediction among an indigenous South Asian
+population in India using the Indian Diabetes Risk Score, Public Health (2018), https://doi.org/10.1016/j.puhe.2018.09.012

subfolder_0/Changes in Heart Rate Variability Following Yogic Visual Concentration (Trataka)_unlocked.txt

@@ -0,0 +1,335 @@
+15
+Heart India, Vol 2 / Issue 1 / Jan-Mar 2014
+Changes in Heart Rate Variability Following Yogic Visual 
+Concentration (Trataka)
+B R Raghavendra, V Ramamurthy
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India
+The literal meaning of the Sanskrit word trataka is “to gaze steadily.” 
+Looking intently with an unwavering gaze at a small point until tears 
+are shed is known as trataka (Hatha Yoga Pradipika, Ch:2, V:31). 
+Hatha Yoga Pradipika mentions that, practice of trataka eradicates 
+all the eye diseases, fatigue and lethargy (Hatha Yoga Pradipika, Ch:2, 
+V:32). Though trataka is considered as cleansing technique, the final 
+stage of trataka leads to meditative mental state.[3]
+Recently, a study has been conducted to assess the immediate effect 
+of trataka on critical flicker fusion (CFF).[4] The CFF is defined as the 
+frequency at which a flickering stimulus is perceived to be continuous. 
+There was a significant increase in CFF following trataka suggesting 
+changes at the cortical level in the processes that mediate fusion.
+Meditation and autonomic changes are researched extensively and 
+shown a shift toward vagal tone during meditation.[5-7] However, 
+there was no study evaluating autonomic changes during trataka 
+which is similar to meditation. Hence, in the present study, we 
+used heart rate variability (HRV) which is a well-known and 
+extensively used method to evaluate autonomic modulation.
+MATERIALS AND METHODS
+Participants
+A total of 30 male volunteers with ages ranging from 20 to 33 
+years (group mean age ± SD, 23.8 ± 3.5) were recruited for this 
+A b s t ra ct
+Background: The yogic visual concentration technique, trataka is similar to meditation. Research studies have shown 
+a shift toward the vagal tone during meditation. However, autonomic changes in trataka were not studied. Objectives: 
+The present study was planned to assess the changes in heart rate variability (HRV) following trataka. Materials and 
+Methods: HRV and breath rate were assessed in thirty healthy male volunteers with ages ranging from 20 to 33 years 
+(group mean age ± SD, 23.8 ± 3.5) before and after yogic visual concentration (trataka) and control session on 2 separate 
+days. Repeated measures analysis of variance (ANOVA) were performed with two “within subjects” factors, i.e., Factor 1: 
+Sessions; trataka and control and Factor 2: States; “Pre”, and “Post”. This was followed by post-hoc analyses with Bonferroni 
+adjustment comparing “Post” with “Pre” values. Results: There was a significant decrease in LF (RM ANOVA with 
+Bonferroni adjustment P < 0.01) and increase in high frequency (P < 0.01) after trataka. Breath rate (P < 0.001) and heart rate 
+(P < 0.01) were significantly reduced after trataka compared to before. Control session showed no change. Conclusions: The 
+practice of trataka leads to increased vagal tone and reduced sympathetic arousal. Though trataka is known as cleansing 
+technique, it could induce calm state of mind which is similar to a mental state reached by the practice of meditation. 
+Key words: Heart rate variability, high frequency, low frequency, trataka
+Address for correspondence:  
+Dr. B R Raghavendra,  
+Swami Vivekananda Yoga Anusandhana Samsthana,  
+# 19, Eknath Bhavan, Gavipuram Circle, K G Nagar,  
+Bengaluru - 560 019, Karnataka, India.
+INTRODUCTION
+Yoga is an ancient Indian science and the way of life. Sage 
+Patanjali (circa 900 B.C) explains the theoretical aspects yoga in 
+196 aphorisms called Yoga Sutras.[1] Patanjali evolved Astanga 
+yoga (eight limbed) to reach the ultimate reality. Later around 10th 
+Century CE Sage Svatmarama wrote a text called Hatha Yoga 
+Pradipika in which he explains the method of yoga techniques. 
+He prescribes six cleansing techniques (kriyas) viz., dauti, basti, 
+neti, trataka, nauli and kapalabhati to purify the body. The goal of 
+Hatha Yoga is to prepare the body and mind for the practice of 
+Raja yoga or Astanga yoga.[2]
+O riginal Article
+Access this article online
+Quick Response Code:
+Website:
+www.heartindia.net
+DOI:
+10.4103/2321-449x.127975
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+16
+Raghavendra and Ramamurthy: Trataka and HRV
+Heart India, Vol 2 / Issue 1 / Jan-Mar 2014
+study. They were all students of a yoga university in Southern 
+India. Their health status was evaluated by a routine clinical 
+examination and case history. They had normal health and 
+were not on any medication. The predetermined conditions to 
+exclude participants from the trial were any chronic illness. Male 
+volunteers alone were selected as autonomic and respiratory 
+variables are known to vary with the phases of the menstrual 
+cycle.[8] The project was approved by the institution’s ethics 
+committee. The study protocol was explained to the participants 
+and their signed consent was obtained.
+Design
+Self as control design was used. Each participant was assessed in 
+two sessions (trataka and control session) on 2 separate days. Half 
+the subjects practiced trataka on 1st day and control session on 2nd 
+day. The other half was having the order of the session reversed. 
+Duration of both the sessions were of 25 min. Participants were 
+assessed before and immediately after the sessions.
+Assessment
+Electrocardiogram (ECG) and respiration were recorded using 
+a four channel polygraph (Biopac MP 100, USA).
+HRV and heart rate
+The ECG was recorded using a standard bipolar limb lead II 
+configuration and an AC amplifier with 100 Hz high cut filter 
+and 1.5 Hz low cut filter settings. The EKG was digitized using 
+a 12-bit analog-to-digital converter at a sampling rate of 1024 Hz 
+and was analyzed off-line to obtain the HRV spectrum.
+Breath rate
+Respiration was be recorded using a volumetric pressure 
+transducer fixed around the trunk about 8 cm below the lower 
+costal margin as the participants sat erect.
+Intervention
+Trataka (a yogic visual concentration)
+Fifteen days orientation program was conducted to train 
+participants in trataka. Theoretical aspects of  trataka was 
+explained by a senior yoga teacher on day one. The pre-recorded 
+audio instructions for trataka was played during the session. 
+Trataka practice consists of two distinct stages. The first stage, 
+consisted of eye exercises, which is a preparatory practice for 
+trataka. The eye exercise includes eyeball movements in the 
+horizontal, vertical and diagonal direction directions and circular 
+movements. These was performed with eyes open, in a well-lit 
+room. This was followed by the practice of palming to relax the 
+eyes. Palming consisted of putting slightly cupped palms over 
+the eyes, so that the eyes perceive complete darkness. First stage 
+lasted for 10 min. The second stage, trataka, was practiced in a 
+dark room. Subjects were asked to fix the gaze on the flame of 
+the candle for about 2 to 3 min, suppressing the urge to blink 
+as far as possible. Then visualize the candle flame in between 
+the eyebrows. This process was repeated for 2-3 rounds. Finally, 
+subjects were asked to defocus and the practice ended with silence 
+and then prayer. The second stage lasted for 15 min. The duration 
+of the whole practice was 25 min.
+Control session
+During control session participants were asked to practice the 
+first stage (eye exercise) for 10 min and then for next 15 min 
+they sat quietly with closed eyes without doing any concentration 
+or meditation.
+Data extraction
+HRV
+Frequency domain analysis of HRV were carried out. The energy 
+in the HRV spectrum in the following specific frequency bands 
+were studied. The low frequency (LF) (0.04-0.15 Hz) and high 
+frequency (HF) band (0.15-0.4 Hz). According to guidelines, 
+LF and HF band values will be expressed as normalized units.[9]
+Herat rate
+The heart rate in beats per minute was calculated by counting 
+the R waves of the QRS complex in the EKG in 60 s epochs, 
+continuously.
+Breath rate
+The breath rate in cycles per minute was calculated by counting 
+the breath cycles in 60 s epochs, continuously.
+Data analysis
+Statistical analysis was performed using SPSS (version 16.0). 
+Since the same individuals were assessed in repeat sessions on 
+separate days (i.e., trataka and control), repeated measures analysis 
+of variance was used (ANOVA). Repeated measures ANOVA 
+were performed with two “within subjects” factors, i.e., Factor 
+1: Sessions; trataka and control and Factor 2: States; “Pre” and 
+“Post.” This was followed by post-hoc analyses with Bonferroni 
+adjustment comparing “Post” with “Pre” values.
+RESULTS
+The group mean values and standard deviation for frequency 
+domain measures of HRV, heart rate and breath rate are shown 
+in Table 1.
+Repeated measures ANOVA
+Repeated measures ANOVA were conducted where subjects 
+were measured before and after trataka as well as control session.
+There was a significant difference between the states for 
+1.	
+LF F(1, 29) = 7.58, P < 0.01;
+2.	
+HF F(1, 29) = 7.60, P < 0.01;
+3.	
+Hear rate F(1, 29) = 13.08, P < 0.01;
+4.	
+Breath rate F(1, 29) = 20.52, P < 0.001.
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+17
+Raghavendra and Ramamurthy: Trataka and HRV
+Heart India, Vol 2 / Issue 1 / Jan-Mar 2014
+There was a significant difference between the sessions for
+1.	
+Heart rate F(1, 29) = 6.75, P < 0.05; and
+2.	
+Breath rate F(1, 29) = 9.38, P < 0.01.
+There was also a significant interaction between Session and 
+State for
+1.	
+Breath rate F (1, 29) = 14.14, P < 0.001.
+Post-hoc analyses with Bonferroni 
+adjustment
+There was a significant decrease in LF (P < 0.01) and significant 
+increase in HF (P < 0.01) after trataka. Breath rate (P < 0.001) 
+and heart rate (P < 0.01) were significantly reduced after trataka 
+compared to before. Control session did not show any change.
+DISCUSSION
+In the current study, HRV and breath rate were assessed before 
+and after the practice of trataka and control session in thirty 
+healthy male volunteers. There was a significant decrease in LF 
+and increase in HF after trataka compared to before. Breath rate 
+and heart rate were significantly reduced after trataka compared 
+to before. Control session showed no change.
+HRV refers to beat-to-beat alterations in the heart rate. In general 
+two type of HRV analysis are used. These are frequency domain 
+analysis and time domain analysis. In the preset study, we have 
+used only frequency domain analysis. Earlier it was believed 
+that the LF (LF, 0.04-0.15 Hz) band of the HRV is an index of 
+cardiac sympathetic activity and HF (HF, 0.15-0.4 Hz) band is 
+correlated with parasympathetic activity.[9] However this has been 
+questioned subsequently. Recent research findings says, neither 
+the LF band (LF) nor the HF, are considered exclusive markers of 
+sympathetic and parasympathetic tone respectively.[10] It is found 
+that, sympathetic activity can also regulate the HF component 
+of HRV, though to a lesser extent than the parasympathetic 
+influence on the LF power. The association between HF power 
+and cardiac parasympathetic activity is stronger. Hence the HRV 
+provides broad changes in cardiac parasympathetic regulation and 
+changes in the LF power and LF/HF ratio have to be considered 
+carefully. The decrease in LF power and increase in HF power 
+after trataka suggests increased vagal modulation after trataka.
+The changes in hear rate are due to several factors. The heart rate 
+is under the control of sympathetic and parasympathetic nerves 
+as well as humeral factors.[11] Hence, it is difficult to conclude 
+that decrease in hear rate is only due to increased vagal tone or 
+due to sympathetic withdrawal.
+Breath rate depends upon numerous factors ranging from the 
+level of physical activity to psychological stress.[12] In general, 
+a decrease in breath rate is correlated with relaxation. Though 
+trataka practice involves intense focusing, it ends with defocusing 
+and silence. This might induce relaxation after the practice which 
+can explain the decrease in breath rate.
+The findings in the current study are similar to the earlier study on 
+autonomic change sand two meditative states described in yoga 
+texts, which showed reduced sympathetic arousal and increased 
+vagal tone during dhyana.[7] Hence, it is speculated that the practice 
+of trataka leads mental state which similar to meditation.
+One of the main limitations of the study is that, assessments were 
+not performed during the practice of trataka. Changes in HRV 
+during trataka might have conveyed much more information. It 
+will be interesting to have a longer duration of “Post” session (10 
+or 15 min) by which we can understand how much time effect 
+of trataka sustains. In future, along with HRV other autonomic 
+variables can be studied before during and after trataka.
+In summary, considering changes in HRV
+, heart rate and breath rate, 
+the present results show that, practice of trataka leads to increased 
+vagal tone and reduced sympathetic arousal. Though trataka is known 
+as cleansing technique, it could induce calm state of mind which is 
+similar to a mental state reached by the practice of meditation.
+REFERENCES
+1.	
+Taimni IK. The Science of YogaMadras: Theosophical Publishing 
+House; 1999.
+2.	
+Muktibodhananda S. Hatha Yoga Pradipika. Munger: Yoga 
+Publications Trust; 1993.
+3.	
+Nagaratha R, Nagendra H. Yoga for Promotion of Positive Health. 
+Bangalore: Swami Vivekananda Yoga Prakashana; 2000.
+4.	
+Mallick T, Kulkarni R. The effect of trataka, a yogic visual concentration 
+practice, on critical flicker fusion. J Altern Complement Med 
+2010;16:1265-7.
+5.	
+Orme-Johnson DW. Autonomic stability and transcendental 
+meditation. Psychosom Med 1973;35:341-9.
+Table 1: Changes in heart rate variability and breath rate before and after trataka and control session
+Variables
+Control
+Trataka
+Pre
+Post
+Pre
+Post
+LF in n.u.(Hz)
+64.40±14.92
+62.21±16.17
+63.85±14.25
+53.58±15.41**↓
+HF in n.u.(Hz)
+35.60±14.92
+37.79±16.14
+36.15±14.25
+46.42±15.41**↑
+LF/HF ratio
+2.79±2.42
+2.54±2.64
+2.41±1.73
+2.24±1.96
+Heart rate (bpm)
+72.87±6.61
+70.91±8.11
+71.20±8.83
+67.29±5.84**↓
+Breath rate (cpm)
+15.20±1.34
+14.85±1.36
+15.13±0.96
+13.85±1.22***↓
+**P<0.01, ***P<0.001. Repeated measures analysis of variance with Bonferroni adjustment comparing post values with pre values. ↑: Increase, ↓: Decrease, LF: Low 
+frequency, HF: High frequency
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+18
+Raghavendra and Ramamurthy: Trataka and HRV
+Heart India, Vol 2 / Issue 1 / Jan-Mar 2014
+6.	
+Wallace RK. Physiological effects of transcendental meditation. Science 
+1970;167:1751-4.
+7.	
+Telles S, Raghavendra BR, Naveen KV, Manjunath NK, Kumar S, 
+Subramanya P. Changes in autonomic variables following two 
+meditative states described in yoga texts. J Altern Complement Med 
+2013;19:35-42.
+8.	
+Yildirir A, Kabakci G, Akgul E, Tokgozoglu L, Oto A. Effects 
+of menstrual cycle on cardiac autonomic innervation as assessed 
+by heart rate variability. Ann Noninvasive Electrocardiol 
+2002;7:60-3.
+9.	
+Heart rate variability. Standards of measurement, physiological 
+interpretation, and clinical use. Task Force of the European Society 
+of Cardiology and the North American Society of Pacing and 
+Electrophysiology. Eur Heart J 1996;17:354-81.
+10.	
+Lombardi F, Stein PK. Origin of heart rate variability and turbulence: 
+An appraisal of autonomic modulation of cardiovascular function. 
+Front Physiol 2011;2:95.
+11.	
+Andreassi JL. Psychophysiology: Human Behavior and Physiological 
+Response. Mahwah, NJ: Lawrence Earl Baum Associates; 2007.
+12.	
+Stevenson I, Ripley HS. Variations in respiration and in respiratory 
+symptoms during changes in emotion. Psychosom Med 1952;14:476-90.
+How to cite this article: Raghavendra BR, Ramamurthy V. Changes 
+in heart rate variability following yogic visual concentration (Trataka). 
+Heart India 2014;2:15-8.
+Source of Support: Nil Conflict of Interest: Nil.
+Announcement
+iPhone App
+A free application to browse and search the journal’s content is now available for iPhone/iPad. The application 
+provides “Table of Contents” of the latest issues, which are stored on the device for future offline browsing. 
+Internet connection is required to access the back issues and search facility. The application is Compatible 
+with iPhone, iPod touch, and iPad and Requires iOS 3.1 or later. The application can be downloaded from http://
+itunes.apple.com/us/app/medknow-journals/id458064375?ls=1&mt=8. For suggestions and comments do 
+write back to us.
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]

subfolder_0/Combination of Ayurveda and Yoga therapy reduces pain intensity and improves quality of life in patients with migraine headache.txt

@@ -0,0 +1,1390 @@
+Accepted Manuscript
+Combination of Ayurveda and Yoga therapy reduces pain intensity and improves
+quality of life in patients with migraine headache
+Vasudha M. Sharma, N.K. Manjunath, H.R. Nagendra, Csaba Ertsey
+PII:
+S1744-3881(18)30100-2
+DOI:
+10.1016/j.ctcp.2018.05.010
+Reference:
+CTCP 876
+To appear in:
+Complementary Therapies in Clinical Practice
+Received Date: 18 February 2018
+Revised Date:
+8 May 2018
+Accepted Date: 25 May 2018
+Please cite this article as: Sharma VM, Manjunath NK, Nagendra HR, Ertsey C, Combination of
+Ayurveda and Yoga therapy reduces pain intensity and improves quality of life in patients with migraine
+headache, Complementary Therapies in Clinical Practice (2018), doi: 10.1016/j.ctcp.2018.05.010.
+This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
+our customers we are providing this early version of the manuscript. The manuscript will undergo
+copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
+note that during the production process errors may be discovered which could affect the content, and all
+legal disclaimers that apply to the journal pertain.
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+Combination of Ayurveda and Yoga therapy reduces pain intensity and 
+improves Quality of life in patients with Migraine Headache 
+ 
+ 
+ 
+Vasudha M. Sharma1*., Manjunath N. K1., Nagendra H.R1., and Ertsey 
+Csaba2 
+ 
+ 
+1. Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) A 
+Deemed to be University, Bengaluru, Karnataka, India  
+2. Department of Neurology, Faculty of Medicine, Semmelweis 
+University Budapest, 1083 Hungary 
+ 
+ 
+ 
+ 
+ 
+ 
+* Address for correspondence: Dr. Vasudha M. Sharma, Division of Yoga 
+and Life Sciences, S-VYASA University, Prashanthi Kutiram, Jigani 
+(Hobli), Anekal (Talluk), Bengaluru – 560106, Karnataka, India. E-mail: 
+[email protected] 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+Objectives: To Understand the efficacy of Ayurveda and Yoga in the management of 
+Migraine Headache. 
+Methods: 30 subjects recruited to Ayurveda and Yoga (AY) group underwent traditional 
+Panchakarma (Bio-purificatory process) using therapeutic Purgation followed by Yoga 
+therapy, while 30 subjects of Control (CT) group continued on symptomatic treatment 
+(NSAID's) for 90 days. Body constitution questionnaire was administered to both groups. 
+The outcome measures included Symptom check list, Comprehensive Headache related 
+Quality of Life Questionnaire and Visual Analogue Scale. 
+Results: Forty-six (76.6%) out of 60 subjects belonging to both groups had Pitta based body 
+constitution. Following 90 days of intervention the AY group showed significant reduction in 
+Migraine symptoms including pain intensity (p<.001) and improvement in Headache related 
+Quality of Life (p<.001). The CT group showed no significant change (p>.05). 
+Conclusion: Traditional Ayurveda along with Yoga therapy reduces symptoms, intensity of 
+pain and improves Quality of life in Migraine patients. 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+1. Introduction  
+Migraine is a primary headache disorder which is vastly prevalent across the world. It contributes 
+extensively to the disease-related burden resulting in lowered Quality of life (1). Migraine is the 
+10th most disabling disorder amongst both genders in the world (2), triggered by psychological and 
+physiological stressors (3). Stress as a risk factor attributes to the problem in 50% of the mi-
+graineurs (4). Studies have shown that the adherence to prophylactic treatment is low and more than 
+50% of migraineurs discontinue such treatment, regardless of the class of medicine taken (5). Medi-
+cation overuse is also an associated issue in Migraine patients owing to use of Non-Steroidal Anti 
+Inflammatory Drugs (NSAIDS) with or without doctor’s prescription (6). 
+ 
+The use of Complementary and Alternative medicine in migraine or in patients with severe head-
+ache is popular as they feel it is congruent to their beliefs in health and lifestyle and has lesser-
+known side effects with less dependency on medication (7). The idea of Integrative medicine is 
+gaining popularity and its use is increasing in the management of chronic conditions (8).  In a study 
+on the prevalence of CAM use in Migraine patients, among several therapies acupuncture, massage 
+and chiropractice were found to be the most commonly used methods. 47.7% participants reported 
+potential improvement in headache (9).  
+ 
+Ayurveda is an ancient Indian system of medicine, which considers health as a state of wellbeing 
+resulting from a synergistic balance in Doshas (Principal systems functions - Vata, Pitta, and 
+Kapha), Agni (Digestive fire), Dhatu (Body tissues) and Mala (Excretory products). It also empha-
+sizes on a blissful state of Atma (spirit), Indriya (sense organs) and Manas (mind) (10). Migraine 
+headache finds its mention as Ardhavabedhaka under the classification of Shiroroga (Diseases re-
+lated to the Head region) in Ayurveda treatises (11). Acharya Sushruta, an ancient Indian Ayurveda 
+Physician opines Ardhavabhedaka to be a Tridoshaja vyadhi (a disease with involvement of Vata 
+Pitta and Kapha) (11) and Acharya Charaka mentions it as a Vata-kaphaja Vyadhi (Disease involv-
+ing Vata and Kapha) (12). There are visible Pitta lakshana’s (signs of Pitta) and involvement of 
+Rakta (blood) in the pathogenesis of Ardhavabhedaka (13). The line of treatment involves admin-
+istration of Samshodhana (Panchakarma-Bio-purificatory techniques) with special mention of Kaya 
+virechana (Therapeutic Purgation) (12), diet and lifestyle regulation. Scientific literature also shows 
+that diet, lifestyle and stress can contribute to increased prevalence of Migraine Headache (14).  
+ 
+A study on five Ayurveda oral medicines administered for 90 days provided a preliminary evidence 
+for the effectiveness of an Ayurveda based treatment protocol in the management of Migraine 
+Headache (15).   
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+ 
+According to Yoga, Migraine is considered as an Adhija Vyadhi (mind-body disorder) where the 
+disturbances in the mind influence the flow of Prana (the vital force/breath) resulting in physical 
+problems and affecting the weakest system in the body (16).  
+ 
+Studies have shown the beneficial effects of Yoga not only in stress and lifestyle-related diseases 
+but also in the management of pain related conditions (17). In two different studies, Yoga therapy 
+for three months and the use of transcendental meditation have demonstrated a significant reduction 
+in frequency and severity of pain in migraine patients (18) (19). Therefore, Yoga therapy compli-
+ments Ayurveda by adding physical activity, breath regulation, relaxation, and meditation.  
+ 
+Identifying the need for generating more scientific evidence for integrative treatment protocols, the 
+present study was designed to evaluate the use of traditional Ayurveda based Virechana (Therapeu-
+tic purgation) followed by Yoga therapy in the management of Migraine in comparison to sympto-
+matic conventional treatment. 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+2. Methods 
+2.1. Setting 
+The study was conducted as a prospective matched controlled trial comparing an Ayurveda-Yoga 
+group (AY) with a Control group (CT) on symptomatic conventional treatment. Participants for 
+both the groups were recruited at a Center for Integrative Medicine in South India. The participants 
+in both groups had consulted a neurologist or a physician. The study protocol was approved by the 
+Institutional Ethics Committee of S-VYASA (a Deemed to be University), Bengaluru, India. The 
+study was conducted between 2015-2017 and registered with the Clinical Trials Registry of India 
+(CTRI/2017/10/010074). 
+ 
+2.2 Participants    
+Eighty-six individuals who were clinically diagnosed with Migraine Headache were screened pro-
+spectively based on inclusion and exclusion criteria and sixty participants were selected for the 
+study. 
+ 
+The recruitment was based on self-selection by the participants to either Ayurveda and Yoga (AY) 
+or Control (CT) group. Participants were explained about the study protocol and an informed con-
+sent was obtained before recruitment. They were also given the choice to withdraw from the study 
+at any stage. 
+ 
+The sample size was calculated using the G Power software with the Mean values and Standard 
+deviations derived from a previous study (18) with an effect size of 1.31, α = 0.05 and power = 
+0.95. The required sample size was 19 participants in each group. Considering the compliance-
+related issues, and to improvise the statistical impact, a sample size of 30 participants in each group 
+was considered in the present study.  
+The diagnostic criteria were based on the International Classification of Headache Disorders (3rd 
+edition) of the International Headache Society, 2013 (20). 
+ 
+2.2.1 Inclusion criteria: The participants included in the study were from both genders, between 
+18-46 years of age with a headache history for more than one year, 5 or more attacks of headache in 
+3 months and willingness to follow the dietary restrictions and complete the headache diary. The 
+Participants in Ayurveda and Yoga group had to be willing to take oral Ayurveda medicine for 75 
+days. 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+2.2.2 Exclusion criteria: The participants with primary Psychiatric disorders (Depression, Anxiety, 
+Psychosis), major medical illness (Renal, Hepatic, Neurological and Cardiac diseases), Pregnancy, 
+pure menstrual migraine, women who have attained Menopause, participants on Ayurveda or Yoga 
+intervention for the past six months and participants on conventional prophylactic treatment were 
+excluded from the study.  
+ 
+2.3 Study Design 
+The present study was a prospective matched controlled trial, with a pre-post design. Participants 
+were recruited as and when they approached the physician who referred them to the investigator.  
+Those willing to undergo Ayurveda and Yoga intervention were allocated to AY group, while the 
+others who chose to continue with symptomatic treatment were recruited to the Control (CT) group. 
+The groups were matched for age and gender. Participants of AY group and CT group were as-
+sessed on Day 1, Day 30 and Day 90.  
+ 
+2.4 Assessment 
+After the participants volunteered for the study, the Sushruta Prakriti Inventory, Comprehensive 
+Headache-related Quality of life Questionnaire (CHQQ) and Visual analogue scale (VAS) were 
+administered to both the groups on day 1 and day 90 of the study. The symptom checklist was ad-
+ministered on day 1, day 30 and day 90, since it was essential to closely monitor the response to 
+therapeutic purgation (Virechana) in the AY group. The assessments were carried out in headache-
+free states.   
+ 
+2.4.1 Prakriti Analysis: The Body constitution (Prakriti) was assessed using Sushruta Prakriti In-
+ventory (SPI) which has two parts i.e., SPI-Q (Questions) with 90 items and SPI-C (Checklist) with 
+60 items. Participants were asked to answer all 90 questions of SPI-Q, while an Ayurveda physician 
+evaluated the SPI-C. The scoring of SPI-Q and SPI-C were added to quantify the Tridosha domi-
+nance of respective participants.  
+Sushrutha Prakriti Inventory (SPI) is a standardized tool for assessing body constitution (Prakriti) 
+and the combination of dosha of an individual. SPI has been assessed for reliability and validity in 
+the Indian population with a test-retest reliability for Vata, Pitta, and Kapha items as 0.994, 0.975 
+and 0.976 respectively based on Pearson Correlation coefficient. The Content and consensual valid-
+ity based on Cronbach’s alpha was between 0.61 and 0.80 respectively (21).  
+As seen in other Ayurveda studies, the individuals were grouped as Vata-Pitta, Pitta-Kapha, and 
+Vata-Kapha based on the total score of the questionnaire (22).  
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+2.4.2 Symptom Checklist: It was used to understand the influence of Ayurveda and Yoga on num-
+ber and severity of symptoms. The symptom checklist had 10 questions based on the number of 
+attacks, duration of attack, intensity of pain, use of analgesics, associated with nausea and or vomit-
+ing. The checklist was completed based on an individual’s experience of the above-mentioned 
+symptoms over the past three months. The intensity of being moderate or severe was assessed based 
+on the pointer which was set between 1-10, where 1-3 was considered as mild, 4-6 was considered 
+as moderate and 7-10 was considered severe. 
+ 
+2.4.3 Comprehensive headache-related quality of life (CHQQ): CHQQ is a 23 item question-
+naire, used to understand the subjective experience of an individual and to note the way in which 
+migraine headache affected their daily life. The questionnaire has been found to be reliable with 
+Cronbach’s alpha being 0.913 for the whole instrument when used in Migraine and Tension-Type 
+Headache patients. The questions have been categorized under physical, mental and social dimen-
+sions with a total score of 0-100 (23). An earlier pilot study in an Indian population has demonstrat-
+ed the possible correlations between Ayurveda based Prakriti (Body Constitution) on Headache 
+related Quality of Life (24).    
+ 
+2.4.4 Visual Analogue Scale (VAS): The scale included a 10 cm long straight line, marked with 
+‘No Pain’ on one side and ‘extreme pain’ on the other side. The VAS was used to assess the head-
+ache intensity on Day 1and Day 90. Participants were asked to mark the pain level on the straight 
+line by drawing a perpendicular line. A measuring scale was used to identify the self-rated pain   
+intensity between 0 and 10 (25). 
+ 
+No Pain 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+    Extreme Pain  
+  
+  0 
+1 
+2 
+3 
+4 
+5 
+6 
+7 
+8 
+9 
+10 
+    
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+3. Intervention 
+Ayurveda treatment of Virechana (Therapeutic Purgation) followed by Yoga therapy was given to 
+the Participants of AY group for 90 days.  
+ 
+3.1 Ayurveda: Following the assessment, on day 1 for Deepana - Pachana (Stomachic and Diges-
+tive) 2.5 grams - 5 grams of Hinguvachadi churna (polyherbal powder) (26) was given twice a day 
+after food in the morning and evening with warm water for first 3 days. From Day 4, Abhyantara 
+Snehapana (Internal Oleation) with Kallyanaka Ghrita (polyherbal preparation made with Clarified 
+butter) (27) was administered on empty stomach between 7 am to 8 am in arohana pramana (in-
+creasing dosage from 30-150 ml) for 3-5 days until Samyak Snighdha Lakshanas (adequacy of in-
+ternal oleation) were seen (28). Following this, Sarvanga Abhyanga (external oil application) with 
+Shuddha Tila taila (Pure Sesame oil) and Swedana (steam bath) was administered for 3 days. The 
+next day (approximately day 9), Virechana (Therapeutic Purgation) was induced by administering 
+Trivrit lehyam (polyherbal paste) (29) based on their Prakriti (body constitution) and Koshta (na-
+ture of the digestive tract). As documented in an earlier study, the process of Virechana was safe 
+and efficacious with no imbalance in serum electrolyte levels (30). Samsarjana krama (dietary reg-
+imen) for 3-5 days (Day 7-9/12) was specified based on the Shuddhi (degrees of cleansing) (31). 
+ 
+Shamana Oushadhi (oral pacificatory medicines) were started between the Days 10-13 based on 
+individual response to purgation. The following medicine was used for oral administration for a 
+span of 75 days: Pathyakshadhatradi Kashaya (polyherbal decoction) (32) – 15 ml, 30 minutes be-
+fore breakfast and dinner with 45 ml of warm water. Kachoradi churna (polyherbal powder) (33) 
+was used for topical application on the forehead, once a day as a paste mixed with milk (at room 
+temperature). There was special mention of Pathya and Apathya (Do’s and Don’ts regarding diet 
+and lifestyle). 
+The composition of each polyherbal formulation is mentioned in Table - 1. 
+ 
+The Participants were allowed to take an oral analgesic (NSAID) only on need, based on the inten-
+sity of pain tolerable to the subject and the same was noted in their diary for medication use. 
+ 
+3.2 Yoga therapy: The specially designed integrated Yoga therapy module for Migraine included 
+loosening exercises, breathing exercises, asana (postures), pranayama (regulated breathing), relaxa-
+tion techniques and Chanting. This was practiced for a duration of 40 minutes daily. Yoga practices 
+were introduced on Day 10/11/12 of the treatment for 7 days as personalized sessions under the 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+guidance and supervision of a trained Yoga therapist. The Participants were asked to practice the 
+same module at home, 5 days in a week till day 90.  
+The female Participants were advised not to practice yoga during the first three days of menstrual 
+cycle. The Yoga therapy module is detailed in Table 2. 
+ 
+3.3 Control Group: The participants who agreed to participate in the trial but preferred to continue 
+on oral Analgesics (Non-Steroidal Anti Inflammatory Drug's) for symptomatic relief as per the pre-
+scription of a general physician or neurologist were included under the control group. They were 
+asked not to practice Yoga or follow Ayurveda during the study period. They were given an option 
+to undergo the same therapy protocol as given for AY group after the study period. 
+ 
+Participants of AY and CT groups were asked to maintain a daily diary to record the regularity of 
+the practice of Yoga or Physical activity respectively along with medication use. They were moni-
+tored once in two weeks over a telephonic call. The Participants were free to withdraw from the 
+study at any stage if they felt that the conditions weren’t conducive.  
+ 
+ 
+4. Data Analysis 
+The data were analyzed using Statistical Package for Social Sciences, SPSS version 23. The nor-
+mality and homogeneity were assessed using Kolmogorov-Smirnov test. Since the data were found 
+to be normally distributed, the CHQQ data and Visual analogue scale data collected on day 1 and 
+on day 90 in both AY and CT groups respectively were analyzed using paired sample t-test, while 
+the between-group comparisons were made using a one-way analysis of variance (ANOVA). The 
+values were considered significant if p<.05. The missing values of participants in AY and CT group 
+were replaced using intention to treat analysis.  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+5. Results 
+The Ayurveda and Yoga (AY) group had 30 participants with 8 male and 22 female participants 
+with an average age of 33.83 + 6.84 years. The CT Group had an equally matched number of Par-
+ticipants (8male and 22 female) with an average age of 31.46 + 7.81years. There was one drop out 
+in AY group on Day 90 and one from the CT group on Day 30 and Day 90.  
+ 
+5.1 Sushruta Prakriti Inventory: The Prakriti analysis showed that there were 15 participants 
+with Vata Pitta Prakriti, 31 with Pitta Kapha Prakriti and 14 with Vata Kapha Prakriti. This indi-
+cated that Pitta dosha was predominantly seen (76.6%) in the Prakriti of 46 participants either as 
+pravara (primary) or madhayama (moderate) dosha. The details of the Prakriti are mentioned in 
+Table - 3. 
+ 
+5.2 Comprehensive headache-related quality of life (CHQQ): The headache-related quality of 
+life included scores from physical, mental, social domains and their total score. The data of Day 1 
+compared to Day 90 in AY group showed significant improvement (p<.001, for all comparisons), 
+while the CT group did not show any change (p>.05). There was a significant difference between 
+the groups (AY and CT) when compared using a one-way ANOVA (p<.001). The group mean and 
+SD of AY and CT group is mentioned in Table - 4.  
+Participants with Pitta Kapha Prakriti had higher CHQQ scores (average score - 84.92) compared 
+to the Vata Pitta and Vata- Kapha Prakriti. 
+ 
+5.3 The Symptom Checklist: The number of attacks and the average maximum duration of an at-
+tack reduced in the AY group compared to the CT group when assessed on Day 30 and Day 90 
+compared to Day 1 of the study. The number of participants with severe headache, nausea and/or 
+vomiting reduced across Day 30 and day 90 in the AY group compared to the CT group. The anal-
+gesic requirement on need basis which was noticed in all 30 participants of the AY group (100%) 
+on Day 1 reduced to 14 participants (46.6%) by Day 30 and was noticed in 6 participants (20%) on 
+Day 90 compared to the CT group. Table 5 represents the changes in symptom checklist. 
+ 
+5.4 Visual Analogue Scale (VAS): The pain intensity as measured by visual analogue scale has 
+shown a significant reduction in AY group (p<.001) in comparison to CT group (p>.05) which 
+showed no change. The between-group comparison also showed a significant difference between 
+AY and CT groups (p<.001). Table 6 represents the changes in VAS. 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+6. Discussion 
+ 
+An Integrated approach of Ayurveda combined with Yoga therapy administered for 90 days in 30 
+patients with Migraine Headache showed a significant reduction in migraine-related symptoms and 
+improvement in the quality of life in comparison to Control group where there was no change. 
+ Migraine is a disabling headache related disorder due to its impact on quality of life, affecting 
+14.7% of the world population (34). Conventional line of treatment has focused on symptomatic 
+pain management and is associated with side effects due to long term use of drugs. Hence, the pre-
+sent study was an attempt to understand the influence of an Ayurveda and Yoga-based intervention 
+in the treatment of Migraine.   
+Studies on Ayurveda provide scientific understanding to the Tridosha (Principal systems functions) 
+theory on which Ayurveda system of Medicine is developed. In a previous report, Prasher et al. 
+introduced Ayurveda based phenotyping with reference to body constitution as a method to under-
+stand the predisposition of individuals to certain diseases (35). This supports the traditional descrip-
+tion that a person is prone to a disease caused by the same dosha as his Prakriti (36). While at-
+tempting to document and correlate body constitution with Migraine related symptoms, the present 
+study showed a clear involvement of Pitta in the body constitution (76.6 %) of individuals making 
+them prone to Migraine headache.  
+ 
+Similar correlations reported earlier, with respect to Rheumatoid Arthritis (37) demonstrated that 
+the concept of Prakriti specific disease susceptibility mentioned in Ayurveda is important in both 
+diagnosis and treatment of diseases.  
+ 
+The association of Pitta with inflammatory processes was speculated (38) and in Pitta individuals, 
+the genes related to Oxidative stress pathway were up-regulated (37). Oxidative stress is considered 
+a key for Migraine trigger (39) and the Phospholipase C in the Cerebrospinal fluid is increased in 
+migraineurs (40). Evidence on Panchakarma (mild virechana and nasya based) have shown a sig-
+nificant reduction in certain plasma metabolites (41) 
+Perhaps, the choice of Virechana (Therapeutic purgation) as part of bio-purificatory treatment given 
+to AY group was customized based on the predominance of Pitta and the positive results observed 
+here are in line with the expected outcomes as mentioned in traditional Ayurveda texts (12).  
+ 
+The changes in symptom scores observed in the present study suggest reduced frequency, lowered 
+intensity, and the improved ability to recover from an attack. The changes observed can be attribut-
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+ed to modifying pain perception both at physical and mental levels as pain is a complex sensory and 
+emotional experience that can vary widely between people and even within an individual. A simple 
+psychological manipulation, such as distraction, can modify perception of pain (42), and a negative 
+emotional state increases pain, whereas a positive state lowers the same (43). The neuroimaging 
+studies in chronic pain suggest that the activity in afferent pain pathways can be altered by the at-
+tentional state, positive and negative emotions, empathy and administration of a placebo (44). It is 
+also understood that psychological factors activate intrinsic modulatory systems in the brain, includ-
+ing those involved in opioid-related pain relief (45). 
+Using real-time Functional MRI (rtfMRI), attempts were made in healthy volunteers to modulate 
+the activation of their own anterior cingulate cortex (ACC) in order to alter their pain experience 
+(46). Several studies on Yoga and Meditation have demonstrated activation of areas which regulate 
+attentional process and emotions in the Brain. The association between increased cortical thickness 
+in pain-related brain regions (including ACC, bilateral parahippocampal gyrus) and lowered pain 
+sensitivity in Zen meditators compared to non-meditators has added the much needed supporting 
+evidence for the underlying mechanisms (47).  
+ 
+John et al, have reported that the practice of Yoga can reduce the levels of stress biomarkers such as 
+serum cortisol and Superoxide dismutase levels (48). Yoga in Migraineurs can bring in autonomic 
+modulation by improving vagal tone and also reduction of drug dosage when used along with con-
+ventional care (49). 
+ 
+While there are few studies on Yoga and Migraine, the studies on Ayurveda are limited to poly-
+herbal combinations (15). In this study, the emphasis was on the classical line of Ayurveda treat-
+ment combined with Yoga for a better clinical outcome (50).  
+ 
+For the process of Virechana (therapeutic purgation) few poly herbal combinations were used in the 
+present study. Kallyanaka ghrita is one of the combinations mentioned in Bower manuscript and 
+traditional Ayurveda texts and its HPTLC has been studied for qualitative analysis (51). 
+ 
+The orally administered decoction (Pathyakshadhatyradi Kashaya) used in this study for 75 days 
+has 7 herbs. The herbs in the combination are Triphala (formula with 3 herbs) which has adap-
+togenic, antimutagenic, chemoprotective, radioprotective effects (52), Neem which has anti-
+inflammatory, apoptotic and antiproliferative properties (53), Turmeric with the active ingredient 
+Curcumin has potential therapeutic roles against many pro-inflammatory diseases such as cancer, 
+arthritis etc (54), Tinospora cordifolia has anti-oxidant, immunomodulatory and anti-inflammatory 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+properties (55) and Andrographis paniculata which is studied for Hepatoprotective activity, Im-
+munostimulant activity, antioxidant activity and anti-inflammatory activity. (56).  
+ 
+While Ayurveda believes that Yoga is a part of Swastha Vritha (Preventive medicine), Yoga thera-
+py has grown as an independent system of complementary medicine. Ayurveda can primarily work 
+at a physical level to bring in balance in Dosha (body constituents) and Agni (digestive fire) while 
+Yoga therapy has contributed extensively to psychological well-being and mental relaxation. 
+Hence, a combination of Ayurveda and Yoga therapy given for 90 days has shown to complement 
+and augment the beneficial effects. This study adds much-needed evidence to demonstrate the 
+promising future of integrative medicine. The process also provides an opportunity to manage the 
+condition in a holistic perspective than a system-oriented, symptom-based approach.  
+ 
+However, a larger sample size and long-term follow up for a minimum period of 1 year is needed.  
+Further studies involving neuroimaging and biochemical measures are warranted for deeper scien-
+tific understanding. 
+ 
+7. Conclusion 
+Ayurveda and Yoga therapy as combined intervention reduces symptoms and improves quality of 
+life in patients with Migraine headache. The inference of this study is therefore, promising to look 
+at synergistic integration of two or more systems of Medicine for better clinical outcome. 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+References 
+1. 
+   Leonardi M, Steiner TJ, Scher AT, Lipton RB. The global burden of migraine: measuring 
+disability in headache disorders with WHO's classification of Functioning, Disability and 
+Health (ICF). J Headache Pain. 2005; 6:429-440 
+2. Stovner LJ, Hagen K, Jensen R et al. The global burden of headache: a documentation of 
+headache prevalence and disability worldwide. Cephalalgia. 2007; 27(3):193-210 
+3. Menken M, Munsat TL, Toole JF. The Global Burden of Disease Study Implications for 
+Neurology. Arch Neurol. 2000; 57(3):418-420 
+4. Sevillano-Garcia MD, Manso-Calderón R, Cacabelos-Pérez P. Comorbidity in the migraine: 
+depression, anxiety, stress and insomnia. Rev Neurol. 2007;45(7):400-405 
+5. 
+  Berger A, Bloudek LM, Varon SF, Oster G. Adherence with migraine prophylaxis in clinical 
+practice. Pain Pract. 2012; 12(7):541–549 
+6. Miller S, Matharu MS. Migraine is underdiagnosed and undertreated. Practitioner. 2014; 
+258(1774):19-24 
+7. Wells RE, Bertisch SM, Buettner C, Phillips RS, McCarthy EP. Complementary and alter-
+native medicine use among adults with migraines/severe headaches. Headache. 2011; 
+51(7):1087-97. 
+8.  Millstone D, Chen CY, Bauer B. Complementary and integrative medicine in the manage-
+ment of headache. BMJ. 2017; 357: j1805  
+9. Rossi P, Di Lorenzo G, Malpezzi MG et al. Prevalence, pattern and predictors of use of 
+complementary and alternative medicine (CAM) in migraine patients attending a headache 
+clinic in Italy. Cephalalgia. 2015; 25(7):493-506 
+10. 
+ Shastry AD, editor. Sushrutha Samhita of Maharshi Sushruta with Hindi commentary, Su-
+trasthana; Doshadhatumalakshayavriddhivigyaniyaadhyayam (Chap 15/48), 9th edn, Chau-
+khambha Sanskrit Samsthan; Varanasi, India; 1995: pp 64 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+11. 
+Shastry AD, editor. Sushrutha Samhita of Maharshi Sushruta with Hindi commentary, Ut-
+tara Tantra; Shirorogavigyaniyaadhyayaya (Chap 25/15), 11th ed, Chaukhambha Sanskrit 
+Samsthan: Varanasi, India;1997: pp128 
+12. 
+Shastry K, Chaturvedi G. editors. Charaka Samhita of Agnivesha with Vidyotini Hindi 
+Commentary, Siddhi Sthana; Trimarmiyasiddhi (Chap 9/75-78), 22nd ed, Chaukhambha 
+Bharati Academy; Varanasi, India; 2001: pp1067   
+13. 
+ Sharma RK, Vaidya BD. Charaka Samhita of Agnivesha with English translation, Su-
+trasthana; Kiyantahashirasiyamadhyayam (Chap 17/11), 4th edn, Chaukhambha Sanskrit Se-
+ries Office; Varanasi, India,1995: pp 312 
+14. 
+Fukui PT, Gonçalves TR, Strabelli CG et al. Trigger factors in migraine patients. Arq Neu-
+ropsiquiatr. 2008; 66(3A):494-499  
+15. 
+ Vaidya PB, Vaidya BS, Vaidya SK. Response to Ayurvedic therapy in the treatment of mi-
+graine without aura. Int J Ayurveda Res. 2010;1(1): 30–36 
+16. 
+S. Venkatesananda. The Concise Yoga Vasistha. (Chap 2) 1st edn, State University of New 
+York, New York, USA, 1985: verses 709–723  
+17. 
+ Kim DH, Moon YS, Kim HS et al. Meditation and yoga reduce emotional stress of chronic 
+pain. Prog Neuropsychopharmacol Biol Psychiatry. 2005;29: 327- 331 
+18. 
+ John PJ, Sharma N, Sharma CM, Kankane A. Effectiveness of yoga therapy in the treat-
+ment of migraine without aura: a randomized controlled trial. Headache. 2007; 47(5):654-
+661 
+19. 
+ Lovell-Smith HD. Transcendental meditation and three cases of migraine. N Z ed J. 
+1985;98(780):443-445 
+20. 
+ International Headache Society. International classification of headache disorders. Cepha-
+lalgia .2013; 33(9) 629–808 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+21. 
+Ramakrishna BR, Kishore KR, Vaidya V, Nagaratna R, Nagendra HR. Standardization of 
+Sushruta Prakriti inventory- SPI an Ayurveda based personality assessment tool with scien-
+tific methods. JAHM. 2014; 2(9):1-8  
+22. 
+Mahalle NP, Kulkarni MV, Pendse NM, Naik SS. Association of constitutional type of 
+Ayurveda with cardiovascular risk factors, inflammatory markers and insulin resistance. J 
+Ayurveda Integr Med. 2012; 3: 150-157 
+23. 
+Manhalter N, Bozsik G, Palasti A, Csepany E, Ertsey C. The validation of a new compre-
+hensive headache-specific quality of life questionnaire. Cephalalgia. 2012; 32(9): 668-682 
+24. 
+Ertsey C, Csepany E, Manjunath NK et al. The comprehensive headache-related quality of 
+life questionnaire: status report. Cephalalgia, 2015; vol. 35:181-182 (Meeting Abstract) 
+25. 
+ Haefeli M, Elfering A. Pain assessment. Eur Spine J. 2006;15(1): S17–S24 
+26. 
+Yadunandan U. editor of Ashtanga Hrudayam of Vagbhata with Vidyotini Hindi commen-
+tary, Chikitsa sthana; Gulma chikitsitam (Chap 14/ 31-33), 12th edn, Chaukhambha Sanskrit 
+Sansthan; Varanasi: 1997; pp380 
+27. 
+Yadunandan U. editor of Ashtanga Hrudayam of Vagbhata with Vidyotini Hindi commen-
+tary, Uttarasthana; Unmada pratishedham (Chap 6/ 26-28), 12th ed, Chaukhambha Sanskrit 
+Sansthan; Varanasi: 1997; pp 474 
+28. 
+Shastry K, Chaturvedi G. editors. Charaka Samhita of Agnivesha with Vidyotini Hindi 
+Commentary, Siddhi Sthana; Kalpana Siddhi adhyaya (Chap 1/6), 22nd ed, Chaukhambha 
+Bharati Academy; Varanasi, India:  2001; pp 960   
+29. 
+Yadunandan U.editor of Ashtanga Hrudayam of Vagbhata with Vidyotini Hindi commen-
+tary, kalpasiddhisthana; Virechanakalpam (Chap 2/9), 12th ed, Chaukhambha Sanskrit 
+Sansthan; Varanasi: 1997; pp 432 
+30. 
+ Rais A and Bhatted S. Clinical study to evaluate the effect of Virechanakarma on serum 
+electrolytes. Ayu. 2013; 34(4): 379–382 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+31. 
+Shastry K, Chaturvedi G. editors. Charaka Samhita of Agnivesha with Vidyotini Hindi 
+Commentary, Siddhi Sthana; Kalpana Siddhi adhyaya (Chap 1/11), 22nd ed, Chaukhambha 
+Bharati Academy; Varanasi, India:  2001; pp 961   
+32. 
+Shastri P, editor. Sharangadhara Samhita, Madhyama Khanda. Chapter 2/145-147, Oriental 
+Publishers & Distributors; Varanasi, India: 1985  
+33. 
+Niteshwar K, Vidayanath R. Sahasra yoga churnaprakarana 62, Chaukhambha Bharati 
+Academy; Varanasi, India: 2007 
+34. 
+Steiner TJ,  Stovner LJ, Birbeck GL. Migraine: The seventh disabler. The Journal of Head-
+ache and Pain. 2013;14(1): 1 
+35. 
+Prasher B, Negi S, Aggarwal S et al. Whole-genome expression and biochemical correlates 
+of extreme constitutional types defined in Ayurveda. J Transl Med. 2008;6:48 
+36. 
+ Acharya Y T. editor. Charaka Samhita of Agnivesha, Sutrasthana; (Chap 7/40), Chau-
+khambha Orientalia Varanasi, India: 2016; pp 52 
+37. 
+Juyal RC, Negi S, Wakhode P, Bhat S, Bhat B, Thelma BK. Potential of Ayurgenomics Ap-
+proach in Complex Trait Research: Leads from a Pilot Study on Rheumatoid Arthritis. 
+PLOS. 2012; 7(9): e45752 
+38. 
+Gokani T. Ayurveda -  the science of healing. Headache. 2014; 54(6):1103-1106 
+39. 
+ Nassini R, Materazzi S, Benemei S, Geppetti P. The TRPA1 channel in inflammatory and 
+neuropathic pain and migraine. Rev Physiol Biochem Pharmacol. 2014; 167:1-43  
+40. 
+ Fonteh AN, Pogoda JM, Chung R, Cowan RP, Harrington MG. Phospholipase C activity 
+increases in cerebrospinal fluid from migraineurs in proportion to the number of comorbid 
+conditions: a case-control study. J Headache Pain. 2013; 14(1): 60 
+41. 
+ Peterson CT, Lucas J, St. John-Williams L et.al. Identification of Altered Metabolomic Pro-
+files Following a Panchakarma-based Ayurvedic Intervention in Healthy Participants: The 
+Self-Directed Biological Transformation Initiative (SBTI). Sci Rep. 2016; 6: 32609 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+42. 
+ Villemure C, Bushnell MC. Cognitive modulation of pain: how do attention and emotion 
+influence pain processing?  Pain. 2002; 95:195-199 
+43. 
+Villemure C, Bushnell MC. Mood influences supraspinal pain processing separately from 
+attention. J Neurosci. 2009; 29: 705-715 
+44. 
+ Schweinhardt P, Bushnell MC. Pain imaging in health and disease - how far have we 
+come? J Clin Invest. 2010;120: 3788-3797 
+45. 
+ Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption 
+in chronic pain. Nat Rev Neurosci. 2013;14(7): 502-511 
+46. 
+deCharms RC, Maeda F, Glover GH et al. Control over brain activation and pain learned by 
+using real-time functional MRI. Proc Natl Acad Sci USA. 2005;102: 18626-18631 
+47. 
+ Grant JA, Courtemanche J, Duerden EG, Duncan GH, Rainville P. Cortical thickness and 
+pain sensitivity in Zen meditators. Emotion. 2010;10: 43-53 
+48. 
+ John PJ, Sharma N, Sharma CM, Kankane A. Effectiveness of yoga therapy in the treat-
+ment of migraine without aura: A randomized controlled trial. Headache. 2007; 47:654-661.  
+49. 
+ Kisan R, Sujan M, Adoor M et al. Effect of Yoga on migraine: A comprehensive study us-
+ing clinical profile and cardiac autonomic functions. Int J Yoga. 2014; 7(2): 126-132 
+50. 
+Wahbeh H, Elsas SM, Oken BS. Mind-body interventions, Applications in neurology. Neu-
+rology. 2008; 70 (24): 2321-2328  
+51. 
+Natsume Y, Neeraj K , Tripathi SM, Nose M, Bhutani KK. Kalyanaka ghrita: an example of 
+intertextuality among the Bower manuscript, Charak Samhita, Susruta Samhita, As-
+tangahrdayam Samhita and Ayurvedic Formulary of India (AFI). Ind J Trad Knowl. 
+2015;14(4): 519-524  
+52. 
+  Peterson CT, Denniston K, Chopra D. Therapeutic Uses of Triphala in Ayurvedic Medi-
+cine. J Altern Complement Med. 2017; 23(8): 607–614  
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+53. 
+Marc S, Claudia C, Simon R, Mario D and Marc D. Anti-inflammatory, pro-apoptotic, and 
+anti-proliferative effects of a methanolic neem (Azadirachta indica) leaf extract are mediated 
+via modulation of the nuclear factor-κB pathway. Genes Nutr. 2011; 6(2): 149-160 
+54. 
+ Gupta SC, Patchva S, and  Aggarwal B. Therapeutic Roles of Curcumin: Lessons Learned 
+from Clinical Trials. AAPS J. 2013; 15(1): 195-218 
+55. 
+ Subramanian M, Chintalwar GJ, Chattopadhyay S. Antioxidant properties of a Tinospora 
+cordifolia polysaccharide against iron-mediated lipid damage and gamma-ray induced pro-
+tein damage. Redox Rep. 2002; 7:137-143 
+56. 
+Chua LS. Review on liver inflammation and anti-inflammatory activity of Androgra-
+phis paniculata for hepatoprotection. Phytother Res. 2014;28(11):1589-1598 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+ 
+Table1: List of polyherbal preparations (with their botanical names) used across Ayurveda 
+treatment period and their prescribed quantity in the formulation.  
+ 
+1a-Hinguvachadi Churna (26) 
+It is prepared with one part of each of the ingredients mentioned below. They are powdered 
+separately and mixed together. 
+Dosage: 2.5grams - 5 grams, 30 minutes before food with warm water.  
+ 
+ 
+Sanskrit name 
+Botanical name 
+Shuddha 
+Hingu 
+(Processed with Ghee) 
+Ferula asafetida 
+Vacha 
+Acorus calamus 
+Vijaya 
+Terminalia chebula 
+Pashugandha 
+Cleome gynandra 
+Dadima 
+Punica granatum 
+Dipyaja(Ajwain) 
+Trachyspermum ammi 
+Dhanya 
+Coriandrum sativum 
+Pata 
+Cyclea peltata 
+Pushkaramoola 
+Inula racemosa 
+Shati 
+Hedychium spicatum 
+Hapusha 
+Sphaeranthus indicus 
+Agni 
+Plumbago zeylanica 
+Yavakshar 
+Alkali preparation made of 
+Hordeum vulgare 
+Svarjika kshara 
+Sarjika kshara 
+Saindava lavana 
+Rock salt 
+Sauvarchala lavana 
+Black salt 
+Vida lavana 
+Type of black salt 
+Shunti 
+Zingiber officinalis 
+Maricha 
+Piper nigrum 
+Pippali 
+Piper longum 
+Ajaji 
+Cuminum cyminum 
+Chavya 
+Piper chaba 
+Tintidika 
+Rhus parviflora 
+Vetasamla(Amlavetasa) Garcinia morella 
+ 
+Manufacturer -Arya Vaidya Pharmacy, GMP certified company  
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+ 
+ 
+Table 1b- Kallyanaka Ghrita (27) 
+12g each of the below mentioned ingredients are used to make a medicated ghee (clarified butter) 
+ 
+Sanskrit name 
+Botanical name 
+Haritaki  
+Terminalia chebula 
+Vibhitaki  
+Terminalia bellirica 
+Amalaki 
+Emblica officinalis 
+Vishala 
+Citrulus cholocynthis 
+Bhadra ela  
+Amomum subulatum 
+Devadaru  
+Cedrus deodara 
+Elavaluka  
+Prunus avium 
+Sariva  
+Hemidesmus indicus 
+Haridra  
+Turmeric 
+Daruharidra  
+Berberis aristata 
+Shalaparni  
+Desmodium gangeticum 
+Prishnaparni  
+Uraria picta 
+Phalini  
+Callicarpa macrophylla 
+Nata  
+Valeriana wallichi 
+Brihati  
+Solanum indicum 
+Kushta 
+Saussurea lappa 
+Manjishta 
+Rubia cordifolia 
+Nagakeshara  
+Mesua ferrea 
+Dadimaphalatwak  
+Punica granatum 
+Vella 
+Embelia ribes 
+Talisapatra  
+Abbies webbiana 
+Ela  
+Elettaria cardamomum 
+Malati 
+Jasminum sambac 
+Utpala  
+Nymphea stellata 
+Danti  
+Baliospermum montanum 
+Padmaka  
+Prunus poddum 
+Hima  
+Sandalwood -Santalum album 
+Sarpi  
+ghee – 768 g 
+ 
+Manufacturer- Arya Vaidya Pharmacy, Coimbatore, India. 
+ 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+Table 1c- Trivrit Lehyam (29) 
+Trivrit – Operculina turpethum  
+Preparation- 25 grams of the powder is added with 400 ml of water, boiled and reduced to 100 ml, 
+filtered. To this Trivrit Kashaya, 25 grams of Trivrit powder is again added, along with 50 grams of 
+sugar and mixed well. 25 ml of honey and 5 grams of each of cinnamon, cardamom and cinnamon 
+leaves fine powder is added to obtain the sweet paste. 
+Sl. No. 
+Ingredients 
+Quantity 
+1 
+Trivrit  Kashaya 
+100 ml 
+2 
+Trivrit Churna 
+25 grams 
+3 
+Sugar 
+50 grams 
+4 
+Honey 
+25 ml 
+5 
+Cinnamon 
+5 grams 
+6 
+Cardamom 
+5 grams 
+7 
+Cinnamon leaves powder 
+5 grams 
+ 
+Manufacturer- Arya Vaidya Pharmacy, Coimbatore, India 
+ 
+ 
+ 
+ 
+Table 1d-Pathyakshadhatradi Kashaya (32)  
+Herbal decoction is prepared from 10 grams each of the following herbs 
+ 
+Sanskrit name 
+Botanical name 
+Pathya   
+Terminalia chebula 
+Aksha  
+Terminalia bellirica 
+Dhatri  (Amla)  
+Emblica officinalis 
+Bhunimba   
+Andrographis paniculata 
+Nisha (Turmeric)   
+Curcuma longa 
+Nimba (Neem)   
+Azadirachta indica 
+Amruta  
+Tinospora cordifolia 
+ 
+Dosage-15 ml twice daily before breakfast and dinner mixed with 45 ml of warm water.  
+Manufacturer- Arya Vaidya Pharmacy 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+Table 1e-Kachoradi churna (33).  
+Equal quantities of herbal powders mentioned below are used to make the powder. 
+ 
+Sanskrit name 
+Botanical name 
+Kachora   
+Curcuma zedoaria 
+Dhatri   
+Emblica officinalis 
+Manjishta   
+Rubia cordifolia 
+Yashti   
+Glycyrrhiza glabra 
+Daru   
+Cedrus deodara 
+Silajitu   
+Asphaltum 
+Vedhi   
+Ferula foetida 
+Rohini   
+Andrographis paniculata 
+Tintrinisira   
+Tamarindus indicus 
+Kumkuma   
+Crocus sativus 
+Indu  
+Camphor 
+Varivaha   
+Cyperus rotundus 
+Rochanam   
+Mallotus phillippenensis 
+Bala   
+Sida cordifolia 
+Laja   
+Oryza sativa 
+Jala  
+Coleus zeylanicus 
+Usira  
+Vetiveria zizanioides 
+Pushkaramoola   
+Innula racemosa 
+ 
+Dosage- ½ tsp to be mixed with milk and applied on the forehead. 
+Manufacturer- Arya Vaidya Pharmacy, Coimbatore, India 
+ 
+ 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+Table 2: Details of Yoga program specially designed for the Migraine patients are listed below. 
+The description includes the category of practices, duration of each practice, number of repetitions, 
+and the sequence of practices.  
+ 
+Sl.No 
+ 
+Practices 
+Number 
+of 
+rounds                       
+Duration 
+1. 
+Loosening practices (Shithilikarana vyayama) 
+5 rounds 
+5 minutes 
+ 
+Neck up and down movement  
+Neck side to side movement 
+Shoulder rotation- Clockwise and Anti clockwise 
+Shoulder cuff rotation -Clockwise and Anti 
+clockwise 
+Head rolling - Clockwise and Anti clockwise, Up 
+and Down movement 
+ 
+ 
+2. 
+Instant Relaxation Technique 
+ 
+1 Round 
+1 minute 
+3. 
+Breathing Practices 
+5 rounds each 
+5 minutes 
+ 
+Ankle stretch breathing 
+Shashankasana breathing 
+Tiger stretch breathing 
+Uttanapadasana breathing- Single leg  
+ 
+ 
+4. 
+Quick Relaxation Technique                                                 
+1 round 
+3 minutes 
+5. 
+Postures (Asanas) 
+1 round each 
+12 minutes 
+5a 
+Standing: 
+Padahasthasana 
+Ardha Chakrasana 
+Ardhakati Chakrasana 
+Trikonasana 
+30 seconds each 
+approximately 
+2.5 minutes 
+ 
+Relaxation in standing posture                        
+30 seconds 
+30 seconds 
+5b 
+Sitting: 
+Janushirasana 
+Vajrasana 
+Ushtrasana 
+Shashankasana 
+Suptavajrasana 
+Vakrasana 
+30 seconds each 
+approximately 
+4 minutes 
+ 
+Relaxation in sitting posture 
+30 seconds 
+30 seconds 
+5c 
+Supine: 
+Viparita karani/ Sarvangasana 
+Matsyasana 
+Pavanamukthasana 
+Naukasana 
+Setubandhasana 
+30 seconds each 
+2.5 minutes 
+ 
+Relaxation in supine position 
+30 seconds 
+30 seconds 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+5d 
+Prone:  
+Bhujangasana 
+Shalabhasana 
+Dhanurasana 
+30 seconds each 
+1.5 minutes 
+6. 
+Deep relaxation technique 
+ 
+7 minutes 
+7. 
+Kriyas                                                                                                                             
+Kapalabhati                                                  
+ 
+1 minute 
+8. 
+Regulated breathing practices (Pranayama) 
+1 minute each 
+3 minutes 
+ 
+Nadishodhana Pranayama 
+Bhramari Pranayama  
+Ujjayi Pranayama 
+1 minute each 
+3 minutes 
+9. 
+Nadanusandhana  ( chanting ) 
+ 
+3 minutes 
+ 
+ 
+ 
+ 
+ 
+Table 3: The combination of the Prakriti seen in all 60 subjects 
+ 
+Prakriti 
+Ayurveda and Yoga group 
+Control group 
+Total 
+Vata- Pitta 
+3 
+5 
+8 
+Pitta- Vata 
+4 
+3 
+7 
+Pitta-Kapha 
+9 
+12 
+21 
+Kapha-Pitta 
+6 
+4 
+10 
+Vata-Kapha 
+4 
+4 
+8 
+Kapha-Vata 
+4 
+2 
+6 
+ 
+Vata-Pitta Prakriti- 15 
+Pitta-Kapha Prakriti- 31 
+Vata –Kapha Prakriti- 14 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+Table 4: Comprehensive headache related quality of life questionnaire measuring quality of life at 
+physical, mental and social domains recorded on Day 1 and Day 90 in Both AY as well as CT 
+Groups. Values are Group mean ± SD.    
+ 
+Sl. No. 
+Domains 
+Ayurveda and Yoga group 
+Control group 
+ 
+ 
+Day 1 
+Day 90 
+Day 1 
+Day 90 
+1 
+Physical 
+50.93 
+86.63*** 
+55.72 
+55.81 
+ 
+ 
+±13.41 
+±10.66 
+± 17.77 
+± 16.75 
+2 
+Mental 
+50.06 
+80.04*** 
+55.91 
+51.98 
+ 
+ 
+±15.18 
+±9.49 
+± 16.88 
+± 13.49 
+3 
+Social 
+55.16 
+85.68*** 
+59.00 
+59.31 
+ 
+ 
+±14.35 
+±10.06 
+±20.14 
+±17.60 
+4 
+Total 
+51.47 
+83.56***$ 
+56.52 
+54.91 
+ 
+ 
+±13.24 
+±9.12 
+±17.05 
+±14.19 
+ 
+*** p <.001, Paired Sample t-test comparing the Mean values of the groups on Day 90 compared to 
+Day 1 values respectively. $ p<.001, Oneway ANOVA comparing the between group differences  
+ 
+ 
+Table 5: Symptom checklist measuring the change in subjective symptoms recorded on Day 1 and 
+Day 90 in Both AY Group as well as Control Group. Values are Number of subjects reporting a 
+particular symptom for items 1,3,4 and 5, while values for item number 2 are group mean in hours.    
+ 
+Sl. 
+No. 
+Symptoms 
+Ayurveda and Yoga group 
+ 
+Control group 
+ 
+ 
+Day 1 
+Day 30 
+Day 90 
+Day 1 
+Day 30 
+Day 90 
+1. 
+Number of subjects 
+with 5 or more 
+migraine attacks in 
+last 3 months 
+30 
+8 
+5 
+30 
+29 
+26 
+(100%) 
+(26.6%) 
+(16.66%) (100%) 
+(96.6%) 
+(86.66%) 
+2. 
+Average score of 
+maximum duration 
+of attack in hours 
+27.8 
+8.86 
+5.62 
+43.6 
+29.8 
+45 
+3. 
+Number of subjects 
+with severe 
+headache 
+21 
+10 
+4 
+18 
+20 
+21 
+(70%) 
+(33.3%) 
+(13.33%) 
+(60%) 
+(66.66%) 
+(70%) 
+4. 
+Number of subjects 
+with nausea and/ or 
+vomiting 
+30 
+17 
+4 
+30 
+27 
+28 
+(100%) 
+(56.6%) 
+(13.33%) (100%) 
+(90%) 
+(93.33%) 
+5. 
+Number of subjects 
+with analgesic 
+requirement on need 
+30 
+14 
+6 
+30 
+27 
+26 
+(100%) 
+(46.66%) 
+(20%) 
+(100%) 
+(90%) 
+(86.66%) 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+Table 6: Visual Analogue Scale (VAS) measuring pain intensity recorded on Day 1 and Day 90 in 
+Both AY Group as well as Control Group. Values are Group mean ± SD.    
+ 
+Sl. No. 
+Ayurveda and Yoga 
+Control 
+ 
+Day 1 
+Day 90 
+Day 1 
+Day 90 
+VAS 
+7.30 
+2.20***$ 
+7.13 
+7.37 
+ 
+± 1.53 
+± 1.24 
+± 1.35 
+± 1.06 
+ 
+ *** p <.001, Paired Sample t-test comparing the Mean values of both groups on Day 90 compared 
+to Day 1 values respectively.  
+$ p <.001, One-way ANOVA comparing the Mean values of both groups on Day 90 compared to 
+Day 1 values respectively.  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+MANUSCRIPT
+ 
+ACCEPTED
+ACCEPTED MANUSCRIPT
+Highlights 
+•   The present study is the first attempt to evaluate the influence of Ayurveda and Yoga 
+on symptoms and quality of life in patients with Migraine Headache as a prospective 
+matched controlled trial. 
+•   The AY group underwent Virechana (Therapeutic Purgation) for the first 15 days 
+followed by Shamanaushadha (pacificatory oral medicines) and Yoga therapy for 75 
+days. The CT group continued on symptomatic treatment using conventional 
+medicine for 90 days.  
+•    Prakriti questionnaire (SPI-Q and SPI-C) was administered to both groups on Day 1 
+to understand their body constitution. The outcome measures included Symptom 
+checklist (recorded on Day 1, Day 30 and Day 90), Comprehensive Headache related 
+Quality of Life Questionnaire (CHQQ) and Visual Analogue Scale (VAS) (both 
+recorded on Day 1 and Day 90).  
+•   Out of the 60 subjects belonging to both groups, 46 (76.6%) had Pitta based Prakriti 
+(either as pravara (primary) or as madhyama (secondary)).  
+•   The AY group showed a significant reduction in the Migraine related symptoms viz., 
+number of attacks, duration of each attack, associated with nausea and vomiting, 
+severity of headache and analgesic requirements. 
+•   There was a significant improvement in the total score of Headache related Quality of 
+Life along with a reduction in pain intensity.  
+•   The CT group showed no significant change. 
+•   An Integrated Ayurveda and Yoga-based intervention reduced symptoms, the intensity 
+of pain and improved Quality of life in Migraine patients.  
+ 
+ 

subfolder_0/Comments to Health realizationInnate health Can a quiet mind and a positive feeling state be accessible over the lifespan wit.txt

@@ -0,0 +1,734 @@
+Health Realization/Innate Health: Can a quiet mind 
+and a positive feeling state be accessible over the 
+lifespan without stress-relief techniques?
+Judith A. Sedgeman
+Department of Community Medicine, West Virginia Initiative for Innate Health, West Virginia University, 
+Morgantown, WV, U.S.A.
+Source of support: Departmental sources
+Summary
+ 
+ 
+Health Realization/Innate Health (HR/IH) questions long-held assumptions about chronic stress, 
+and challenges current defi
+ nitions of both stress and resiliency. HR/IH sets forth principles that 
+explain why the experience of psychological stress is not an effect of causal factors beyond peo-
+ple’s control, but is an artifact of the energetic potential of the mind. HR/IH describes the “cog-
+nitive factor” in stress not as the content of people’s thinking in response to stressors, but rather as 
+a quality of the way people hold and use their thinking, referred to as state of mind.
+ 
+ 
+HR/IH hypothesizes that understanding principles that explain the nature and origin of thinking 
+and experience offers a means to access innate protective processes that are healing and antibi-
+osenescent reliably and consistently, without techniques. HR/IH suggests that the primary effort 
+of mental health care could be to initiate life-long prevention of the state of chronic stress. In ad-
+dition, HR/IH suggests that addressing mental well-being would have a broad impact on the inci-
+dence and course of the many physical illnesses that are known to be stress-related.
+ 
+ 
+The brief therapeutic interactions of HR/IH draw upon people’s innate wisdom and recognition 
+of the healthy perspective available to everyone. Anecdotal results suggest that people who gain 
+insight into the principles that explain the nature of thought and experience and who realize how 
+to re-access a natural, positive state of mind can and do experience sustained day-to-day peace of 
+mind, wisdom and well-being, regardless of circumstances. HR/IH deserves rigorous scientifi
+ c eval-
+uation.
+ 
+key words: 
+resiliency theory • resiliency application • stress • coping • health • innate • 
+Health Realization • Innate Health
+ 
+Full-text PDF: 
+http://www.medscimonit.com/fulltxt.php?IDMAN=8224
+ 
+Word count: 
+3436
+ 
+Tables: 
+—
+ 
+Figures: 
+—
+ 
+References: 
+66
+ Author’s address: 
+Judith A. Sedgeman, Assistant Professor, Department of Community Medicine, West Virginia University Health 
+Sciences Center, P.O. Box 9147, Morgantown, WV 26506, U.S.A., e-mail: [email protected]
+Received: 
+2005.09.28
+Accepted: 2005.11.02
+Published: 2005.12.01
+HY47
+Hypothesis
+WWW.MEDSCIMONIT.COM
+© Med Sci Monit, 2005; 11(12): HY47-52
+PMID: 16319796
+HY
+Current Contents/Clinical Medicine • SCI Expanded • ISI Alerting System • Index Medicus/MEDLINE • EMBASE/Excerpta Medica • Chemical Abstracts • Index Copernicus
+BACKGROUND
+The state of chronic stress underlies many disease states that 
+diminish quality of life and reduce life expectancy [1–5]. 
+And the state of chronic stress is a major contributor to the 
+infl
+ ation of national health care costs [6].
+Evidence has coalesced around the idea that the ultimate 
+answer to stress may not lie in addressing external stressors 
+but in exploring and enhancing internal human capacities. 
+The intent to develop means to comprehend, build and but-
+tress human resiliency is predominant in both behavioral 
+[7–10] and biological [1,11–20] investigations.
+This dual shift towards recognizing the experience of chron-
+ic stress itself as an underlying contributor to many disease 
+states and towards seeing intrinsic human capacity as a heal-
+ing mechanism has led to investigation of the biochemis-
+try of a psychological immune system that addresses chron-
+ic stress systemically.
+Research has established the positive physiological and psy-
+chological effects of resilience, as well as the extensive nega-
+tive physiological and psychological effects of chronic stress 
+[1,8]. The persistent assumption that stress is a consequence 
+of factors outside of the control of the individual, howev-
+er, has kept research attention on the relationship between 
+stressors and the individuals who are subject to them. As a 
+result, studies focus on how best to protect people from 
+stressors or equip them to respond to stressors as success-
+fully as possible. A question for further study is how peo-
+ple access their internal resiliency. What allows some peo-
+ple to draw upon their internal strengths when they most 
+need them, while others are easily overwhelmed? What ex-
+plains the power of the psychological immune system, and 
+why is it not consistently engaged or functioning?
+The mechanisms of acute stress are readily apparent, and 
+have been for a century, since they were fi
+ rst described by 
+Walter Cannon [21]. But the mechanisms of chronic stress 
+are less clear. Hans Selye described the fi
+ nal, chronic stage 
+in his general adaptation response to stress as “exhaustion��� 
+[22]. That remains a potent metaphor, although an inaccu-
+rate scientifi
+ c description, of the effect of the state of stress 
+unrelieved over time, which has been shown to redirect the 
+body’s resources and thus leave the person vulnerable to dis-
+ease [2]. But as Sapolsky points out [3], chronic stress does 
+not actually deplete hormonal resources, but keeps the body 
+in a constant, unrelieved state of hormonal imbalance, which 
+creates a “hormonal milieu” that fosters disease states [5].
+But why are people vulnerable to chronic stress? Why doesn’t 
+the body return to homeostasis after every encounter with 
+“stressors”? Why are some people in good circumstances un-
+able to keep their bearings, while others in the worst of cir-
+cumstances are able to remain stable? What is the common 
+underlying explanation for the varied responses to the same 
+stressors among different individuals? Why does each person 
+respond differently to the same stressors at different times?
+Assumptions of current research
+Current investigations of chronic stress are governed by un-
+challenged assumptions. From the outset, stress has been 
+studied as an inevitable result of pressures beyond the con-
+trol of those experiencing the stress. Cannon and Selye, both 
+using animal studies, established the scientifi
+ c basis for the 
+study of stress. Their work focused on physiologic responses 
+of animals to stressful external pressures, such as heat and 
+cold, prolonged restraint, surgical procedures. Ideas about 
+psychological stress in human beings were extrapolated from 
+the study of physiological stress responses in animals. Then, 
+early studies of human stress by Richard Rahe and others 
+[23–26] established the prevailing view that there are distinct, 
+measurable life stressors that cause stress, and even that those 
+life stressors can be ranked according to their level of infl
+ u-
+ence on the degree of stress people experience. The stres-
+sors were ranked by median responses to various situations. 
+Thus the question was never raised why one person might 
+call “going to the dentist” a 20 on the stress scale, while an-
+other called it an 85. The broad variations in responses to 
+the same stressors have never been addressed.
+Psychologists now refer to “toxic” circumstances, relation-
+ships, emotions and events when describing stress-related syn-
+dromes. Stress-coping presentations address “noxious” events 
+or “insults” to the psyche. Psychiatrists document “allostatic 
+load,” the weight of stressful and negative circumstances in 
+a person’s life history [27]. It is assumed that some degree 
+of stress is inevitable for all people, given the life demands 
+and challenges everyone must face. It is assumed that “re-
+lief” from stress is a desirable, if temporary, departure from 
+that normal expectation. Techniques and methods that pro-
+vide a respite from stress are seen as the appropriate focus 
+of stress remediation. The premise is that people who prac-
+tice such techniques or methods still must cope with a re-
+lentlessly stress-inducing milieu but are better equipped to 
+withstand and recover from stress [28–36].
+THE HEALTH REALIZATION/INNATE HEALTH CONCEPTUAL MODEL
+Since the late 1970’s, a completely different way of under-
+standing and addressing stress has been quietly spreading 
+through the helping professions. Known primarily as Health 
+Realization, or Innate Health, this work emerged from the 
+insights of Sydney Banks, a man who had spent much of his 
+life until the early 1970’s in a state of extreme stress and in-
+security. The insights that set him free to transcend a life-
+time of limitations came out of the blue, unsought, in a pro-
+found experience. When he realized how much these simple, 
+but extraordinary, insights had changed him, he began to 
+share his knowledge with others, offering free public talks. 
+After a few psychologists and psychiatrists were exposed to 
+his insights and began to see and experience life different-
+ly for themselves [37–40], they changed their minds about 
+what is possible in mental health and well-being, and de-
+veloped a new approach to clients. The work ultimately be-
+came a psychoeducational approach that is based on the 
+assumptions that (1) people have an innate wellspring of 
+psychological well-being from which to draw, and (2) any-
+one can realize that and live from a healthy, wise, balanced 
+state of mind, regardless of the “stressors” and external cir-
+cumstances encountered over time [38,40–42].
+Principles underlying HR/IH
+Health Realization/Innate Health (HR/IH) suggests that 
+the prevailing fundamental assumptions about chronic 
+Hypothesis
+Med Sci Monit, 2005; 11(12): HY47-52
+HY48
+stress are inherently fl
+ awed [43–46]. It proposes to replace 
+the theories of how and why stressors induce and sustain 
+stress from the outside-in with principles that explain how 
+and why the experience of stress is created from the inside-
+out, regardless of circumstances. HR/IH describes univer-
+sal principles that explain how people arrive at so many dif-
+ferent ideas about the world and so many strategies about 
+how to cope with it [43–47]. Current therapeutic methods 
+concern themselves with what people think and how peo-
+ple deal with what they think, and what has caused them to 
+think the way they think, all of which exist in the realm of 
+already-created experience. HR/IH addresses the fact that 
+people think, which represents the fundamental source of 
+experience, experience inchoate [38,43,47–49].
+The principles underlying HR/IH are Mind, Thought and 
+Consciousness [43,47]. The principle of Mind describes 
+the formless, infi
+ nite energy of all things. The principle of 
+Thought describes the capacity for the personal mind to 
+use that energy to form an infi
+ nitely variable personal real-
+ity to express unique life. The principle of Consciousness 
+describes the capacity to be aware of the reality being cre-
+ated, i.e. to perceive, recognize and experience ever-chang-
+ing life [43,47]. These three principles combined refer to 
+a universal dynamic of creation that is constant. Each per-
+son’s moment-to-moment thinking is variable, representing 
+the boundless array of potential forms energy can take. The 
+essential meaning of the principles is that thoughts are no 
+different from any other “forms” of life, always in motion, 
+ever-changing through an infi
+ nitude of possibilities, origi-
+nating from the one formless, energetic source.
+HR/IH operates at the emergent impetus for human in-
+quiry and self-expression. There are ideas that point to it in 
+the current literature regarding the mind and the brain, for 
+example the defi
+ nition of the mind proposed by Stefano, 
+Fricchione, Slingsby & Benson [4, p6]: 
+“…in order for cognitive ability to develop and succeed, however, 
+there must fi
+ rst be a unifying consciousness to control or regulate 
+the many individual neural processes that potentially summate a 
+decision-making process. …That is, the brain represents only neu-
+ral tissues organized into various neural patterns that can work 
+together or separately. Without a unifying component being able 
+to cope with a focus, the signifi
+ cance and uniqueness of this cop-
+ing strategy would be lost. … Moreover, a unifi
+ ed entity, a ‘mind’, 
+would only be involved with experience-related phenomena (both 
+exteroceptive and interoceptive) since this is the realm in which cop-
+ing strategies are designed.”
+But HR/IH is a unique perspective because of its neutral 
+and non-specifi
+ c treatment of the creative power of thought 
+as evidence of the universal energy of Mind, rather than as 
+evidence of the strength of discrete external situations with 
+which the personal mind must interact. Most therapeutic 
+work focuses on the specifi
+ c content of people’s thinking as 
+though it were absolute, with no acknowledgement of the 
+subtle variations in thinking that arise from an ever-chang-
+ing state of mind or feeling state. Once the process of think-
+ing is realized, once people understand how their thinking 
+works to create reality and how powerful the transitory and 
+illusory images of thinking appear to be, they are set free 
+from living at the mercy of any thoughts they think. They 
+can see that the experience of stress and distress is actually 
+their own thought-consciousness manifesting negative, wor-
+risome, distressing thoughts in the form of negative, worri-
+some, distressing experience, and that those thoughts have 
+no life beyond the moment they are created and held in 
+their minds. They see the illusory, kaleidoscopic nature of 
+all formed thoughts.
+THE HEALTH REALIZATION/INNATE HEALTH THERAPEUTIC 
+MODEL
+HR/IH assumes that the state of stress is an occasional brief 
+and temporary interruption of life lived naturally in a heal-
+ing, positive, antibiosenescent state. Moments of stress, reg-
+istered as recognizable physical and psychological changes, 
+are regarded as valuable information about the temporari-
+ly deteriorating quality of one’s state of mind (feeling state 
+and quality of thinking), rather than as upsetting informa-
+tion about the negative reality of life circumstances. One 
+might say that the feeling of stress is a measure of the bar-
+ometric pressure of the human mind, not the baromet-
+ric pressure of life. If these assumptions hold under scruti-
+ny, the need to develop and teach stress coping and stress 
+management strategies would be drastically reduced, if not 
+eliminated. People could recognize and access their own 
+natural resiliency to address life situations. By using their 
+feeling state as a guide to the quality of their thinking, with 
+the understanding that all thinking is illusory and fl
+ eeting 
+and will pass, they would naturally default to a quiet mind 
+and a positive feeling state.
+HR/IH is innovative because it demands a departure from 
+prevailing assumptions. But because prevailing assumptions 
+are so strong, HR/IH is often linked with recognized ther-
+apeutic models by people who try to explain it. For exam-
+ple, it is often confused with, but is not related to, many 
+theories that draw on human spirituality and the ability 
+people consistently show to attain positive feeling states 
+and quietude under controlled or induced circumstanc-
+es [9,12,34,50–54]. It is important to note that even spirit-
+ually advanced and profound therapeutic approaches do 
+not depart from the notion that “stressors” are real and in-
+evitable and must be dealt with by marshalling human re-
+sources. Even when psychoneuroimmunology suggests that 
+“innate processes” are at work, it is taken for granted that 
+these arise from “remembered wellness” or primal learned 
+responses to external stressors [4,55]. The word “innate” 
+in that context appears to mean “internal to processes that 
+naturally occur within the body and brain.” But the word 
+“innate” in the context of HR/IH means the common, uni-
+versal, infi
+ nite, intrinsic energy before the formation of the 
+body and the brain.
+Comparison with current therapy models
+Prevailing therapeutic assumptions, even those that are at the 
+leading edge of the discoveries of psychoneuroimmunology, 
+consistently seek to analyze, treat or stave off stressors that 
+are presumed to exist as factors separate from, and threat-
+ening to, the people who must deal with them [1]. HR/IH 
+proposes that “stressors” are the moment-to-moment per-
+ceptions of a mind innocently caught up in negative, up-
+setting thinking without recognition and understanding of 
+the process that is driving the experience. HR/IH does not 
+question the existence of external life circumstances that 
+Med Sci Monit, 2005; 11(12): HY47-52
+Sedgeman JA – Innate health theory
+HY49
+HY
+affect people – physical discomfort or limitations, the up-
+heavals of war and weather, unforeseen tragedies, etc. It 
+explains that there is an internal mediating factor between 
+such external factors and each individual’s experience of 
+them; the factors do not have the power to determine a per-
+son’s reaction to them, the person has the power to deter-
+mine how factors will affect him or her.
+Because the principles of Mind, Consciousness and Thought 
+are linked to the idea of empowerment, they are often at-
+tached by observers to familiar concepts of “reframing think-
+ing” or “assertiveness” or “locus of control”. Yet the empow-
+erment that arises from the principles in action is a much 
+different quality. It is not an experience of effort or willpow-
+er. It is an experience of freedom before the thought of any 
+particular activity or frame of reference.
+The power of the principles in action is seen as the very 
+ability to have and hold such ideas, i.e. the natural, intrin-
+sic capacity of individual minds continually to make things 
+up and see them as real. Willpower, exercising personal 
+control, is thus a byproduct of that power, not an aspect of 
+it. It is a use of the personal mind – just as apathy is a use of 
+the mind, negativity is a use of the mind, positivity is a use 
+of the mind, anger is a use of the mind, good will is a use 
+of the mind, quietude is a use of the mind.
+The principles distinguish Health Realization/Innate Health 
+from theories, such as cognitive-behavioral theory, or rational-
+emotive theory, or behavior modifi
+ cation, or positive psychol-
+ogy – or other conceptual frameworks – as means of “improv-
+ing” thought or experience [38,44]. All theoretical teachings 
+are derived from the power of thought; they are thoughts or 
+thought systems made up by people using their own power 
+to see the world and make sense of what they see.
+Therapeutic impact of HR/IH
+The strength of HR/IH is that it opens hope and possibil-
+ity even to those who have been caught in a certain way of 
+thinking for years because it allows them to pull back the 
+curtain and recognize themselves at the controls before the 
+thoughts they create. HR/IH practitioners do not try to talk 
+clients out of negative thoughts, or ask them to replace them 
+with other, more encouraging, thoughts or teach them how 
+to empty their mind of certain thoughts. HR/IH practition-
+ers explain to clients that fundamental and powerful prin-
+ciples are at work, and that they are experiencing the fact 
+of those principles as surely as a glass of water experiences 
+gravity when it slips out of someone’s hand and drops to the 
+fl
+ oor. As long as they have not yet realized their own ability to 
+create experience via thinking, they’re bound to get caught 
+in little whirlwinds of upsetting experiences. They may fi
+ ght 
+the content of the thoughts that create them and thus keep 
+them spinning in their minds, rather than allowing them to 
+pass as new thoughts come to mind. When they begin to see 
+the nature of thought, they are able to use distress as a warn-
+ing sign to stop ruminating. Then their natural, resilient fl
+ ow 
+of thinking can resume. Upsetting thoughts lose their power; 
+they are no more real, and just as real, as any other thoughts. 
+The person becomes an artist holding the paintbrush, able 
+to create a constantly changing reality, rather than a victim 
+painted into a frightening scenario by thoughts that seem 
+out of his control and seem to be coming from life.
+People realize they can navigate life using their feeling state 
+as a reliable guide to the moment-to-moment quality of their 
+thinking, knowing that the thinking process naturally self-
+corrects. Unattended thoughts pass, the mind clears, con-
+sciousness lifts, and from a quieter mind and positive feeling 
+state, people get increasingly functional ideas. The natural 
+tendency of the human mind at peace is towards wisdom 
+and insight [8,43,46,47], which might be called psycholog-
+ical homeostasis. Chronic stress is not an actual enemy of 
+human well-being with which one must do battle; chron-
+ic stress is an artifact of the human imagination in a nega-
+tive state of mind.
+IMPLICATIONS FOR RESEARCH
+For more than 20 years, psychiatrists, psychologists, coun-
+selors and social workers who have shared the principles 
+underlying Health Realization with clients from all walks 
+of life and across all diagnoses have consistently reported 
+common results [40,45,46]. Clients come to see life from 
+a perspective that allows them to operate from wisdom, 
+peace of mind, insight and strength and to accept negative 
+states of mind as an indicator of the quality of their think-
+ing. Common sense tells them to allow their thinking to 
+pass in such cases until more constructive thinking comes 
+to mind [46,56–59].
+The logic of Health Realization indicates that research now 
+providing increasing evidence that a quiet mind, such as the 
+state of meditation, is a healing state that not only prevents 
+the effects of chronic stress [9,15,32,60–63] but may even re-
+verse them [8,18,19,64,65] should be directed towards the 
+study of the unique and growing population [40,42,45,59] 
+of HR/IH clients. In that population are people who have 
+realized how to live day to day in a serene state of mind 
+regardless of past experiences, external challenges in the 
+present, or uncertainty about the future.
+A study population could readily be identifi
+ ed. Over the 
+years, HR/IH has been a grassroots movement, spread 
+through demand from clients who saw others come to a 
+peace and sense of well-being they did not think possible, 
+and through word of mouth by practitioners and colleagues 
+who found hopefulness in working with clients that had elud-
+ed them previously. There are thousands of practitioners 
+and many thousands of clients across the U.S. and in oth-
+er countries. Many practitioners have gathered an exten-
+sive array of qualitative and anecdotal results that fall out-
+side current parameters for expected outcomes in mental 
+health [40,45,59]. Health Realization is now beginning to 
+be recognized by and incorporated into university programs 
+(e.g., San Jose State in California, UBC in British Columbia, 
+University of Minnesota, Portland State University in Oregon, 
+State University of West Georgia, West Virginia University) 
+and is appearing in curricula and textbooks in counseling, 
+education and prevention [66].
+CONCLUSIONS
+Health Realization/Innate Health represents a paradigm 
+shift in the understanding and study of chronic stress. It ex-
+plains the experience of stress as an inside-out process, orig-
+inating within the mind. It suggests that people can recog-
+nize how to access their own innate health and resiliency 
+Hypothesis
+Med Sci Monit, 2005; 11(12): HY47-52
+HY50
+to live in a quiet mind and a positive feeling state. It sug-
+gests that the experience of stress can be temporary, regard-
+less of circumstances, and should be seen as a warning sig-
+nal to allow the mind to quiet, rather than to focus on the 
+content of the thinking that is creating the negative feel-
+ing state. HR/IH sees the research demonstrating that qui-
+etude fosters psychological and physiological benefi
+ ts that 
+can ameliorate, or even reverse, the effects of chronic stress 
+as evidence for the pressing need to investigate its effects. 
+HR/IH is a new prevention strategy in mental health which 
+may hold promise for a signifi
+ cant reduction in the problem 
+of chronic stress. Evidence to date is anecdotal but compel-
+ling and warrants carefully designed clinical studies.
+Acknowledgements
+William F. Pettit, MD, Medical Director of the West Virginia 
+Initiative for Innate Health, and a long-time practitioner of 
+Innate Health, provided guidance and useful commentary. 
+Sarah S. Quesen, MPH, Statistics Lecturer at West Virginia 
+University, provided editing suggestions regarding organi-
+zation and clarity of material. Robert M. D’Alessandri, MD, 
+Vice President for Health Sciences, West Virginia University, 
+provided input and has consistently provided support and 
+mentorship to the evolution of Innate Health in theory and 
+practice. Sydney Banks, author, philosopher and friend, con-
+tinues to inspire all those who pursue the dream of higher 
+levels of well-being for all people.
+REFERENCES:
+ 1. Stefano GB et al: The Stress Response: Always Good and When 
+It Is Bad. New York: Medical Science International Co., 2005, 152
+ 2. Charney DS: Psychobiological mechanisms of resilience and vul-
+nerability: implications for successful adaptation to extreme stress. Am 
+J Psychiatry, 2004. 161(2): 195–216
+ 3. Sapolsky RM: Why Zebras Don’t Get Ulcers. Henry Holt & Co., 
+LLC, 2004; 539
+ 4. Stefano GB et al: The placebo effect and relaxation response: 
+neural processes and their coupling to constitutive nitric oxide. Brain 
+Res Brain Res Rev, 2001; 35(1): 1–19
+ 5. Vanitallie T: Stress: A Risk Factor for Serious Illness. Metabolism: 
+Clinical and Experimental, 2002; 51(6 Suppl.1): 40–45
+ 6. Goetzel RZ et al: The relationship between modifi
+ able health 
+risks and health care expenditures. An analysis of the multi-employer 
+HERO health risk and cost database. The Health Enhancement Research 
+Organization (HERO) Research Committee. J Occup Environ Med, 
+1998; 40(10): 843–54
+ 7. Csikszentmihalyi M: Flow: The Psychology of Optimal Experience, 
+1990
+ 8. Frederickson BL: The value of positive emotions. American 
+Scientist, 2003; 91: 330–35
+ 9. Frederickson BL: The Role of Positive Emotions in Positive 
+Psychology. American Psychologist, 2001; 56(3): 218–26
+ 10. Seligman ME, Csikszentmihalyi M: Positive psychology. An introduc-
+tion. Am Psychol, 2000; 55(1): 5–14
+ 11. Benson H: The relaxation response: history, physiological basis and 
+clinical usefulness. Acta Med Scand Suppl, 1982; 660: 231–37
+ 12. Benson H, Goodale IL: The relaxation response: your inborn capacity 
+to counteract the harmful effects of stress. J Fla Med Assoc, 1981; 68(4): 
+265–67
+ 13. Benson H, Klemchuk HP, Graham JR: The usefulness of the relaxation 
+response in the therapy of headache. Headache, 1974; 14(1): 49–52
+ 14. Benson H, Kotch JB, Crassweller KD: The relaxation response: a bridge be-
+tween psychiatry and medicine. Med Clin North Am, 1977; 61(4): 929–38
+ 15. Esch T, Fricchione GL, Stefano GB: The therapeutic use of the relax-
+ation response in stress-related diseases. Med Sci Monit, 2003; 9(2): 
+RA23–RA34
+ 16. Esch T et al: Stress-related diseases – a potential role for nitric oxide. 
+Med Sci Monit, 2002; 8(6): RA103–RA118
+ 17. Esch T et al: The role of stress in neurodegenerative diseases and men-
+tal disorders. Neuroendocrinol Lett, 2002; 23(3): 199–208
+ 18. Fricchione GL, Mendoza A, Stefano GB: Morphine and its psychiatric 
+implications. Adv Neuroimmunol, 1994; 4(2): 117–31
+ 19. Fricchione GL, Stefano GB: The stress response and autoimmunoreg-
+ulation. Adv Neuroimmunol, 1994; 4(1): 13–27
+ 20. Stefano GB et al: Nitric oxide inhibits norepinephrine stimulated con-
+traction of human internal thoracic artery and rat aorta. Pharmacol 
+Res, 2001; 43(2): 199–203
+ 21. Cannon W: The Wisdom of the Body. 2nd ed., NY: Norton Pubs, 1939
+ 22. Selye H: Stress and the general adaptation syndrome. Br Med J, 1950; 
+4667: 1383–92
+ 23. Rahe RH, Arthur RJ: Life change and illness studies: past history and 
+future directions. J Human Stress, 1978; 4(1): 3–15
+ 24. Rahe RH et al: Psychosocial predictors of illness behavior and failure 
+in stressful training. J Health Soc Behav, 1972; 13(4): 393–97
+ 25. Rahe RH, Mahan JL Jr, Arthur RJ: Prediction of near-future health 
+change from subjects’ preceding life changes. J Psychosom Res, 1970; 
+14(4): 401–6
+ 26. Rahe RH et al: The stress and coping inventory: an educational and re-
+search instrument. Stress Medicine, 2000; 16: 199–208
+ 27. McEwen BS: Allostasis and allostatic load: implications for neuropsy-
+chopharmacology. Neuropsychopharmacology, 2000; 22(2): 108–24
+ 28. Antoni MH: Stress management effects on psychological, endocrino-
+logical, and immune functioning in men with HIV infection: empiri-
+cal support for a psychoneuroimmunological model. Stress, 2003; 6(3): 
+173–88
+ 29. Ashby FG, Isen AM, Turken AU: A neuropsychological theory of pos-
+itive affect and its infl
+ uence on cognition. Psychol Rev, 1999; 106(3): 
+529–50
+ 30. Benson H, Greenwood MM, Klemchuk H: The relaxation response: psy-
+chophysiologic aspects and clinical applications. Int J Psychiatry Med, 
+1975; 6(1–2): 87–98
+ 31. Greenwood MM, Benson H: The effi
+ cacy of progressive relaxation in sys-
+tematic desensitization and a proposal for an alternative competitive re-
+sponse – the relaxation response. Behav Res Ther, 1977, 15(4): 337–43
+ 32. Lutgendorf SK, Costanzo ES: Psychoneuroimmunology and health psychol-
+ogy: an integrative model. Brain Behav Immun, 2003, 17(4): 225–32
+ 33. Richardson GE, Waite PJ: Mental health promotion through resilience 
+and resiliency education. Int J Emerg Ment Health, 2002; 4(1): 65–75
+ 34. Salovey P, Rothman AJ, Detweiler JB, Steward WT: Emotional States and 
+Physical Health. American Psychologist, 2000; 55(1): 1101–121
+ 35. Sapolsky RM: Organismal stress and telomeric aging: an unexpected 
+connection. Proc Natl Acad Sci USA, 2004; 101(50): 17323–24
+ 36. Taylor SE, Kemeny ME, Reed GM et al: Psychological Resources, Positive 
+Illusions and Health. American Psychologist, 2000, 55(1): 99–109
+ 37. Mills RC: Realizing Mental Health, New York: Sulzburger & Graham 
+Publishing, Ltd., 1995; 207
+ 38. Pransky G, Mills RC, Sedgeman J, Blevens K: An emerging paradigm 
+for brief treatment and prevention. Innovations in Clinical Practice: A 
+Sourcebook, 1995; 15: 401–20
+ 39. Pransky G: Renaissance of Psychology. New York: Sulzburger & Graham, 
+1998; 268
+ 40. Pransky J: Prevention from the Inside Out. Bloomington, IN: 1st Books, 
+2003
+ 41. Howard M, Mansheim K: Myths & Realities: Questions and Answers 
+about Health Realization. Santa Clara County Department of Alcohol 
+and Drug Services, Health Realization Services Division, 2005; 1–17
+ 42. Mills RC: Empowering Communities: Prevention from the Inside Out. 
+in Creating a Dialogue Between Science and Spirituality. Morgantown, 
+WV: West Virginia Initiative for Innate Health, 2005
+ 43. Banks S: The Missing Link. Renton, WA: Lone Pine Publishing, 1998; 
+142
+ 44. Kelley TM: Positive Psychology and Adolescent Mental Health: False 
+Promise or True Breakthrough? Adolescence, 2004; 39(154): 257–77
+ 45. Marshall KM: Resilience Research and Practice, in Educational Resiliency: 
+Student, Teacher and School Perspectives, Waxman HC, Padron Y, Gray 
+JP, editor. Information Age Publishing: Greenwich, CT, 2004; 63–84
+ 46. Mills RC, Spittle E: The Wisdom Within. Renton, WA: Lone Pine 
+Publishing, 2001; 176
+Med Sci Monit, 2005; 11(12): HY47-52
+Sedgeman JA – Innate health theory
+HY51
+HY
+ 47. Banks S: The Enlightened Gardener. Renton, WA: Lone Pine Publishing, 
+2001; 176
+ 48. Banks S: Second Chance. Tampa, FL: Duval-Bibb Publishing Co., 1989; 
+91
+ 49. Banks S: In Quest of the Pearl. Tampa, FL: Duval-Bibb Publishing Co., 
+1989; 113
+ 50. Benson H: The relaxation response: therapeutic effect. Science, 1997; 
+278(5344): 1694–95
+ 51. Kabat-Zinn J: Full Catastrophe Living. New York: Dell Publishing, 
+1990
+ 52. Lazar SW et al: Functional brain mapping of the relaxation response 
+and meditation. Neuroreport, 2000; 11(7): 1581–85
+ 53. Miller WR Thoresen CE: Spirituality, religion, and health. An emerg-
+ing research fi
+ eld. Am Psychol, 2003; 58(1): 24–35
+ 54. Richmond LJ: Religion, spirituality, and health: a topic not so new. Am 
+Psychol, 2004; 59(1): 52
+ 55. Pert CB: The wisdom of the receptors: neuropeptides, the emotions, 
+and bodymind. 1986. Adv Mind Body Med, 2002; 18(1): 30–35
+ 56. Pransky J: Modello: A Story of Hope for the Inner City and Beyond. 
+Cabot VT: NEHRI Publications, 1998; 280
+ 57. Bailey J: The Speed Trap. San Francisco: HarperSanFrancisco, 1999; 
+188
+ 58. Carlson R, Bailey J: Slowing Down to the Speed of Life. San Francisco: 
+HarperSanFrancisco, 1997; 209
+ 59. Borg M: The Impact of Training in the Health Realization/Community 
+Empowerment Model on Affective States of Psychological Distress and 
+Well-Being, in Psychology. California School of Professional Psychology: 
+Los Angeles, CA, 1997
+ 60. Benson H et al: Decreased blood-pressure in pharmacologically treat-
+ed hypertensive patients who regularly elicited the relaxation response. 
+Lancet, 1974; 1(7852): 289–91
+ 61. Benson H, Alexander S, Feldman CL: Decreased premature ventricu-
+lar contractions through use of the relaxation response in patients with 
+stable ischaemic heart-disease. Lancet, 1975; 2(7931): 380–82
+ 62. Ray O: How the Mind Hurts and Heals the Body. American Psychologist, 
+2004; 59(1): 29–40
+ 63. Sapolsky RM, Krey LC, McEwen BS: The neuroendocrinology of stress 
+and aging: the glucocorticoid cascade hypothesis. Endocr Rev, 1986; 
+7(3): 284–301
+ 64. Niess JH et al: Review on the infl
+ uence of stress on immune mediators, 
+neuropeptides and hormones with relevance for infl
+ ammatory bowel 
+disease. Digestion, 2002; 65(3): 131–40
+ 65. Stefano GB et al: Morphine stimulates iNOS expression via a rebound 
+from inhibition in human macrophages: nitric oxide involvement. Int 
+J Immunopathol Pharmacol, 2001; 14(3): 129–38
+ 66. Capuzzi D, Gross DR: Counseling and Psychotherapy: Theories and 
+Interventions. 3rd ed. Upper Saddle River: Merrill Prentice Hall, 2003; 
+500
+Hypothesis
+Med Sci Monit, 2005; 11(12): HY47-52
+HY52
+Index 
+Copernicus 
+integrates
+www.IndexCopernicus.com
+Index Copernicus
+Global Scientific Information Systems  
+for Scientists by Scientists
+Index 
+Copernicus 
+integrates
+IC Virtual Research Groups [VRG]
+Web-based complete research 
+environment which enables researchers 
+to work on one project from distant 
+locations. VRG provides: 
+ 
+customizable and individually  
+self-tailored electronic research 
+protocols and data capture tools, 
+ 
+statistical analysis and report 
+creation tools, 
+ 
+profiled information on literature, 
+publications, grants and patents 
+related to the research project, 
+ 
+administration tools.
+IC Scientists
+Effective search tool for 
+collaborators worldwide. 
+Provides easy global 
+networking for scientists.  
+C.V.'s and dossiers on selected 
+scientists available. Increase 
+your professional visibility.
+IC Patents
+Provides information on patent 
+registration process, patent offices 
+and other legal issues. Provides 
+links to companies that may want 
+to license or purchase a patent.
+IC Lab & Clinical Trial Register
+Provides list of on-going laboratory 
+or clinical trials, including  
+research summaries and calls for  
+co-investigators. 
+IC Grant Awareness
+Need grant assistance?  
+Step-by-step information on 
+how to apply for a grant. Provides 
+a list of grant institutions and 
+their requirements.
+IC Journal Master List
+Scientific literature database, 
+including abstracts, full text, 
+and journal ranking. 
+Instructions for authors 
+available from selected journals. 
+IC Conferences
+Effective search tool for 
+worldwide medical conferences 
+and local meetings.
+Index 
+Copernicus 
+integrates
+EVALUATION & BENCHMARKING
+PROFILED INFORMATION
+NETWORKING & COOPERATION
+VIRTUAL RESEARCH GROUPS
+GRANTS
+PATENTS
+CLINICAL TRIALS
+JOBS
+STRATEGIC & FINANCIAL DECISIONS
+EVALUATION & BENCHMARKING
+PROFILED INFORMATION
+NETWORKING & COOPERATION
+VIRTUAL RESEARCH GROUPS
+GRANTS
+PATENTS
+CLINICAL TRIALS
+JOBS
+STRATEGIC & FINANCIAL DECISIONS

subfolder_0/Comparative study on effect of neutral spinal bath and neutral spinal spray on blood pressure, heart rate and heart rate variability in healthy vol.txt

@@ -0,0 +1,515 @@
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Journal of Complementary and Integrative Medicine. 2018; 20180118
+Arundhati Goley1 / A. Mooventhan2 / NK. Manjunath3
+Comparativestudyon effect of neutral spinal
+bathand neutralspinal spray on blood pressure,
+heart rateand heart rate variability in healthy
+volunteers
+1 Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), A Deemed to be Univer-
+sity, #19, Eknath Bhavan, Gavipuram Circle, Kepegowda Nagar, Bengaluru, Karnataka, India
+2 Division of Yoga and Life Sciences, Department of Research and Development, Swami Vivekananda Yoga Anusandhana Sam-
+sthana (S-VYASA), A Deemed to be University, #19, Eknath Bhavan, Gavipuram Circle, Kepegowda Nagar, Bengaluru, Kar-
+nataka, India, E-mail: [email protected]
+3 Division of Yoga and Life Sciences & Head, Department of Research and Development, Swami Vivekananda Yoga Anusand-
+hana Samsthana (S-VYASA), A Deemed to be University, #19, Eknath Bhavan, Gavipuram Circle, Kepegowda Nagar, Ben-
+galuru, Karnataka, India
+Abstract:
+Background: Hydrotherapeutic applications to the head and spine have shown to improve cardiovascular and
+autonomic functions. There is lack of study reporting the effect of either neutral spinal bath (NSB) or neutral
+spinal spray (NSS). Hence, the present study was conducted to evaluate and compare the effects of both NSB
+and NSS in healthy volunteers.
+Methods: Thirty healthy subjects were recruited and randomized into either neutral spinal bath group (NSBG)
+or neutral spinal spray group (NSSG). A single session of NSB, NSS was given for 15 min to the NSBG and
+NSSG, respectively. Assessments were taken before and after the interventions.
+Results: Results of this study showed a significant reduction in low-frequency (LF) to high-frequency (HF)
+(LF/HF) ratio of heart rate variability (HRV) spectrum in NSBG compared with NSSG (p=0.026). Within-group
+analysis of both NSBG and NSSG showed a significant increase in the mean of the intervals between adjacent
+QRS complexes or the instantaneous heart rate (HR) (RRI) (p=0.002; p=0.009, respectively), along with a signif-
+icant reduction in HR (p=0.002; p=0.004, respectively). But, a significant reduction in systolic blood pressure
+(SBP) (p=0.037) and pulse pressure (PP) (p=0.017) was observed in NSSG, while a significant reduction in dias-
+tolic blood pressure (DBP) (p=0.008), mean arterial blood pressure (MAP) (p=0.008) and LF/HF ratio (p=0.041)
+was observed in NSBG.
+Conclusion: Results of the study suggest that 15 min of both NSB and NSS might be effective in reducing HR
+and improving HRV. However, NSS is particularly effective in reducing SBP and PP, while NSB is particularly
+effective in reducing DBP and MAP along with improving sympathovagal balance in healthy volunteers.
+Keywords: autonomic functions, blood pressure, heart rate, hydrotherapy, naturopathy, spine
+DOI: 10.1515/jcim-2018-0118
+Received: July 31, 2018; Accepted: September 4, 2018
+Introduction
+Hydrotherapy uses water in its various forms (water, ice and steam) at various temperatures for health promo-
+tion and disease prevention and management [1]. Spinal bath is a local, non-pressurized hydratic measure in
+which the pre-spinal and para-spinal area is immersed in water of required temperature for a specific duration
+to get the desired effects [2]. Spinal spray is a local, slightly pressurized hydratic measure in which the spinal
+area is exposed to water of certain temperature for a specific duration to get the desired effects [3]. Cardiovas-
+cular diseases (CVDs) are the main cause of mortality worldwide. CVD is associated with lifestyle, especially
+physical inactivity, the use of tobacco, unhealthy diet habits, and psychosocial stress. The World Health Organi-
+zation has stated that over three-quarters of CVD deaths could be prevented with lifestyle changes. Immersion
+in thermo-neutral water and spa bathing were used to treat cardiovascular risk factors. Evidence suggests that
+A. Mooventhan is the corresponding author.
+© 2018 Walter de Gruyter GmbH, Berlin/Boston.
+1
+Brought to you by | Université de Strasbourg
+Authenticated
+Download Date | 10/20/18 12:18 PM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+Goley et al.
+DE GRUYTER
+the thermo-neutral water has antihypertensive effect, which is essential for the prevention as well as the man-
+agement of lifestyle diseases like CVD [4].
+Heart rate variability (HRV) is one of the most commonly used non-invasive tools that measures cardiac au-
+tonomic nervous system and helps to distinguish sympathetic from the parasympathetic activity [5]. There are
+various studies reporting the effect of either cold water [6, 7] or hot water applications [8–11] on cardiovascu-
+lar variables. But, though neutral water is being widely used in many of the naturopathic hospitals in India for
+general health promotion and treatment of various diseases including CVDs, there is a lack of studies reporting
+its effect on cardiovascular [12] and autonomic functions [13]. Hydrotherapeutic applications to the head and
+spine have shown to improve cardiovascular [14] and autonomic functions [1], However, there is lack of study
+reporting the effect of either neutral spinal bath (NSB) or neutral spinal spray (NSS). Hence, the present study
+was conducted with the objective to evaluate and compare the effects of NSB and NSS on BP, heart rate (HR)
+and HRV in healthy volunteers.
+Materials and methods
+Study design
+This is a parallel-group pilot randomized comparative trial. Recruited subjects were randomly (1:1 ratio) allo-
+cated to either a neutral spinal bath group (NSBG) or a neutral spinal spray group (NSSG). The NSBG subjects
+received one session of NSB, while the NSSG received one session of NSS for the duration of 15 min. Assess-
+ments were taken prior to and after the respective intervention.
+Subjects
+Thirty healthy subjects of both the genders were recruited from a residential university located in South India.
+Both male and female genders aged 18 years and above who are willing to participate in the study were included
+in the study. Subjects with the history of any systemic and/or mental illness, chronic smoking and alcoholism
+and females during menstruations were excluded from the study. The study protocol was approved by the
+institutional ethics committee and informed consents were obtained from all the subjects.
+Interventions
+Neutralspinal bath group
+Spinal bath tubs are made up of fibre material and are water proof and non-allergic. The water level in the tub
+was one and half inches to two inches. The subjects were asked to lie down in a spinal bath tub [filled with water
+(32–33 °C)] with minimum dress for 15 min, with the head on the side that was most slanted, while the buttock
+was at the opposite side end. Upper and lower limbs were kept outside the tub and adjusted in such manner
+that water should immerse the entire length of the spine, from the nape of the neck to the lowest portion of the
+spine [2].
+Neutral spinal spraygroup
+A spinal spray tub consists of a fiber perforated tube at the center of the tub. This tube is connected with a pipe
+to a 0.5 H.P. motor adjusted below the tub which is connected to water supply. The subjects were asked to be
+in minimum dress and made to lie down in supine posture resting the entire back in a spinal spray tub filled
+with water (32–33 °C) in such manner that the pores present in tub were occupied by the subject’s spine and
+keeping the head and limbs outside the tub for the duration of 15 min [3].
+Temperature of the water was measured using hydratic thermometer (water thermometer).
+Assessments
+The primary (BP) and secondary (HR and HRV) outcome measures were taken before and after the intervention
+by one of the authors who was blind to NSBG and NSSG.
+2
+Brought to you by | Université de Strasbourg
+Authenticated
+Download Date | 10/20/18 12:18 PM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Goley et al.
+Blood pressure (BP): Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured before
+and after the intervention using sphygmomanometer.
+HR and HRV: HR and HRV were assessed (5 min at baseline and 5 min after intervention) using a four-
+channel polygraph (Polyrite D, Recorders and Medicare Systems, Chandigarh, India). The Ag/AgCl pre-gelled
+electrodes were placed according to the standard limb lead II configuration to record electrocardiogram. Data
+were acquired at the sampling rate of 1,024 Hz [1].
+Data extraction
+Time domain and frequency domain analysis of baseline and post-intervention HRV data were performed
+using HRV analysis software (Kubios-HRV version 2.0) developed by the Biomedical Signal Analysis Group
+(University of Kuopio, Finland) [15]. The time domain HRV variables such as (1) the mean of the intervals
+between adjacent QRS complexes or the instantaneous HR (RRI), (2) standard deviation of RR intervals (SDNN),
+(3) HR, (4) the square root of the mean of the sum of the squares of differences between adjacent NN intervals
+(RMSSD), (5) the number of interval differences of successive NN intervals greater than 50 ms (NN50) and
+(6) the proportion derived by dividing NN50 by the total number of NN intervals (pNN50) were analysed [1].
+Similarly, the frequency domain of HRV such as low-frequency (LF) band (0.04–0.15 Hz) and high-frequency
+(HF) band (0.15–0.4 Hz) in normalized units and LF/HF ratio were also analysed [16]. Assessments such as
+pulse pressure (PP) and mean arterial pressure (MAP) were derived using the following formulas. PP was
+calculated by using (SBP −DBP) and MAP by using (DBP + ￿PP) [14]
+Sample size
+Thirty healthy subjects of both the genders with the age varying from 18 to 25 years were recruited from a
+residential university located in South India. Sample size was not calculated based on any previous study.
+Randomization
+All the subjects were randomly allocated to either a NSBG or a NSSG using computerized randomization. A
+simple randomization procedure with 1:1 ratio was done for 30 subjects to get a sample size of (n=15) in each
+group. Until interventions were assigned, the random allocation of the intervention was kept in opaque sealed
+envelopes. An author who did not involve in assessments performed the randomization.
+Blinding
+Subjects were not blinded to their intervention. However, the investigator was kept blind to the NSBG and
+NSSG.
+Data analysis
+Data were checked for normality using Kolmogorov–Smirnov test. Statistical analysis of within group was
+performed using Student’s paired samples t-test (data that assumed normal distribution) and Wilcoxon signed
+ranks test (data that did not assume normal distribution) and between group was performed using independent
+samples t-test (data that assumed normal distribution) and Mann–Whitney U test (data that did not assume
+normal distribution) using Statistical Package for the Social Sciences (SPSS) for Windows, Version 16.0. Chicago,
+SPSS Inc. p-value<0.05 was kept as significant.
+Results
+Recruited 30 subjects were randomly allocated to either a NSBG or a NSSG. The details of the demographic
+variables of both NSBG and NSSG are given in Table 1. There were no significant differences in the baseline of
+all the variables between NSBG and NSSG except PP. Results of this study showed a significant reduction in
+3
+Brought to you by | Université de Strasbourg
+Authenticated
+Download Date | 10/20/18 12:18 PM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+Goley et al.
+DE GRUYTER
+LF/HF ratio in NSBG compared with NSSG. Within-group analysis showed a significant increase in RRI and
+insignificant increase in SDNN, RMSSD, NN50, pNN50 and HF spectrum of HRV with a significant reduction
+in HR and insignificant reduction in LF spectrum of HRV both in NSBG and in NSSG. However, a significant
+reduction in SBP and PP was observed in NSSG, while a significant reduction in DBP, MAP and LF/HF ratio
+was observed in NSBG (Table 2).
+Table 1: Demographic variables of the neutral spinal bath and neutral spinal spray groups.
+Variables
+Neutral spinal bath group (n=15)
+Neutral spinal spray group (n=15)
+Age, years
+20.53 ± 1.77
+21.27 ± 2.09
+Gender
+Males (n=4), females (n=11)
+Males (n=6), females (n=9)
+Height, m
+1.60 ± 0.07
+1.632 ± 0.07
+Weight, kg
+52.33 ± 6.42
+54 ± 5.67
+Body mass index, kg/m2
+20.35 ± 1.73
+20.32 ± 2.18
+Table 2: Baseline and post-test assessments of neutral spinal bath group (n=15) and neutral spinal spray group (n=15).
+Variables
+Assessment
+Neutral spinal bath group (n=15) with
+within-group analysis
+Neutral spinal spray
+group (n=15) with within-
+group analysis
+Between-group
+analysis
+t/z
+value
+p-value
+SBP,
+mmHg
+Baseline
+109.87 ± 10.10
+113.73 ± 11.41
+0.983
+0.334!
+Post-test
+108.00 ± 10.14
+108.53 ± 11.70
+0.133
+0.895!
+t=0.969
+p=0.349*
+t=2.312
+p=0.037*
+DBP,
+mmHg
+Baseline
+71.07 ± 9.47
+66.67 ± 11.18
+1.346
+0.178ˆ
+Post-test
+63.60 ± 6.56
+68.80 ± 8.94
+1.817
+0.080!
+z=2.661
+p=0.008
+z=0.911
+p=0.362
+PP,
+mmHg
+Baseline
+38.80 ± 11.00
+47.07 ± 9.88
+2.165
+0.039!
+Post-test
+44.40 ± 10.37
+39.73 ± 12.98
+1.088
+0.286!
+t=1.844
+p=0.087*
+t=2.700
+p=0.017*
+MAP,
+mmHg
+Baseline
+84.00 ± 8.18
+82.36 ± 10.25
+0.486
+0.631!
+Post-test
+78.40 ± 6.25
+82.04 ± 7.84
+1.408
+0.170!
+t=3.076
+p=0.008*
+t=0.139
+p=0.891*
+RRI, ms
+Baseline
+745.40 ± 74.99
+745.47 ± 133.24
+0.002
+0.999!
+Post-test
+789.65 ± 67.63
+791.39 ± 133.79
+0.768
+0.443ˆ
+t=3.889
+p=0.002*
+z=2.613
+p=0.009
+SDNN,
+ms
+Baseline
+53.67 ± 14.41
+52.46 ± 15.92
+0.436
+0.663ˆ
+Post-test
+54.12 ± 12.15
+60.64 ± 21.29
+1.030
+0.312!
+t=−0.159
+p=0.876*
+z=1.108
+p=0.268
+HR,
+beat-
+s/mint
+Baseline
+81.79 ± 8.88
+82.85 ± 11.91
+0.276
+0.784!
+Post-test
+76.90 ± 6.86
+77.89 ± 10.16*
+0.312
+0.757!
+t=3.838
+p=0.002*
+t=3.482
+p=0.004*
+RMSSD,
+ms
+Baseline
+34.92 ± 8.65
+38.17 ± 17.24
+0.652
+0.520!
+Post-test
+42.82 ± 16.15
+47.70 ± 29.24
+0.394
+0.693ˆ
+z=1.534
+p=0.125
+z=1.563
+p=0.118
+NN50,
+count
+Baseline
+60.53 ± 36.33
+55.87 ± 45.87
+0.312
+0.755ˆ
+Post-test
+64.00 ± 32.02
+77.13 ± 59.91
+0.749
+0.460!
+t=0.898
+p=0.384*
+z=1.449
+p=0.147
+pNN50,
+%
+Baseline
+15.57 ± 10.21
+15.49 ± 14.89
+1.038
+0.299ˆ
+Post-test
+16.97 ± 8.63
+21.67 ± 19.18
+0.866
+0.394!
+t=0.145
+p=0.887*
+z=1.761
+p=0.078
+4
+Brought to you by | Université de Strasbourg
+Authenticated
+Download Date | 10/20/18 12:18 PM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Goley et al.
+LF, n.u.
+Baseline
+57.54 ± 14.44
+60.29 ± 16.73
+1.329
+0.184ˆ
+Post-test
+49.99 ± 11.69
+59.91 ± 16.95
+1.867
+0.072!
+t=1.973
+p=0.069*
+z=0.454
+p=0.649
+HF, n.u.
+Baseline
+42.46 ± 14.44
+39.78 ± 16.71
+1.329
+0.184ˆ
+Post-test
+50.04 ± 11.71
+40.09 ± 16.95
+1.871
+0.072!
+t=1.980
+p=0.068*
+z=0.454
+p=0.649
+LF/HF
+ratio
+Baseline
+1.88 ± 2.03
+1.75 ± 1.73
+1.246
+0.213ˆ
+Post-test
+1.18 ± 0.91
+2.05 ± 1.58
+2.220
+0.026ˆ
+z=2.045
+p=0.041
+z=−0.114
+p=0.910
+Note: All values are in mean  ±  standard deviation. Values in bold=p-value <0.05. *=Paired samples t-test; ¶=Wilcoxon signed ranks test;
+!=Independent samples t-test; ˆ=Mann-Whitney U test. SBP, systolic blood pressure; DBP, diastolic blood pressure; PP, pulse pressure;
+MAP, mean arterial pressure; RRI, the intervals between adjacent QRS complexes or the instantaneous heart rate; standard deviation of
+RR intervals (SDNN); HR, heart rate; the square root of the mean of the sum of the squares of differences between adjacent NN intervals
+(RMSSD); NN50=the number of interval differences of successive NN intervals greater than 50 ms; pNN50=proportion derived by
+dividing NN50 by the total number of NN intervals; LF, low frequency; HF, high frequency; n.u.=Normalized units; LF/HF ratio, ratio of
+low frequency to high frequency.
+Discussion
+SBP, DBP, PP and MAP are the commonest and most important indicator of CVD risks [17]. Physical, mental,
+cognitive and emotional activities modulate the HR. A beat-to-beat modulation in HR following physiologi-
+cal variation is called HRV. Evidence suggests that HR and HRV are the most sensitive and easily accessible
+indicators of parasympathetic and sympathetic activity and autonomic regulation [16].
+Results of this study showed a significant reduction in DBP, MAP in NSBG and a significant reduction in
+SBP and PP in NSSG. It suggests that application of 15 min of NSB was effective in reducing DBP and MAP,
+while the application of 15 min of NSS was effective in reducing the SBP and PP in healthy volunteers.
+The hydrostatic pressure created by the head-out water immersion shifts peripheral blood into the thoracic
+vasculature, thereby increasing central blood volume, stroke volume, cardiac output (CO) and central venous
+pressure. This increase in central venous pressure is likely to stimulate arterial pressure and lower cardiopul-
+monary pressure. This process is known to augment parasympathetic activity and inhibit sympathetic activity,
+leading to bradycardia [2]. Thus, in the present study, reduction in the blood pressure (BP) variables might
+possibly attributed primarily to the effects on reduction of HR. Because BP is the outcome of both CO and
+peripheral resistance, wherein CO is the outcome of HR and stroke volume and thus HR forms one of the de-
+terminants of BP; hence the reduction of HR in this study might reduce the BP indices by decreasing CO [14].
+Other possible reason for the reduction of BP might be due to humoral control mechanisms, because in a previ-
+ous study on immersion at 32 °C it has shown to produce a significant reduction in HR, SBP and DBP along with
+a significant reduction in plasma renin activity, plasma cortisol and aldosterone concentrations, and thus the
+physiological changes induced by water immersion were reported to mediate by humoral control mechanisms
+[12]. However, the reduction in DBP and MAP only in NSBG and a reduction in SBP and PP only in NSSG is
+not clear and needs to be explored in future studies.
+The time domain analysis of HRV mainly reflects parasympathetic activity, while the frequency domain
+analysis reflects overall autonomic balance. Results of this study showed a significant reduction in HR and
+a significant increase in RRI along with insignificant increase in all the other time domain variables such as
+SDNN, RMSSD, NN50 and pNN50 both in NSBG and in NSSG compared to its respective baseline. Likewise,
+there was a trend towards reduction (insignificant) in LF spectrum of HRV and increase (insignificant) in HF
+spectrum of HRV both in NSBG and in NSSG. It suggests that 15 min of both NSB and NSS might have ef-
+fect in reducing HR and in improving HRV towards parasympathetic dominance or sympathetic withdrawal.
+Because the time domain measures of the HRV, i. e. mean RRI, HR, RMSSD and NN50, have been recognized
+as stronger predictors of vagal modulation [1]. However, a significant reduction in LF/HF ratio in NSBG in
+within- and between-group analysis, unlike NSSG, revealed the presence of better sympathovagal balance in
+NSBG compared to NSSG. Previous studies on thermo-neutral water immersion [13] and NSS [3] also reported
+the enhanced parasympathetic activity [3, 13], which is supporting the results of the present study.
+Strength of the study: To the best of our knowledge, this is the first ever study evaluating the effect of NSB
+and comparing the effect of NSB with NSS on HRV and BP in healthy subjects. None of the subjects reported
+any adverse effect during intervention.
+Limitations of the study: 1) Study was conducted in the healthy subjects that limit the scope of this study in
+pathological conditions, 2) Small sample size and sample size calculation was not performed using any previ-
+ous/pilot study, 3) Lack of control group to differentiate the effect of NSB and NSS from a simple supine lying,
+5
+Brought to you by | Université de Strasbourg
+Authenticated
+Download Date | 10/20/18 12:18 PM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+Goley et al.
+DE GRUYTER
+and 4) Long-term effect of NSB and NSS on HRV and BP was not assessed. Hence, further studies with a control
+group are required in a large sample size for a better understanding of its precise cardiovascular effects.
+Conclusions
+Results of the study suggest that 15 min of both NSB and NSS might be effective in reducing HR and in improv-
+ing HRV. However, NSS is particularly effective in reducing SBP and PP while NSB is particularly effective in
+reducing DBP and MAP along with improving sympathovagal balance in healthy volunteers.
+Author contributions: All the authors have accepted responsibility for the entire content of this submitted
+manuscript and approved submission.
+Research funding: None declared.
+Employment or leadership: None declared.
+Honorarium: None declared.
+Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis
+and interpretation of data; in the writing of the report or in the decision to submit the report for publication.
+References
+[1] Mooventhan A, Nivethitha L. Effects of ice massage of the head and spine on heart rate variability in healthy volunteers. J Integr Med.
+2016;14:306–10.
+[2] Shetty GB, Shetty P
+, Shetty B. Immediate effect of cold spinal bath on autonomic and respiratory variables in hypertensives. World J
+Pharm Med Res. 2016;2:236–40.
+[3] Avanthika G, Sujatha KJ, Shetty P
+. Immediate effect of cold and neutral spinal spray on autonomic functions in healthy volunteers – A
+comparative study. IOSR J Dental Med Sci. 2017;16:18–24.
+[4] Naumann J, Sadaghiani C, Bureau N, Schmidt S, Huber R. Outcomes from a three-arm randomized controlled trial of frequent immersion
+in thermoneutral water on cardiovascular risk factors. BMC Complem Altern Med. 2016;16:250.
+[5] Muralikrishnan K, Balakrishnan B, Balasubramanian K, Visnegarawla F. Measurement of the effect of Isha Yoga on cardiac autonomic
+nervous system using short-term heart rate variability. J Ayurveda Integr Med. 2012;3:91–6.
+[6] Roberts LA, Muthalib M, Stanley J, Lichtwark G, Nosaka K, Coombes JS, et al. Effects of cold water immersion and active recovery on
+hemodynamics and recovery of muscle strength following resistance exercise. Am J Physiol Regul Integr Comp Physiol. 2015;309:R389–
+98.
+[7] Radtke T, Poerschke D, Wilhelm M, Trachsel LD, Tschanz H, Matter F, et al. Acute effects of Finnish sauna and cold-water immersion on
+haemodynamic variables and autonomic nervous system activity in patients with heart failure. Eur J Prev Cardiol. 2016;23:593–601.
+[8] Thomas KN, Van Rij AM, Lucas SJ, Gray AR, Cotter JD. Substantive hemodynamic and thermal strain upon completing lower-limb hot-
+water immersion; comparisons with treadmill running. Temp (Austin). 2016;3:286–97.
+[9] Thomas KN, Van Rij AM, Lucas SJ, Cotter JD. Lower-limb hot-water immersion acutely induces beneficial hemodynamic and cardiovascu-
+lar responses in peripheral arterial disease and healthy, elderly controls. Am J Physiol Regul Integr Comp Physiol. 2017;312:R281–91.
+[10] Brunt VE, Howard MJ, Francisco MA, Ely BR, Minson CT. Passive heat therapy improves endothelial function, arterial stiffness and blood
+pressure in sedentary humans. J Physiol. 2016;594:5329–42.
+[11] Findikoglu G, Cetin EN, Sarsan A, Senol H, Yildirim C, Ardic F. Arterial and intraocular pressure changes after a single-session hot-water
+immersion. Undersea Hyperb Med. 2015;42:65–73.
+[12] Srámek P
+, Simecková M, Janský L, Savlíková J, Vybíral S. Human physiological responses to immersion into water of different tempera-
+tures. Eur J Appl Physiol. 2000;81:436–42.
+[13] Florian JP
+, Simmons EE, Chon KH, Faes L, Shykoff BE. Cardiovascular and autonomic responses to physiological stressors before and after
+six hours of water immersion. J Appl Physiol (1985). 2013;115:1275–89.
+[14] Mooventhan A. Immediate effect of ice bag application to head and spine on cardiovascular changes in healthy volunteers. Int J Health
+Allied Sci. 2016;5:53–6.
+[15] Tarvainen MP
+, Niskanen JP
+, Lipponen JA, Ranta-Aho PO, Karjalainen PA. Kubios HRV-heart rate variability analysis software. Comput
+Methods Prog Biomed. 2014;113:210–20.
+[16] Tyagi A, Cohen M. Yoga and heart rate variability: A comprehensive review of the literature. Int J Yoga. 2016;9:97–113.
+[17] Nivethitha L, Mooventhan A, Manjunath NK. A pilot study on evaluating cardiovascular functions during the practice of Bahir Kumbhaka
+(external breath retention). Adv Integr Med. 2017;4:7–9.
+6
+Brought to you by | Université de Strasbourg
+Authenticated
+Download Date | 10/20/18 12:18 PM

subfolder_0/Coping Strategy, Life Style and Health Status During Phase 3 of Indian National Lockdown for COVID-19 Pandemic—A Pan-India Survey.txt

@@ -0,0 +1,2005 @@
+ORIGINAL RESEARCH
+published: 18 May 2022
+doi: 10.3389/fpubh.2022.814328
+Frontiers in Public Health | www.frontiersin.org
+1
+May 2022 | Volume 10 | Article 814328
+Edited by:
+Larry K. Olsen,
+Logan University, United States
+Reviewed by:
+Parmeshwar Satpathy,
+Indian Institute of Technology
+Kharagpur, India
+Mujeeb Zafar Banday,
+Government Medical College
+(GMC), India
+*Correspondence:
+Raghuram Nagarathna
+[email protected];
+[email protected]
+Akshay Anand
+[email protected]
+Specialty section:
+This article was submitted to
+Public Health Education and
+Promotion,
+a section of the journal
+Frontiers in Public Health
+Received: 13 November 2021
+Accepted: 06 April 2022
+Published: 18 May 2022
+Citation:
+Nagarathna R, Sharma MNK,
+Ilavarasu J, Kulkarni R, Anand A,
+Majumdar V, Singh A, Ram J, Rain M
+and Nagendra HR (2022) Coping
+Strategy, Life Style and Health Status
+During Phase 3 of Indian National
+Lockdown for COVID-19
+Pandemic—A Pan-India Survey.
+Front. Public Health 10:814328.
+doi: 10.3389/fpubh.2022.814328
+Coping Strategy, Life Style and
+Health Status During Phase 3 of
+Indian National Lockdown for
+COVID-19 Pandemic—A Pan-India
+Survey
+Raghuram Nagarathna 1*, Manjunath N. K. Sharma 1, Judu Ilavarasu 1, Ravi Kulkarni 1,
+Akshay Anand 2,3,4*, Vijaya Majumdar 1, Amit Singh 1, Jagat Ram 5, Manjari Rain 2 and
+Hongasandra R. Nagendra 1
+1 Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India, 2 Neuroscience Research Lab, Department of
+Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India, 3 CCYRN – Collaborative Centre for
+Mind Body Intervention Through Yoga, Post Graduate Institute of Medical Education and Research, Chandigarh, India,
+4 Centre of Phenomenology and Cognitive Sciences, Panjab University, Chandigarh, India, 5 Department of Ophthalmology,
+Postgraduate Institute of Medical Education and Research, Chandigarh, India
+The implementation of timely COVID-19 pan-India lockdown posed challenges to the
+lifestyle. We looked at the impact of lifestyle on health status during the lockdown in
+India. A self-rated scale, COVID Health Assessment Scale (CHAS) was circulated to
+evaluate the physical health or endurance, mental health i.e. anxiety and stress, and
+coping ability of the individuals under lockdown. This is a pan-India cross-sectional
+survey study. CHAS was designed by 11 experts in 3 Delphi rounds (CVR = 0.85)
+and was circulated through various social media platforms, from 9th May to 31st May
+2020, across India by snowball circulation method. CHAS forms of 23,760 respondents
+were downloaded from the Google forms. Logistic regression using R software was
+used to compare vulnerable (>60 years and with chronic diseases) with non-vulnerable
+groups. There were 23,317 viable respondents. Majority of respondents included males
+(58·8%). Graduates/Postgraduates (72·5%), employed (33·0%), businessmen (6·0%),
+and professionals (9·7%). The vulnerable group had significantly (OR 1.31, p < 0.001)
+higher representation of overweight individuals as compared to non-vulnerable group.
+Regular use of tobacco (OR 1.62, p = 0.006) and other addictive substances (OR
+1.80, p = 0.039) showed increased vulnerability. Respondents who consume junk food
+(OR 2.19, p < 0.001) and frequently snack (OR 1.16, p < 0.001) were more likely to
+be vulnerable. Respondents involved in fitness training (OR 0.57, p < 0.001) or did
+physical works other than exercise, yoga, walk or household activity (OR 0.88, p =
+0.004) before lockdown were less likely to be vulnerable. Majority had a very good
+lifestyle, 94.4% never smoked or used tobacco, 92.1% were non-alcoholic, 97.5% never
+used addictive substances, 84.7% had good eating habits, 75.4% were vegetarians,
+Nagarathna et al.
+Lifestyle During Lockdown in India
+82.8% had “good” sleep, 71.7% did physical activities. Only 24.7% reported “poor”
+coping ability. Depression with somewhat low feeling were more likely to be vulnerable
+(OR 1.26, p < 0.001). A healthy lifestyle that includes healthy eating, proper sleep,
+physical activeness and non-addictive habits supports better coping ability with lesser
+psychological distress among Indian population during lockdown.
+Keywords: COVID-19, public health, stress, coping strategy, lockdown
+INTRODUCTION
+The past two decades have witnessed three highly pathogenic,
+novel zoonotic CoVs, first SARS-CoV-1 was recognized in 2002,
+followed by MERS-CoV in 2012 and now as a more virulent
+strain, the SARS-CoV-2 causing COVID-19 (1). Based on the
+estimated report of the instantaneous reproduction number
+(Rt) on the severity in China, several countries implemented
+social distancing, hygiene etiquettes, contact tracing, wearing face
+masks, temperature checks, and avoided premature relaxation of
+the lockdown (2). The largest timely lockdown was enforced in
+India after its first case on 30th Jan 2020 (3).
+The
+present
+COVID-19
+pandemic
+affected
+global
+mental
+health,
+as
+evidenced
+initially
+by
+panic-buying,
+worldwide.
+Following
+any
+natural
+disaster,
+survivors
+are
+prone to develop post-traumatic stress disorder (PTSD).
+For instance, survivors of the August 2008 floods in India
+(Bihar) had shown higher scores for PTSD (4). Similarly,
+studies in China showed high level of depression with low
+health-related
+quality
+of
+life
+(HRQoL)
+and
+high
+scores
+on PTSD symptoms with no significant changes during
+COVID-19 (5, 6).
+The first large-scale community-based cohort study on
+387,109 adults in UK concluded that an unhealthy lifestyle
+(smoking, physical inactivity, obesity, and excessive alcohol
+intake) is a risk factor for hospital admission for COVID-
+19 (7). A study on Italian children observed increased screen
+time and sleep time, increased consumption of potato chips,
+red meat, and sugary drink and decrease in time spent in
+sports activities, which may have lasting impact on adiposity
+(8). The incidence, progression and death rate during this
+pandemic in India seems to be much lesser than other
+countries [COVID-19 Worldwide Dashboard | WHO Live
+World Statistics]. The reasons being India’s relatively younger
+population, early biggest national lockdown (9), and a unique
+mutation in the spike surface glycoprotein [A930V (24351C
+> T)] in the Indian SARS-CoV-2 (10). A recent survey in
+Indian cohort showed that the level of psychological distress
+was lesser than the Chinese population on IES-R (11). There
+are unpublished observations that the traditional life style of
+the Indian families may also be a contributory factor. As
+there were no nationwide studies looking at the impact of
+life style on vulnerability during first wave and lockdown, we
+executed this pan-India on-line survey. The objective of the study
+was to investigate physical and mental health, lifestyle and to
+examine activities adapted by people to cope with COVID-19
+and lockdown.
+MATERIALS AND METHODS
+CHAS Survey and Study Subjects
+This was a nationwide survey on general Indian population
+during the 3rd phase of lockdown for COVID-19 pandemic that
+had respondents from all States/Union Territories except Ladakh
+and Lakshadweep. COVID Health Assessment Scale (CHAS),
+prepared in 10 languages by a committee of 11 experts through
+3 Delphi rounds [Content Valid Ratio (CVR) was 0.85], had
+questions related to life style behavior (exercise, diet, additive
+substances, and sleep), physical health (BMI, chronic diseases,
+and endurance), mental health (fear, anxiety, depression, stress),
+and coping ability [refer to CHAS questionnaire from reference
+(12)]. Endurance under physical health signifies durability or
+ability to perform physical work for longer duration of time
+without feeling breathlessness. Further, coping ability is defined
+as conscious and unconscious efforts and strategies acquired
+by respondents such as reading, cooking and others to reduce
+emotional impact of challenging situation created by pandemic
+and lockdown.
+Phone calls and special requests were sent to different
+sections of the society (∼200 universities, corporate companies,
+healthcare institutions, government organizations, wellness
+centers, and their networks) to acquire data by snowball method.
+Participants filled the online forms, if they were willing to answer
+the subjected questions. Hence, there were no exclusion and
+inclusion criteria for participants.
+The responses were collected from May 9, 2020 to May 31,
+2020. Responses from non-Indians and aged <18 years were not
+considered for analysis. After quality control, the participants
+were divided into vulnerable and non-vulnerable groups based
+on presence of co-morbidities and age >60 years. Respondents
+were considered vulnerable when their age was above 60 years
+and/or they have any chronic disease as these two conditions
+increases the risk of getting infected with COVID-19 and risk of
+severe outcome. For zone wise analyses, the 34 states/UTs were
+divided into 3 zones based on the number of positive cases in
+the state as on 31st May 2020 (source: Ministry of health and
+Family Welfare, Government of India). The groups were red
+zone (>10,000 cases including Maharashtra, Tamil Nadu, Delhi,
+Gujarat), orange zone (5,000 to 10,000 cases including Rajasthan,
+Madhya Pradesh, Uttar Pradesh), and green zone (<5,000 cases
+including remaining states and UTs).
+Statistical Analysis
+The CHAS data received from the Google drive in ten
+languages were combined into one dataset. R Statistical software,
+Frontiers in Public Health | www.frontiersin.org
+2
+May 2022 | Volume 10 | Article 814328
+Nagarathna et al.
+Lifestyle During Lockdown in India
+version 4.0.0, was used for data cleaning, extraction, and
+analyses. Incomplete and unreliable responses were excluded.
+Logistic regression was used to compare respondents under two
+categories viz. vulnerable and non-vulnerable. Arsenal package
+was used to test significance on cross tabulations on categorical
+variables. Reference for Odd’s ratio (OR) calculation was set to
+sequential contrast for all ordinal variables and first row and first
+column for nominal variables.
+RESULTS
+Of the 23,760 respondents, participants from other countries
+(n = 401) and marked as other genders (n = 42) were excluded.
+Data was analyzed for 23,317 respondents. Logistic regression
+to compare 4,416 vulnerable participants with 18,901 non-
+vulnerable participants showed that graduates (OR 0.77, p <
+0.001) were less likely to and postgraduates (OR 1.11, p =
+0.027) were more likely to be associated with vulnerability
+than non-graduates (Table 1). Students were less likely to be
+associated with vulnerability than agriculturists (OR 0.26, p <
+0.001). Businessmen (OR 1.87, p < 0.001), homemakers (OR
+2.91, p < 0.001), professionals (OR 1.72, p < 0.001) and those
+in other occupations (OR 1.40, p = 0.005) were more likely
+to be vulnerable as compared to agriculturists (Table 1). Of
+note, only 3.2% were agriculturists and 48.7% were actively
+working professionals (6.0% business, 9.7% professionals, 33.0%
+employees) among the total respondents.
+During the lockdown, those who were not working were more
+vulnerable than who worked from home (OR 1.22, p < 0.001).
+Those who had stayed away from home (OR 0.41, p < 0.001)
+or with friends (OR 0.62, p = 0.017) or colleagues (OR 0.41, p
+< 0.001) were less likely to be in the vulnerable group as they
+were younger and did not have illnesses. Individuals experiencing
+symptoms like cough (OR 2.08, p < 0.001), breathing difficulty
+(OR 7.52, p < 0.001) and others (OR 1.74, p < 0.001), except
+fever, were more likely to be vulnerable (Table 1).
+Life Style
+Table 2 summarizes the life style variables. Good eating habits
+was reported by 84.7% and strict vegetarian diet was reported
+by 75.4% of the total respondents. Vulnerable group had better
+eating habit (0.89, p = 0.032) and more strict vegetarians (OR
+0.49, p < 0.001). However, consumption of junk food (OR 2.19,
+p < 0.001) and frequent snacking (OR 1.16, p < 0.001) was
+positively associated with vulnerability.
+Substance users were minimal in this cohort as majority said
+they “never” used tobacco (94.4%), or alcohol (92.1%) or other
+substances (97.5%) before lockdown; only 1.1% “agreed” they
+had increased the use of alcohol and tobacco during lockdown.
+Regular consumers of tobacco (OR 1.62, p = 0.006) and other
+substance users (very few in this cohort; OR 1.80, p = 0.039) were
+more likely to be vulnerable.
+Looking at the quality of sleep, 82.8% and 79.1% said
+they had “good” sleep quality before and during lockdown,
+respectively in total respondents. Those who had average
+sleep before (OR 1.31, p < 0.001) or during (OR 1.22, p
+< 0.001) lockdown were more likely to be vulnerable than
+those who had good sleep. Individuals having bad sleep quality
+had increased from 2.4% to 4.2% during lockdown among
+total respondents.
+Logistic regression further showed that those who went for
+fitness training (OR 0.57, p < 0.001) or did works other than
+exercise, yoga, walk or household activity (OR 0.88, p = 0.004)
+before lockdown were less likely to be vulnerable. Walking before
+lockdown did not reduce the risk of vulnerability (OR 1.28, p <
+0.001). Individual practicing fitness training during the lockdown
+were less likely to be vulnerable (OR 0.56, p < 0.001). Very
+few individuals never did any physical activity during lockdown.
+Those who were involved in physical activity for <30 min (OR
+0.79, p = 0.004) or for 30 to 60 min (OR 1.15, p = 0.004)
+were more in non-vulnerable group. Individuals involved in
+physical activity for more than an hour were more in vulnerable
+group (OR 1.12, p = 0.004). It is to be noted that 54.0% did
+yoga during lockdown while 46.6% were already practicing yoga
+(before lockdown).
+Physical Health
+Majority had “good/average” endurance as marked on a 3 point
+scale (good, average, and bad). Respondents with average (OR
+1.72, p < 0.001) and bad (OR 1.55, p = 0.014) endurance were
+more likely to be vulnerable than respondents who had good
+endurance. BMI was high in vulnerable group at 25·49 ± 4·34
+kg/m2 than non-vulnerable at 24·05 ± 4·31 kg/m2 group (p <
+0.001). The BMI between 23 and 24.9 kg/m2 (OR 1.63, p < 0.001)
+and above 25 kg/m2 (OR 1.31, p < 0·001) were more likely to be
+vulnerable (Table 3).
+Mental Health
+Majority did not feel depressed (low feeling) in vulnerable
+group. Those with depression with somewhat low feeling were
+more likely to be vulnerable (OR 1.26, p < 0.001) (Table 3).
+Anxiety about implication of COVID-19 on life did not associate
+with increased vulnerability. Interestingly, who were “somewhat
+anxious” were less likely to be vulnerable (OR 0.83, p < 0.001)
+(Table 3).
+We enquired on five aspects of fear. Fear of getting infected
+with COVID-19 and associated physical suffering was associated
+with vulnerability (OR 1.29, p < 0.001). Concerns about financial
+implications (OR 0.74, p < 0.001) and fear of infecting near and
+dear ones (OR 0.76, p < 0.001 for somewhat; OR 0.79, p = 0.001
+for very much) were not associated with vulnerability (Table 3).
+About 21% of the respondents were not sure about stress and
+insecurity, which did not associated with vulnerability (OR 0.84, p
+< 0.001). Those who agreed that they were stressed and insecure
+were less likely to be in vulnerable category (OR 0.83, p = 0.007).
+Coping
+Coping ability was good in 75.3% and poor in 24.7% of the
+total respondents but was non-significant between vulnerable
+and non-vulnerable respondents.
+Those who did not spend time reading (OR 1.27, p < 0.001) or
+cooking activity (OR 1.28, p < 0.001) or spend time on exercise
+(OR 1.25, p < 0.001), or did not do Yogasana (OR 1.18, p < 0.001)
+were more likely to be vulnerable (Table 3). The respondents who
+spend less time on internet were more likely to be vulnerable (OR
+1.50, p < 0.001).
+Frontiers in Public Health | www.frontiersin.org
+3
+May 2022 | Volume 10 | Article 814328
+Nagarathna et al.
+Lifestyle During Lockdown in India
+TABLE 1 | Comparison of demographic details of vulnerable with non-vulnerable groups.
+Variables
+Variable
+Non-
+vulnerable
+(n = 18,901)
+Vulnerable
+(n = 4,416)
+Total
+(n = 23,317)
+Odd’s
+Ratio
+CI: 2.5%
+CI:
+97.5%
+p-Value
+Gender
+Female
+7,727 (40.9%)
+1,883 (42.6%)
+9,610 (41.2%)
+Ref
+Male
+11,174
+(59.1%)
+2,533 (57.4%)
+13,707
+(58.8%)
+1.10
+1.00
+1.21
+0.052
+States zones*
+Red
+6,925 (36.7%)
+1,731 (39.2%)
+8,656 (37.2%)
+Ref
+Orange
+4,215 (22.3%)
+825 (18.7%)
+5,040 (21.6%)
+0.99
+0.89
+1.10
+0.839
+Green
+7,737 (41.0%)
+1,857 (42.1%)
+9,594 (41.2%)
+1.02
+0.93
+1.13
+0.663
+Occupation
+Agriculture
+647 (3·4%)
+101 (2·3%)
+748 (3.2%)
+Ref
+Business
+1.070 (5.7%)
+321 (7·3%)
+1,391 (6.0%)
+1.87
+1.47
+2.41
+<0.001
+Employed
+6,648 (35.2%)
+1,036 (23.5%)
+7,684 (33.0%)
+1.18
+0.95
+1.48
+0.152
+Homemaker
+1,916 (10.1%)
+891 (20.2%)
+2,807 (12.0%)
+2.91
+2.29
+3.73
+<0.001
+Student
+4,377 (23.2%)
+188 (4.3%)
+4,565 (19.6%)
+0.26
+0.20
+0.34
+<0.001
+Professional
+1,831 (9·7%)
+436 (9·9%)
+2,267 (9·7%)
+1.72
+1.36
+2.20
+<0.001
+Other
+2,142 (11.3%)
+449 (10.2%)
+2,591 (11.1%)
+1.40
+1.11
+1.79
+0.005
+Education
+Less than
+Graduation
+5,127 (27.1%)
+1,296 (29.3%)
+6,423 (27.5%)
+Ref
+Graduate
+7,569 (40.0%)
+1,640 (37.1%)
+9,209 (39.5%)
+0.77
+0.70
+0.84
+<0.001
+Post-
+graduate
+6,205 (32.8%)
+1,480 (33.5%)
+7,685 (33.0%)
+1.11
+1.01
+1.21
+0.027
+During lockdown staying
+with
+Family
+15.781
+(83.5%)
+3,942 (89.3%)
+19,723
+(84.6%)
+Ref
+Friends
+278 (1.5%)
+32 (0.7%)
+310 (1.3%)
+0.62
+0.41
+0.90
+0.017
+Colleagues
+903 (4.8%)
+79 (1.8%)
+982 (4.2%)
+0.41
+0.31
+0.52
+<0.001
+Alone
+1,064 (5.6%)
+254 (5.8%)
+1,318 (5.7%)
+1.01
+0.86
+1.18
+0.947
+Away from
+home
+875 (4.6%)
+109 (2.5%)
+984 (4.2%)
+0.41
+0.52
+0.81
+<0.001
+During lockdown are
+you
+Working
+from home
+7,474 (39.5%)
+1,479 (33.5%)
+8,953 (38.4%)
+Ref
+Working
+from office
+4,185 (22.1%)
+604 (13.7%)
+4,789 (20.5%)
+0.79
+0.70
+0.88
+<0.001
+Not
+working
+7,242 (38.3%)
+2,333 (52.8%)
+9,575 (41.1%)
+1.22
+1.12
+1.33
+<0.001
+Are you experiencing
+any of the following?
+No
+symptoms
+16,866
+(89.2%)
+3,791 (85.8%)
+20,657
+(88.6%)
+Ref
+Cough
+202 (1.1%)
+66 (1.5%)
+268 (1.1%)
+2.08
+1.52
+2.81
+<0.001
+Fever
+27 (0.1%)
+5 (0.1%)
+32 (0.1%)
+1.24
+0.41
+3.06
+0.674
+Breathing
+Difficulty
+23 (0.1%)
+24 (0.5%)
+47 (0.2%)
+7.52
+3.95
+14.37
+<0.001
+Other
+1.783 (9.4%)
+530 (12.0%)
+2.313 (9.9%)
+1.74
+1.55
+1.95
+<0.001
+Have you undertaken
+International travel since
+January 2020?
+Yes
+372 (2·0%)
+110 (2·5%)
+482 (2·1%)
+Ref
+No
+18,529
+(98.0%)
+4,306 (97.5%)
+22,835
+(97.9%)
+1.01
+0.79
+1.30
+0.969
+*States in red zone (>10,000 positive cases in the state)—Maharashtra, Tamil Nadu, Delhi, Gujarat; orange zone (5,000 to 10,000 cases)—Rajasthan, Madhya Pradesh, Uttar Pradesh;
+and green zone (<5,000 cases)—All other states and Union Territories. Odds ratio was calculated using sequential contrasts for ordinal variables and odds ratio calculated with first row
+and first column as reference for nominal variables. Ref indicates reference group.
+DISCUSSION
+This first largest pan-India online survey, during the third
+phase of nation-wide Indian lockdown, looked at the life style,
+physical health, mental health and the coping abilities using
+logistic regression.
+There is a well-established association between old age and
+co-morbidities such as hypertension (30%), diabetes (19%), and
+coronary heart disease (8%) with risk of COVID-19 infection
+(13–15). UK risk factor estimates had shown a dose-dependent
+increase in risk of COVID-19 with 4-fold higher risk in
+individuals with most adverse life style (51% of severely infected
+Frontiers in Public Health | www.frontiersin.org
+4
+May 2022 | Volume 10 | Article 814328
+Nagarathna et al.
+Lifestyle During Lockdown in India
+TABLE 2 | Lifestyle in vulnerable and non-vulnerable groups.
+Domain
+Variable
+Non-
+vulnerable
+(n = 18,901)
+Vulnerable
+(n = 4,416)
+Total
+Odd’s
+Ratio**
+CI: 2.5%
+CI:
+97.5%
+p-value
+Addictions
+Tobacco
+Never
+17,807
+(94.2%)
+4,198 (95.1%)
+22,005
+(94.4%)
+Ref
+Occasionally
+837 (4.4%)
+146 (3.3%)
+983 (4.2%)
+1.09
+0.89
+1.33
+0·381
+Regularly
+257 (1.4%)
+72 (1.6%)
+329 (1·4%)
+1·62
+1·14
+2·28
+0·006
+Alcohol
+Never
+17,299
+(91.5%)
+4,165 (94.3%)
+21,464
+(92.1%)
+Ref
+Occasionally
+1,509 (8.0%)
+233 (5.3%)
+1,742 (7.5%)
+1.00
+0.84
+1.17
+0·959
+Regularly
+93 (0.5%)
+18 (0.4%)
+111 (0.5%)
+0.77
+0.40
+1.43
+0·431
+Substance use
+Never
+18,407
+(97.4%)
+4,332 (98.1%)
+22,739
+(97.5%)
+Ref
+Occasionally
+378 (2.0%)
+55 (1.2%)
+433 (1.9%)
+0.77
+0.57
+1.02
+0·081
+Regularly
+116 (0.6%)
+29 (0.7%)
+145 (0.6%)
+1.80
+1.02
+3.12
+0·039
+Increased substance
+abuse during lockdown
+Yes
+221 (1.2%)
+34 (0.8%)
+255 (1.1%)
+Ref
+No
+5,273 (27.9%)
+990 (22.4%)
+6,263 (26.9%)
+1.10
+0.76
+1.65
+0·618
+Not
+Applicable
+13,407
+(70.9%)
+3,392 (76.8%)
+16,799
+(72.0%)
+1.21
+0.83
+1.80
+0·34
+Diet
+Eat discipline before
+Yes
+15,852
+(83.9%)
+3,898 (88.3%)
+19,750
+(84.7%)
+Ref
+No
+3,049 (16.1%)
+518 (11·7%)
+3,567 (15.3%)
+0·89
+0·80
+0·99
+0·032
+Strict vegetarian/vegan
+Yes
+13,732
+(72.7%)
+3842 (87.0%)
+17574
+(75.4%)
+Ref
+No
+5,169 (27.3%)
+574 (13.0%)
+5,743 (24.6%)
+0.49
+0.44
+0.54
+<0·001
+I like eating junk food
+Yes
+4,684 (24·8%)
+454 (10.3%)
+5,138 (22.0%)
+Ref
+No
+14,217
+(75.2%)
+3,962 (89.7%)
+18,179
+(78.0%)
+2.19
+1.96
+2.45
+<0·001
+I tend to frequently
+snack
+Yes
+7,273 (38.5%)
+1,279 (29.0%)
+8,552 (36.7%)
+Ref
+No
+11,628
+(61.5%)
+3,137 (71.0%)
+14,765
+(63.3%)
+1.16
+107
+1.25
+<0·001
+Sleep
+Quality of sleep before
+lockdown
+Good
+15,707
+(83.1%)
+3,599 (81.5%)
+19,306
+(82.8%)
+Ref
+Ok
+2,724 (14.4%)
+731 (16.6%)
+3,455 (14.8%)
+1.31
+1.17
+1.47
+<0·001
+Bad
+470 (2.5%)
+86 (1.9%)
+556 (2.4%)
+0.82
+0.63
+1.07
+0·157
+Quality of sleep during
+lockdown
+Good
+14,964
+(79.2%)
+3,472 (78.6%)
+18,436
+(79.1%)
+Ref
+Ok
+3,093 (16.4%)
+799 (18.1%)
+3892 (16.7%)
+1.22
+1.09
+1.37
+<0·001
+Bad
+844 (4.5%)
+145 (3.3%)
+989 (4.2%)
+0.96
+0.77
+1.18
+0·685
+Activity
+Physical activity before
+lock-down
+Did yoga
+8,493 (44.9%)
+2,377 (53.8%)
+10,870
+(46.6%)
+Ref
+Went
+fitness
+1,271 (6.7%)
+107 (2.4%)
+1,378 (5.9%)
+0.57
+0.45
+0.71
+<0·001
+Went
+walking
+3,546 (18.8%)
+925 (20.9%)
+4,471 (19.2%)
+1.28
+1.13
+1.43
+<0·001
+Did
+household
+2,071 (11.0%)
+417 (9.4%)
+2,488 (10.7%)
+0.88
+0.75
+1.03
+0·102
+Other
+3,520 (18.6%)
+590 (13.4%)
+4,110 (17.6%)
+0.81
+0.71
+0.93
+0·004
+Physical activity during
+lock-down
+Yoga
+9,864 (52.2%)
+2,721 (61.6%)
+12,585
+(54.0%)
+Ref
+Fitness
+893 (4.7%)
+74 (1.7%)
+967 (4.1%)
+0.56
+0.43
+0.73
+<0·001
+(Continued)
+Frontiers in Public Health | www.frontiersin.org
+5
+May 2022 | Volume 10 | Article 814328
+Nagarathna et al.
+Lifestyle During Lockdown in India
+TABLE 2 | Continued
+Domain
+Variable
+Non-
+vulnerable
+(n = 18,901)
+Vulnerable
+(n = 4,416)
+Total
+Odd’s
+Ratio**
+CI: 2.5%
+CI:
+97.5%
+p-value
+Walking
+2,377 (12.6%)
+534 (12.1%)
+2,911 (12.5%)
+0.96
+0.84
+1.10
+0·591
+Household
+work
+3,070 (16.2%)
+622 (14.1%)
+3,692 (15.8%)
+0.94
+0.82
+1.07
+0·36
+Other
+2,697 (14.3%)
+465 (10.5%)
+3,162 (13.6%)
+0.93
+0.80
+1.08
+0·326
+Duration of the Activity
+During Lock-Down
+Never
+1,239 (6.6%)
+256 (5.8%)
+1,495 (6.4%)
+Ref
+< 30 min
+4,783 (25.3%)
+890 (20.2%)
+5,673 (24.3%)
+0.79
+0.68
+0.93
+0·004
+30
+min−1 h
+7,381 (39.1%)
+1,703 (38.6%)
+9,084 (39.0%)
+1.15
+1.05
+1.26
+0·004**
+> 1 h
+5,498 (29.1%)
+1,567 (35.5%)
+7,065 (30.3%)
+1.12
+1.04
+1.22
+0·004**
+Odds ratio was calculated using sequential contrasts for ordinal variables and odds ratio was calculated with first row and first column as reference for nominal variables. Ref indicates
+reference group.
+cases) compared to those with optimal lifestyle (7). Although our
+survey did not target COVID-19 positive cases, we looked at the
+potential associations between life style correlates of respondents,
+vulnerable to COVID-19 infection, with the non-vulnerable.
+We observed similar gender distribution among vulnerable
+and non-vulnerable. However, it is reported that males are more
+vulnerable (13). Graduates/post graduates and those who had
+employment or business were more likely to be vulnerable than
+unemployed persons or agriculturists, who are physically active,
+similar to observations in China (16). This observation indicates
+that individuals having stressful job in urban regions make
+them vulnerable. It is important to state here that individuals
+residing in urban regions are at risk of getting infected, where
+day to day physical contact with each other is high, such as at
+offices, institutes, colleges, airport, markets, due to fast-pace life
+style. Good lifestyle before lockdown seems to have contributed
+to adopting healthy activities (reading, writing, cooking, yoga,
+exercise, and household) with good psychological coping ability
+during lockdown. Higher education and good life style seen
+in this cohort may not reflect the lifestyle or the behavioral
+characteristics of the general Indian population. The limitation
+being that response to a call on social media may reflect the
+social responsibility of those with good life style by responding
+voluntarily to this unstructured survey.
+Eating Habits
+A healthy diet, rich in fruits and vegetables and low in sugar
+and calorie-dense processed foods, is essential to health, which
+was observed in majority of our respondents with majority
+being strict vegetarians. Diet rich in saturated fat, refined
+carbohydrates, and sugars with low levels of fiber that promotes
+obesity and type-2 diabetes poses increased risk for severe
+COVID-19 pathology and mortality by inhibiting adaptive
+immune system (17).
+Sleep
+In a study, during the present pandemic, the prevalence of
+clinical insomnia in France was 19%, close to prevalence reported
+in China (20·1%) and Italy (19·8%) but lower than in Greece
+(37·6%) (18–21). We observed much lower prevalence with only
+2·4% and 4·2% respondents reporting “bad” insomnia before and
+during lockdown. This appears to be because of the milder form
+of the disease in India and good family support.
+Addictions
+Studies have observed that past or current smokers (18%)
+with COVID-19 had double the risk of progression to severe
+disease compared with never-smokers (9%) (22, 23). A small
+percentage (1.1%) who agreed that they had increased the
+consumption of addictive substances during lockdown did show
+increased vulnerability.
+Physical Health
+Further, obesity is known to be an important contributor for
+many non-communicable diseases and also for respiratory and
+other infections (17). Pietrobelli et al. reported that children
+during social isolation in Italy gained weight which may have
+long term implications (8). We observed that the vulnerable
+group had higher representation of overweight individuals
+as compared to non-vulnerable group. Higher BMI denotes
+disturbed metabolism and an overall inflammatory state that
+could further increase the likelihood of COVID-19 infection in
+the vulnerable individuals (24).
+Physical activity maintaining regular exercise with good
+physical endurance counteracts the negative effects of the
+pandemic stress on immune competency (25). In the present
+study, 71.7% did physical activities and those who did not do
+exercises and reported poor physical endurance were more likely
+to be vulnerable. Yoga, practiced by 54.0% of our respondents
+during lockdown, is an unexpected observation of this study
+(Table 2). Duggal et al. observed that exercise augments
+host immune defenses by catecholamine-mediated preferential
+mobilization of lymphocytes primed to recognize and kill virus-
+infected cells (26). Exercise also enhances proliferation of virus-
+specific memory T-cells and promotes their mobilization to
+the site.
+Frontiers in Public Health | www.frontiersin.org
+6
+May 2022 | Volume 10 | Article 814328
+Nagarathna et al.
+Lifestyle During Lockdown in India
+TABLE 3 | Comparison of health and coping between vulnerable and non-vulnerable groups.
+Domain /Variable
+Non-
+vulnerable
+(n = 18,901)
+Vulnerable
+(n = 4,416)
+Total N (%)
+OR
+CI: 2.5%
+CI:
+97.5%
+p-value
+Physical health
+How do you rate your physical
+strength and endurance?
+Good
+16,973
+(89.8%)
+3,662 (82.9%)
+20,635
+(88.5%)
+Ref
+Average
+1,824 (9.7%)
+693 (15.7%)
+2,517 (10.8%)
+1.72
+1.55
+1.89
+<0.001
+Bad
+104 (0.6%)
+61 (1.4%)
+165 (0.7%)
+1.55
+1.09
+2.18
+0.014
+BMI
+(N) mean
+± SD
+(17,666)
+24.05 ± 4.31
+(4,139)
+25.49 ± 4.34
+< 0.001
+<23
+7,489 (42.4%)
+1,140 (27.5%)
+8,629 (39.6%)
+Ref
+23–24·9
+3,703 (21.0%)
+903 (21.8%)
+4,606 (21.1%)
+1.63
+1.48
+1.79
+<0.001
+>25
+6,474 (36.6%)
+2,096 (50.6%)
+8,570 (39.3%)
+1.31
+1.20
+1.43
+<0.001
+Mental health
+Depression: Do you feel you are
+low in energy and downhearted
+during this lock-down period?
+Not at all
+15,653
+(82.8%)
+3,735 (84.6%)
+19,388
+(83.1%)
+Ref
+Somewhat
+3,000 (15.9%)
+629 (14.2%)
+3,629 (15.6%)
+1.26
+1.13
+1.40
+<0.001
+Very much
+248 (1.3%)
+52 (1.2%)
+300 (1·3%)
+1.06
+0.77
+1.45
+0.718
+Anxiety: How anxious are you
+about the implications of
+COVID-19 in your life?
+Not at all
+10,399
+(55.0%)
+2,856 (64.7%)
+13,255
+(56.8%)
+ref
+Some what
+6,495 (34.4%)
+1,256 (28.4%)
+7,751 (33.2%)
+0.83
+0.76
+0.91
+<0.001
+Very much
+2,007 (10.6%)
+304 (6·9%)
+2,311 (9.9%)
+0.89
+0.77
+1.03
+0.113
+Fear: How much do the following issues worry you during this lock-down period?
+Fear of getting infected and the
+associated physical suffering
+Not at all
+11,726
+(62.0%)
+2,982 (67.5%)
+14,708
+(63.1%)
+Ref
+Somewhat
+5,818 (30.8%)
+1,239 (28.1%)
+7,057 (30.3%)
+1.29
+1.17
+1.42
+<0.001
+Very much
+1,357 (7.2%)
+195 (4.4%)
+1,552 (6.7%)
+0.97
+0.80
+1.17
+0.741
+Fear of death
+Not at all
+15,303
+(81.0%)
+3,802 (86.1%)
+19,105
+(81.9%)
+Ref
+Somewhat
+2,825 (14.9%)
+505 (11.4%)
+3,330 (14.3%)
+1.02
+0.91
+1.15
+0.743
+Very much
+773 (4.1%)
+109 (2.5%)
+882 (3.8%)
+1.01
+0.79
+1.28
+0.925
+Fear of a possible financial burden
+Not at all
+10,359
+(54.8%)
+2,939 (66.6%)
+13,298
+(57.0%)
+Ref
+Somewhat
+6,299 (33.3%)
+1,130 (25.6%)
+7,429 (31.9%)
+0.74
+0.67
+0.80
+<0.001
+Very much
+2,243 (11.9%)
+347 (7.9%)
+2,590 (11.1%)
+1.01
+0.87
+1.16
+0.94
+Fear of unknown related to
+COVID 19
+Not at all
+11,566
+(61.2%)
+3,110 (70.4%)
+14,676
+(62.9%)
+Ref
+Somewhat
+5,625 (29.8%)
+1,078 (24.4%)
+6,703 (28.7%)
+0.96
+0.87
+1.06
+0.456
+Very much
+1,710 (9.0%)
+228 (5.2%)
+1,938 (8.3%)
+0.90
+0.75
+1.07
+0.231
+Fear of spreading infection to near
+and dear ones
+Not at all
+9,564 (50.6%)
+2744 (62.1%)
+12,308
+(52.8%)
+Ref
+Somewhat
+6,353 (33.6%)
+1260 (28.5%)
+7,613 (32.6%)
+0.76
+0.70
+0.83
+<0.001
+Very much
+2,984 (15.8%)
+412 (9.3%)
+3,396 (14.6%)
+0.79
+0.69
+0.91
+0.001
+Stress: Do you always feel
+insecure; stressed and have
+mood swings
+disagree
+12,470
+(66.0%)
+3,251 (73·6%)
+15,721
+(67.4%)
+Ref
+Maybe
+4,117 (21.8%)
+790 (17.9%)
+4,907 (21.0%)
+0.84
+0.77
+0.92
+<0.001
+Agree
+2,314 (12.2%)
+375 (8.5%)
+2,689 (11.5%)
+0.83
+0.72
+0.95
+0.007
+Coping ability
+Poor
+4,727 (25.0%)
+1,036 (23.5%)
+5,763 (24.7%)
+Ref
+Good
+14,174
+(75.0%)
+3,380 (76.5%)
+17,554
+(75.3%)
+1.00
+0.92
+1.08
+0.965
+(Continued)
+Frontiers in Public Health | www.frontiersin.org
+7
+May 2022 | Volume 10 | Article 814328
+Nagarathna et al.
+Lifestyle During Lockdown in India
+TABLE 3 | Continued
+Domain /Variable
+Non-
+Vulnerable
+(n = 18,901)
+Vulnerable
+(n = 4,416)
+Total N (%)
+OR
+CI: 2.5%
+CI:
+97.5%
+p-value
+How do you prefer spending time (apart from your regular, work-related engagements) during this national lock-down period?
+TV
+Yes
+10,018
+(53.0%)
+2,188 (49.5%)
+12,206
+(52.3%)
+Ref
+No
+8,883 (47.0%)
+2,228 (50.5%)
+11,111
+(47.7%)
+0.92
+0.86
+0.99
+0.022
+Read/Write
+Yes
+16,199
+(85.7%)
+3,676 (83.2%)
+19,875
+(85.2%)
+Ref
+No
+2,702 (14.3%)
+740 (16.8%)
+3,442 (14.8%)
+1.27
+1.15
+1.39
+<0.001
+Cook
+Yes
+13.658
+(72.3%)
+2,995 (67.8%)
+16,653
+(71.4%)
+Ref
+No
+5,243 (27.7%)
+1,421 (32.2%)
+6,664 (28.6%)
+1.28
+1.19
+1.38
+<0.001
+Exercise
+Yes
+14,962
+(79.2%)
+3,329 (75.4%)
+18,291
+(78.4%)
+Ref
+No
+3,939 (20.8%)
+1,087 (24.6%)
+5,026 (21.6%)
+1.25
+1.15
+1.37
+<0.001
+Yoga-asana
+Yes
+12,671
+(67·0%)
+2,903 (65·7%)
+15,574
+(66·8%)
+Ref
+No
+6,230 (33.0%)
+1,513 (34.3%)
+7,743 (33.2%)
+1.18
+1.08
+1.28
+<0.001
+Meditation
+Yes
+14,481
+(76.6%)
+3,838 (86.9%)
+18,319
+(78.6%)
+Ref
+No
+4,420 (23.4%)
+578 (13.1%)
+4,998 (21.4%)
+0.42
+0.38
+0.47
+<0.001
+Faith practice
+Yes
+14,095
+(74·6%)
+3,374 (76·4%)
+17,469
+(74·9%)
+Ref
+No
+4,806 (25.4%)
+1,042 (23.6%)
+5,848 (25.1%)
+0.97
+0.90
+1.06
+0.497
+Internet
+Yes
+14,353
+(75.9%)
+2,929 (66.3%)
+17,282
+(74.1%)
+Ref
+No
+4,548 (24.1%)
+1,487 (33.7%)
+6,035 (25.9%)
+1.50
+1.39
+1.62
+<0.001
+Odds ratio was calculated using sequential contrasts for ordinal variables and odds ratio was calculated with first row and first column as reference for nominal variables. Ref indicates
+reference group.
+Mental Health
+Anxiety and Depression
+A meta-analysis of 65 studies during severe infections of
+SARS had noted that apart from the immediate mental health
+effects, PTSD could emerge at a later stage (27). “Somewhat”
+depressive low feeling and anxiety was noted in 15.6% and
+33.2%, respectively while 1.3% and 9.9% were “very much”
+depressed and anxious, respectively. Similar observations have
+been reported by studies during this pandemic using different
+psychological battery. The first mental health survey in India
+during the initial phase of pandemic showed 33.2% had
+significant (mild/moderate/severe) psychological impact (11).
+Qiu et al. reported 29% had mild to moderate and 5%
+had severe psychological distress in China (28). Wang et al.
+reported psychological impact in higher percentage (53.8%) of
+respondents with higher stress scores that remained high in the
+4th week (5). Thus, anxiety (28.8% in Wang et al. vs. 9·9%
+in present study) and depression (16·5% in Wang et al. vs.
+1·3% in present study) seemed to be higher in China. This
+may be attributed to the good lifestyle in our respondents with
+higher educational level. In another Indian study, Rehman et al.
+observed that people who do not have enough supplies to sustain
+the lockdown were most affected and the affluent were negatively
+correlated with psychological distress (29).
+Fear and Stress
+A smaller percentage of respondents in our study were
+stressed (11.5%) or expressed “very much” fear of death
+(3.8%) or getting infected (6.7%) or financial burden (11.1%)
+as compared to Chinese respondents with high level of
+education (75%) similar to our cohort (72.5%), who experienced
+higher levels of stress (52.1% felt horrified and apprehensive)
+(15). Milder form of the disease, stricter lockdown and
+higher family support in Indian community may explain
+this difference.
+The growing stress highlights the importance of funding
+translational and alternative medicine research (30) over
+fundamental research in vitro (31), in vivo (32–36) and
+biomarker
+studies
+(37–41),
+which
+is
+often
+restricted
+to
+publications. Translating this knowledge into practice may
+accelerate the pace of discovery and practice of integrative
+medicine. Several online surveys were conducted in India
+during this period; however, these surveys reported data
+on a small sample size (42–44), specific cohort (43, 45, 46),
+selective
+parameters
+such
+as
+psychological
+or
+life
+style
+or coping strategy (41, 44, 45, 47–49) as compared to
+our study. Another uniqueness of this study is that we
+used Delphi protocol to develop CHAS questionnaire for
+the survey.
+Frontiers in Public Health | www.frontiersin.org
+8
+May 2022 | Volume 10 | Article 814328
+Nagarathna et al.
+Lifestyle During Lockdown in India
+Limitations
+Although, this survey was aimed at general population, the
+responses were received by only those with high level of
+education which prevents us from drawing any conclusion
+related to Indian race in general.
+CHAS was prepared to suit the research question as we did not
+find a scale that had all the components we planned to assess. As
+the scale was self-reported, social desirability factor influencing
+the answers may be a limitation.
+CONCLUSION
+This is the first nationwide large scale health survey, covering
+34 states of India during the 3rd phase of lockdown of COVID-
+19 pandemic that shows that those with a good lifestyle
+including good eating, sleeping, and non-addictive habits with
+good physical activities adopt good coping abilities during
+the challenging times of life, irrespective of gender. Increased
+weight, unhealthy food, addictions and history of international
+travel increase the risk of getting infected with COVID-19 in
+vulnerable individuals. This study provides evidence for the
+media, policy makers and general population to include good life
+style recommendations for prevention.
+DATA AVAILABILITY STATEMENT
+The raw data supporting the conclusions of this article will be
+made available by the authors, without undue reservation.
+ETHICS STATEMENT
+The studies involving human participants were reviewed
+and approved by Swami Vivekananda Yoga Anusandhana
+Samsthana, Bengaluru, India. Written informed consent for
+participation was not required for this study in accordance with
+the national legislation and the institutional requirements.
+AUTHOR CONTRIBUTIONS
+RN: concept, design, definition of intellectual content, literature
+search, manuscript preparation, manuscript editing, manuscript
+review, and guarantor. MS: concept, design, definition of
+intellectual content, manuscript preparation, manuscript editing,
+and manuscript review. RK: concept, design, definition of
+intellectual content, data acquisition, data analysis, statistical
+analysis, manuscript preparation, manuscript editing, and
+manuscript review. JI: concept, design, definition of intellectual
+content, data acquisition, data analysis, statistical analysis,
+manuscript editing, and manuscript review. AA: concept. VM:
+design, definition of intellectual content, literature search, data
+acquisition, manuscript editing, and manuscript review. AS:
+concept, design, definition of intellectual content, literature
+search, data acquisition, manuscript editing, and manuscript
+review. JR and MR: manuscript editing and manuscript
+review. HN: concept, design, definition of intellectual content,
+data acquisition, manuscript editing, and manuscript review.
+All authors contributed to the article and approved the
+submitted version.
+REFERENCES
+1. Lipsitch
+M,
+Swerdlow
+DL,
+Finelli
+L.
+Defining
+the
+epidemiology
+of
+Covid-19
+-
+studies
+needed.
+N
+Engl
+J
+Med.
+(2020)
+382:1194–
+6. doi: 10.1056/NEJMp2002125
+2. Xu S, Li Y. Beware of the second wave of COVID-19. Lancet. (2020) 395:1321–
+2. doi: 10.1016/S0140-6736(20)30845-X
+3. Andrews MA, Areekal B, Rajesh KR, Krishnan J, Suryakala R, Krishnan B et al.
+First confirmed case of COVID-19 infection in India: a case report. Indian J
+Med Res. (2020) 151:490–2. doi: 10.4103/ijmr.IJMR_2131_20
+4. Telles S, Singh N, Joshi M. Risk of posttraumatic stress disorder and
+depression in survivors of the floods in Bihar, India. Indian J Med Sci. (2009)
+63:330–4. doi: 10.4103/0019-5359.55883
+5. Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, et al. A longitudinal study
+on the mental health of general population during the COVID-19 epidemic
+in China. Brain Behav Immun. (2020) 87:40–8. doi: 10.1016/j.bbi.2020.
+04.028
+6. Tian
+F,
+Li
+H,
+Tian
+S,
+Yang
+J,
+Shao
+J,
+Tian
+C.
+Psychological
+symptoms
+of
+ordinary
+Chinese
+citizens
+based
+on
+SCL-90
+during
+the level I emergency response to COVID-19. Psychiatry Res. (2020)
+288:112992. doi: 10.1016/j.psychres.2020.112992
+7. Hamer M, Kivimäki M, Gale CR, Batty GD. Lifestyle risk factors,
+inflammatory mechanisms, and COVID-19 hospitalization: a community-
+based cohort study of 387,109 adults in UK. Brain Behav Immun. (2020)
+87:184–7. doi: 10.1016/j.bbi.2020.05.059
+8. Pietrobelli A, Pecoraro L, Ferruzzi A, et al. Effects of COVID-19
+lockdown on lifestyle behaviors in children with obesity living in Verona,
+Italy: a longitudinal study. Obesity (Silver Spring). (2020) 28:1382–
+85. doi: 10.1002/oby.22861
+9. The
+Lancet.
+India
+under
+COVID-19
+lockdown.
+Lancet.
+(2020)
+395:1315. doi: 10.1016/S0140-6736(20)30938-7
+10. Gupta R, Misra A. COVID19 in South Asians/Asian Indians: heterogeneity
+of dta and implications for pathophysiology and research. Diabetes Res Clin
+Pract. (2020) 165:108267. doi: 10.1016/j.diabres.2020.108267
+11. Varshney
+M,
+Parel
+JT,
+Raizada
+N,
+Sarin
+SK.
+Initial
+psychological
+impact
+of
+COVID-19
+and
+its
+correlates
+in
+Indian
+Community:
+an
+online
+(FEEL-COVID)
+survey.
+PLoS
+ONE.
+(2020)
+15:e0233874. doi: 10.1371/journal.pone.0233874
+12. Nagarathna
+R,
+Anand
+A,
+Rain
+M,
+Srivastava
+V,
+Sivapuram
+MS,
+Kulkarni R et al. Yoga practice is beneficial for maintaining healthy
+lifestyle
+and
+endurance
+under
+restrictions
+and
+stress
+imposed
+by
+lockdown
+during
+COVID-19
+pandemic.
+Front
+Psychiatry.
+(2021)
+12:613762. doi: 10.3389/fpsyt.2021.613762
+13. Clark A, Jit M, Warren-Gash C, Guthrie B, Wang HHX, Mercer SW et al.
+Global, regional, and national estimates of the population at increased risk of
+severe COVID-19 due to underlying health conditions in 2020: a modelling
+study. Lancet Glob Health. (2020) 8:e1003–17.
+14. Schiffrin EL, Flack JM, Ito S, Muntner P, Webb RC. Hypertension and
+COVID-19. Am J Hypertens. (2020) 33:373–4. doi: 10.1093/ajh/hpaa057
+15. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course
+and risk factors for mortality of adult in patients with COVID-19 in
+Wuhan, China: a retrospective cohort study. Lancet. (2020) 395:1054–
+62. doi: 10.1016/S0140-6736(20)30566-3
+16. Zhang Y, Ma ZF. Impact of the COVID-19 pandemic on mental
+health and quality of life among local residents in Liaoning Province,
+China: a cross-sectional study. Int J Environ Res Public Healt. (2020)
+17:2381. doi: 10.3390/ijerph17072381
+17. Belanger MJ, Hill MA, Angelidi AM, Dalamaga M, Sowers JR, Mantzoros
+CS. Covid-19 and disparities in nutrition and obesity. N Engl J Med. (2020)
+383:e69. doi: 10.1056/NEJMp2021264
+18. Kokou-Kpolou CK, Megalakaki O, Laimou D, Kousouri M. Insomnia
+during COVID-19 pandemic and lockdown: prevalence, severity, and
+Frontiers in Public Health | www.frontiersin.org
+9
+May 2022 | Volume 10 | Article 814328
+Nagarathna et al.
+Lifestyle During Lockdown in India
+associated risk factors in France population. Psychiatry Res. (2020)
+290:113128. doi: 10.1016/j.psychres.2020.113128
+19. Huang
+Y,
+Zhao
+N.
+Generalized
+anxiety
+disorder,
+depressive
+symptoms
+and
+sleep
+quality
+during
+COVID-19
+outbreak
+in
+China:
+a
+web-based
+cross-sectional
+survey.
+Psychiatry
+Res.
+(2020)
+288:112954. doi: 10.1016/j.psychres.2020.112954
+20. Rossi R, Socci V, Pacitti F, Di Lorenzo G, Di Marco A, Siracusano A et al.
+Mental health outcomes among frontline and second-line health care workers
+during the Coronavirus Disease 2019 (COVID-19) pandemic in Italy. JAMA
+Netw Open. (2020) 3:e2010185. doi: 10.1001/jamanetworkopen.2020.10185
+21. Voitsidis
+P,
+Gliatas
+I,
+Bairachtari
+V,
+Papadopoulou
+K,
+Papageorgiou G, Parlapani E et al. Insomnia during the COVID-
+19
+pandemic
+in
+a
+Greek
+population.
+Psychiatry
+Res.
+(2020)
+289:113076. doi: 10.1016/j.psychres.2020.113076
+22. Young K. COVID-19: Smoking / Convalescent Plasma / Asthma / Poison
+Control Center Calls. (2020). Available online at: https://www.jwatch.org/
+fw116556/2020/04/16/covid-19-smoking-convalescent-plasma-asthma-
+poison (accessed September 11, 2020).
+23. Patanavanich
+R,
+Glantz
+SA.
+Smoking
+is
+associated
+with
+COVID-
+19
+progression:
+a
+meta-analysis.
+Nicotine
+Tob
+Res.
+(2020)
+22:1653–56. doi: 10.1093/ntr/ntaa082
+24. GBD 2015 Obesity Collaborators, Afshin A, Forouzanfar MH, Reitsma MB,
+Sur P, Estep K, et al. Health effects of overweight and obesity in 195 countries
+over 25 years. N Engl J Med. (2017) 377:13–27. doi: 10.1056/NEJMoa1614362
+25. Chen P, Mao L, Nassis GP, Harmer P, Ainsworth BE Li F. Coronavirus disease
+(COVID-19): the need to maintain regular physical activity while taking
+precautions. J Sport Health Sci. (2020) 9:103–4. doi: 10.1016/j.jshs.2020.02.001
+26. Duggal
+NA,
+Niemiro
+G,
+Harridge
+SD,
+Simpson
+RJ,
+Lord
+JM.
+Can
+physical
+activity
+ameliorate
+immunosenescence
+thereby
+reduce
+age-related
+multi-morbidity?
+Nat
+Rev
+Immunol.
+(2019)
+19:563–72. doi: 10.1038/s41577-019-0177-9
+27. Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli
+P, et al. Psychiatric and neuropsychiatric presentations associated with
+severe coronavirus infections: a systematic review and meta-analysis with
+comparison to the COVID-19 pandemic. Lancet Psychiatry. (2020) 7:611–
+27. doi: 10.1016/S2215-0366(20)30203-0
+28. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y, et al. nationwide
+survey of psychological distress among Chinese people in the COVID-19
+epidemic: implications and policy recommendations. Gen Psychiatr. (2020)
+33:e100213. doi: 10.1136/gpsych-2020-100213
+29. Rehman U, Shahnawaz MG, Khan NH, Kharshiing KD, Khursheed
+M, Gupta K et al. Depression, anxiety and stress among Indians in
+times of Covid-19 lockdown. Community Ment Health J. (2021) 57:42–
+8. doi: 10.1007/s10597-020-00664-x
+30. Mathur D, Goyal K, Koul V, Anand A. The molecular links of re-emerging
+therapy: a review of evidence of Brahmi (Bacopa monniera). Front pharmacol.
+(2016) 7:44. doi: 10.3389/fphar.2016.00044
+31. Abburi C, Prabhakar S, Kalra J, Huria A, Anand A. Vascular endothelial
+growth factor (VEGF) induced proliferation of human fetal derived ciliary
+epithelium stem cells is mediated by jagged-N cadherin pathway. Curr
+Neurovasc Res. (2013) 10:93–102. doi: 10.2174/1567202611310020002
+32. Bammidi S, Bali P, Kalra J, Anand A. Transplantation efficacy of human ciliary
+epithelium cells from fetal eye and Lin-ve stem cells from umbilical cord blood
+in the murine retinal degeneration model of laser injury. Cell Transplant.
+(2020) 29:0963689720946031. doi: 10.1177/0963689720946031
+33. Bali P, Bammidi S, Banik A, Nehru B, Anand A. CD34 and CD117 Stemness of
+lineage-negative cells reverses memory loss induced by amyloid beta in mouse
+model. Front Behav Neurosci. (2018) 12:222. doi: 10.3389/fnbeh.2018.00222
+34. Kumar S, Modgil S, Bammidi S, Minhas G, Shri R, Kaushik S, et al.
+Allium cepa exerts neuroprotective effect on retinal ganglion cells of
+pterygopalatine artery (PPA) ligated mice. J Ayurveda Integr Med. (2020)
+11:489–94. doi: 10.1016/j.jaim.2019.08.002
+35. Saraf MK, Prabhakar S, Khanduja KL, Anand A. Bacopa monniera attenuates
+scopolamine-induced impairment of spatial memory in mice. Evid Based
+Complement Alternat Med. (2011) 2011:236186. doi: 10.1093/ecam/neq038
+36. Anand A, Saraf MK, Prabhakar S. Antiamnesic effect of B. monniera on L-
+NNA induced amnesia involves calmodulin. Neurochem Res. (2010) 35:1172–
+81. doi: 10.1007/s11064-010-0171-x
+37. Sharma NK, Gupta A, Prabhakar S, Singh R, Sharma SK, Chen W,
+et al. Association between CFH Y402H polymorphism and age related
+macular
+degeneration
+in
+North
+Indian
+cohort.
+PLoS
+ONE.
+(2013)
+8:e70193. doi: 10.1371/journal.pone.0070193
+38. Kaur I, Katta S, Reddy RK, Narayanan R, Mathai A, Majji AB et al. The
+involvement of complement factor B and complement component C2 in an
+Indian cohort with age-related macular degeneration. Invest Ophthalmol Vis
+Sci. (2010) 51:59–63. doi: 10.1167/iovs.09-4135
+39. Anand
+A,
+Thakur
+K,
+Gupta
+PK.
+ALS
+and
+oxidative
+stress:
+the
+neurovascular
+scenario.
+Oxid
+Med
+Cell
+Longev.
+(2013)
+2013:635831. doi: 10.1155/2013/635831
+40. Vinish M, Prabhakar S, Khullar M, Verma I, Anand A. Genetic screening
+reveals high frequency of PARK2 mutations and reduced Parkin expression
+conferring risk for Parkinsonism in North West India. J Neurol Neurosurg
+Psychiatry. (2010) 81:166–70. doi: 10.1136/jnnp.2008.157255
+41. Sharma NK, Gupta A, Prabhakar S, Singh R, Sharma S, Anand A. Single
+nucleotide polymorphism and serum levels of VEGFR2 are associated
+with age related macular degeneration. Curr Neurovasc Res. (2012) 9:256–
+65. doi: 10.2174/156720212803530681
+42. Akhouri D, Madiha M, Ahmed J. COVID-19 lockdown: online survey
+of psychosocial factors of adolescents. Ind Psychiatry J. (2021) 30:S45–
+51. doi: 10.4103/ipj.ipj_32_20
+43. Singh GP, Arun P. Subjective well-being among migrant workers residing
+in a shelter home during lockdown: a pilot survey from North India. Prim
+Care Companion CNS Disord. (2021) 24:21m02991. doi: 10.4088/PCC.21m
+02991
+44. Singh VV, Patra P, Singal A. Coping with COVID: cross-sectional study
+to assess the psychological impact and coping strategies utilized by Indian
+internet users during the lockdown of the COVID-19 pandemic. Ind
+Psychiatry J. (2021) 30:29–35. doi: 10.4103/ipj.ipj_202_20
+45. Gupta N, Luthra A, Shailaja B, Chaudhury S, Saldanha D. Impact of COVID-
+19 pandemic on mental health of health-care workers in a tertiary care
+teaching and dedicated COVID-19 hospital. Ind Psychiatry J. (2021) 30:S56–
+62. doi: 10.4103/0972-6748.328790
+46. Verma SK, Kumar BD, Singh N, Kumari P, Ranjan M, Verma A. The impact
+of COVID-19-induced factors on “work from home” of employees. J Pharm
+Bioallied Sci. (2021) 13:S1000–2. doi: 10.4103/jpbs.jpbs_247_21
+47. Ghosh R, Jana PK, Bhattacharya S, Mallik S. Understanding social problems
+during lockdown and its relationship to perceived stress - An online survey
+among adult residents of India. J Family Med Prim Care. (2021) 10:3625–
+31. doi: 10.4103/jfmpc.jfmpc_2519_20
+48. Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan
+A,
+et
+al.
+Psychological
+impact
+of
+COVID-19
+lockdown:
+an
+online
+survey
+from
+India.
+Indian
+J
+Psychiatry.
+(2020)
+62:354–
+62. doi: 10.4103/psychiatry.IndianJPsychiatry_427_20
+49. Singh V, Raghav P, Singh G, Pritish Baskaran TB, Bishnoi A, Gautam
+V, et al. Lifestyle and behavioral changes during nationwide lockdown in
+India-A cross-sectional analysis. J Family Med Prim Care. (2021) 10:2661–
+7. doi: 10.4103/jfmpc.jfmpc_2464_20
+Conflict of Interest: The authors declare that the research was conducted in the
+absence of any commercial or financial relationships that could be construed as a
+potential conflict of interest.
+Publisher’s Note: All claims expressed in this article are solely those of the authors
+and do not necessarily represent those of their affiliated organizations, or those of
+the publisher, the editors and the reviewers. Any product that may be evaluated in
+this article, or claim that may be made by its manufacturer, is not guaranteed or
+endorsed by the publisher.
+Copyright © 2022 Nagarathna, Sharma, Ilavarasu, Kulkarni, Anand, Majumdar,
+Singh, Ram, Rain and Nagendra. This is an open-access article distributed under the
+terms of the Creative Commons Attribution License (CC BY). The use, distribution
+or reproduction in other forums is permitted, provided the original author(s) and
+the copyright owner(s) are credited and that the original publication in this journal
+is cited, in accordance with accepted academic practice. No use, distribution or
+reproduction is permitted which does not comply with these terms.
+Frontiers in Public Health | www.frontiersin.org
+10
+May 2022 | Volume 10 | Article 814328

subfolder_0/Correlation between Excessive Smartphone usage, Basic Psychological Needs, and Mental Health of University Students.txt

@@ -0,0 +1,736 @@
+© 2023 Journal of Mental Health and Human Behaviour | Published by Wolters Kluwer - Medknow
+65
+Abstract
+Original Article
+Introduction
+Smartphones have become indispensable in the current mode 
+of communication and in doing our daily life activities. Among 
+many technology‑related addictions, smartphone addiction 
+is newer and emerged as a more serious menace than other 
+addictions. Recent statistics show a significant rise in the 
+usage of smartphones every year. The estimated prevalence of 
+smartphone addiction is in the range of 10%–30%.[1] Studies 
+have reported the prevalence of problematic smartphone use 
+among children and adolescents is as high as 10% in the 
+United Kingdom,[2] 16.7% in Taiwan,[3] 16.9% in Switzerland,[4] 
+30.9% in Korea,[5] and 31% in India.[6] Further, a survey among 
+the six Asian countries showed the highest prevalence of 
+internet addiction through smartphone ownership is 62%.[7] 
+Although addiction was previously defined as “a pathologic 
+condition that one cannot tolerate without continuous 
+administration of substances,” it is now applied to behavioral 
+addictions, such as gaming and internet use.[8] These symptoms 
+have a negative influence on the psychophysiological 
+problems[9] with low psychological well‑being,[10] depression, 
+loneliness,[11] social anxiety,[12] cognitive disorders,[13] 
+and distressed interpersonal relationships. A high level of 
+gamma‑aminobutyric acid has been found in the brains of 
+those who use smartphones excessively, causing impaired 
+attention and control, as well as being more easily distracted.[14] 
+Because of the ease of access to information, adolescents’ 
+Objectives: The primary aim of the current study was to examine the unique contribution of psychological need frustration and need 
+satisfaction in the prediction of excessive usage of smartphones and its relation to psychological distress and mindfulness. Methods: We 
+conducted a correlational study using the smartphone addiction scale – shorter version, basic psychological needs satisfaction and frustration 
+scale, psychological distress, and mindfulness among 423 graduate and postgraduate engineering students from Bengaluru, South India. 
+Results: The results showed that excessive usage of smartphones is positively correlated with the time spent on the phone r = 0.19, P ≤ 0.05; 
+and basic psychological needs frustration r = 0.18, P ≤ 0.05; and negatively correlated with basic psychological needs satisfaction r = −0.19, 
+P ≤ 0.05 and mindfulness r = −0.39, P ≤ 0.001. However, among the optimal users of the smartphone group, time spent is positively correlated 
+with satisfaction at r = 0.13, P ≤ 0.05, and further, basic psychological needs satisfaction is negatively correlated with frustration at r = 0.30, 
+P ≤ 0.001 and also found a positive correlation between mindfulness and basic psychological needs satisfaction at r = 0.31, P ≤ 0.001. 
+Conclusion: The results suggest that excessive usage of smartphones is associated with frustration, psychological distress, and time spent on 
+the mobile. However, there is a positive trend in the time spent on the phone among the optimal users of smartphones suggests that smartphones 
+are used as a coping mechanism to gain momentary satisfaction.
+Keywords: Basic psychological needs, excessive usage of smartphone, mindfulness, psychological distress, smartphone addiction, time 
+spent on the phone
+Address for correspondence: Dr. Singh Deepeshwar,
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana 
+Samsthana (S‑VYASA, Deemed to be University), Bengaluru, Karnataka, 
+India.
+E‑mail: [email protected]
+Access this article online
+Quick Response Code:
+Website: 
+https://journals.lww.com/mhhb
+DOI: 
+10.4103/jmhhb.jmhhb_158_22
+How to cite this article: Putchavayala KC, Sasidharan KR, Krishna D, 
+Deepeshwar S. Correlation between excessive smartphone usage, basic 
+psychological needs, and mental health of university students. J Mental 
+Health Hum Behav 2023;28:65-71.
+Correlation between Excessive Smartphone usage, Basic 
+Psychological Needs, and Mental Health of University Students
+Krishna Chaitanya Putchavayala, K. Rajesh Sasidharan, Dwivedi Krishna1, Singh Deepeshwar1
+Division of Yoga and Physical Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S‑VYASA, Deemed to be University), 1Division of Yoga and Life 
+Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S‑VYASA, Deemed to be University), Bengaluru, Karnataka, India
+ This is an open access journal, and articles are distributed under the terms of the Creative 
+Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to 
+remix, tweak, and build upon the work non‑commercially, as long as appropriate credit 
+is given and the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+Submitted: 01‑Jul‑2022
+Accepted: 20‑Aug‑2022
+Revised: 10‑Aug‑2022
+Published: 21-Jul-2023
+Downloaded from http://journals.lww.com/mhhb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
+nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/20/2023
+Putchavayala, et al.: Relation between smartphone addiction and psychological health
+66
+Journal of Mental Health and Human Behaviour  ¦  Volume 28  ¦  Issue 1  ¦  January-June 2023
+smartphones can lead to reduced attention spans as well.[15] As 
+adolescents are neurologically immature, they tend to become 
+reliant on instant rewards provided by smartphones rather 
+than those derived from interactions with friends or family 
+members, or their hobbies.[16] Excessive smartphone use may 
+affect the connectivity in brain regions that control emotions, 
+decision‑making, inhibition, and impulsive control.[17]
+Excessive usage of smartphones and distress
+Research has indicated that a maladaptive use of smartphones 
+can lead to psychological distress. In a systematic review of 
+11 studies measuring depressive symptoms in children and 
+adolescents, there was a small but statistically significant 
+association between social media use and depression.[18] A 
+meta‑analysis of 23 studies reported problematic use of Facebook 
+is associated with psychological distress in adolescents and 
+young adults.[19] When adolescents become overly reliant on 
+smartphones, especially to connect with others, they lose the 
+opportunity to practice nonverbal skills like understanding 
+facial expressions or emotional reactions. Furthermore, they 
+are inflexible in their communication and less sensitive to their 
+behaviors.[20] It has been found that checking new messages 
+and notifications obsessively can lead to personal stress and a 
+high frequency of texting is reported to be associated with a 
+reduced level of emotional connection with others.[21]
+Compulsive smartphone users struggle to refrain from using the 
+devices for a short time, owing to how much of their lives revolve 
+around the device.[22] As a result, their performance at school or 
+during other activities can suffer when they do not have access 
+to these devices. In some adolescents, smartphones serve as a 
+coping mechanism to alleviate depression and boredom.[21,22] As 
+a result of using devices, they feel less distressed and can divert 
+their attention away from more important problems in their lives. 
+In the short term, such behavior may provide adolescents with 
+relief and as a means of escaping from their problems, but it is 
+not beneficial in the long run as the issues remain unresolved. As 
+a result, more people will become dependent on smartphones to 
+cope with psychological problems.[23] In addition, those seeking 
+out companionship in a safe virtual environment may develop 
+depression or being more depressed as they become more 
+socially isolated, but just focused on their phone.[24]
+Basic psychological needs and frustration
+Self‑determination theory (SDT) is postulated by Deci and 
+Ryan for human motivation developed through empirical 
+evidence. It is a framework of mini‑theories that taps into 
+multiple facets of human motivation. It has been widely used 
+in sports, education, health, and employment sectors.[25] Basic 
+psychological needs form the core of SDT. It is understood 
+that every human has to satisfy their set of basic psychological 
+needs for their growth and wellbeing. The primary focus is 
+on fulfilling three basic needs: autonomy, relatedness, and 
+competence.[26] Basic psychological needs theory (BPNT) 
+encompasses both the satisfaction of these thr three needs, 
+as well as their frustration, with frustration being a stronger 
+and more threatening experience than a purely lacking need. 
+Autonomy describes the capacity for free will and willingness 
+to act. Satisfaction generates a feeling of integrity that 
+permeates our actions, thoughts, and feelings. Feelings of 
+frustration can often manifest as pressure and conflict, such 
+as feeling pushed in an undesirable direction. Relatedness 
+includes the desire to feel connected, be a part of, and 
+feel significant to others, as well as a feeling of warmth. 
+Relatedness frustration is associated with feelings of social 
+exclusion, loneliness, and alienation. We relate competence 
+to mastery and effectiveness. It becomes satisfied as one 
+capably engages in activities and experiences opportunities 
+for using and extending skills and expertise. The frustrated 
+often feel ineffective, or outright helpless. A growing number 
+of researchers have drawn attention to the concept of need 
+frustration, where they demonstrate adverse effects when 
+the basic psychological needs for autonomy, competence, 
+and relatedness are interfered with.[27,28] Further, the need 
+frustration is viewed as a separate process rather than being 
+at the other end of a continuum of need satisfaction.[29,30] Need 
+frustration is more common when the social context actively 
+undermines the basic psychological needs.[31] Performing a 
+particular role when one is forced to, being told they are not 
+capable, or being discouraged or rejected result in a loss of 
+autonomy, competence, or relatedness. Consequently, need 
+frustration can be distinguished from lack of need satisfaction, 
+which is more passively inhibited psychological needs. Need 
+satisfaction and frustration be in an asymmetrical relationship, 
+in which the absence of need satisfaction does not necessarily 
+indicate the presence of need frustration, but the existence of 
+need frustration is implied the absence of need satisfaction.[32] 
+In addition, research has shown that need frustrations result in 
+adverse outcomes as a direct threat to psychological needs.[33]
+Mindfulness
+Mindfulness can be defined as “an openhearted, 
+moment‑to‑moment, nonjudgmental awareness” or 
+maintenance of the attention to the present moment.[34] By 
+practicing mindfulness, one can pay attention to one’s self 
+and surroundings nonjudgmentally and with purpose, leading 
+to happiness, self‑awareness, inner calm, and self‑respect.[35] 
+Many researchers have applied mindfulness as a treatment 
+modality for behavioral addictions, such as pathological 
+gambling, workaholics, and Internet addiction.[36‑38] Students 
+with excessive usage of smartphones have reported that 
+mindfulness‑based interventions resulted in a decline in phone 
+usage time and self‑reported scores.[39]
+Van Gordon proposed that the mindfulness approach may 
+be suitable for behavioral addictions for several reasons: (a) 
+substitution of addictive behaviors with meditation can 
+reduce relapse and withdrawal symptoms; (b) cultivation of 
+compassion helps with addiction‑related negative emotions; (c) 
+shift of focus to the intrinsic value of life and life priorities from 
+the instant reward from addictive activities; (d) reduce salience; 
+and (e) improve on patience.[36] Mindfulness was also found 
+to have a positive relationship with well‑being[40] including 
+higher levels of positive emotions, vitality, life satisfaction, 
+Downloaded from http://journals.lww.com/mhhb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
+nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/20/2023
+Putchavayala, et al.: Relation between smartphone addiction and psychological health
+67
+Journal of Mental Health and Human Behaviour  ¦  Volume 28  ¦  Issue 1  ¦  January-June 2023
+and adaptive emotion regulation and lower levels of negative 
+emotions and psychopathological symptoms.[41]
+In the present study, we intend to investigate the relation 
+between basic psychological needs satisfaction and frustration, 
+and mindfulness with psychological distress and excessive 
+usage of smartphones among college students.
+Methods
+Participants
+A total of 423 graduate and postgraduate students from 
+an engineering college in Bengaluru, South India were 
+recruited for the present study. The sample was distributed 
+as (76% of males; 24% of females) with a mean age = 20.29, 
+standard deviation (SD) =1.38 years. These participants were 
+screened by using the smartphone addiction scale – shorter 
+version (SAS‑SV) and 164 participants reported to be having 
+excessive usage with cutoff scores ≥31 for males and ≥33 for 
+females and 259 students are found to be optimal users of the 
+smartphone below the cutoff scores. The average time spent 
+on the phone by the participants is 3.26 ± 0.86 h/day. Among 
+them, the excessive users spend 3.91 ± 0.70 h and optimal 
+users of smartphones spend 2.85 ± 0.67 h/day
+Procedure
+We have contacted students through their college WhatsApp 
+groups. Students who are interested in the study took part 
+by filling up the forms using a pen and pencil. The data 
+were collected during the 2021–2022 academic year. The 
+Institutional Ethics Committee of S‑VYASA Yoga University 
+approved this study with a reference number of IEC (RES/
+IEC‑SVYASA/113/2017).
+Measures
+The questionnaires include demographic data such as age, 
+gender, education qualification, time spent on the smartphone 
+in a day, and how long they are using the smartphones. The 
+following questionnaires were included: the SAS‑SV,[42] Basic 
+psychological needs Satisfaction and Frustration Scale,[28] 
+Psychological Distress Scale (K‑10),[43] and Mindful Attention 
+Awareness Scale (MAAS).[44]
+Smartphone addiction scale shorter version
+The SAS is a 10‑item questionnaire. The sores on this scale are 
+measured on a 6‑point Likert scale. The six factors analyzed 
+by this questionnaire were daily‑life disturbance, positive 
+anticipation, withdrawal, cyberspace‑oriented relationship, 
+overuse, and tolerance. The cutoff levels to be considered as 
+addicted were 31 for males and 33 for females. The SAS‑SV 
+showed good reliability and validity for the assessment of 
+smartphone addiction.
+Basic psychological needs satisfaction and frustration 
+scale
+Basic Psychological Need Theory, the satisfaction of the 
+psychological needs for Autonomy, competence, and 
+relatedness are said to represent essential nutrients of growth, 
+and their psychological well‑being and health should be 
+enhanced. The Basic Psychological Need Satisfaction 
+and Frustration Scale were developed, which includes a 
+balanced combination of satisfaction and frustration items. 
+The scale consists of 24 items, four items for each of the six 
+subscales (i.e. autonomy satisfaction, autonomy frustration, 
+relatedness satisfaction, relatedness frustration, competence 
+satisfaction, and competence frustration). Respondents 
+answered the questions concerning their feelings about their 
+jobs during the previous 4 weeks, on a 7‑point response scale 
+ranging from 1 (strongly disagree) to 7 (strongly agree).
+Kessler psychological distress scale (K‑10)
+The Kessler psychological distress scale (K‑10) is a widely 
+used, simple self‑report measure of psychological distress 
+which can be used to identify those in need of further 
+assessment for anxiety and depression. This measure was 
+designed for use in the general population; however, it may also 
+serve as a useful clinical tool. The scale comprises 10 questions 
+that are answered using a five‑point scale (where 5 = all of the 
+time, and 1 = none of the time). For all questions, the client 
+circles the answer truest for them in the past 4 weeks. Scores 
+are then summed with a maximum score of 50 indicating severe 
+distress, and a minimum score of 10 indicating no distress.
+Mindful attention awareness scale
+The MAAS was used to measure dispositional mindfulness. 
+This instrument consists of 15 items, all of which indicate a 
+lack of mindfulness. These items are rated on a 6‑point Likert 
+scale ranging from 1 (almost always) to 6 (almost never); 
+higher scores indicate more mindfulness, and the total score 
+can range from 15 to 90. The measures assess the quality of 
+attention and awareness that individuals apply to their daily 
+lives. The MAAS has good convergent and discriminant 
+validity, as well as good psychometric properties.
+Data collection and statistical analysis
+Data were collected by using paper and pencil for all the 
+questionnaires. The data were statistically analyzed using the 
+Statistical Package for the Social Sciences (SPSS) (version 
+21, IBM Corp., Armonk, NY, USA). The mean and SD were 
+calculated for the participant’s age and time spent on the phone. 
+Data were checked for the normality using Shapiro test. Data 
+were not normally distributed hence Mann–Whitney U‑test 
+was used for between‑groups analysis. Spearman correlation 
+was used to predict the correlation between the variables. The 
+results were considered statistically significant if the P ≤ 0.05.
+Results
+The Mann–Whitney U‑test showed significant differences 
+in excessive usage of the smartphone compared to optimal 
+users of the smartphone. The excessive usage of smartphone 
+group reported significant differences in the variables 
+including time spent (U = 6134.5, P < 0.001, r = 0.711), 
+SAS (U = 5.5, P < 0.001, r = 1), frustration (U = 18824, 
+P  <  0.05, r  =  0.114), K‑10  (U  =  16426.5, P  <  0.001, 
+Downloaded from http://journals.lww.com/mhhb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
+nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/20/2023
+Putchavayala, et al.: Relation between smartphone addiction and psychological health
+68
+Journal of Mental Health and Human Behaviour  ¦  Volume 28  ¦  Issue 1  ¦  January-June 2023
+r = 0.227), satisfaction (U = 17767.5, P < 0.01, r = 0.163), 
+and MAAS (U = 18804, P < 0.05, r = 0.115). These results 
+are illustrated in Table 1.
+Mann–Whitney U‑test  (To compare the differences of 
+Variables) between excessive usage and optimal usage 
+participants.
+The results of correlation analyses were reported as: among 
+the excessive usage of smartphones group, excessive usage 
+of smartphones is positively correlated with time spent on 
+the mobile at r = 0.19, P ≤ 0.05; basic psychological needs 
+frustration at r = 0.18, P ≤ 0.05; and negatively correlated with 
+basic psychological needs satisfaction at r = −0.19, P ≤ 0.05; 
+and mindfulness at r = −0.39, P ≤ 0.001. Further, time spent 
+on the smartphone is positively correlated with psychological 
+distress at r = 0.18, P ≤ 0.05; and basic psychological needs 
+frustration at r = 0.19, P ≤ 0.05; and negatively correlated with 
+basic psychological needs satisfaction at r = 0.24, P ≤ 0.01; and 
+mindfulness at r = −0.20, P ≤ 0.01. Furthermore, mindfulness 
+is negatively correlated with frustration at r = −0.16, P ≤ 0.05.
+The correlation analysis among the optimal usage group 
+reported as time spent is positively correlated with satisfaction 
+at r = 0.13, P ≤ 0.05; and mindfulness is positively correlated 
+with basic psychological needs satisfaction at r  =  0.31, 
+P ≤ 0.001 and negatively correlated with basic psychological 
+needs frustration at r = −0.17, P ≤ 0.05; and further, basic 
+psychological needs satisfaction is negatively correlated with 
+frustration at r = 0.30, P ≤ 0.001. The correlation analysis 
+results are reported in Table 2.
+Discussion
+Smartphone usage has been on a drastic rise among 
+college‑going students. The research fraternity has extensively 
+discussed the implications of excessive usage. However, 
+this study intends to understand the intricacies of excessive 
+usage of smartphones and its relationship with the theory of 
+basic psychological needs satisfaction and frustration with 
+psychological distress and mindfulness.
+The prevalence of excessive usage of smartphones in this 
+study is reported at 39%. This shows an ongoing trend 
+of an upsurge in excessive usage of smartphones among 
+college students.[45] It is reported that the excessive usage of 
+smartphones ratio in this study is higher among males. The 
+results from the current study suggest that the correlations are 
+significant but, relatively weak. Among them, time spent on the 
+smartphone is positively correlated with basic psychological 
+needs frustration, excessive usage of smartphone scores, and 
+psychological distress implying low emotion regulation and 
+psychological well‑being. However, smartphone excessive 
+usage is significantly and negatively associated with 
+mindfulness and also, the mindfulness is negatively correlated 
+with basic psychological needs and frustration among the 
+excessive usage of smartphone group.
+The results from the optimal users of smartphone group reflect 
+that time spent on the smartphone is also positively associated 
+with basic psychological need satisfaction suggesting that the 
+smartphone is used as a coping mechanism to negate boredom 
+and loneliness.[11] Furthermore, basic psychological need 
+satisfaction has a strong correlation with mindfulness. This 
+could imply that basic psychological need satisfaction has 
+a major role in defining the symptoms of excessive usage of 
+the smartphone. In the absence, it may lead to psychological 
+distress and frustration and low levels of mindfulness 
+suggesting low psychosocial well‑being.
+Excessive usage of smartphones and psychological 
+distress
+The present study found that psychological distress is 
+positively correlated with excessive usage of smartphone. 
+It is understood that psychological distress, which includes 
+anxiety and depression are key symptoms of excessive usage of 
+smartphones. We found that distress levels are more prominent 
+in the excessive usage of the smartphone group when compared 
+to the optimal users of the smartphone group. Similarly, a study 
+on university students found that psychological distress and 
+neuroticism are positively correlated with excessive usage of 
+smartphones[46] which were similar to our research findings.
+Excessive usage of smartphones and basic psychological 
+needs, satisfaction, and frustration
+According to Ryan, the satisfaction of the basic psychological 
+needs are essential for an individual’s growth, health, and 
+psychological well‑being. Looking at the recent studies, it 
+is increasingly clear that the absence of basic psychological 
+needs satisfaction does not by definition imply it is frustration. 
+Psychological needs frustration involves more than a mere 
+Table 1: Mean and standard deviation of excessive usage of smartphone and optimal usage participants
+Variables
+Excessive usage
+Optimal usage
+U
+P
+Effect size (r)
+Time spent
+3.91±0.7
+2.85±0.67
+6134.5
+<0.001
+0.711
+SAS
+37.28±5.04
+22.83±4.33
+5.50
+<0.001
+1.000
+Need frustration
+27.34±7.86
+25.64±6.75
+18824
+<0.05
+0.114
+K‑10
+20.71±3.46
+19.27±3.79
+16426.5
+<0.001
+0.227
+Need satisfaction
+22.62±6.53
+24.21±6.53
+17767.5
+<0.01
+0.163
+MAAS
+46.52±8.03
+48.21±9.42
+18804
+<0.05
+0.115
+Mann–Whitney U‑test (to compare the differences of variables) between excessive usage and optimal usage participants. SAS: Smartphone addiction 
+scale – shorter version, K‑10: Psychological distress scale, MAAS: Mindfulness attention awareness scale, Satisfaction, and Frustration: Basic 
+psychological needs satisfaction and frustration scale, Time spent: Time spent on the smartphone in a day
+Downloaded from http://journals.lww.com/mhhb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
+nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/20/2023
+Putchavayala, et al.: Relation between smartphone addiction and psychological health
+69
+Journal of Mental Health and Human Behaviour  ¦  Volume 28  ¦  Issue 1  ¦  January-June 2023
+deficit of one’s needs. Given this asymmetrical relation 
+between need satisfaction and need frustration, a moderate 
+negative relationship between both can be theoretically 
+expected. Our findings reflect the theoretical presumptions 
+being excessive usage of the smartphone has a significant 
+negative relation with satisfaction and a positive correlation 
+with frustration and the time spent on the mobile phone. 
+Between‑group analyses showed that students with excessive 
+usage of the smartphone have a significant negative correlation 
+with satisfaction and vice versa with frustration and time 
+spent on their mobile phones. These results were similar to 
+the earlier studies on need frustration with the smartphone 
+over‑usage.[47] However, it is also reported that there is a 
+positive relationship between the time spent on the mobile and 
+satisfaction among the optimal usage as well. We can interpret 
+this result by drawing a comparison with the earlier reports, 
+that smartphones can be used as a coping mechanism to give 
+temporary satisfaction and happiness to negate the proneness 
+to boredom and loneliness.
+Time spent on the smartphones
+According to a survey, the average time spent on smartphones 
+is 5 h a day.[48] This has become a key predictor in defining 
+excessive usage of the smartphone. The current study shows 
+an average time spent is around 3 h excluding their academic 
+activity on smartphones due to the COVID situation. This is 
+less than the predicted values. However, we found that the time 
+spent on the mobile has a positive relationship with excessive 
+usage of smartphone scores, psychological distress, and need 
+frustration;[49] and is negatively correlated with mindfulness.
+Excessive usage of smartphones and mindfulness
+Based on the empirical evidence, higher mindfulness 
+levels were significantly associated with lower levels of 
+proneness to boredom, impulsivity, and problematic usage 
+of smartphones.[50] Our study findings suggest that higher 
+mindfulness is associated with higher satisfaction levels and 
+negatively associated with frustration and psychological 
+distress scores among smartphone the optimal usage group. 
+As per the previous studies, lower mindfulness levels may lead 
+to lower attention levels and academic performance.[51] This 
+report suggests that the practice of mindfulness may lead to 
+minimizing the symptoms of excessive usage of smartphones.
+Limitations and future scope
+This is a basic study constrained to only engineering graduate 
+students and one particular geographical location. Hence, 
+future studies should focus on finding the results with 
+multi‑ethnic populations to generalize the results. The data are 
+a selfreported which can be further explored with objective 
+variables. This study tried to establish the primary relation 
+between the BPNT and excessive usage of smartphones. 
+Further, doing randomized controlled trial with mindfulness as 
+an adjunct modality can be studied to understand the intricacies 
+of the relation between the BPNT and excessive usage of 
+smartphone symptoms.
+Conclusion
+Results suggest that there is a positive association between 
+excessive usage of smartphones, psychological distress, time 
+spent on the mobile, and need frustration. These results linked 
+to the smartphone as a coping mechanism to gain momentary 
+satisfaction. However, prolonged time spent on the phone 
+may lead to frustration and maladaptive behavior in the 
+future. Moreover, the negative association between the need 
+satisfaction and frustration in the optimal users of smartphone 
+group suggests that fulfillment of need satisfaction plays a key 
+role in controlling the symptomatic nature of excessive usage 
+of the smartphone.
+Acknowledgments
+We acknowledge the management of Jain University, 
+Bengaluru for giving permission to conduct the study on 
+students of engineering on their campus.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+References
+1.	 Sohn  SY, Rees  P, Wildridge  B, Kalk  NJ, Carter  B. Prevalence of 
+problematic smartphone usage and associated mental health outcomes 
+amongst children and young people: A systematic review, meta‑analysis 
+and GRADE of the evidence. BMC Psychiatry 2019;19:356.
+2.	 Lopez‑Fernandez  O, Honrubia‑Serrano  L, Freixa‑Blanxart  M, 
+Gibson  W. Prevalence of problematic mobile phone use in British 
+adolescents. Cyberpsychol Behav Soc Netw 2014;17:91‑8.
+Table 2: Spearman’s correlation between variables in 
+excessive usage of smartphones and optimal usages’ 
+participants
+Variables
+Spearman’s, r
+Excessive users
+Optimal usage
+Time spent
+SA
+0.19*
+‑
+K‑10
+0.18*
+‑
+Need frustration
+0.19*
+‑
+Need satisfaction
+−0.24**
+0.13*
+MAAS
+−0.20**
+‑
+SAS
+MAAS
+−0.39***
+‑
+Need frustration
+0.18*
+‑
+Need satisfaction
+−0.19*
+‑
+MAAS
+Need satisfaction
+‑
+0.31***
+Need frustration
+−0.16*
+−0.17*
+Satisfaction
+Need frustration
+‑
+−0.30***
+*P<0.05, **P<0.01, and **P<0.001. SAS: Smartphone addiction 
+scale – shorter version, K‑10: Psychological distress scale, MAAS: 
+Mindfulness attention awareness scale, Satisfaction, and frustration: Basic 
+psychological needs satisfaction and frustration scale, Time spent: Time 
+spent on the smartphone in a day
+Downloaded from http://journals.lww.com/mhhb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
+nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/20/2023
+Putchavayala, et al.: Relation between smartphone addiction and psychological health
+70
+Journal of Mental Health and Human Behaviour  ¦  Volume 28  ¦  Issue 1  ¦  January-June 2023
+3.	 Yen CF, Tang TC, Yen JY, Lin HC, Huang CF, Liu SC, et al. Symptoms 
+of problematic cellular phone use, functional impairment and its 
+association with depression among adolescents in Southern Taiwan. 
+J Adolesc 2009;32:863‑73.
+4.	 Haug  S, Castro  RP, Kwon  M, Filler  A, Kowatsch  T, Schaub  MP. 
+Smartphone use and smartphone addiction among young people in 
+Switzerland. J Behav Addict 2015;4:299‑307.
+5.	 Cha SS, Seo BK. Smartphone use and smartphone addiction in middle 
+school students in Korea: Prevalence, social networking service, and 
+game use. Health Psychol Open 2018;5.
+6.	 Schacht JP, Anton RF, Myrick H. Functional neuroimaging studies of 
+alcohol cue reactivity: A  quantitative meta‑analysis and systematic 
+review. Addict Biol 2013;18:121‑33.
+7.	 Mak KK, Lai CM, Watanabe H, Kim DI, Bahar N, Ramos M, et al. 
+Epidemiology of internet behaviors and addiction among adolescents in 
+six Asian countries. Cyberpsychol Behav Soc Netw 2014;17:720‑8.
+8.	 Kwon  M, Lee  JY, Won  WY, Park  JW, Min  JA, Hahn  C, et  al. 
+Development and validation of a Smartphone Addiction Scale (SAS). 
+PLoS One 2013;8:e56936.
+9.	 Kee  IK, Byun  JS, Jung  JK, Choi  JK. The presence of altered 
+craniocervical posture and mobility in smartphone‑addicted teenagers 
+with temporomandibular disorders. J Phys Ther Sci 2016;28:339‑46.
+10.	 Lai  CM, Mak  KK, Watanabe  H, Jeong  J, Kim  D, Bahar  N, et  al. 
+The mediating role of Internet addiction in depression, social 
+anxiety, and psychosocial well‑being among adolescents in six Asian 
+countries: A  structural equation modelling approach. Public Health 
+2015;129:1224‑36.
+11.	 Bian M, Leung L. Linking loneliness, shyness, smartphone addiction 
+symptoms, and patterns of smartphone use to social capital. Soc Sci 
+Comput Rev 2015;33:61‑79.
+12.	 Kim  H. Exercise rehabilitation for smartphone addiction. J  Exerc 
+Rehabil 2013;9:500‑5.
+13.	 Deshpande A. Mobile addiction and associated factors amongst youth. 
+Indian J Ment Health 2015;2:244.
+14.	 Ting CH, Chen YY. Smartphone addiction. In: Essau CA, Delfabbro PH, 
+editors. Adolescent Addiction.Cambridge, MA, USA: Academic Press; 
+2020. p. 215‑40.
+15.	 Kim Y, Jeong JE, Cho H, Jung DJ, Kwak M, Rho MJ, et al. Personality 
+factors predicting smartphone addiction predisposition: Behavioral 
+inhibition and activation systems, impulsivity, and self‑control. PLoS 
+One 2016;11:e0159788.
+16.	 Kim SG, Park J, Kim HT, Pan Z, Lee Y, McIntyre RS. The relationship 
+between smartphone addiction and symptoms of depression, anxiety, 
+and attention‑deficit/hyperactivity in South  Korean adolescents. Ann 
+Gen Psychiatry 2019;18:1.
+17.	 Chen J, Liang Y, Mai C, Zhong X, Qu C. General deficit in inhibitory 
+control of excessive smartphone users: Evidence from an event‑related 
+potential study. Front Psychol 2016;7:511.
+18.	 McCrae  N, Gettings  S, Purssell  E. Social media and depressive 
+symptoms in childhood and adolescence: A systematic review. Adolesc 
+Res Rev 2017;2:315‑30.
+19.	 Marino C, Gini G, Vieno A, Spada MM. A comprehensive meta‑analysis 
+on problematic Facebook use. Comput Human Behav 2018;83:262‑77.
+20.	 Hong FY, Chiu SI, Huang DH. A model of the relationship between 
+psychological characteristics, mobile phone addiction and use of mobile 
+phones by Taiwanese university female students. Comput Human Behav 
+2012;28:2152‑9.
+21.	 Sansone RA, Sansone LA. Cell phones: The psychosocial risks. Innov 
+Clin Neurosci 2013;10:33‑7.
+22.	 Thomée S. Mobile phone use and mental health. A review of the research 
+that takes a psychological perspective on exposure. Int J Environ Res 
+Public Health 2018;15:2692.
+23.	 Alhassan  AA, Alqadhib  EM, Taha  NW, Alahmari  RA, Salam  M, 
+Almutairi AF. The relationship between addiction to smartphone usage 
+and depression among adults: A cross sectional study. BMC Psychiatry 
+2018;18:148.
+24.	 Hinduja  S, Patchin  JW. Bullying, cyberbullying, and suicide. Arch 
+Suicide Res 2010;14:206‑21.
+25.	 Ryan RM, Deci EL. Self‑Determination Theory: Basic Psychological 
+Needs in Motivation, Development, and Wellness. New York: Guilford 
+Publications; 2017.
+26.	 Van den Broeck A, Ferris DL, Chang CH, Rosen CC. A review of self-
+determination theory’s basic psychological needs at work. Journal of 
+Management, 2016;42:1195-229.
+27.	 Bartholomew 
+KJ, 
+Ntoumanis 
+N, 
+Thøgersen‑Ntoumani 
+C. 
+Self‑determination theory and the darker side of athletic experience: The 
+role of interpersonal control and need thwarting. Sport Exerc Psychol 
+Rev 2011;7:23‑8.
+28.	 Deci  EL, Olafsen AH, Ryan  RM. Self‑determination theory in work 
+organizations: The state of a science. Annu Rev 2017;4:19‑43.
+29.	 Chen  B, Vansteenkiste  M, Beyers  W, Boone  L, Deci  EL, 
+Van der Kaap‑Deeder J, et  al. Basic psychological need satisfaction, 
+need frustration, and need strength across four cultures. Motiv Emot 
+2014;39:216‑36.
+30.	 Cordeiro P, Paixão P, Lens W, Lacante M, Luyckx K. The Portuguese 
+validation of the Basic Psychological Need Satisfaction and Frustration 
+Scale: Concurrent and longitudinal relations to well‑being and ill‑being. 
+Psychol Belg 2016;56:193‑209.
+31.	 Vansteenkiste  M, Ryan  RM, Soenens  B. Basic psychological need 
+theory: Advancements, critical themes, and future directions. Motiv 
+Emot 2020;44:1‑31.
+32.	 Vansteenkiste M, Ryan RM. On psychological growth and vulnerability: 
+Basic psychological need satisfaction and need frustration as a unifying 
+principle. J Psychother Integr 2013;23:263‑80.
+33.	 Martinent  G, Guillet‑Descas  E, Moiret  S. Reliability and validity 
+evidence for the French Psychological Need Thwarting Scale (PNTS) 
+scores: Significance of a distinction between thwarting and satisfaction 
+of basic psychological needs. Psychol Sport Exerc 2015;20:29‑39.
+34.	 Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, 
+et al. Mindfulness: A proposed operational definition. Clin Psychol Sci 
+Pract 2004;11:230‑41.
+35.	 Shapiro  SL, Carlson  LE, Astin  JA, Freedman  B. Mechanisms of 
+mindfulness. J Clin Psychol 2006;62:373‑86.
+36.	 Van Gordon W, Shonin E, Garcia‑Campayo J. Are there adverse effects 
+associated with mindfulness? Aust N Z J Psychiatry 2017;51:977‑9.
+37.	 van Son  J, Nyklíček I, Pop  VJ, Pouwer  F. Testing the effectiveness 
+of a mindfulness‑based intervention to reduce emotional distress in 
+outpatients with diabetes (DiaMind): Design of a randomized controlled 
+trial. BMC Public Health 2011;11:131.
+38.	 de Lisle  SM, Dowling  NA, Allen  JS. Mindfulness and problem 
+gambling: A review of the literature. J Gambl Stud 2012;28:719‑39.
+39.	 Lan Y, Ding JE, Li W, Li J, Zhang Y, Liu M, et al. A pilot study of a group 
+mindfulness‑based cognitive‑behavioral intervention for smartphone 
+addiction among university students. J Behav Addict 2018;7:1171‑6.
+40.	 Sauer  S, Walach  H, Kohls  N. Gray’s behavioural inhibition system 
+as a mediator of mindfulness towards well‑being. Pers Individ Dif 
+2011;50:506‑11.
+41.	 Keng  SL, Smoski  MJ, Robins  CJ. Effects of mindfulness on 
+psychological health: A review of empirical studies. Clin Psychol Rev 
+2011;31:1041‑56.
+42.	 Kwon M, Kim DJ, Cho H, Yang S. The smartphone addiction scale: 
+Development and validation of a short version for adolescents. PLoS 
+One 2013;8:e83558.
+43.	 Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, 
+et al. Short screening scales to monitor population prevalences and trends 
+in non‑specific psychological distress. Psychol Med 2002;32:959‑76.
+44.	 Brown  KW, Ryan  RM. The benefits of being present: Mindfulness 
+and its role in psychological well‑being. J  Pers Soc Psychol 
+2003;84:822‑48.
+45.	 Lei  LY, Ismail  MA, Mohammad  JA, Yusoff  MS. The relationship of 
+smartphone addiction with psychological distress and neuroticism 
+among university medical students. BMC Psychol 2020;8:97.
+46.	 Liu  H, Zhou  Z, Huang  L, Zhu  E, Yu  L, Zhang  M. Prevalence of 
+smartphone addiction and its effects on subhealth and insomnia: 
+A  cross‑sectional study among medical students. BMC Psychiatry 
+2022;22:305.
+47.	 Butt  AK, Arshad  T. The relationship between basic psychological 
+needs and phubbing: Fear of missing out as the mediator. Psych J 
+2021;10:916‑25.
+48.	 Mobile Phone News. Indians Spend About Five Hours Daily on Mobile 
+Downloaded from http://journals.lww.com/mhhb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
+nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/20/2023
+Putchavayala, et al.: Relation between smartphone addiction and psychological health
+71
+Journal of Mental Health and Human Behaviour  ¦  Volume 28  ¦  Issue 1  ¦  January-June 2023
+Phones in 2021: Study. The Economic Times; 20 June, 2022. Available 
+from: https://economictimes.indiatimes.com/tech/technology/indians-
+spend-about-five-hours-daily-on-mobile-phones-in‑2021‑study/
+articleshow/88968361.cms. [Last accessed on 2022 Jun 20].
+49.	 Chamarro A, Oberst U, Cladellas R, Fuster H. Effect of the frustration of 
+psychological needs on addictive behaviors in mobile videogamers‑the 
+mediating role of use expectancies and time spent gaming. Int J Environ 
+Res Public Health 2020;17:6429.
+50.	 Regan T, Harris B, Van Loon M, Nanavaty N, Schueler J, Engler S, 
+et al. Does mindfulness reduce the effects of risk factors for problematic 
+smartphone use? Comparing frequency of use versus self‑reported 
+addiction. Addict Behav 2020;108:106435.
+51.	 Vorontsova‑Wenger  O, Ghisletta  P, Ababkov  V, Barisnikov  K. 
+Relationship between mindfulness, psychopathological symptoms, 
+and academic performance in university students. Psychol Rep 
+2021;124:459‑78.
+Downloaded from http://journals.lww.com/mhhb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
+nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/20/2023

subfolder_0/DEVELOPMENT AND STANDARDIZATION OF JATARAGNI IMPAIRMENT CHECKLIST (JIC).txt

@@ -0,0 +1,983 @@
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+DEVELOPMENT AND STANDARDIZATION OF JATARAGNI 
+IMPAIRMENT CHECKLIST (JIC) 
+PKL Nandini1, Raghavendra Rao M2, Malur R Usharani2 
+Naik Radheshyam2, Nagarathna R1, Shubha H3 
+Dr. Mariyamma philip4 Shekhar G Patil2, Diwakar B Ravi2 
+ H P Shashidhara2, C T Satheesh2,  Basavalinga S Ajaikumar2 
+1. Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru 
+2. Health Care Global Enterprises Ltd., Bengaluru 
+3. Sri Kalabhireshwara Ayurvedic Medical College, Bengaluru 
+4. Department of Biostatistics, National Institute of Mental Health and Neurosciences, 
+Bangalore, 
+ 
+Introduction   
+Cancer treatment cause both physical & psychological distress (Haes 
+et al, 1990). Multiple physical distress symptoms are observed in 
+majority of patients during chemotherapy, either alone or cluster of 
+symptoms like nausea & vomiting, loss of appetite, taste alteration etc. 
+(Barsevick et al, 2006). Their intensity varies with type, stage and 
+treatment of the disease. (Rebecca Siegel, et al, 2012) It is observed 
+that, nausea does not occur as a single symptom, but a conglomeration 
+of symptoms like feeling sick, retching, loss of appetite and other 
+abdominal discomfort (GI disturbances) (Dodd et al,  2001, 2004). 
+Also, nausea has been relatively compared to vomiting as an ‘urge to 
+vomit’(Trikamji, 1935 Chap 20 Verse 6)Though vomiting is fairly 
+controlled with new antiemetic therapies, delayed nausea still remains 
+the most distressing concern experienced by seventy per cent of the 
+patients undergoing moderately emetogenic chemotherapy. As a result, 
+this subjective symptom is less understood and more so less treated. 
+Although Antiemetic’s are used to ease temporary nausea and 
+vomiting, some are known to cause side effects despite their clinical 
+benefits. (Osoba et al, 1997), (Feyer & Jordan, 2011) & (Roila et al, 
+2005) But use of antiemetic is necessary in CCINV.  
+1
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+Another significant problem is that, substantial gap remains between 
+antiemetic guidelines and practice (Angelis et al, 2003)with majority 
+of patients poorly controlled for Cancer Chemotherapy induced nausea 
+and vomiting –CCINV in developing countries.  Conventional 
+antiemetic questionnaires (Functional living Index Emesis and 
+Morrow Assessment of Nausea and Emesis) only measure nausea and 
+emesis and their impact on quality of life(Martin et al, 2003), whereas 
+other 
+accompanying 
+symptoms 
+such 
+as 
+anorexia, 
+abdominal 
+discomfort etc. causing patients’ distress are not elicited. Health in 
+Ayurveda is defined in individuals as equilibrium of dosha (three vital 
+Bio energy), Agni (Bio energy),dhatu (Tissue),mala (Waste products), 
+kriya (Physiology)  with sound soul, sense and mind (Trikamji, 1935 
+Chap 1 Verse 53 & 1981 Chap 15 Verse 44) •.  
+In order to address the problem in holistic way, we used concept of 
+“Agni” from Ayurveda scriptures to address this cluster of symptoms as 
+a manifestation of “Agni impairment” and that there are thirteen types 
+of Agni governing all cellular metabolic processes such as anabolism 
+and catabolism in all organ systems to bring about a change. (Haridasa 
+Samskritha Granthamala 106 Chap 11 Verse 34) & (Trikamji, 1935 
+Chap 15 Verse 3)Jataragni is the bio energy present in the GI tract. 
+Epicentred in duodenum and regulates the complete digestion and 
+assimilation process including gastric emptying phase of digestion and 
+regulates transit of food through the GI tract facilitating digestion 
+(Akash Kumar et al 2010)   The discomforts caused due to 
+chemotherapy are related to formation of “ama” because of sluggish 
+digestion 
+or 
+impaired 
+jataragni 
+(Haridasa 
+Samskritha 
+Granthamala 106 Chap 13 Verse 25 & 27) resulting in Vata 
+Pittajachardilakshanas, taken in the present study as CCINV (Trikamji, 
+1935 Chap 20 Verse 7 & 20)Ayurveda texts prescribe correction of 
+dosha imbalance and Agni ultimately through VayuNiyantrana 
+(directing the energy channels) (Trikamji, 1935 Chap 28 Verse 3 & 4). 
+2
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+So, improving Agni and gastric motility play a vital role in management 
+of CCINV. In this study we attempted to measure the impairment of 
+Jataragni using a checklist that measures symptomatic manifestation 
+of Agni impairment. This was done by collectively using all available 
+information from Ayurveda texts on impairment of Jataragni. 
+Aim and objective 
+To develop a comprehensive checklist to evaluate impaired Jataragni 
+level among the CCINV patients, test the measurability of the items in 
+the checklist and examine the reliability and validity of Checklist-JIC 
+Methods 
+Checklist development procedure 
+Comprehensive description of methods and steps are as follows: 
+(Vranda-2009) & (Kiran Rao et al, 1989,) 
+Phase-1 Pooling of items. Item reduction, Scale construction,   
+consensual validation. 
+Pooling of items 
+As a first step identification of the universe of item pool for the 
+checklist (Nunnaly, 1978; Messick1980), the researcher contacted 
+thirty different Ayurveda experts, explained the rationale of the study 
+and documented their views on Agni with respect to its various 
+functionalities and manifestations. In short, experts suggested that the 
+checklist should be based on symptoms of jataragni impairment, as the 
+study covers the role of jataragni in CCINV. A total of about 30 
+Jataragni impaired symptoms were listed as per the experts’ suggestion 
+with 
+references 
+from 
+Charakasamhitha, 
+Sushrutha 
+samhitha 
+Madhavanidana, Ashtangahrudaya, Ashtangahsangraha and text book-
+concept of Jataragni in Ayurveda with special reference to Jataragni 
+bala pariksha by Vd. Bhagwan Dash. Common Chemotherapy side 
+3
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+effects and cancer symptoms were also referred as per CTCAE criteria. 
+The original Sanskrit phrases, their meanings in English were compiled 
+as a checklist. Thus, thirty original sanskrit symptoms on jataragni 
+impairment formed the initial item pool of JIC. 
+Item reduction 
+Focus Group Discussion (FGD) I- In order to minimize the number of 
+symptoms in JIC, researcher conducted a group discussion programme-
+FGD I at Bangalore where a team of 10 Ayurveda experts were present 
+in the focus group discussion  for corrections and inclusions based on 
+appropriateness. The researcher posed each of the symptoms to the 
+group of experts. Those items which were completely agreed and voted 
+by five or more judges were retained in the checklist. Overlapping, 
+repeated, irrelevant ambiguous or vague items were eliminated. Thus a 
+total of nineteen symptoms formed the checklist and eleven were 
+eliminated. 
+Scale construction:  
+The scale was constructed keeping in mind the criteria for uniformity 
+in scoring using a Likert scale - none, mild, moderate and severe 
+(Likert-Zyzanski et al, 1974). After considering different bias of scale 
+construction, the experts also confirmed that the items of the checklist 
+were linguistically equivalent (Sanskrit terms were translated to 
+English). 
+FGD II- the researcher posed each of the 19 symptoms to the group 
+comprising five oncologists to conform the appropriateness of items. 
+Those items that received three or more votes were retained in the 
+checklist. They suggested that the symptom checklist be modelled on 
+Common Terminology Criteria for Adverse Events (CTCAE) Version 
+3.0. Field testing for confirming the measurability of the checklist was 
+carried out among both non cancer patients taking Ayurveda treatment 
+4
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+and those with cancer on chemotherapy. The provisional checklist was 
+customised and prepared accordingly. Field testing 1-was conducted at 
+Ayurveda collage Bangalore on ten patients. Outcome: checklist was 
+able to show the difference in the level of Agni impairment before and 
+after panchakarma treatment. Field testing 2-was conducted on cancer 
+patients at HCG who were undergoing first cycle of chemotherapy. It 
+was observed that the majority of patients had zero score for nausea 
+and vomiting items at baseline before chemotherapy. Verbal consent 
+was first obtained from all subjects prior to their study activities and 
+confidentiality was maintained regarding the information collected for 
+the research. No invasive procedures were used in the study. 
+Consensual and content validity 
+FGD III-Consensual and content validation of the JIC was done by 
+convening a expert group of 17 members from Ayurveda, oncology, yoga 
+and clinical psychology.  The experts were asked to validate each of the 
+items for, cultural relevance, clarity and ease with comprehension, 
+readability and suitability for a 4-point rating format. Those items 
+which were completely agreed and voted by nine or more judges 
+confirmed validity and were retained in the checklist. The experts 
+accepted the items subject to following conditions:  
+1.   To change the rating of scale from none, mild, moderate and severe 
+to none, asymptomatic but present occasionally or evident on clinical 
+examination, symptomatic and frequent but does not interfere with 
+GI function, Symptomatic but interferes with GI function in lines of 
+CTCAE criteria version 3 for a clear definition of the grade severity 
+(See JIC checklist).   
+2.  To capture symptoms other than Nausea and Vomiting to prove 
+divergent validity. 
+3.   To retain only thirteen symptoms for the checklist (Annexsure-1) 
+5
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+4. The patients simultaneously were to complete Visual analogue Scale 
+(Objective assessment).for 2 symptoms- Time interval between each 
+meal and Quantity taken at each meal. The provisional checklist was 
+customised and prepared accordingly Final JIC comprised of 13 
+symptoms (Annexsure-1).                                                     
+Phase-2 Pilot Study 
+Patients for pilot study were chosen from a randomised controlled 
+study conducted at Health Care Global (HCG) Bangalore i.e. from first 
+sixty randomized patients, 15 patients were randomly chosen 
+representing all the 3 groups equally- Random 5 from each group. Pilot 
+study was carried out with 13 items of checklist. Sampling procedure 
+was similar to main study. (Usharani et al, 2014)  
+The aim was to assess the feasibility and comprehensibility of checklist.  
+This 
+self-reported 
+checklist 
+was 
+found 
+to 
+be 
+readable 
+and 
+comprehendible. The checklist was able to capture the difference in the 
+jataragni impairment level before and after chemotherapy. The mean 
+time taken to complete the checklist was found to be 10minutes.                                     
+Phase-3       
+The final 13 items of JIC were tested to examine the measurability of 
+the checklist, to establish the norms for final interpretation of scores 
+and Standardization of Final 13-Items- for Validity and Reliability. 
+Sampling Procedure: 
+Study subjects: The study was carried out at Health Care Global 
+(HCG) Bangalore over 16 months period. (Usharani RM, et al)  
+Sample Size:  The sample size was based on the three arm original 
+study to evaluate the effects of yoga intervention to manage CCINV 
+(Usharani et al, 2014).    
+6
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+This study included patients with solid malignancies except those with 
+brain metastasises/ brain tumours and GI malignancies. 
+Ethical issues: The study was approved by institutional ethics 
+committee and written informed consent was taken from all 
+participants prior to their participation in the study.  
+JIC was administered prior to chemotherapy and post 6 days for 1st, 
+2nd, 3rd cycles of chemotherapy. Here simultaneously patient 
+completed the Jataragni checklist on par with FLIE quality-of-life (Qol) 
+questionnaire.  
+Results 
+The mean age of study sample was 49.3 ± 11.3 years. Data was not 
+normally distributed. 
+Reliability and validity: 
+Reliability: The reliability of 13 item JIC was good with Cronbachs 
+alpha=0.74 and inter rater reliability between three raters varied 
+between 0.68 to 0.80 
+Validity: Good divergent validity of JIC with FLIE indicating that it 
+captured items that were not captured in the FLIE. The kappa values, 
+ranges  between  0.01 to 0.09 across four cycles of chemotherapy in the 
+overall study sample, indicating divergent validity. Values within each 
+group also showed similar divergent validity compared to overall study 
+sample indicating that intervention did not influence validity of the 
+scale. This strong validity demonstrates the robustness of the scale to 
+capture Jataragni symptoms independent of FLIE (See table 1&2). The 
+evidence of content validity has already been established in the initial 
+phase. 
+ 
+ 
+7
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+Table 1: Divergent validity of Jataragni checklist with FLIE 
+TIME 
+Agni & 
+FLIE 
+similar 
+Agni & FLIE 
+dissimilar 
+ 
+Kappa 
+ 
+p-value 
+No (%) 
+D0 (n=120) 
+45  (37.5) 
+75  (62.5) 
+- 
+- 
+D7 (n=112) 
+57  (50.9) 
+55  (49.2) 
+0.064 
+0.318 
+C2 (n=104) 
+45  (43.3) 
+59   (56.7) 
+0.019 
+0.769 
+C3 (n=94) 
+48  (51.1) 
+46   (48.9) 
+0.097 
+0.097 
+- couldn’t calculate Kappa, as FLIE @ D0 was 0 for all 
+ 
+Symptom severity Symptoms were graded based on their presence 
+(subjective/clinical) and interference with GI function. Anorexia, taste 
+alteration and dry mouth were some of the major symptoms that 
+interfered with GI function.  Though most of these symptoms were 
+reported by patients many of them did not interfere with GI function 
+(See Table 2 &3).   
+ 
+Table 2:  Severity of symptoms related to agni in Jataragni 
+checklist 
+Cycle 
+Mild (1) 
+No (%) 
+Moderate (2)       
+No (%) 
+Severe (3) 
+ No (%) 
+D0 (n=120) 
+45 (37.5) 
+38 (31.7) 
+37(30.7) 
+D7 (n=120) 
+43(35.9) 
+38 (31.6) 
+39 (32.5) 
+C2 (n=109) 
+ 41  (37.6) 
+46  (42.2) 
+22   (20) 
+C3 (n=102) 
+ 39  (38.2) 
+32   (31.3) 
+31   (30.4) 
+ 
+ 
+8
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+Table 3: Severity of individual symptoms in Jataragni checklist 
+Symptoms 
+None 0 
+No (%) 
+Mild 1  
+No (%) 
+Moderate 
+2 
+No (%) 
+Severe 
+3 
+No (%) 
+Anorexia D5/7 
+41 (37) 
+45(40) 
+22(20) 
+3 (3) 
+C2 
+74 (69.2) 
+21 (19.6) 
+10 (9.3) 
+2 (1.9) 
+C4 
+61 (61.0) 
+25 (25.0) 
+11 (11.0)  
+3(3.0) 
+ConstipationD5/7 
+75 (68) 
+28 (25) 
+7 (6) 
+1(1) 
+C2 
+91 (85.0) 
+14 (13.1) 
+2 (1.9) 
+ 
+- 
+C4 
+81 (81.0)  
+16 (16.0)  
+2 (2.0)  
+1 (1.0) 
+Diarrhea D5/7 
+87(78.4) 
+19 (17.1) 
+4 (3.6) 
+1 (0.9) 
+C2 
+100 
+(93.5) 
+6 (5.6) 
+1 (0.9) 
+- 
+C4 
+90 (90.0) 
+9 (9.0) 
+1 (1.0) 
+- 
+Distention D5/7 
+75 (67.6) 
+29 (26.1) 
+5 (4.5) 
+2 (1.8) 
+C2 
+96 (89.7) 
+9 (8.4) 
+2 (1.9) 
+- 
+C4 
+80 (80.8) 
+14 (14.1) 
+4 (4.0) 
+1 (1.0) 
+Drymouth D5/7 
+48 (43.2) 
+51(45.9) 
+11(9.9) 
+1(0.9) 
+C2 
+63 (58.9) 
+31 (29.0) 
+12 (11.2) 
+1 (0.9) 
+C4 
+56 (56.0) 
+38 (38.0) 
+5 (5.0) 
+1 (1.0) 
+Flatulence D5/7 
+79 (71.2) 
+23 (20.7) 
+8 (7.2) 
+1 (0.9) 
+C2 
+89 (84.0) 
+11 (10.4) 
+6 (5.7) 
+- 
+C4 
+72 (72.0) 
+24 (24.0) 
+4 (4.0) 
+- 
+Heartburn D5/7 
+71 (64.0) 
+31 (27.9) 
+7 (6.3) 
+2((1.8) 
+C2 
+93 (86.9) 
+10 (9.3) 
+4 (3.7) 
+- 
+C4 
+78 (78.8) 
+17 (17.2) 
+4 (4.0) 
+ 
+Taste alteration 
+D5/7 
+40 (36.0) 
+46 (41.4) 
+24 (21.6) 
+1 (0.9) 
+C2 
+55 (51.4) 
+39 (36.4) 
+13 (12.1) 
+- 
+C4 
+37 (37.0) 
+37 (37.0) 
+25 (25.0) 
+1 (1.0) 
+Heaviness D5/7 
+75 (67.6) 
+28 (25.2) 
+8 (7.2) 
+- 
+C2 
+93 (86.9) 
+10 (9.3) 
+3 (2.8) 
+1 (0.9) 
+C4 
+80 (80.0) 
+17 (17.0) 
+3 (3.0) 
+- 
+Gurgling D5/7 
+81 (73.0) 
+28 (25.2) 
+2 (1.8) 
+- 
+C2 
+96 (90.6) 
+9 (8.5) 
+1 (0.9) 
+- 
+C4 
+81 (81.0) 
+17 (17.0) 
+2 (2.0) 
+- 
+Eructation D5/7 
+74 (66.7) 
+31 (27.9) 
+5 (4.5) 
+1 (0.9) 
+9
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+C2 
+88 (83.0) 
+17 (16.0) 
+1 (0.9 
+- 
+C4 
+82 (82.0)  
+14 14.0) 
+4 (4.0) 
+- 
+Excess salivation 
+D5/7 
+92 (82.9) 
+16 (14.4) 
+2 (1.8) 
+1 (0.9) 
+C2 
+101 
+(94.4) 
+5 (4.7) 
+1 (0.9) 
+- 
+C4 
+84 (84.0) 
+13 (13.0) 
+3 (3.0) 
+- 
+Quantity at each 
+meal D5/7 
+35 (31.5) 
+37 (33.3) 
+23 (20.7) 
+16 (14.4) 
+C2 
+51 (47.7) 
+36 (33.6) 
+16 (15.0) 
+4 (3.7) 
+C4 
+39 (39.0) 
+38 (38.0) 
+15 (15.0) 
+8 (8.0) 
+ 
+Cut off scores  
+The 33rd percentile cut off scores was 2 (mean across all chemo cycles) 
+and 66th percentile cut off was 6 (mean across all chemo cycles) in this 
+study for Jataragni impairment checklist.  
+Convergent Validity 
+Quantity of meal is an extrapolation of Agni quality as per ancient 
+texts (Trikamji, 1935 Chap 12 Verse 11). We compared the convergent 
+validity of all items on JIC with quantity of meal at chemotherapy 
+cycle. There  was a strong correlation on Spearmans rank correlation 
+at different chemotherapy cycles of total Agni of JIC with quantity of 
+each meal (All p’s=0.001). 
+ 
+ 
+ 
+ 
+ 
+ 
+10
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+4: Spearmans rank correlation between total agni with 
+quantity of each meal at different chemotherapy cycles.  
+ 
+Quantity of each meal at 
+various chemotherapy 
+cycles 
+         
+TOTALA
+GNI C1 
+TOTALAG
+NID5/7 
+TOTALA
+GNIC2 
+TOTALAG
+NIC4 
+Quantity At Each 
+Meal{C1}, N=116 
+.619**
+Quantity At Each 
+Meal{D5/D7}, N=111 
+.674**
+Quantity At Each 
+meal{C2}, N=107 
+.673**
+Quantity At Each 
+Meal{C4}, N=100 
+.641**
+**p<0.01, using Sperman’s rank correlation 
+Findings: 
+There was strong reliability for JIC to measure impairment in Agni. 
+There was a poor agreement between FLIE and Agni scores indicating 
+strong discriminant validity and suggesting that JIC measures a 
+construct different from that of FLIE. However this Checklist measures 
+only impairment of Agni and is more suited to chemotherapy setting as 
+it’s known to measure some acute effects. The results suggest that this 
+questionnaire captures subtleties of symptoms that need not 
+individually impair GI function but can collectively increase distress. 
+These symptoms so mentioned are subjective and similar to concept of 
+symptom clusters proposed by Dodd et al, 2001and 2004. 
+Secondly, this did show divergent validity with FLIE, but does not 
+mean that these symptoms had no impact on quality of life as FLIE 
+11
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+measured only the impact of nausea or emesis on their respective 
+quality of life domains and not a collective or global quality of life. 
+Third, being subjective checklist the ensuing psychologic distress could 
+have increased the symptomatology in these patients confounding the 
+effects. However despite these limitations these subjective symptoms 
+still elucidate impairment in jataragni. Ayurvedic texts also describe 
+that psychological distress is known to affect Agni imbalance, therefore 
+the presence of these symptoms and distress give more credence to 
+studying agni in this current context.  
+As per ancient texts Jataragni is a physiological entity which converts 
+the substance from biological level to physiological level. It is subtle and 
+its presence can only be felt and observed but not seen. JIC assessment 
+helps in clinical evaluation of the diseased- in predicting severity of the 
+adverse effects, planning management (dietary and pharmacological,) 
+and in prognosis. But it is a self-reported measure to capture distress 
+and not a diagnostic tool. It measures only presence or absence of 
+symptoms and its severity, if present. Thus a comprehensive tool to 
+evaluate and asses the whole aspects of GI disturbances in its literal 
+sense, as Western point of view is not contributing much in 
+understanding the complex mechanism and subtler aspect of patient’s 
+problems at a time because Chemotherapy further simulates these 
+symptoms, leading to hypo or hyper functioning of JatarJataragni 
+affecting Pachaka Pitta) (Trikamji, 1935 Chap 8 Verse 20) .Vitiated 
+Jataragni  ,situated as pachaka pitta influences and have a cascading 
+effect on other Jataragnis, and further aggravates pranadivayus 
+resulting in Nausea and Vomiting. 
+Suggestions: 
+There is a need to validate if this checklist can be used in other chronic 
+illnesses as well. Future studies should look at a larger population and 
+to develop ideal subscales using factor analysis.  
+12
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+References:  
+1. Akash Kumar Agrawal, C. R. Yadav and M. S. Meena .(2010) .  
+Physiological 
+aspectsof 
+Agni.Ayu. 
+Jul-Sep; 
+31(3):395–398.doi:  
+10.4103/0974-8520.77159PMCID: PMC3221079.  
+2. Andrea M. Barsevick, , Kyra Whitmer,, Lillian M. Nail, Susan L. and 
+William N. Dudley.(2006). Symptom Cluster Research: Conceptual, 
+Design, Measurement, and Analysis Issues. Journal of Pain and 
+Symptom Management Vol.31. 
+3. De Angelis V, Roila F, Sabbatini R. (Eds.). (2003) Cancer 
+chemotherapy-induced delayed emesis: antiemetic prescriptions in 
+clinical practice. 
+4. Dodd M, Miaskowski C & Paul SM. (2001). Symptom clusters and 
+their effect on the functional status of patients with    cancer. Oncol 
+Nurs  Forum; 28:465--470.  
+5. Dodd MJ, Miaskowski C & Lee KA. (2004). Occurrence of symptom 
+clusters. J Natl Cancer Inst Monogr 32:76--78. .  
+6. Feyer P and Jordan K. (2011). Update and new trends in antiemetic 
+therapy: the continuing need for novel therapies. Annals of 
+Oncology. 22(1):30-8.  
+7. Haridasa Samskritha Granthamala 106.  Ashtanga Hrudaya of 
+Vagbhata, Sootra Sthana; Doshadivijnaneedi: Chapter 11, Verse 34 
+.Chowkamba Press. 
+8. Haridasa Samskritha Granthamala 106.  Ashtanga Hrudaya of 
+Vagbhata, Sootra Sthana; Doshopakramaniyam: Chapter 13, Verse 
+25. Chowkamba Press. 
+9. Haridasa Samskritha Granthamala 106.  Ashtanga Hrudaya of 
+Vagbhata, Sootra Sthana; Doshopakramaniyam: Chapter 13, Verse 
+27 Chowkamba Press 
+13
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+10. J.C.J.M de Haes', F.C.E. van Knippenberg and  J.P. Neijt3. (1990). 
+Measuring psychological and physical distress in cancer patients: 
+structure and application of the Rotterdam Symptom Checklist. Br. 
+J. Cancer, 62, 1034-1038. 
+11. Kiran Rao,1 D.K. Subbakrishna,2 and G.G. Prabhu3. (1989) 
+development of a coping checklist—a preminary report, Indian J 
+Psychiatry Apr-Jun; 31(2): 128–133. PMCID: PMC2991673.  
+12. Martin AR, Pearson JD and Cai. B. (2003).  Assessing the impact of 
+chemotherapy-induced nausea and vomiting on patients' daily lives: 
+a modified version of the Functional Living Index-Emesis (FLIE) 
+with 5-day recall. Support Care Cancer. 11:522-7 
+13. Messick, S. (1980) Test validity and the ethics of assessment. 
+14. Nunnally, J.C. (1978) The psychological theory. New York: 
+MaGraw- Hill Company 
+15. Osoba D, Zee B, Pater J, Warr D, Latreille J and Kaizer L. 
+(1997).Determinants of postchemotherapy nausea and vomiting in 
+patients with cancer. Quality of Life and Symptom.  Journal of 
+clinical oncology. 15(1):116-23.  
+16. Rebecca Siegel, Carol DeSantis, Katherine Virgo, Kevin Stein, 
+Angela Mariotto, Tenbroeck Smith, Dexter Cooper, Ted Gansler, 
+Catherine Lerro, Stacey Fedewa, Chunchieh Lin, Corinne Leach, 
+Rachel Spillers Cannady, Hyunsoon Cho, Steve Scoppa, Mark 
+Hachey, Rebecca Kirch, Ahmedin Jemal, and Elizabeth Ward.(2012) 
+Cancer Treatment and Survivorship Statistics 
+17. Roila F, Warr D, Clark-Snow RA, Tonato M, Gralla RJ ,Einhorn LH 
+et al. (2005). Delayed emesis: moderately emetogenic chemotherapy. 
+Supportive care in cancer.;13(2):104-8. 
+14
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+18. Usharani RM, PKL Nandini, Raghavendra Rao M, Mahesh Kavya, S 
+Aishvarrya, et al. (2014) Comparison of Yoga vs. Relaxation on 
+Chemotherapy Induced Nausea and Vomiting Outcomes: A 
+Randomized 
+Controlled 
+Trial. 
+J 
+Integr 
+Oncol 
+3:116. 
+doi: 
+10.4172/2329-6771.1000116 
+19. Vaidya Jadavji Trikamji Acharya. (Ed.). (1935). Charaka Samhita of 
+Agnivesha revised by Charaka and Dridahabala. Sootra Sthana; 1I 
+ed. Chapter1 Verse 53. Nirnaya Sagar Press.  
+20. Vaidya Jadavji Trikamji Acharya. (Ed.). (1935). Charaka Samhita of 
+Agnivesha revised by Charaka and Dridahabala. Vimana Sthana;; 1I 
+ed. Chapter8 Verse 20 Nirnaya Sagar Press.  
+21. Vaidya Jadavji Trikamji Acharya. (Ed.). (1935). Charaka Samhita of 
+Agnivesha revised by Charaka and Dridahabala. Sootra Sthana; 1I 
+ed. Chapter12 Verse 11 Nirnaya Sagar Press.  
+22. Vaidya Jadavji Trikamji Acharya. (Ed.). (1935). Charaka Samhita of 
+Agnivesha revised by Charaka and Dridahabala. Sootra Sthana; 1I 
+ed. Chapter15 Verse 3. Nirnaya Sagar Press.  
+23. Vaidya Jadavji Trikamji Acharya. (Ed.). (1935). Charaka Samhita of 
+Agnivesha revised by Charaka and Dridahabala. Chikitsa Sthana; 1I 
+ed. Chapter20 Verse 6 Nirnaya Sagar Press.  
+24. Vaidya Jadavji Trikamji Acharya. (Ed.). (1935). Charaka Samhita of 
+Agnivesha revised by Charaka and Dridahabala. Chikitsa Sthana; 1I 
+ed. Chapter20 Verse 7  Nirnaya Sagar Press.  
+25. Vaidya Jadavji Trikamji Acharya. (Ed.). (1935). Charaka Samhita of 
+Agnivesha revised by Charaka and Dridahabala. Chikitsa Sthana; 1I 
+ed. Chapter20 Verse 20  Nirnaya Sagar Press.  
+15
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+26. Vaidya Jadavji Trikamji Acharya. (Ed.). (1935). Charaka Samhita of 
+Agnivesha revised by Charaka and Dridahabala. Chikitsa Sthana; 1I 
+ed. Chapter28 Verse 3&4 Nirnaya Sagar Press.  
+27. Vaidya Jadavji Trikamji Acharya. (Ed.). (1981). Sushrutha Samhita 
+of Sushrutacharya, Sootra Sthana; 1 ed,  Chapter 15 Verse 44. 
+Nirnaya Sagar Press.  
+28. M.N Vranda. (2009).Development and standardization of life skills 
+scale, Indian Journal of Social Psychiatry. 25(1-2), 17 - 28.  
+29. Zyzanski, S.J., Hulka, B.S., Cassel. J.C. (1974) Scale for 
+measurement of satisfaction with medical care: Modification of 
+content format scoring. Medical Care, 3, 294-323. American 
+Psychologist, 35, 1012-1027.         
+16
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+CHECKLIST FOR EVALUATING STATE OF AGNI WITH SPECIAL REFERENCE TO 
+JATARAGNI - JIC                                                                    
+Symptom 
+0 
+1 
+2 
+3 
+1. Anorexia 
+none 
+Loss of appetite without 
+alteration in eating 
+habits 
+Oral intake altered 
+without significant 
+weight loss or 
+malnutrition, oral 
+nutritional 
+supplements 
+indicated 
+Associated with significant 
+weight loss or malnutrition, IV 
+fluids, tube feeding or TPN 
+indicated  
+ 2. Constipation 
+none 
+Occasional or 
+intermittent symptoms, 
+occasional use of stool 
+softeners, laxatives, 
+dietary modification or 
+enema 
+Persistent 
+symptoms with 
+regular use of 
+laxatives or enema 
+indicated  
+Symptoms interfering with 
+ADL, obstipation with manual 
+evacuation indicated 
+3. Diarrhea 
+none 
+Increase of <4stools 
+/day over baseline,  
+Increase of 4-6 
+stools/day over 
+baseline, IV fluids 
+indicated <24hrs,  
+Increase of _> 7 stools/day over 
+baseline, incontinence, IV 
+fluids _>24hrs hospitalization,  
+4. Distension/ 
+bloating,  
+none 
+Asymptomatic but 
+evident on clinical 
+Symptomatic but 
+not interfering with 
+Symptomatic, interfering with 
+GI function 
+17
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+abdominal 
+examination 
+GI function 
+5. Dry mouth  
+none 
+Symptomatic(dry or 
+thick saliva) without 
+significant dietary 
+alteration,   
+Symptomatic and 
+significant oral 
+intake alteration,  
+Symptoms leading to inability 
+to adequately aliment orally, IV 
+fluids, tube feedings or TPN 
+indicated,  
+6. Flatulence 
+none 
+Asymptomatic but 
+evident on clinical 
+examination 
+Symptomatic but 
+not interfering with 
+GI function 
+Symptomatic, interfering with 
+GI function ---- 
+7. Heart 
+burn/Dyspepsia 
+none 
+Asymptomatic but 
+evident on clinical 
+examination 
+Symptomatic but 
+not interfering with 
+GI function 
+Symptomatic, interfering with 
+GI function 
+8. Taste 
+alteration 
+none 
+Altered taste but no 
+change in diet 
+Altered taste with 
+change in diet, 
+noxious or 
+unpleasant taste, 
+loss of taste. 
+---- 
+9. Gastro-
+intestinal-others 
+a) Heaviness of 
+abdomen 
+none 
+Asymptomatic but 
+evident on clinical 
+examination 
+Symptomatic but 
+not interfering with 
+GI function 
+Symptomatic, interfering with 
+GI function 
+18
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+b) Gurgling 
+sound in the 
+intestine 
+none 
+Asymptomatic but 
+evident on clinical 
+examination 
+Symptomatic but 
+not interfering with 
+GI function 
+Symptomatic, interfering with 
+GI function 
+c) Eructations 
+none 
+Asymptomatic or very 
+occasional 
+Symptomatic and 
+frequent  but not 
+interfering with GI 
+function 
+Symptomatic, interfering with 
+GI function 
+d) Excessive 
+salivation 
+none 
+Asymptomatic or very 
+occasional 
+Symptomatic and 
+frequent but not 
+interfering with GI 
+function 
+Symptomatic, interfering with 
+GI function 
+ 
+ Note: The symptoms mentioned as 9a, b, c, d categorized under gastrointestinal-others is graded 
+depending on the patient’s response (Subjective response) 
+19
+INTERNATIONAL JOURNAL OF MULTIDISCIPLINARY EDUCATIONAL RESEARCH 
+ISSN : 2277-7881; IMPACT FACTOR - 2.735; IC VALUE:5.16 
+VOLUME 3, ISSUE 8(4), AUGUST 2014 
+ 
+ 
+Reference: The grading of symptoms mentioned in the above checklist 
+is customized for this study based on Common Terminology Criteria for 
+Adverse Events (CTCAE) Version 3.0 published by U.S. Department of 
+health and human services, National Institutes of Health and National 
+Cancer Institute 
+20

subfolder_0/Design and validation of integrated yoga therapy module for antarctic expeditioners.txt

@@ -0,0 +1,406 @@
+Original Research Article
+Design and validation of Integrated Yoga Therapy module for Antarctic
+expeditioners
+Ragavendrasamy Balakrishnan a, Ramesh Mavathur Nanjundaiah a, *, Mohit Nirwan b,
+Manjunath Krishnamurthy Sharma c, Lilly Ganju b, Mantu Saha b, Shashi Bala Singh d,
+Nagendra Hongasandra Ramarao e
+a Molecular Biosciences Laboratory, Anvesana Research Laboratories, S-VYASA University, Bangalore, India
+b Defence Institute of Physiology and Allied Sciences, New Delhi, India
+c Anvesana Research Laboratories, S-VYASA University, Bangalore, India
+d Life Sciences Research Board, Defence Research and Development Organisation, New Delhi, India
+e S-VYASA University, Bangalore, India
+a r t i c l e i n f o
+Article history:
+Received 20 July 2017
+Received in revised form
+27 October 2017
+Accepted 18 November 2017
+Available online xxx
+Keywords:
+Yoga module
+Antarctica
+Stress
+IAYT
+a b s t r a c t
+Background: Extreme environments are inherently stressful and are characterized by a variety of physical
+and psychosocial stressors, including, but not limited to, isolation, confinement, social tensions, minimal
+possibility of medical evacuation, boredom, monotony, and danger. Previous research studies recom-
+mend adaptation to the environment to maintain optimal function and remain healthy. Different in-
+terventions have been tried in the past for effective management of stress. Yoga practices have been
+shown to be beneficial for coping with stress and enhance quality of life, sleep and immune status.
+Objective: The current article describes preparation of a Yoga module for better management of stressors
+in extreme environmental condition of Antarctica.
+Materials and methods: A Yoga module was designed based on the traditional and contemporary yoga
+literature as well as published studies. The Yoga module was sent for validation to forty experts of which
+thirty responded.
+Results: Experts (n ¼ 30) gave their opinion on the usefulness of the yoga module. In total 29 out of 30
+practices were retained. The average content validity ratio and intra class correlation of the entire
+module was 0.89 & 0.78 respectively.
+Conclusion: A specific yoga module for coping and facilitating adaptation in Antarctica was designed and
+validated. This module was used in the 35th Indian Scientific expedition to Antarctica, and experiments
+are underway to understand the efficacy and utility of Yoga on psychological stress, sleep, serum bio-
+markers and gene expression. Further outcomes shall provide the efficacy and utility of this module in
+Antarctic environments.
+© 2018 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
+Characteristics
+and
+determinants
+of
+human
+response
+to
+extreme environmental conditions prevailing in the Antarctic
+continent has interested psychologists and physiologists. Extreme
+environments are inherently stressful and are characterised by a
+variety of physical and psychosocial stressors including but not
+limiting
+to
+capsule
+environment,
+isolation,
+social
+tensions,
+boredom, monotony and danger [1]. The international commit-
+tees, COMNAP (The Council of Managers for National Antarctic
+Program) and SCAR (Scientific Committee of Antarctic Research),
+in addition to the organisers of the expedition from individual
+countries, are primarily concerned to enhance the overall well-
+ness of the members sent to the Antarctic stations. Even though
+scientific research is the primary goal of Antarctic expedition,
+equal importance is given to take care of the physical and psy-
+chological health of the expeditioners starting from selection of
+expeditioners to emergency evacuation to involving behavioural
+* Corresponding author.
+E-mail: [email protected] (R.M. Nanjundaiah).
+Peer review under responsibility of Transdisciplinary University, Bangalore.
+Contents lists available at ScienceDirect
+Journal of Ayurveda and Integrative Medicine
+journal homepage: http://elsevier.com/locate/jaim
+https://doi.org/10.1016/j.jaim.2017.11.005
+0975-9476/© 2018 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/).
+Journal of Ayurveda and Integrative Medicine xxx (2018) 1e4
+Please cite this article in press as: Balakrishnan R, et al., Design and validation of Integrated Yoga Therapy module for Antarctic expeditioners,
+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005
+scientist and psychologists to offering periodic support through
+online group or individual psychological counselling sessions for
+helping expeditioners deal with the stress [2].
+Several psychological and physiological changes are observed in
+Antarctic expeditioners. Psychological changes range from behav-
+ioural changes like aggression, mood swings to psychiatric prob-
+lems like depression [3]. Isolation seems to have a considerable
+effect. Isolation and inherent danger associated in Antarctic envi-
+ronment might enhance the extent of repetitive negative thinking
+based on the personality of the individual. Reports suggest an in-
+crease in smoking, loneliness, homesickness and a reduction in
+rapport during the isolated dark winter months [4]. Physiologically,
+decreased immune responsiveness accompanied with variations in
+circulating insulin, thyroid stimulating hormones, testosterone,
+cortisol, melatonin, pro-inflammatory Cytokines, 25-OH-vitamin D
+and a significant increase in total cholesterol have been recorded
+[5e8]. Some studies also suggest that such challenging environ-
+ments also turn to be salutogenic in certain individuals. With
+limited access to health care in the Antarctic environment, strate-
+gies are required to be adopted to promote overall psycho-physical
+wellness of an individual and also the group. Interestingly, Yoga
+practices have been known to be beneficial and promote psycho-
+physiological wellbeing across human cultures.
+Physical postures (asana), voluntarily regulated breathing (pra-
+nayama), and meditation (dhyana) are the three main components
+of Yoga practiced in India over thousands of years. In the past
+decade, Yoga has gained popularity as a fitness strategy and as well
+as an adjunct therapeutic tool in the management of obesity [9],
+diabetes [10], hypertension [11] and even auto-immune disorders
+[12]. Yoga practices have been shown to alleviate anxiety, fear
+[13,14], negative thinking [15], and enhance cardio-pulmonary
+fitness [16], immune status [17,18], and also telomere length [19]
+in regular practitioners. Yoga practices improve the overall sleep
+efficiency and total sleep time [20]. Yoga practice in high altitudes
+showed a lower reduction in oral temperature and lower increase
+in Oxygen consumption and energy expenditure compared to
+physical therapy [21]. Meta-analysis of data on Yoga recommend
+Yoga to be considered as an ancillary treatment option in the
+management of depressive disorders [22].
+A study was conducted on the summer and wintering over
+members of the 35th Indian Scientific Expedition Members to
+Antarctica to understand the role of Yoga practices on facilitating
+human adaptation to extreme climatic conditions. Even though
+Yoga practices are known to be beneficial for individuals irre-
+spective of their health and disease states, it is essential to structure
+specific Yoga practices that are intended to provide most benefits.
+Yoga practices for Antarctica were designed with the following
+objectives:
+i. To regulate mood and alleviate psychological stress caused
+due to isolation
+ii. To enhance physical wellness, overcome fatigue and regulate
+metabolism
+iii. To enable better thermoregulation
+iv. To
+enhance
+better
+sleep
+and
+promote
+interpersonal
+relationship
+The objectives were listed based on the earlier reports on the
+psychological and physiological changes in Antarctic expeditioners.
+Practices identified were compiled together to promote calmness of
+mind and sleep, overcome stress and fatigue, promote overall
+endurance of the body, regulate digestion, metabolism and enable
+better pulmonary functions (supplementary material 1). The cur-
+rent study present the data on the designing and validation of the
+Yoga module that was implemented in the expedition members.
+2. Materials and methods
+The classical and contemporary yoga texts were reviewed to
+develop the content of the Yoga module. Texts on Yoga Sutras of
+Patanjali, Hatha Yoga Pradipika, Shiva Samhitha, Gheranda Samhita,
+Hatharathnavali, Bhagavad Gita, Upanishads, Yoga Vashishta and
+Yogic Sukshma Vyayama were reviewed [23e31]. Practices that
+might be difficult for the expeditioners to practice and those that
+are contra-indicated in common disorders such as hypertension
+and cardiovascular disorders were not included. Similarly, those
+practices that were difficult to objectively verify and certain
+Sükshma vy€
+ay€
+ama (loosening exercise) practices that might not be
+feasible to practice in group inside the Antarctic stations like
+Jangha Shakti vikasaka [31] were not included. The Yoga module
+that was designed consisted of postures with slow movements
+and breath
+awareness, loosening exercises, suryanamaskara,
+asana, pra€
+eayama, relaxation and nadanusandhana. The duration
+of the entire practice is 1 h.
+The Yoga module was sent along with the objectives to forty
+yoga experts out of whom thirty responded with their scores and
+comments. Members with allopathic & AYUSH streams of med-
+icine with post graduate medical degree in Yoga therapy, re-
+searchers with doctoral degree in yoga, and yoga & naturopathic
+physicians with over 7 years of clinical experience were consid-
+ered to be included in the expert panel for validating the Yoga
+module. The experts rated the usefulness of the module on a
+scale of 1e5 (1 not at all useful, 2 a little useful, 3 moderately
+useful, 4 very useful, 5 extremely useful). Content Validity Ratio
+(CVR) for suitability of items was calculated following Lawshe's
+method [32]. Dichotomous (yes/no) responses were obtained to
+determine the duration of the individual practice and the entire
+yoga session.
+2.1. Statistical analysis
+Lawshe's CVR ratio was calculated [32] for each item in the
+module. Items with a CVR of 0.6 and above were considered beyond
+change agreement (p < 0.05, one tailed) for 30 experts. Intra class
+correlation was calculated for inter-rater reliability [33].
+3. Results
+Thirty experts in Yoga therapy and research consented to
+contribute to the content validation of the Yoga module for
+extreme Antarctic environmental conditions. These Yoga experts
+had experience in various traditions of Yoga. The experts age
+ranged from 32 to 50 years (mean 36.3 ± 4.17 years). The average
+experience following formal yoga training was 12.3 years
+ranging between 8 and 26 years. The scores obtained for the
+individual practices and the calculated CVR are shown in the
+supplementary material 2. One practice viparitakarani with CVR
+<0.6 was excluded. The average CVR for the entire Yoga module
+was 0.89. Good agreement is noted for most practices listed in
+the yoga module. Intra Class Correlation [33] for the entire
+module was 0.78.
+All
+the experts opined on the need
+for practicing
+Sur-
+yanamaskara (sun salutation), relaxation and breath awareness
+based practices and pranayama. Most experts agreed on the dura-
+tion of 1 h for the Yoga practices (Table 1). In addition to the
+practices that were asked to be scored by experts, seven experts
+recommended to include vaman dhauti kriya (voluntarily induced
+vomiting after drinking saline water in empty stomach). But, was
+not considered in module due to challenges in water treatment and
+discharge at Antarctica.
+R. Balakrishnan et al. / Journal of Ayurveda and Integrative Medicine xxx (2018) 1e4
+2
+Please cite this article in press as: Balakrishnan R, et al., Design and validation of Integrated Yoga Therapy module for Antarctic expeditioners,
+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005
+4. Discussion
+The Yoga module for application in the extreme Antarctic con-
+ditions appears to be acceptable for most of the experts. Similar
+strategy was used in earlier studies for validating yoga modules for
+various pathological conditions [34,35].
+The experts from different schools of yoga were in agreement
+with the contents of the module. Only viparitakarani was not fav-
+oured to be included in the final module as indicated by the CVR
+score (<0.6). Seven experts suggested including vaman dhauti kriya.
+However, with concerns over processing the waste water and
+maintenance in the Antarctic stations and the decision of experts
+not being unanimous, the recommendation was not taken further
+into validation.
+Several interventions like psychiatric counselling, group ther-
+apy, medications and diet are tried on the expeditioners to reduce
+their psycho-physiological stress. Yoga, a widely accepted reliever
+of stress [36], has never been tried in Antarctica until now. Also, the
+strengths of this module is that it consists of simple postures that
+are easy to follow and as the practices are derived from traditional
+yoga texts, yoga instructor following any school of Yoga should be
+able to teach the module. The classical Yoga texts does not describe
+specific symptom based guidelines for their practice e as the pri-
+mary objective of Yoga practices is to gain mastery over mind [26]
+and the observed physical and mental benefits might be actual by-
+product of yoga practice. Therefore, the practices have been
+selected from the texts based on the approximating descriptions of
+mental and physical health benefits of specific Yoga practices and
+that are feasible to be practiced at the Indian Antarctic station. This
+is the first attempt made to administer structured Yoga practices
+with an objective to understand its mechanisms of action in iso-
+lated, stressful and extreme Antarctic conditions. The effect of the
+Yoga intervention will be known when the study on the summer
+[Voyage team] and wintering over [Bharati, Larsemann hills,
+(692402800S 761101400E)] members of the 35th Indian Scientific
+Expedition to Antarctica will be analysed for changes in their psy-
+chological stress, sleep, serum biomarkers, and gene expression
+regulations.
+5. Conclusion
+A comprehensive and traditional text based Yoga module was
+developed as an intervention to facilitate coping up with the psy-
+chological and physiological stressors in the Antarctica. The Yoga
+module was validated by 30 experts who agreed to most of the
+practices. The final module was used as an intervention in the 35th
+Indian Scientific Expedition to Antarctica. Testing of efficacy of the
+intervention on alleviating psycho-physiological stress at genetic
+and molecular level is underway and might prove to be an efficient
+way to deal the stressors associated with the extreme Antarctic
+environments.
+Funding
+This project was funded by Defence Institute of Physiology and
+Allied Sciences, New Delhi (TC/DIP-265/CARS-05/DIPAS/2-15).
+Acknowledgements
+The authors acknowledge all the experts for offering their
+comments and inputs to develop this module.
+Appendix A. Supplementary data
+Supplementary data to this article can be found online at
+https://doi.org/10.1016/j.jaim.2017.11.005.
+References
+[1] Suedfeld P. Applying positive psychology in the study of extreme environ-
+ments. Hum Perform Extreme Environ 2001;6. p 21e5.
+[2] Suedfeld P, Steel GD. The environmental psychology of capsule habitats. Annu
+Rev Psychol 2000;51. p 227e53.
+[3] Gunderson EKE. Emotional symptoms in extremely isolated groups. Arch Gen
+Psychiatr 1963;9. p 362.
+[4] Bhargava R, Mukerji S, Sachdeva U. Psychological impact of the Antarctic
+winter on Indian expeditioners. Environ Behav 2000;32. p 111e27.
+[5] Muller HK, Lugg DJ, Ursin H, Quinn D, Donovan K. Immune responses during
+an Antarctic summer. Pathology 1995;27. p 186e90.
+[6] Sawhney RC, Malhotra AS, Prasad R, Pal K, Kumar R, Bajaj AC. Pituitary-
+gonadal hormones during prolonged residency in Antarctica. Int J Biometeorol
+1998;42. p 51e4.
+Table 1
+List of Practices.
+R. Balakrishnan et al. / Journal of Ayurveda and Integrative Medicine xxx (2018) 1e4
+3
+Please cite this article in press as: Balakrishnan R, et al., Design and validation of Integrated Yoga Therapy module for Antarctic expeditioners,
+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005
+[7] Farrace S, Cenni P, Tuozzi G, Casagrande M, Barbarito B, Peri A. Endocrine and
+psychophysiological aspects of human adaptation to the extreme. Physiol
+Behav 1999;66. p 613e20.
+[8] Steinach M, Kohlberg E, Maggioni MA, Mendt S, Opatz O, Stahn A, et al. Sleep
+quality changes during overwintering at the German antarctic stations neu-
+mayer II and III: the gender factor. PLoS One 2016;11, e0144130.
+[9] Bernstein AM, Bar J, Ehrman JP, Golubic M, Roizen MF. Yoga in the manage-
+ment of overweight and obesity. Am J Lifestyle Med 2014;8. p 33e41.
+[10] Nagarathna R, Usharani MR, Rao AR, Chaku R, Kulkarni R, Nagendra HR. Ef-
+ficacy of yoga based life style modification program on medication score and
+lipid profile in type 2 diabetesda randomized control study. Int J Diabetes
+Dev Ctries 2012;32. p 122e30.
+[11] Hagins M, States R, Selfe T, Innes K. Effectiveness of yoga for hypertension:
+systematic review and meta-analysis. Evid base Compl Alternative Med
+2013;2013. p 649836.
+[12] Dash M, Telles S. Improvement in hand grip strength in normal volunteers
+and rheumatoid arthritis patients following yoga training. Indian J Physiol
+Pharmacol 2001;45. p 355e60.
+[13] Smith C, Hancock H, Blake-Mortimer J, Eckert K. A randomised comparative
+trial of yoga and relaxation to reduce stress and anxiety. Compl Ther Med
+2007;15. p 77e83.
+[14] Telles S, Naveen KV, Dash M. Yoga reduces symptoms of distress in tsunami
+survivors in the Andaman Islands. Evid base Compl Alternative Med 2007;4.
+p 503e9.
+[15] Frewen PA, Evans EM, Maraj N, Dozois DJA, Partridge K. Letting go: mind-
+fulness and negative automatic thinking. Cognit Ther Res 2008;32. p 758e74.
+[16] Raub JA. Psychophysiologic effects of Hatha yoga on musculoskeletal and
+cardiopulmonary function: a literature review. J Alternative Compl Med
+2002;8. p 797e812.
+[17] Jiang Q, Li A, Zhang X. Research on the effect of yoga on the lgG level of college
+students. J Mianynag Norm Univ 2009;5.
+[18] Rao RM, Nagendra HR, Raghuram N, Vinay C, Chandrashekara S, Gopinath KS,
+et al. Influence of yoga on mood states, distress, quality of life and immune
+outcomes in early stage breast cancer patients undergoing surgery. Int J Yoga
+2008;1. p 11e20.
+[19] Epel E, Daubenmier J, Moskowitz JT, Folkman S, Blackburn E. Can meditation
+slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres. Ann
+N Y Acad Sci 2009;1172. p 34e53.
+[20] Khalsa SBS. Treatment of chronic insomnia with yoga: a preliminary study
+with
+sleep-wake
+diaries.
+Appl
+Psychophysiol
+Biofeedback
+2004;29.
+p 269e78.
+[21] Selvamurthy W, Ray US, Hegde KS, Sharma RP. Physiological responses to cold
+(10C) in men after six months' practice of yoga exercises. Int J Biometeorol
+1988;32. p 188e93.
+[22] Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: a systematic
+review and meta-analysis. Depress Anxiety 2013;30. p 1068e83.
+[23] Müller FM, Friedrich M. Upanishads : the holy spirit of Vedas : earliest phil-
+osophical compositions also known as Vedanta. Vijay Goel; 2007.
+[24] Swami SP. The Bhagavad Gita, vol. 19. Books Abroad; 1945. p. 150.
+[25] Iyengar BKS. Light on the Yoga Su
+̄
+tras of Patan
+e
+jali. Harper Collins; 1996.
+[26] Taimni IK, Iqbal K, Patan
+e
+jali. The science of yoga : the yoga sutras of Patanjali.
+Theosophical Publishing House; 1999.
+[27] Satyananda Saraswati S. Four chapters on freedom : commentary on Yoga
+sutras of Patanjali. Yoga Publications Trust; 2002.
+[28] Gharote ML, Devnath P, Jha VK. S
+́
+ri
+̄
+niva
+̄
+sayogi
+̄
+active 17th century. India):
+Hatharatna
+̄
+vali
+̄
+. Lonavala Yoga Institute; 2002.
+[29] Muktibodhananda SS, Satyananda SS. Hatha yoga Pradipika. Bihar, Yoga
+Publications Trust; 1998.
+[30] Niranjanananda Saraswati S. Gheranda Samhita. Bihar, Yoga Publications
+Trust; 2012.
+[31] Brahmachari Dhirendra. Yogic suksma vyayasama. Illustrated. Indian Book
+Company; 1975.
+[32] Lawshe CH. A Quantitative approach to content validity. Person Psychol
+1975;28. p 563e75.
+[33] Harris JA. On the calculation of intra-class and inter-class coefficients of cor-
+relation from class moments when the number of possible combinations is
+large. Biometrika 1913;9. p 446e72.
+[34] Kakde N, Metri KG, Varambally S, Nagaratna R, Nagendra HR. Development
+and validation of a yoga module for Parkinson disease. J Compl Integr Med
+2017;14.
+[35] Varambally S, Varambally P, Thirthalli J, Basavaraddi I, Gangadhar B,
+Hariprasad V. Designing, validation and feasibility of a yoga-based interven-
+tion for elderly. Indian J Psychiatr 2013;55. p 3442.
+[36] Li AW, Goldsmith CAW. The effects of yoga on anxiety and stress. Altern Med
+Rev 2012;17. p 21e35.
+R. Balakrishnan et al. / Journal of Ayurveda and Integrative Medicine xxx (2018) 1e4
+4
+Please cite this article in press as: Balakrishnan R, et al., Design and validation of Integrated Yoga Therapy module for Antarctic expeditioners,
+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005

subfolder_0/Development of a Trans-disciplinary Intervention Module for Adolescent Girls on Self-awareness.txt

@@ -0,0 +1,643 @@
+Journal of Clinical and Diagnostic Research. 2017 Aug, Vol-11(8): VC07-VC10
+7
+DOI: 10.7860/JCDR/2017/25765.10462
+Original Article
+Psychiatry/Mental 
+Health Section
+Development of a Trans-disciplinary 
+Intervention Module for Adolescent 
+Girls on Self-awareness 
+Jasmine Mary John1, Janardhan Navneetham2, H R Nagendra3
+Keywords:	Adolescence, Females, Mental health promotion
+ABSTRACT
+Introduction: Mental health promotion among adolescents 
+has been a key area of intervention for professionals working 
+with children and adolescents. The opinions of experts in the 
+field of mental health have taken to frame a trans-disciplinary 
+intervention for adolescent girls on self awareness. 
+Aim: To discuss the development and validation of a structured 
+intervention by combining the knowledge from different 
+disciplines in helping adolescents enhancing self awareness.
+Materials and Methods: Both qualitative and quantitative 
+methodologies were followed for the development and validation 
+of the module. First phase of the development of intervention 
+module was the framing of intervention module after conducting 
+in-depth interviews with experts in both mental health and yoga 
+fields. Six experts each from mental health and yoga field were 
+chosen for interview through convenient sampling. Validated 
+interview guides were used for the process. The framed 
+intervention module was given to six mental health experts 
+and six yoga experts for content validation. The experts rated 
+the usefulness of the intervention on a scale 0-4 (4=extremely 
+helpful).
+Results: The themes derived in the interviews were importance 
+of self awareness, autonomy of self, physical level of self 
+understanding, self regulation of emotions and self monitoring. 
+The interviews were consolidated to frame the intervention 
+module consisting of eight sessions having two parts in each 
+session. Part one of each session is activities and interactions 
+on mental health and part two is guided instructions for body 
+focused meditation.  Sessions were finalized with rating and 
+suggestions from the experts. The final version of the module 
+was pilot tested and had found to have enhanced self awareness 
+among adolescent girls. 
+Conclusion: Integration of multiple disciplines brought in novel 
+perspectives in intervention. 
+INTRODUCTION
+Adolescence is a developmental period with many major internal and 
+external changes. Developmental challenges during adolescence 
+includes increased need for independence, evolving sexuality, 
+consolidating advanced cognitive abilities, negotiating changing 
+relationships in family, peers and broader social connections [1]. 
+This paper discusses the development of a structured intervention 
+in combining the knowledge from different disciplines in helping 
+adolescents enhancing self awareness. The opinions of experts in 
+the field of mental health and yoga were sought to frame a trans-
+disciplinary intervention for adolescent girls on self awareness. 
+Interventions aimed at adolescent population in Indian context 
+majorly include adolescent health education, sexual and 
+reproductive health, sexuality and sexual abstinence etc., [2]. Life 
+skills education programmes and resilient training have brought in 
+significant changes in the self-esteem, motivation and self-efficacy 
+of adolescents [3]. 
+The concept of self awareness has higher meanings in transcendental 
+terms but for an adolescent who is going through the developmental 
+stage; it is about knowing about the physical changes in oneself 
+and understanding where their thoughts and emotions take them. 
+Studies on awareness in adolescents had majorly looked into their 
+knowledge about the physical changes [4,5]. Self as a construct 
+in an individual is developed in relation with their interaction with 
+others in the society. Recent understanding of self could be seen 
+as the accumulation of experiences one gains by the continuous 
+interaction with the environment [6]. 
+Children could safely practice meditation and simple breathing 
+exercises as long as the breath is never held. Children trained in 
+these techniques are better able to manage emotional upsets and 
+cope with stressful events [7]. A study recommended carefully 
+constructed research to enhance understanding of sitting meditation 
+and its future use as an effective treatment modality among younger 
+population [8]. Body focused techniques help in understanding the 
+subtle changes of physical body frame [9] and subjective features of 
+internal body responses [10]. Although self awareness and physical 
+changes of adolescence has been addressed in many of these 
+studies, we couldn’t find any intervention modules with combined 
+modalities like knowledge, awareness relaxation, breathing exercises 
+or meditation. 
+The current research was carried out between the months of 
+February, 2015 to October, 2015 in Bengaluru, Karnataka, India, 
+with the aim of developing a trans-disciplinary intervention module 
+for adolescent girls on self awareness.
+MATERIALS AND METHODS 
+The development of the module was carried out in two phases. 
+The Phase 1 was the consolidation of ideas and techniques into 
+framing the intervention module through literature reviews and in-
+depth interviews with experts in the field. Interview guides were 
+prepared through literature review [10-12]. Separate probes were 
+framed for mental health experts and yoga professionals and 
+validated. In-depth interviews were conducted among six mental 
+health experts and six yoga practitioners to know the preferences 
+of the professionals in aspects of designing the intervention like the 
+structure and content of intervention module. Mental health experts 
+included psychiatric social workers, clinical psychologists and 
+psychiatrists who had knowledge and experience in child mental 
+health. All of the experts were professors in the respective fields. Six 
+mental health experts from three different institutions were chosen 
+for the in-depth interview. Yoga professionals were those experts in 
+Jasmine Mary John et al., Development of a Trans-Disciplinary Intervention Module for Adolescent Girls on Self-Awareness	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2017 Aug, Vol-11(8): VC07-VC10
+8
+yoga and meditation who were professors and practitioners in yoga 
+education. Experts for the interview were selected by convenient 
+sampling method. Researcher personally contacted the experts 
+and interviews were conducted at their offices. The interviews were 
+later transcribed and themes were identified. Thematic analysis 
+was carried out to categorize the commonly accepted themes from 
+the interview. Intervention module was prepared from the topics 
+discussed and themes derived. 
+Phase 2 was a quantitative phase wherein the validation of the 
+framed module was done quantitatively. Six experts from each field 
+who were not part of the interview were contacted personally by 
+researcher for validation. Out of the six experts in mental health field, 
+two were psychiatric social workers, two were clinical psychologists 
+and two were psychiatrists; all working as professors and assistant 
+professors. All the six experts in yoga were having Doctoral degree 
+in yoga. 
+Ethical consideration: Prior permission was taken from each of the 
+experts for in-depth interviews and validation. Interviews were done 
+by researcher by visiting their offices with prior appointment. The 
+objectives of the interview were explained and informed consent 
+was taken from each of them. Consent for audio recording was 
+sought for and done for all who agreed for. Confidentiality maintained 
+while transcribing the interviews. The research had received ethical 
+clearance from Institute Ethical Committee, National Institute of 
+Mental Health and Neuro Sciences, Bengaluru, Karnataka, India. 
+RESULTS
+Phase 1
+In-depth Interview
+The main theme derived was the importance of self awareness. 
+There were four sub themes emerged from the interview. Some 
+of the voices corresponding to the theme and sub themes are 
+discussed below.  
+Main theme: Importance of self-awareness
+Most of the experts had given their opinion on the importance of 
+self awareness. 
+“Awareness of what they are good at; what they  are not good at; 
+what their strengths are; weaknesses are; those things.”(MH 4)
+“A holistic approach is needed to enhance awareness in the girl. 
+(MH 5) 
+With better awareness of oneself, they would gain confidence to 
+face and deal with day to day issues in a better way. The yoga 
+practitioners opined the need of clearly demarcating the self 
+awareness in adolescent period from that of older people. 
+Sub themes
+1. Autonomy of self: Experts viewed that seeking autonomy is a 
+prime factor during adolescence, and intervention on self awareness 
+helps in the achievement of autonomy. 
+“..so as part of the development itself during that phase, their style 
+of functioning was of seeking freedom and also they do not want to 
+get dependant on the parents.” (MH 1)
+Experts shared that though dependence on peers is seen in 
+adolescents, they want to experience their freedom and hence the 
+responsibility of understanding about self can be given to a growing 
+individual. 
+2. Physical level of self understanding: The need for physical 
+level of understanding for adolescent was enquired into. 
+Mental Health 
+intervention 
+sessions 
+Scoring (0-4) (Number of 
+experts)
+n (%) of 
+experts rat­
+ing  ≥2
+Content 
+Validity 
+Ratio
+MH session 1
+0 (0)
+1 (1)
+2 (1)
+3 (4)
+4 (0)
+5 (83.33)
+0.6
+MH session 2
+0 (0)
+1 (0)
+2 (1)
+3 (3)
+4 (2)
+6 (100)
+1.0
+MH session 3
+0 (0)
+1 (0)
+2 (0)
+3 (4)
+4 (2)
+6 (100)
+1.0
+MH session 4
+0 (0)
+1 (0)
+2 (0)
+3 (3)
+4 (3)
+6 (100)
+1.0
+MH session 5
+0 (0)
+1 (0)
+2 (1)
+3 (3)
+4 (2)
+6 (100)
+1.0
+MH session 6
+0 (0)
+1 (0)
+2 (0)
+3 (2)
+4 (4)
+6 (100)
+1.0
+MH session 7
+0 (0)
+1 (0)
+2 (0)
+3 (3)
+4 (3)
+6 (100)
+1.0
+MH session 8
+0 (0)
+1 (0)
+2 (0)
+3 (4)
+4 (2)
+6 (100)
+1.0
+[Table/Fig-2]: Content validity ratio of mental health intervention sessions. 
+[Table/Fig-1]: Session wise details of the module: Each session has introduction 
+and conclusion activities ranging from 10 to 15 minutes.
+Part 1: 
+Part 2:
+Session 1
+Mental Health Intervention 
+Introductory session: 
+Ice breaking and knowing 
+oneself. 
+Duration: 25 minutes
+Body Focused Meditation
+Sitting 
+posture 
+was 
+described; 
+Breathing awareness and conclusion 
+with wareness of outer space
+Duration of part 2: 5 minutes
+Session 2
+Self; “I, me and myself”. 
+Session on knowing about 
+oneself.  
+Duration: 30 minutes
+Berating awareness and concluding 
+with awareness of outer space
+Duration was 5 minutes
+Session 3
+Multiple selves, one’s 
+functioning in different 
+social roles. 
+Duration: 28 minutes
+Detailing of breathing-inhaling and 
+exhaling with awareness of physical 
+body part, subtle movement of body 
+while breathing etc. Closure with 
+awareness of outer space
+Duration was 7 minutes 
+Session 4
+Session on physical 
+body awareness. Body 
+mapping. 
+Duration: 25 minutes
+Sitting descriptions and brief outer 
+awareness, detailing of breath with 
+physical awareness, awareness of 
+body part on a bottom to top manner 
+and closure with awareness of outer 
+space.
+From this session onwards, duration 
+of instructions was 10 minutes
+Session 5
+Emotions- identification 
+and regulation.  
+Duration: 25 minutes
+Brief sitting description with more 
+autonomy for them to get settle. 
+Awareness on body parts; to do on 
+their own with freedom given to choose 
+between top to bottom or bottom 
+to top approach, reminding of any 
+incident where emotions experienced 
+with increased awareness about body 
+parts feelings in its memory. 
+Long and slow breathing instructions. 
+(to help them come out of the changes 
+in body created by memory); Brief 
+positive suggestions and closure with 
+outer awareness.
+Duration was 10 minutes
+Session 6
+Identifying emotional 
+responses during 
+interpersonal situations 
+and an activity to letting 
+of oneself (guided 
+instructions)
+Duration: 25 minutes
+Awareness on body parts; to do 
+on their own with freedom given to 
+choose between top to bottom or 
+bottom to top approach with focus on 
+specific sensations which they would 
+be aware of and positive suggestions 
+on 
+confidence 
+and 
+experiencing 
+relaxation.
+Duration was 10 minutes
+Session 7
+3 R’s: Reacting, 
+responding and 
+Responsible.  
+Duration: 25 minutes
+Awareness on body parts; to do 
+on their own with freedom given to 
+choose between top to bottom or 
+bottom to top approach with focus on 
+specific sensations which they would 
+be aware of, positive suggestions 
+and confidence and future life and 
+experiencing relaxation.
+Duration was 10 minutes
+Session 8
+Introducing the concept 
+of monitoring device and 
+conclusion. 
+Duration: 25 minutes
+Sitting descriptions and brief outer 
+awareness Awareness on body parts; 
+to do on their own with freedom given 
+to choose between top to bottom or 
+bottom to top approach with focus on 
+specific sensations which they would 
+be aware of and positive suggestions 
+on 
+confidence 
+and 
+experiencing 
+relaxation.
+Duration was 10 minutes
+www.jcdr.net	
+ Jasmine Mary John et al., Development of a Trans-Disciplinary Intervention Module for Adolescent Girls on Self-Awareness
+Journal of Clinical and Diagnostic Research. 2017 Aug, Vol-11(8): VC07-VC10
+9
+“they can be given guided instruction to focus on big to  smaller 
+things..by starting with awareness of external reality, like listening to 
+the sounds..breath and then each part of the body..”(YP 4)
+The use of physical body as a frame for focusing also was opined 
+by experts. The process helps one in reconstruction of one’s idea 
+about one’s physique. 
+3. Self regulation of emotions: Majority of experts stated that the 
+emotional regulation can be a significant part in self awareness. 
+“ immediate emotional reactivity is something that they need to 
+examine in and learn to tone it down and delay it..” (MH 6)
+They can cognitively understand the world, but the understanding 
+their own emotions and those with whom they interact with, 
+becomes difficult due to their age. 
+4. Self-monitoring: Experts suggested encouraging self monitoring 
+of adolescent even after the intervention. 
+“..They can write it and discuss with someone if required. Recording 
+it and even discussing with peers under supervision helps them to 
+understand them better.” (YP 3)
+Both mental health experts and yoga practitioners shared the view 
+of having self monitoring frameworks for continued understanding 
+of oneself. 
+The Module: After analysing the interviews and conducting further 
+discussions among the authors, the intervention module was framed 
+focusing on three aspects: 
+1.	
+Knowledge of physical changes during adolescent period;
+2.	
+Knowledge about emotional fluctuations during adolescence;
+3.	
+A technique to enable them to understand and accepts these 
+changes. 
+The part I of the intervention addressed the first two aspects and 
+part II of the intervention addresses the third aspect. Thus the 
+intervention module had eight sessions with two parts in each 
+session. The methodology used in Part I was interaction, activity 
+and group based activities. Part II was activity based on body 
+focused meditation, in which, guided instructions were given to the 
+participants of the intervention. 
+[Table/Fig-1] detailed the intervention module which was 
+consolidated from the responses discussed and topics derived. The 
+intervention module has got eight sessions with two parts in each 
+session. Each session had an introductory discussion, followed 
+by the main section of intervention (which had two parts-Mental 
+Health Intervention and Body Focused Meditation) and a conclusion 
+discussion. Each session of the intervention module was timed for 
+45-50 minutes. The introductory discussion was for less than ten 
+minutes of duration. The methodology used in Part I of the main 
+section was that of interaction, individual activity and group based 
+activities. Part II had activity based on body focused meditation, in 
+which, guided instructions are given and it has to be followed by the 
+students. It is prepared in such a way that the beginning sessions, 
+is of shorter duration, and the time increases for the later sessions. 
+The concluding interaction stretches up to ten minutes wherein 
+participants share about their experiences while in the session. 
+Phase 2 
+Validation of the intervention module: Part 1 of each session 
+which had mental health interventions were validated by the 
+mental health experts and Part 2 which has guided instructions 
+for body focused meditation were validated by the yoga experts. 
+Experts were requested to rate the usefulness of the activities in 
+each session in a five point scale ranging from 0 to 4 wherein, ‘0’ 
+signifies the activities in that session ‘not helpful’ and ‘4’ signifies 
+extremely helpful. Activities that were rated with a score (based on 
+their knowledge and experience in the field) of two and above by 
+majority of experts were retained for final module.
+[Table/Fig-2] gives the validation score for Part 1 of the intervention 
+module, that is, the Mental Health Intervention Session. Practices 
+that received a score of 2 or more from 80% of the experts were 
+retained in the final module. Content validity ratio for majority of the 
+sessions was 1.0 which indicated high validity and hence used for 
+the main intervention. [Table/Fig-3] showed the validation score 
+for Part 2 of the intervention module, that is, the Body Focused 
+Meditation part. Practices that received a score of 2 or more from 
+80% of the experts were retained in the final module. All sessions 
+had a content validity ratio of 1.0 which indicated high validity of the 
+intervention as rated by the experts.
+Pilot study was done among 18 adolescent girls by providing the 
+intervention and assessing their self awareness before and after the 
+intervention. The intervention was provided by the researcher for 
+eight days (weekly two sessions) for a period of four weeks during 
+September 2016. The scale used was the Life Skills Assessment 
+Scale (Vranda, 2007), the subsection of self awareness. The data 
+was normally distributed and ANOVA was conducted to find out the 
+changes. The score at baseline was 31.39 (SD=4.975) and at the 
+post intervention was 39.85 (SD=4.590) which indicated significant 
+change at 0.05 level in the perception of self awareness among 
+adolescent girls. 
+DISCUSSION 
+In this study, we attempted to develop an intervention module for 
+adolescent girls with trans-disciplinary approach by combining 
+mental health intervention for adolescents with body focused 
+meditation techniques. The module was developed after in-depth 
+interviews with experts from both the fields and further validated 
+by another set of experts in both fields. The topics derived out of 
+interviews were importance of self awareness, autonomy of self, 
+physical level of understanding, self regulation of emotions and self-
+monitoring. Experts viewed the need for understanding of physical 
+level is crucial for healthy development and that can happen in the 
+beginning of puberty itself. Mental health experts suggested the 
+inclusion of the concept of brain changes and the related changes 
+in behaviour and emotional aspects in adolescent girls for the 
+intervention. Knowing about self in different situations also was 
+stressed on. Aspects of autonomy were given importance by all in 
+the mental health field. 
+The CVR scores show that majority of the experts rated each 
+session as extremely helpful and hence suggested to retain sessions 
+with minor changes. Earlier studies have used similar methodology 
+in validating yoga interventions for persons with different mental 
+illnesses and the content validity scores correspond to the current 
+study [11,12]. Future directions include the testing of the module 
+among adolescent population and assessing the efficacy of this 
+module in enhancing self awareness. The module could be used in 
+the community for promotional mental health interventions among 
+adolescent girls. 
+The pilot study conducted was able to demonstrate change in the 
+variable of self awareness due to the intervention. This marked 
+the need of optimizing the intervention and providing it for a larger 
+population. 
+[Table/Fig-3]: Content validity ratio of body focused meditation sessions.
+Body Focused 
+Meditation ses­
+sions 
+Scoring (0-4) (Number of 
+experts)
+n (%) of 
+experts 
+rating ≥2
+Content 
+Validity 
+Ratio
+BFM session 1
+0 (0)
+1 (0)
+2 (0)
+3 (2)
+4 (4)
+6 (100)
+1.0
+BFM session 2
+0 (0)
+1 (0)
+2 (0)
+3 (2)
+4 (4)
+6 (100)
+1.0
+BFM session 3
+0 (0)
+1 (0)
+2 (0)
+3 (2)
+4 (4)
+6 (100)
+1.0
+BFM session 4
+0 (0)
+1 (0)
+2 (0)
+3 (1)
+4 (5)
+6 (100)
+1.0
+BFM session 5
+0 (0)
+1 (0)
+2 (0)
+3 (2)
+4 (4)
+6 (100)
+1.0
+BFM session 6
+0 (0)
+1 (0)
+2 (0)
+3 (3)
+4 (3)
+6 (100)
+1.0
+BFM session 7
+0 (0)
+1 (0)
+2 (0)
+3 (2)
+4 (4)
+6 (100)
+1.0
+BFM session 8
+0 (0)
+1 (0)
+2 (0)
+3 (2)
+4 (4)
+6 (100)
+1.0
+Jasmine Mary John et al., Development of a Trans-Disciplinary Intervention Module for Adolescent Girls on Self-Awareness	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2017 Aug, Vol-11(8): VC07-VC10
+10
+10
+LIMITATION 
+Experts were contacted only once for the validation of the 
+intervention module. They were not revisited for further opinion after 
+incorporating the suggestions given. Pilot testing was done with 
+single variable; other related variables were to be studied for further 
+evidence.
+CONCLUSION 
+The intervention module provided evidence multiple disciplinary 
+approaches for the promotion of mental health among adolescent 
+girls. Mental health professionals working with children could be 
+trained for implementing this intervention among adolescent girls. 
+Acknowledgements
+The research was carried out by the funding from Indian Council 
+of Medical Research (ICMR) as Junior Research Fellowship (JRF) 
+2011 batch. 
+REFERENCES
+	 Cameron G, Karabanow J. The nature and effectiveness of program models for 
+[1]
+adolescents at risk of entering the formal child protection system. 2003. pp. 443-74.
+	 Jejeebhoy SJ. Adolescent sexual and reproductive behaviour: a review of the 
+[2]
+evidence from India. Social Science and Medicine (1982). 1998;46(10):1275-
+90.
+	 Barry MM, Clarke AM, Jenkins R, Patel V. A systematic review of the effectiveness 
+[3]
+of mental health promotion interventions for young people in low and middle 
+income countries. BMC Public Health. 2013;13(1):835.
+	 Jain RB, Kumar A, Khanna P
+. Assessment of self-awareness among 
+[4]
+rural adolescents: A cross-sectional study. Indian J Endocrinol Metab. 
+2013;17(Suppl1):S367–S372. 
+	 Kumar D, Goel NK, Puri S, Pathak R, Singh Sarpal S, Gupta S, et al. Menstrual 
+[5]
+pattern among unmarried women from Northern India. J Clin Diagn Res. 
+2013;7(9):1926-29.
+	 Gjersoe NL, Hood B. Changing children's understanding of the brain: A 
+[6]
+longitudinal study of the royal institution christmas lectures as a measure of 
+public engagement. PLoS ONE. 2013;8(11):e80928.
+	 Kaley-Isley LC, Peterson J, Fischer C, Peterson E. Yoga as a complementary 
+[7]
+therapy for children and adolescents: a guide for clinicians. Psychiatry (Edgmont 
+(Pa: Township). 2010;7(8):20-32.
+	
+[8]
+Black DS, Milam J, Sussman S. Sitting-meditation interventions among youth: a 
+review of treatment efficacy. Pediatrics. 2009;124(3):e532-41.
+	 Sperduti M, Martinelli P
+, Piolino P
+. A neurocognitive model of meditation based 
+[9]
+on activation likelihood estimation (ALE) meta-analysis. Consciousness and 
+Cognition. 2012;21(1):269-76.
+	 Lutz A, Slagter HA, Dunne JD, Davidson RJ. Attention regulation and monitoring 
+[10]
+in meditation. Trends Cogn Sci.  2008;12(4):163-69.
+	 Bhat S, Varambally S, Karmani S, Gangadhar BN. International Review of 
+[11]
+Psychiatry Designing and validation of a yoga-based intervention for obsessive 
+compulsive disorder. Int Rev Psychiatry. 2016;28(3):327-33.
+	 Govindaraj R, Varambally S, Sharma M. International Review of Psychiatry 
+[12]
+Designing and validation of a yoga-based intervention for schizophrenia. 
+2016;0261(October):2-6.
+PARTICULARS OF CONTRIBUTORS:
+1.	 PhD Scholar, Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India.
+2.	 Associate Professor, Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India.
+3.	 Chancellor, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India.
+NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
+Dr. Jasmine Mary John,
+PhD Scholar, Department of Psychiatric Social Work, NIMHANS, Bengaluru-560029, Karnataka, India.
+E-mail: [email protected]
+Financial OR OTHER COMPETING INTERESTS: None.
+Date of Submission: Dec 01, 2016
+Date of Peer Review: Mar 16, 2017
+Date of Acceptance: Jul 13, 2017
+Date of Publishing: Aug 01, 2017

subfolder_0/Diabetic yoga protocol improves glycemic, anthropometric and lipid levels in high risk individuals for diabetes a randomized controlled trial from Northern India..txt

@@ -0,0 +1,1072 @@
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149  
+https://doi.org/10.1186/s13098-021-00761-1
+SHORT REPORT
+Diabetic yoga protocol improves glycemic, 
+anthropometric and lipid levels in high 
+risk individuals for diabetes: a randomized 
+controlled trial from Northern India
+Navneet Kaur1,4, Vijaya Majumdar2, Raghuram Nagarathna2*, Neeru Malik3, Akshay Anand4* and 
+Hongasandra Ramarao Nagendra2 
+Abstract 
+Purpose:  To study the effectiveness of diabetic yoga protocol (DYP) against management of cardiovascular risk pro-
+file in a high-risk community for diabetes, from Chandigarh, India.
+Methods:  The study was a randomized controlled trial, conducted as a sub study of the Pan India trial Niyantrita 
+Madhumeha Bharath (NMB). The cohort was identified through the Indian Diabetes Risk Scoring (IDRS) (≥ 60) and a 
+total of 184 individuals were randomized into intervention (n = 91) and control groups (n = 93). The DYP group under-
+went the specific DYP training whereas the control group followed their daily regimen. The study outcomes included 
+changes in glycemic and lipid profile. Analysis was done under intent-to-treat principle.
+Results:  The 3 months DYP practice showed diverse results showing glycemic and lipid profile of the high risk indi-
+viduals. Three months of DYP intervention was found to significantly reduce the levels of post-prandial glucose levels 
+(p = 0.035) and LDL-c levels (p = 0.014) and waist circumference (P = 0.001).
+Conclusion:  The findings indicate that the DYP intervention could improve the metabolic status of the high-dia-
+betes-risk individuals with respect to their glucose tolerance and lipid levels, partially explained by the reduction in 
+abdominal obesity. The study highlights the potential role of yoga intervention in real time improvement of cardio-
+vascular profile in a high diabetes risk cohort.
+Trial registration: CTRI, CTRI/2018/03/012804. Registered 01 March 2018—Retrospectively registered, http://​
+www.​
+ctri.​
+nic.​
+in/CTRI/2018/03/012804.
+Keywords:  Diabetic yoga protocol, Indian diabetes risk score, Glycated hemoglobin, Diabetes, Prediabetes
+© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which 
+permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the 
+original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or 
+other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line 
+to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory 
+regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this 
+licence, visit http://​
+creat​
+iveco​
+mmons.​
+org/​
+licen​
+ses/​
+by/4.​
+0/. The Creative Commons Public Domain Dedication waiver (http://​
+creat​
+iveco​
+mmons.​
+org/​
+publi​
+cdoma​
+in/​
+zero/1.​
+0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
+Introduction
+The rise of diabetes in the developing world poses a 
+threat to meager health budgets. Owing to the strong 
+association between various morbidity and mortality 
+outcomes as complications of this dreaded disease, early 
+detection of diabetes risk through non-invasive param-
+eters is a primary requisite. Observational studies show 
+that the risk reduction for diabetes can be decreased by 
+58% or 63–65% if risk factors could be controlled [1, 2]. 
+Open Access
+Diabetology &
+Metabolic Syndrome
+*Correspondence:  [email protected]; [email protected]
+2 Division of Life Sciences, Swami Vivekananda Yoga Anusandhana 
+Samsathana, Bengaluru, Karnataka 560106, India
+4 Department of Neurology, Neuroscience Research Lab, Postgraduate 
+Institute of Medical Education and Research, Chandigarh 160012, India
+Full list of author information is available at the end of the article
+Page 2 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+Many argue that such experimental strategies for the 
+possible halting of conversion of prediabetes into diabe-
+tes must continue to include pharmacological interven-
+tions even though the rates have not been compared 
+[3]. Identification of individuals at increased risk for the 
+disease with invasive measurements of fasting and post 
+challenge (postprandial) blood glucose are costly and 
+time consuming. Hence, it has been advocated that the 
+realistic prevention of diabetes should identify high-risk 
+subjects with the use of the non-invasive risk scores [4]. 
+Such studies should also target subjects with normogly-
+cemia and prevent their progression to poor glycemic 
+status [4].
+Yoga plays a promising role in minimizing the risk of 
+Diabetes for high-risk individuals with prediabetes [5, 6]. 
+It reduces body weight, glucose, and lipid levels, though, 
+most of these studies comply with the guidelines of ran-
+domized controlled trials adhered to the CONSORT 
+statements [7–11] whereas majority of studies have not 
+reported as per CONSORT statements [12–15]. Several 
+review of published studies, in people with diabetes and 
+prediabetes, have concluded that the practice of yoga 
+may reduce insulin resistance and related cardiovascular 
+disease (CVD) risk factors and improve clinical outcomes 
+[16]. Specifically, reports suggest that a yoga-based life-
+style intervention reduces body weight, glucose and lipid 
+levels that should reduce diabetes risk. Keeping in view 
+the high transition rates of diabetes in India, we selected 
+a high-risk cohort from Chandigarh, one of the most 
+affluent Union Territories of India with highest reported 
+prevalence of diabetes in order to establish the efficacy of 
+yoga to alleviate the cardiovascular disease. Indian Dia-
+betes Risk Score (IDRS), specific for Indian ethnicity a 
+validated tool was used for identification of the high-risk 
+population [17]. We developed a national consensus ‘Dia-
+betes Yoga protocol’ based on published reports and clas-
+sical literature with an aim to stimulate weight reduction 
+by combination of postures and meditation techniques 
+[18, 19]. Additionally, cardiometabolic risk reduction has 
+also been recognized as one of the potential outcomes 
+of yoga-based interventions [20]. Yoga has been shown 
+to be regulating the risk parameters of diabetes, waist 
+circumference (WC), body mass index (BMI), oxida-
+tive stress, fasting blood sugar (FBS) and systolic blood 
+pressure (SBP) respectively [21]. Hence, in this study we 
+tested the efficacy of diabetic yoga protocol (DYP) on 
+alleviation of glycemic and lipid imbalances in individu-
+als at high risk of diabetes.
+Materials and methods
+Study population
+Under the multi-region survey of Niyantarita Maduh-
+meha Bharat (NMB-2017) a door-to-door screening 
+was carried out for the identification of high risk indi-
+viduals among the population of Chandigarh (U.T) and 
+Panchkula (District in Haryana state) on the basis of 
+Indian Diabetes Risk Score (IDRS). The data collection 
+was carried out by well trained yoga volunteers for dia-
+betes management (YVDMs). Written informed con-
+sents were taken from every subject during door to door 
+screening as well as at the time of registration. All the 
+experimental protocol, methods and procedures were 
+approved by Ethics committee of Indian Yoga Asso-
+ciation (IYA) (ID: RES/IEC-IYA/001). All experiments 
+methods and procedures were carried out in accordance 
+with relevant guidelines and regulations of ethics com-
+mittee. The study was registered at clinical trial registry 
+of India, CTRI/2018/03/012804 (dated: 01/03/2018).
+Study design
+The present study is the two-armed randomized con-
+trolled trial conducted in the population of Chandigarh 
+and Panchkula regions of northern India. Indian Dia-
+betes Risk Score (IDRS) was used for detection of high 
+risk (≥ 60 score) individuals from the study. Self-declared 
+diabetics and low (< 30  score) and moderate [between 
+30–50 score] risk individuals were excluded from the 
+study. As evident from the flow of patients presented in 
+the flowchart, out of 1214 eligible subjects, there was 
+approximately 50% loss of sample data due to error in the 
+sampling. Further out of 564, we had to exclude as they 
+were self-declared patients with diabetes and did not fur-
+ther participate in the study. However, this led to final 
+participation of only 184 subjects in the study and alloca-
+tion of these subjects diminishing the random selection 
+of the study cohort. A cohort of high diabetes-risk cohort 
+consisting of n = 184 participants was randomized into 
+the interventional and control groups (n = 91:93). After 
+excluding the dropouts from the study, based on CON-
+SORT guidelines, the remaining subjects in the DYP and 
+control group were further assessed for selected anthro-
+pometric, glycemic and lipid parameters. The interven-
+tion group was given the Diabetic Yoga Protocol for three 
+months and control group continued with their daily rou-
+tine activities. The detailed categorization of the samples 
+is shown in Fig. 1. The control group was waitlisted for 
+yoga.
+Randomization
+Simple randomization technique was used to allocate 
+participants into the intervention and the control groups. 
+An independent statistician generated a computer-gen-
+erated random number sequence and the sequence was 
+given to an external staff who had no involvement in the 
+study procedures. The participants were allocated their 
+consecutive numbers, after baseline measurements. 
+Page 3 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+	
+Fig. 1  Flowchart of study design. PCA ��principal component analysis, MIPCA multiple imputations with PCA
+Page 4 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+Blinding of the participants was not possible due to the 
+nature of the intervention. However, the outcome asses-
+sors were blinded.
+Risk assessment
+To identify the individuals at high-risk of diabetes, Indian 
+Diabetes Risk Score (IDRS) was administered as pro-
+posed by Mohan et al. [22]. It consisted of two unmodi-
+fiable (i.e. age, and family history) and two modifiable 
+(physical activity and waist circumference) risk factors 
+for diabetes, which can predict the level of risk for the 
+development of diabetes in the community. The IDRS 
+is one of the easily accessible and budget friendly ques-
+tionnaire to be administered. The aggregate score of the 
+unmodifiable and modifiable risk used to probe the level 
+of risk among the population (i.e. High risk > 60, Moder-
+ate risk-30–50, Low risk < 30).
+Sample size
+Sample size estimation for the main Pan India study 
+was focused for prediabetes subjects [23]. However, for 
+the present pilot scale study we calculated sample size 
+assuming a small effect size 0.3 [5] of DYP vs waitlist con-
+trol 0.25, α = 0.80 as 180 (n = 90:90). Further, assuming 
+an attrition rate of 20%, the final sample size was n = 220.
+Study outcomes
+Changes in the glycemic and other metabolic variables 
+(anthropometric and lipid) over 3  months were docu-
+mented. The fasting blood sample was withdrawn. For 
+glucose analysis, fasting samples for 10–12 h were taken 
+early in the morning for the estimation of FBS and after-
+wards 75  g glucose was given to the participants. The 
+blood sampling was repeated after 2 h. for estimation of 
+OGTT.
+Biochemical analysis
+For the estimation of biochemical parameters viz. FBS 
+(Fasting Blood Sugar, Rxl-Max 500), OGTT (Oral Glu-
+cose Tolerance Test), HbA1c (Bio-Rad D-10), Triglycer-
+ides, Cholesterol, HDL, LDL, Chol/HDL ratio, HDL/LDL 
+ratio (Rxl-Max 500) and VLDL about 9 ml of blood was 
+drawn and analyzed by phlebotomist of Sisco Research 
+Laboratories (SRL) of Chandigarh. Anthropometric 
+measurements were also obtained (i.e. height, weight, 
+waist circumference) by trained researcher. The waist cir-
+cumference (WC) was reported in centimeters. The BMI 
+was obtained by using the formula (weight in kg/height 
+(meter)2).
+Interventions
+The study protocol consisted of Diabetic Yoga Protocol 
+(DYP) approved by the Ministry of AYUSH and Quality 
+Council of India as shown in Table 1. This is the first pro-
+tocol to be made specifically for the prediabetics and dia-
+betics. The complete sequence of prayer, yogic postures, 
+breathing and meditative techniques, along with speci-
+fied time, was shown in previously published paper [24]. 
+The Yogic practices were performed for 3  months for 
+60 min. Certified yoga instructors took the yoga classes 
+and they recorded regular attendance. Randomization 
+was done through a computer-generated list of random 
+numbers and allocation was concealed to the participants 
+until the completion of the baseline assessment.
+Statistical analysis
+For the analysis of data SPSS for Windows (version 22; 
+IBM  SPSS  Inc., Chicago IL) 0 and R statistical pack-
+age were used. The normality of data was analyzed 
+using Kolmogorov–Smirnov test. The paired t-test was 
+used to estimate the Baseline and posttest differences 
+of DYP, and control group and the significant level was 
+set at ≤ 0.05. The trial outcomes were analyzed accord-
+ing to the intention-to-treat principle; hence multiple 
+imputation was carried for the missing variables account-
+ing for the loss to follow up. We used absolute change 
+(time and treatment interaction), to estimate interven-
+tion effects refers to the difference in the outcome of 
+the intervention and control over different time-points 
+of assessment. Absolute change was determined as fol-
+lows: absolute change = [(intervention group follow-
+up) – (intervention group baseline)] – [(control group 
+follow-up) – (control group baseline)]. The percentage 
+change, also called the relative change was determined as 
+relative change = (absolute change / intervention group 
+baseline) × 100%. To evaluate the influence of miss-
+ing data, we applied multiple imputations to the data 
+using missMDA R package (v1.13) based on the princi-
+pal component analysis method [25] from the package, 
+using 5 components to reconstruct the data and over 
+1000 imputed datasets. One-way multivariate analysis of 
+covariance (MANCOVA) was conducted to compare the 
+effects of the DYP with control group glycemic and meta-
+bolic measures, while controlling for the age, gender and 
+baseline values of the covariates.
+Results
+Baseline characteristics
+The data used in this study was collected in (NMB-
+2017) the northern region of India i.e. Chandigarh and 
+Panchkula. The age range of participants was 3–70 
+years; [mean age 48.51 (SD 10.08) years]with base-
+line characteristics of the yoga and control groups as 
+shown in Table 2. Mean HbA1c of the high-risk cohort 
+was 5.64% (0.38), mean FBS was 97.13 mg/dl (SD 
+11.10), and mean PPBS were 108.40 mg/dl (SD 28.79). 
+Page 5 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+	
+Distributions of age and gender was similar between 
+the intervention and the control groups. The IDRS and 
+anthropometric values were also similarly distributed 
+between the groups. Overall, there was no significant 
+difference in the distribution of demographic, anthro-
+pometric, or biochemical parameters between the DYP 
+and the control groups at the baseline.
+When analyzed by multivariate analysis of covari-
+ance (MANCOVA), adjusting for age, gender and status 
+of diabetes/prediabetes/normoglycemia, and baseline 
+values of the covariates, yoga intervention was found 
+to have significant influence on few cardinal param-
+eters related to glycemic control (PPBS), and lipid con-
+trol (LDL-C) as shown in Table 3. We also observed a 
+significant influence of DPP on waist circumference 
+reduction [relative changes, − 1.94%. Compared to the 
+control, DYP also resulted in significant reductions in 
+LDL-C and, − 0.16% and − 2.81%, for LDL-Cholesterol 
+and post-prandial blood glucose levels from baseline 
+to 3  months [absolute changes, − 0.18% and −  3.08%, 
+respectively and relative changes, − 0.16% and − 2.81%, 
+respectively].
+Discussion
+We examined the effect of Diabetic Yoga Protocol on 
+baseline and post (3 months) levels of HbA1c and other 
+glycemic (OGTT and FBS), Lipid (Total cholesterol, tri-
+glycerides, HDL-c, LDL-c, and VLDL-c, CDL/HDL, 
+LDL/HDL) and anthropometric parameters (BMI). In the 
+present study, we show the efficacy of DYP in substantial 
+improvement in the waist circumference in a high-risk 
+diabetes population from Chandigarh (relative change of 
+1.94 cm). We could also demonstrate a significant decline 
+in the worsening of post prandial glucose levels with yoga 
+intervention as compared to the wait-list control group 
+(relative change of 2.82  mg/ml). However, for LDL-c 
+levels, there were clinically significant improvements by 
+0.16 units. Notably, over 3 months study duration there 
+was an overall increase in the levels of total cholesterol, 
+triglyceride and VLDL means in the study cohort, while 
+Table 1  Diabetic yoga protocol (DYP)
+S. No.
+Name of practice
+Duration 
+(min)
+1
+Starting prayer: Asatoma Sat Gamaya
+2
+2
+Preparatory Sukshma Vyayamas and Shithililarna Practices
+1. Urdhavahastashvasan(Hand stretching breathing 3 rounds at 90°, 135° and 180o each)
+2. Kati-Shakti Vikasaka (3 rounds) 
+a) Forward and Backward Bending b) Twisting
+3. Sarvangapushti (3 rounds clockwise, 3 rounds anticlockwise)
+6
+3
+Surya Namaskara (SN)
+10 step fast Surya Namaskara 6 rounds
+12 step slow Surya Namaskara 1 round
+Modified version Chair SN 7 rounds
+9
+4
+Asanas (1 min per Asana)
+1 Standing Position (1 min per Asana)
+Trikonasana, Parvritta Trikonasana, Prasarita Padhastasana
+2 Supine Position
+Jatara Parivartanasana, Pawanmuktasana, Viparitakarani
+3 Prone Position
+Bhujangasana, Dharuasana followed by Pawanmuktasana
+4 Sitting Position
+Mandukasana, Vakrasana/ Ardhamatsayendrasana, Paschimatanasana, Ardha Ushtrasana
+At the end, relaxation with abdominal breathing in supine position (vishranti), 10–15 rounds (2 min)
+15
+5
+Kriya
+a. Agnisara:1 min b. Kapalabhati(@60 breaths per minute for 1 min followed by rest for 1 min)
+3
+6
+Pranayama
+Nadishuddhi (for 6 min, with antarkumbhak and jalandhar bandh for 2 s)
+Bhamari 3 min
+9
+7
+Meditation (for Stress, for deep relaxation and silencing of mind)
+Cyclic Meditation
+15
+8
+Resolve (I am Completely Healthy)
+1
+9
+Closing Prayer: Sarvebhavantu Sukhina…………
+1
+Total duration
+60
+Page 6 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+HDL levels had decreased. In particular TG levels have 
+gone from normal range to mildly high (> 150 mg/dl) [26] 
+which draws our attention towards accelerated pace of 
+metabolic dysfunction in the high risk population. These 
+findings comply with Chandigarh being an affluent union 
+territory of India with high per-capita GDP and has 
+been documented to have highest prevalence of diabe-
+tes 13.6%, 12.8–15·2 as compared to other Indian states 
+[27]. As mentioned above, there was a significant influ-
+ence of DYP on the waist circumference, one of the two 
+important modifiable parameters of Indian Diabetes Risk 
+Score [17]. The relevance of WC reduction in context of 
+reduced risk of CVD is well established; a 1 cm increase 
+in WC has been associated with a 2% increase in the rela-
+tive risk of future CVD [28]. The visceral adipose tissue 
+is a primary source of cytokine production and insu-
+lin resistance (IR) [29]. Given the higher susceptibility 
+towards visceral fat accumulation and insulin resistance 
+in Asian populations as compared to their Caucasian 
+counterparts, the observed influence of DYP on WC is 
+of particular relevance to the metabolically obese pheno-
+type of Asian Indians [30].
+In relation to the glucose metabolism, we could also 
+demonstrate a significant decline in the worsening of 
+post prandial glucose levels with DYP as compared to 
+the wait-list control group (relative change = −  2.81%, 
+P < 0.05); however, no significant influence could be 
+established for fasting blood glucose concentration. These 
+findings could be justified by the phenotypic differences 
+underlying fasting and post-challenge hyperglycemia 
+that represent distinct natural histories in the evolution 
+of type 2 diabetes [31]. Postprandial glucose disposal is 
+the primary pathogenic manifestation in impaired glu-
+cose tolerance (IGT), and impaired fasting glucose (IFG) 
+merely signifies an abnormal glucose set point [31, 32]. 
+Our relevance of the study findings is further underlined 
+by the previous results wherein PPG has been reported 
+to contribute more than FBS to overall hyperglycemia 
+and its control was found essential either to decrease or 
+to obtain HbA1c goals of < 7 [33]. Several epidemiological 
+studies have suggested that increased glycemic exposure, 
+especially post challenge or postprandial hyperglycemia, 
+is an independent risk factor for macrovascular disease 
+with no apparent upper or lower threshold. Our results 
+indicate a significant influence of yoga on glycemic con-
+trol integrating postprandial glycemic alterations in the 
+high diabetes risk group. Since in the present study the 
+high-risk cohort was selected through A1c based diag-
+nosis, and IGT was not a primary manifestation in the 
+cohort, hence, the overall improvement in postprandial 
+glucose should be specifically tested in an IGT cohort. 
+The findings of the current study with a 3-month inter-
+vention of yoga on postprandial measures of glucose at-
+risk population deserves clinical attention. Increase in 
+the glucose concentration even in the prediabetes stage, 
+manifests as a chronic inflammatory condition and pre-
+disposes an individual to the risk of pathogenic infections 
+[32, 34, 35].
+The simultaneous reduction in waist circumference 
+observed in the cohort, is also consistent with the obser-
+vation of an association between abdominal obesity 
+and the risk of IGT. Based on a significant association 
+between IGT and CVD risk [32, 33, 36], we note a signifi-
+cant improvement in lipid concentrations [LDL-c] by the 
+DYP protocol as compared to the control group. These 
+results are consistent with the previously reported overall 
+beneficial effect of yoga in the management of hyperlipi-
+demia [36]. These results need validation at larger scale 
+and to ascertain the mechanistic insights into the action 
+of yoga, the indices of monocyte chemotaxis, endothe-
+lial inflammation, oxidation, nitric oxide production, 
+and thrombosis should also be explored [37], including 
+animal models, invitro systems and other approaches 
+[38–44].
+The findings of the present study indicate that identifi-
+cation of high-risk group through IDRS and consequent 
+intervention of Yoga based lifestyle protocol could be an 
+effective strategy to combat the metabolic perturbations 
+Table 2  Baseline characteristics of the participants in the 
+intervention and control group
+Continuous variables are represented as mean (SD) and compared using 
+independent t-test. Categorical variables are represented as number 
+(percentages) and compared using chi-square test. P value < 0.05 were 
+considered significant. FBS fasting blood sugar, PPBG postprandial blood 
+glucose, HbA1c glycated hemoglobin, HDL-c high density lipid-cholesterol, LDL-c 
+low density lipid-cholesterol, VLDL very low density lipid-cholesterol, IDRS Indian 
+diabetes risk score
+Characteristics
+DYP Group
+N = 91
+Control group
+N = 93
+P value
+Gender
+Male, n (%)
+19 (20.88)
+30 (32.26)
+0.096
+Age (years)
+47.77 (9.59)
+49.24 (10.53)
+0.323
+Weight, Kg
+70.93 (10.90)
+70.80 (12.44)
+0.936
+Waist circumference, cm
+99.34 (9.05)
+99.72 (9.05)
+0.794
+BMI, Kg/m2
+28.59 (5.75)
+28.53 (5.01)
+0.949
+IDRS
+74.07 (10.43)
+75.27 (9.95)
+0.425
+Biochemical variables
+FBG, mg/dl
+96.89 (9.95)
+97.36 (12.20)
+0.776
+PPBG, mg/dl
+102.88 (21.91)
+113.78 (33.47)
+0.012*
+HbA1c (%)
+5.61 (0.38)
+5.66 (0.38)
+0.400
+Total cholesterol mg/dl
+186.88 (37.64)
+179.98 (34.98)
+0.199
+Triglycerides, mg/dl
+131.93 (68.59)
+138.44 (68.89)
+0.522
+HDL-c, mg/dl
+47.76 (9.16)
+48.33 (17.43)
+0.780
+LDL-c, mg/dl
+112.75 (31.02)
+104.38 (31.70)
+0.072
+VLDL, mg/dl
+26.39 (13.72)
+28.00 (13.50)
+0.423
+Page 7 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+	
+associated with diabetes, whose co-morbidity is also 
+being reported to be associated with increasing vulner-
+ability to the emerging viral pandemic of COVID-19. 
+Lifestyle interventions are reported to reduce the risk of 
+Type 2 diabetes in high-risk individuals after mid and 
+long-term follow-up. Information on determinants of 
+intervention outcome, adherence and the mechanisms 
+underlying diabetes progression are valuable for a more 
+targeted implementation. Weight loss is a major con-
+tributor in the prevention and management of type 2 dia-
+betes. In many of the earlier lifestyle intervention group 
+of the DPP, weight loss was the dominant predictor of 
+reduced diabetes risk, with a 16% reduction observed for 
+every kilogram of weight loss during the 3.2-year follow-
+up [45]. Though we failed to observe a significant weight 
+loss over 3 months of DYP intervention, the significant 
+reductions in WC indicate the plausibility of significant 
+weight loss on longer interventions and follow ups.
+Whether Yoga alters the conversion of prediabetics 
+into healthy status and if it helps in maintenance of glyce-
+mic index can be assessed by longitudinal studies. There 
+was a significant improvement in the glycemic status of 
+Table 3  Comparative assessment of influence of DYP on biochemical and weight related variables with the control group
+Absolute change = [(intervention group follow-up) – (intervention group baseline)] – [(control group follow-up) – (control group baseline)]. Relative 
+change = (absolute change / intervention group baseline) × 100%; p value for difference between the intervention and the control groups by MANCOVA adjusting for 
+age, gender, status of diabetes/prediabetes/normoglycemia baseline values of glycemic and lipid variables, length of time having had prior exposure of yoga
+Variables
+Baseline
+mean (SD)
+After 3 months
+mean (SD)
+Absolute
+change
+Relative change
+P value
+Partial η2
+Waist circumference (cm)
+DYP
+99.34 (9.05)
+98.14 (6.88)
+− 1.93
+− 1.94
+0.032
+0.029
+Control
+99.72 (9.05)
+100.25 (7.72)
+BMI, kg/m2
+DYP
+28.59 (5.75)
+28.00 (6.84)
+− 0.4
+− 1.40
+0.622
+0.002
+Control
+28.53 (5.01)
+28.34 (4.98)
+Weight, Kg
+DYP
+70.93 (10.90)
+69.04 (9.13)
+− 1.04
+− 1.47
+0.397
+0.005
+Control
+70.80 (12.44)
+69.95 (10.44)
+Postprandial blood glucose, mg/dl
+DYP
+102.88 (21.91)
+118.32 (29.89)
+− 1.51
+− 1.47
+0.006
+0.046
+Control
+113.78 (33.47)
+130.73 (36.98)
+Fasting blood glucose, mg/dl
+DYP
+96.89 (9.95)
+99.82 (9.49)
+1.44
+1.49
+0.287
+0.007
+Control
+97.36 (12.20)
+98.85 (9.26)
+HBA1c (%)
+DYP
+5.61 (0.38)
+5.61 (0.39)
+− 0.02
+− 0.36
+0.077
+0.020
+Control
+5.66 (0.38)
+5.68 (0.38)
+Total Cholesterol, mg/dl
+DYP
+186.88(37.64)
+189.01 (25.64)
+− 0.4
+− 0.21
+0.130
+0.014
+Control
+179.98 (34.98)
+182.51(20.82)
+Triglycerides, TG, mg/dl
+DYP
+131.93 (68.59)
+148.14 (54.92)
+− 13.98
+− 10.60
+0.138
+0.014
+Control
+138.44 (68.89)
+168.63 (75.06)
+HDL-C, mg/dl
+DYP
+47.76 (9.16)
+47.01 (9.16)
+2.2
+4.61
+0.097
+0.017
+Control
+48.33 (17.43)
+45.38 (12.57)
+LDL-C, mg/dl
+DYP
+112.75 (31.02)
+103.39 (21.44)
+− 17.56
+− 15.57
+0.044*
+0.025
+Control
+104.38 (31.70)
+112.58 (21.99)
+VLDL, mg/dl
+DYP
+26.39 (13.72)
+28.85 (10.47)
+− 1.23
+− 4.66
+0.229
+0.009
+Control
+28.00 (13.50)
+31.69 (10.57)
+Page 8 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+the high risk population at administration of DYP. The 
+analysis shows the aptness of Diabetic protocol which is 
+apparently superior to previous studies where no stand-
+ardized protocols were used for intervention [46, 47]. The 
+findings suggest that there is potential of DYP to manage 
+glucose levels in diabetes patients if public intervention is 
+planned through forthcoming wellness centers in India. 
+There are additional studies showing beneficial effects of 
+Yoga on FBS [48], PPBS [49–51], HbA1c [50, 51], total 
+cholesterol, LDL [50, 51]. The analysis of the yoga proto-
+cols used in above said studies reveal the incorporation 
+of some common and important postures in DYP, which 
+seem to be important in managing the disease. It is also 
+the possible that the beneficial effects of mind body tech-
+niques are sensitive to mental disposition of subjects and 
+has been characterized by various measures like psycho-
+metric analysis [52, 53], namely, Tridosha and Triguna 
+scoring [54, 55]. These were not analyzed in this study.
+Briefly, DYP’s promising efficacy on glycemic and met-
+abolic parameters requires mechanistic insights. This can 
+be examined by further studies, and long term follow up 
+which was not possible in this study. As DYP is a non-
+pharmacological, cost-effective method to halt the con-
+version of early diabetes into prediabetes and/or healthy 
+individuals, the success of its integration into public 
+health policy will depend on its wider acceptability and 
+perception of benefits by both public as well as health-
+care workers [56–59]. Yoga’s benefits in maintaining and 
+regulation of the glycemic status are supported by sev-
+eral other studies [49, 50], which might enable its inclu-
+sion in the National Ayushman Bharat scheme or as part 
+COVID pandemic management protocol in which a large 
+number of individuals with diabetes and heart disease are 
+falling prey [60, 61]. This will further encourage molecu-
+lar and Ayurgenomic studies which presumably underlie 
+the stated clinical outcome.
+Limitations
+Moreover, there are some limitations of our study that we 
+only studied in two regions of North India and thus the 
+result of this study cannot be generalized on the remain-
+ing population. Further, in this study, the socio economic 
+status and psychological assessments were not carried 
+out. We were not able to control for the dietary habits 
+and psychological status of the study participants. How-
+ever, the small sample size and absence of long term eval-
+uations limit the strength of the study.
+Conclusion
+The findings indicate that the DYP intervention could 
+improve the metabolic status of the high-diabetes-
+risk individuals with respect to their glucose tolerance 
+and lipid levels, partially explained by the reduction in 
+abdominal obesity. The study highlights the potential role 
+of yoga intervention in real time improvement of cardio-
+vascular profile in a high diabetes risk cohort.
+Abbreviations
+ADA: American Diabetes Association; BMI: Body mass Index; CVD: Cardiovas-
+cular disease; DYP: Diabetic yoga protocol; FBS: Fasting blood sugar; HbA1c: 
+Glycated hemoglobin; HDL-c: High density lipid-cholesterol; IDRS: Indian 
+Diabetes Risk Score; IFG: Impaired fasting glucose; IGT: Impaired glucose 
+tolerance; IYA: Indian Yoga Association; LDL-c: Low density lipid-cholesterol; 
+NMB: Niyantarita Maduhmeha Bharat; OGTT​
+: Oral glucose tolerance test; PPBG: 
+Postprandial blood glucose; SBP: Systolic blood pressure; VLDL: Very low 
+density lipid-cholesterol; WC: Waist circumference; YVDM: Yoga volunteers for 
+diabetes management.
+Acknowledgements
+The authors would like to thank Central Council for Research in Yoga & 
+Naturopathy (CCRYN) for their support for man power, Ministry of Health and 
+Family Welfare (MOHFW) for support the cost of investigations and Indian 
+Yoga Association (IYA) for the overall project implementation. The authors also 
+like to thank to thank Yoga Volunteer for Diabetes Management (YVDMs) for 
+helping in collection of data and also for training participants for yoga.
+Authors’ contributions
+NK: writing of manuscript, collection of data. VM: writing of manuscript, 
+analysis. RN: conceptualization of manuscript, supervision and study design. 
+NM: co-conceptualization of manuscript. AA: conceptualization of manuscript. 
+HRN: supervision. All authors read and approved the final manuscript.
+Funding
+The Project was funded by Ministry of AYUSH, Government of India (grant 
+number 16-63/2016-17/CCRYN/RES/Y&D/ MCT/).
+Availability of data and materials
+The datasets used during the present study are available from the correspond-
+ing author on reasonable request.
+Declarations
+Ethics approval and consent to participate
+Written informed consents were taken from every subject during door to door 
+screening as well as at the time of registration. All the experimental protocol, 
+methods and procedures were approved by Ethics committee of Indian Yoga 
+Association (IYA) (ID: RES/IEC-IYA/001). All experiments methods and proce-
+dures were carried out in accordance with relevant guidelines and regulations 
+of ethics committee.
+Consent for publication
+Not applicable.
+Competing interests
+The authors declare that they have no competing interests.
+Author details
+1 
+Department of Physical Education, Panjab University, Chandigarh 160014, 
+India. 2 
+Division of Life Sciences, Swami Vivekananda Yoga Anusandhana Sam-
+sathana, Bengaluru, Karnataka 560106, India. 3 
+Dev Samaj College of Education, 
+Sector 36B, Chandigarh 160036, India. 4 
+Department of Neurology, Neurosci-
+ence Research Lab, Postgraduate Institute of Medical Education and Research, 
+Chandigarh 160012, India. 
+Received: 26 August 2021   Accepted: 17 November 2021
+Page 9 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+	
+References
+	1.	
+Laaksonen DE, Lindström J, Lakka TA, Eriksson JG, Niskanen L, Wikström K, 
+Aunola S, Keinänen-Kiukaanniemi S, Laakso M, Valle TT, Ilanne-Parikka P. 
+Physical activity in the prevention of type 2 diabetes: the Finnish diabetes 
+prevention study. Diabetes. 2005;54(1):158–65.
+	2.	
+Lindström J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemiö 
+K, Hämäläinen H, Härkönen P, Keinänen-Kiukaanniemi S, Laakso M, 
+Louheranta A. Sustained reduction in the incidence of type 2 diabetes by 
+lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. 
+Lancet. 2006;368(9548):1673–9.
+	3.	
+DREAM (Diabetes REduction Assessment with ramipril and rosiglitazone 
+Medication) Trial Investigators. Effect of rosiglitazone on the frequency of 
+diabetes in patients with impaired glucose tolerance or impaired fasting 
+glucose: a randomised controlled trial. Lancet. 2006;368(9541):1096–105.
+	4.	
+Lindström J, Tuomilehto J. The diabetes risk score: a practical tool to 
+predict type 2 diabetes risk. Diabetes Care. 2003;26(3):725–31.
+	5.	
+McDermott KA, Rao MR, Nagarathna R, Murphy EJ, Burke A, Nagendra 
+RH, Hecht FM. A yoga intervention for type 2 diabetes risk reduction: 
+a pilot randomized controlled trial. BMC Complement Altern Med. 
+2014;14(1):1–4.
+	6.	
+Jyotsna VP. Prediabetes and type 2 diabetes mellitus: evidence for effect 
+of yoga. Indian J Endocrinol Metab. 2014;18(6):745.
+	7.	
+Thind H, Lantini R, Balletto BL, Donahue ML, Salmoirago-Blotcher E, 
+Bock BC, Scott-Sheldon LA. The effects of yoga among adults with 
+type 2 diabetes: a systematic review and meta-analysis. Prev Med. 
+2017;1(105):116–26.
+	8.	
+Singh VP, Khandelwal B. Effect of yoga and exercise on glycemic control 
+and psychosocial parameters in type 2 diabetes mellitus: a randomized 
+controlled study. Int J Yoga. 2020;13(2):144.
+	9.	
+Chen N, Xia X, Qin L, Luo L, Han S, Wang G, Zhang R, Wan Z. Effects of 
+8-week Hatha yoga training on metabolic and inflammatory markers in 
+healthy, female Chinese subjects: a randomized clinical trial. BioMed Res 
+Int. 2016. https://​
+doi.​
+org/​
+10.​
+1155/​
+2016/​
+53872​
+58.
+	10.	 Ramamoorthi R, Gahreman D, Skinner T, Moss S. Development of Sham 
+yoga poses to assess the benefits of yoga in future randomized con-
+trolled trial studies. Life. 2021;11(2):130.
+	11.	 Sreedevi A, Gopalakrishnan UA, Ramaiyer SK, Kamalamma L. A rand-
+omized controlled trial of the effect of yoga and peer support on glycae-
+mic outcomes in women with type 2 diabetes mellitus: a feasibility study. 
+BMC Complement Altern Med. 2017;17(1):1–8.
+	12.	 Ramamoorthi R, Gahreman D, Skinner T, Moss S. The effect of yoga prac-
+tice on glycemic control and other health parameters in the prediabetic 
+state: a systematic review and meta-analysis. PLoS ONE. 2019;14(10): 
+e0221067.
+	13.	 Chimkode SM, Kumaran SD, Kanhere VV, Shivanna R. Effect of yoga on 
+blood glucose levels in patients with type 2 diabetes mellitus. J Clin 
+Diagn Res JCDR. 2015;9(4):CC01.
+	14.	 Kacker S, Saboo N, Sharma S, Sorout J. Quasi prospective comparative 
+study on effect of yoga among prediabetics on progression of cardiovas-
+cular risk factors. Int J Yoga. 2019;12(2):114.
+	15.	 Ebrahimi M, Guilan-Nejad TN, Pordanjani AF. Effect of yoga and aerobics 
+exercise on sleep quality in women with Type 2 diabetes: a randomized 
+controlled trial. Sleep Sci. 2017;10(2):68.
+	16.	 Innes KE, Vincent HK. The influence of yoga-based programs on risk 
+profiles in adults with type 2 diabetes mellitus: a systematic review. Evid-
+Based Complementary Altern Med. 2007;4(4):469–86.
+	17.	 Mohan V, Anbalagan VP. Expanding role of the Madras diabetes research 
+foundation-Indian diabetes risk score in clinical practice. Indian J Endo-
+crinol Metab. 2013;17(1):31.
+	18.	 Wilson PW, Meigs JB, Sullivan L, Fox CS, Nathan DM, D’Agostino RB. 
+Prediction of incident diabetes mellitus in middle-aged adults: the 
+Framingham Offspring Study. Arch Intern Med. 2007;167(10):1068–74.
+	19.	 Chen L, Magliano DJ, Balkau B, Colagiuri S, Zimmet PZ, Tonkin AM, Mitch-
+ell P, Phillips PJ, Shaw JE. AUSDRISK: an Australian Type 2 Diabetes Risk 
+Assessment Tool based on demographic, lifestyle and simple anthropo-
+metric measures. Med J Aust. 2010;192(4):197–202.
+	20.	 Yang K, Bernardo LM, Sereika SM, Conroy MB, Balk J, Burke LE. Utilization 
+of 3-month yoga program for adults at high risk for type 2 diabetes: a 
+pilot study. Evid-Based Complementary Altern Med. 2011;1:2011.
+	21.	 Hegde SV, Adhikari P, Shetty S, Manjrekar P, D’Souza V. Effect of 
+community-based yoga intervention on oxidative stress and glycemic 
+parameters in prediabetes: a randomized controlled trial. Complement 
+Ther Med. 2013;21(6):571–6.
+	22.	 Mohan V, Deepa R, Deepa M, Somannavar S, Datta M. A simplified Indian 
+Diabetes Risk Score for screening for undiagnosed diabetic subjects. J 
+Assoc Phys India. 2005;53:759–63.
+	23.	 Nagarathna R, Rajesh SK, Amit S, Patil S, Anand A, Nagendra HR. Meth-
+odology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a nation-
+wide multicentric trial on the effect of a validated culturally acceptable 
+lifestyle intervention for primary prevention of diabetes: Part 2. Int J Yoga. 
+2019;12(3):193.
+	24.	 Nagarathna Raghuram VR, Vijaya Majumdar RS, Amit Singh SP, Akshay 
+Anand IJ, Srikanta Bhaskara JR. Effectiveness of a yoga-based lifestyle 
+protocol (YLP) in preventing diabetes in a high-risk Indian cohort: a multi-
+center cluster-randomized controlled trial (NMB-trial). Front Endocrinol. 
+2021. https://​
+doi.​
+org/​
+10.​
+3389/​
+fendo.​
+2021.​
+664657.
+	25.	 Josse J, Husson F. missMDA: a package for handling missing values in 
+multivariate data analysis. J Stat Softw. 2016;70(1):31.
+	26.	 Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, 
+et al., ICMR–INDIAB Collaborative Study Group. Prevalence of diabetes 
+and prediabetes (impaired fasting glucose and/or impaired glucose 
+tolerance) in urban and rural India: phase I results of the Indian Council 
+of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia. 
+2011;54(12):3022–7. https://​
+doi.​
+org/​
+10.​
+1007/​
+s00125-​
+011-​
+2291-5. Epub 
+2011 Sep 30. PMID: 21959957.
+	27.	 Rygiel K. Hypertriglyceridemia—common causes, prevention and treat-
+ment strategies. Curr Cardiol Rev. 2018;14(1):67–76.
+	28.	 De Koning L, Merchant AT, Pogue J, Anand SS. Waist circumference and 
+waist-to-hip ratio as predictors of cardiovascular events: meta-regression 
+analysis of prospective studies. Eur Heart J. 2007;28(7):850–6.
+	29.	 McLaughlin T, Lamendola C, Liu A, Abbasi F. Preferential fat deposition in 
+subcutaneous versus visceral depots is associated with insulin sensitivity. 
+J Clin Endocrinol Metab. 2011;96(11):E1756–60.
+	30.	 Jeon J, Jung KJ, Jee SH. Waist circumference trajectories and risk of type 2 
+diabetes mellitus in Korean population: the Korean genome and epide-
+miology study (KoGES). BMC Public Health. 2019;19(1):1–1.
+	31.	 Roumen C, Corpeleijn E, Feskens EJ, Mensink M, Saris WH, Blaak EE. 
+Impact of 3-year lifestyle intervention on postprandial glucose metabo-
+lism: the SLIM study. Diabet Med. 2008;25(5):597–605.
+	32.	 Bock G, Dalla Man C, Campioni M, Chittilapilly E, Basu R, Toffolo G, et al. 
+Pathogenesis of pre-diabetes: mechanisms of fasting and postprandial 
+hyperglycemia in people with impaired fasting glucose and/or impaired 
+glucose tolerance. Diabetes. 2006;55:3536–49.
+	33.	 Gerich JE. The importance of tight glycemic control. Am J Med. 
+2005;118(9):7–11.
+	34.	 Buysschaert M, Medina JL, Bergman M, Shah A, Lonier J. Prediabetes and 
+associated disorders. Endocrine. 2015;48(2):371–93.
+	35.	 Diabetes D. Learning about prediabetes. American Diabetes Association 
+website http://​
+www.​
+diabe​
+tes.​
+org/​
+diabe​
+tes-​
+basics/​
+diagn​
+osis. 2014.
+	36.	 Shantakumari N, Sequeira S. Effects of a yoga intervention on lipid 
+profiles of diabetes patients with dyslipidemia. Indian Heart J. 
+2013;65(2):127–31.
+	37.	 DeGoma EM, Degoma RL, Rader DJ. Beyond high-density lipopro-
+tein cholesterol levels: evaluating high-density lipoprotein function 
+as influenced by novel therapeutic approaches. J Am Coll Cardiol. 
+2008;51(23):2199–211.
+	38.	 Anand A, Saraf MK, Prabhakar S. Sustained inhibition of brotizolam 
+induced anterograde amnesia by norharmane and retrograde amnesia 
+by l-glutamic acid in mice. Behav Brain Res. 2007;182(1):12–20.
+	39.	 Anand A, Saraf MK, Prabhakar S. Antiamnesic effect of B. monniera 
+on L-NNA induced amnesia involves calmodulin. Neurochem Res. 
+2010;35(8):1172–81.
+	40.	 Goyal K, Koul V, Singh Y, Anand A. Targeted drug delivery to cen-
+tral nervous system (CNS) for the treatment of neurodegenerative 
+disorders: trends and advances. Cent Nerv Syst Agents Med Chem 
+(Formerly Current Medicinal Chemistry-Central Nervous System Agents). 
+2014;14(1):43–59.
+	41.	 Gupta PK, Prabhakar S, Abburi C, Sharma NK, Anand A. Vascular endothe-
+lial growth factor-A and chemokine ligand (CCL2) genes are upregulated 
+in peripheral blood mononuclear cells in Indian amyotrophic lateral 
+sclerosis patients. J Neuroinflammation. 2011;8(1):1–6.
+Page 10 of 10
+Kaur et al. Diabetology & Metabolic Syndrome          (2021) 13:149 
+•
+ 
+fast, convenient online submission
+ 
+•
+  
+thorough peer review by experienced researchers in your field
+• 
+ 
+rapid publication on acceptance
+• 
+ 
+support for research data, including large and complex data types
+•
+  
+gold Open Access which fosters wider collaboration and increased citations 
+ 
+maximum visibility for your research: over 100M website views per year 
+•
+  
+At BMC, research is always in progress.
+Learn more biomedcentral.com/submissions
+Ready to submit your research
+Ready to submit your research ?  Choose BMC and benefit from: 
+?  Choose BMC and benefit from: 
+	42.	 Kumar S, Modgil S, Bammidi S, Minhas G, Shri R, Kaushik S, Singh V, Anand 
+A. Allium cepa exerts neuroprotective effect on retinal ganglion cells 
+of pterygopalatine artery (PPA) ligated mice. J Ayurveda Integr Med. 
+2020;11(4):489–94.
+	43.	 Saraf MK, Prabhakar S, Anand A. Neuroprotective effect of Bacopa 
+monniera on ischemia induced brain injury. Pharmacol Biochem Behav. 
+2010;97(2):192–7.
+	44.	 Singh T, Prabhakar S, Gupta A, Anand A. Recruitment of stem cells into 
+the injured retina after laser injury. Stem Cells Dev. 2012;21(3):448–54.
+	45.	 Diabetes Prevention Program Research Group. 10-year follow-up of 
+diabetes incidence and weight loss in the Diabetes Prevention Program 
+Outcomes Study. Lancet. 2009;374(9702):1677–86.
+	46.	 Hegde SV, Adhikari P, Kotian S, Pinto VJ, D’Souza S, D’Souza V. Effect 
+of 3-month yoga on oxidative stress in type 2 diabetes with or 
+without complications: a controlled clinical trial. Diabetes Care. 
+2011;34(10):2208–10.
+	47.	 Sharma M, Knowlden AP. Role of yoga in preventing and controlling 
+type 2 diabetes mellitus. J Evid-Based Complementary Altern Med. 
+2012;17(2):88–95.
+	48.	 Keerthi GS, Pal P, Pal GK, Sahoo JP, Sridhar MG, Balachander J. Effect of 12 
+Weeks of yoga therapy on quality of life and Indian diabetes risk score in 
+normotensive Indian young adult prediabetics and diabetics: rand-
+omized control trial. J Clin Diagn Res. 2017;11(9):CC10.
+	49.	 Sahay BK. Role of yoga in diabetes. JAPI. 2007;55:121–6.
+	50.	 Balaji PA. Effects of yoga-pranayama practices on metabolic parameters 
+and anthropometry in type 2 diabetes. Int Multidiscipl Res J. 2011;1(10).
+	51.	 Cui J, Yan JH, Yan LM, Pan L, Le JJ, Guo YZ. Effects of yoga in adults 
+with type 2 diabetes mellitus: a meta-analysis. J Diabet Investig. 
+2017;8(2):201–9.
+	52.	 Sedlmeier P, Eberth J, Schwarz M, Zimmermann D, Haarig F, Jaeger S, 
+Kunze S. The psychological effects of meditation: a meta-analysis. Psychol 
+Bull. 2012;138(6):1139.
+	53.	 Bonura KB, Tenenbaum G. Effects of yoga on psychological health in 
+older adults. J Phys Act Health. 2014;11(7):1334–41.
+	54.	 Rastogi S. Development and validation of a Prototype Prakriti Analysis 
+Tool (PPAT): Inferences from a pilot study. AYU. 2012;33(2):209.
+	55.	 Govindaraj P, Nizamuddin S, Sharath A, Jyothi V, Rotti H, Raval R, Nayak J, 
+Bhat BK, Prasanna BV, Shintre P, Sule M. Genome-wide analysis correlates 
+Ayurveda Prakriti. Sci Rep. 2015;5(1):1–2.
+	56.	 Singh AK, Kaur N, Kaushal S, Tyagi R, Mathur D, Sivapuram MS, Metri K, 
+Bammidi S, Podder V, Modgil S, Khosla R. Partitioning of radiological, 
+stress and biochemical changes in pre-diabetic women subjected to 
+Diabetic Yoga Protocol. Diabetes Metab Syndr. 2019;13(4):2705–13.
+	57.	 Pal DK, Bhalla A, Bammidi S, Telles S, Kohli A, Kumar S, Devi P, Kaur N, 
+Sharma K, Kumar R, Malik N. Can yoga-based diabetes management 
+studies facilitate integrative medicine in India current status and future 
+directions. Integr Med Int. 2017;4(3–4):125–41.
+	58.	 Bali P, Kaur N, Tiwari A, Bammidi S, Podder V, Devi C, Kumar S, Sivapuram 
+MS, Ghani A, Modgil S, Malik N. Effectiveness of yoga as the public health 
+intervention module in the management of diabetes and diabetes asso-
+ciated dementia in South East Asia: a narrative review. Neuroepidemiol-
+ogy. 2020;54(4):287–303.
+	59.	 Anand A. Narendra Modi’s citizen centered Yoga-Diabetes Manage-
+ment Program: will Indian state install integrative medicine in premier 
+institutes? Ann Neurosci. 2019;26(2):47–8.
+	60.	 Bansal M. Cardiovascular disease and COVID-19. Diabetes Metab Syndr. 
+2020;14(3):247–50.
+	61.	 Peric S, Stulnig TM. Diabetes and COVID-19. Wien Klin Wochenschr. 
+2020;132(13):356–61.
+Publisher’s Note
+Springer Nature remains neutral with regard to jurisdictional claims in pub-
+lished maps and institutional affiliations.

subfolder_0/Differences in Quality of Life Between American and Chinese breast cancer survivors.txt

@@ -0,0 +1,855 @@
+ORIGINAL ARTICLE
+Differences in quality of life between American and Chinese
+breast cancer survivors
+Qian Lu1 & Jin You2 & April Kavanagh3 & Krystal Warmoth1 & Zhiqiang Meng4 &
+Zhen Chen4 & Kavita D. Chandwani5 & George H. Perkins6 & Jennifer Leigh McQuade6 &
+Nelamangala V. Raghuram7 & Raghuram Nagarathna7 & Zhongxing Liao6 &
+Hongasandra Ramarao Nagendra7 & Jiayi Chen4 & Xiaoma Guo4 & Luming Liu4 &
+Banu Arun6 & Lorenzo Cohen6,8
+Received: 17 July 2015 /Accepted: 28 March 2016
+# Springer-Verlag Berlin Heidelberg 2016
+Abstract
+Objective It has been speculated that cancer survivors in Asia
+may have lower quality of life (QOL) compared with their
+Western counterparts. However, no studies have made interna-
+tional comparisons in QOL using a comprehensive measure.
+This study aimed to compare Chinese breast cancer survivors’
+QOL with US counterparts and examine if demographic and
+medical factors were associated with QOL across groups.
+Method The sample consisted of 159 breast cancer patients
+(97 Chinese and 62 American) who completed the Functional
+Assessment for Cancer Therapy Breast Cancer (FACT-B)
+scale before the start of radiotherapy in Shanghai, China and
+Houston, USA.
+Results Higher income was associated with higher QOL total
+scores in both Chinese and American cancer patients, but
+QOL was not significantly associated with other factors in-
+cluding age, education, disease stage, mastectomy, and
+chemotherapy. Consistent with hypotheses, compared to their
+US counterparts, Chinese breast cancer survivors reported
+lower QOL and all four subdimensions including functional
+well-being (FWB), physical well-being (PWB), emotional
+well-being (EWB), and social well-being (SWB); they also
+reported more breast cancer-specific concerns (BCS).
+Differences were also clinically significant for Functional
+Assessment for Cancer Therapy General (FACT-G) scale total
+scores and the FWB subscale. After controlling for demo-
+graphic and medical covariates, these differences remained
+except for the SWB and BCS. Furthermore, Chinese breast
+cancer survivors receiving chemotherapy reported significant-
+ly lower FACT-G scores than those who did not, but this
+difference did not emerge among US breast cancer survivors.
+Discussion Chinese breast cancer survivors reported
+poorer
+QOL on multiple domains compared to US women. Findings
+indicate that better strategies are needed to help improve the
+The University of Texas School of Public Health, Houston, USA.
+Location when analyses were conducted
+The University of Texas MD Anderson Cancer Center, Houston, USA.
+Location when data was collected
+* Qian Lu
+[email protected]
+* Lorenzo Cohen
+[email protected]
+1
+Department of Psychology, University of Houston, 126 Heyne
+Building, Houston 77204, TX, USA
+2
+WuHan University, Wuhan, China
+3
+The University of Texas School of Public Health, Houston, USA
+4
+Fudan University Shanghai Cancer Center, Shanghai, China
+5
+University of Texas Health Science Center, Houston, USA
+6
+The University of Texas MD Anderson Cancer Center,
+Houston, USA
+7
+Swami Vivekananda Yoga Anusandhana Samsthana,
+Bengaluru, India
+8
+Department of Palliative, Rehabilitation, and Integrative Medicine,
+Section of Integrative Medicine, The University of Texas MD
+Anderson Cancer Center, Houston, TX 77030, USA
+Support Care Cancer
+DOI 10.1007/s00520-016-3195-1
+QOL of Chinese breast cancer survivors, especially those who
+underwent chemotherapy.
+Keywords Quality of life . Breast cancer . Culture . Country
+Introduction
+Cancer is one of the leading causes of mortality worldwide
+[1]. Asia represents 60 % of the world’s population [2]. It is
+estimated to experience 45 % of all new cancer cases in the
+world and 50 % of all cancer deaths in 2008 [3]. China is
+seeing a change in cancer rates [4] and currently observing a
+country-wide increase [5]. Breast cancer is among the most
+frequent types of cancer and alone accounted for 1,383,000
+new cancer cases and 519,000 cancer-related deaths in 2008
+worldwide [1]. Since 1990, rates of breast cancer in China
+have increased 3 to 4 % annually, compared to a global annual
+increase of 0.5 % [6]. As the effectiveness of cancer treatments
+continues to develop in China, the number of breast cancer
+patients and survivors will continue to rise. As patients live
+longer, concern for psychological factors and quality of life
+(QOL) among this population has grown [7]. Although a
+growing number of studies have reported QOL in Asian pop-
+ulations, they focus on the validation of measurement and one
+population. Cross-country comparison of QOL can help to
+understand possible areas of intervention and how to design
+culturally sensitive interventions. However, no publications
+have compared the QOL between Asian and Western breast
+cancer patients. This paper aims to compare differences in
+QOL between Chinese and US breast cancer patients.
+In 1993, the World Health Organization (WHO) defined
+QOL as Bindividuals’ perceptions of their position in life in
+the context of the culture and value systems in which they live
+and in relation to their goals, expectations, standards and
+concerns^ [7]. This broad ranging concept is affected, in a
+complex way, by a person’s physical health, psychological
+state, level of independence, social relationships, and relation-
+ship to their environment [7]. Many methods have been doc-
+umented in the literature for the purpose of evaluating the
+QOL in cancer patients. Of the 12 existing measures, the
+two most commonly used were the European Organization
+for Research and Treatment of Cancer’s quality of life ques-
+tionnaire (EORTC QLQ-C30) and the Functional Assessment
+for Cancer Therapy (FACT) scale [8]. The Functional
+Assessment for Cancer Therapy Breast Cancer (FACT-B)
+scale was developed as a means to evaluate a spectrum of
+QOL components in breast cancer patients specifically. The
+FACT-B is validated for Chinese; however, no studies have
+directly compared responses on the FACT-B in Chinese pop-
+ulations to responses from US populations.
+Despite the lack of studies comparing Chinese to US pop-
+ulations, there is reason to expect that Chinese cancer
+survivors may have lower QOL than Americans. For example,
+Asian American breast cancer survivors have reported lower
+QOL than their European counterparts [9, 10]; Chinese
+American survivors are more likely to experience poorer so-
+cioeconomic well-being than non-Hispanic White survivors
+[11]. Qualitative evidence has also shown that Chinese survi-
+vors describe more distress than Americans [12]. Based on
+these findings, we hypothesized that Chinese survivors may
+have lower QOL compared with the US population.
+QOL has become a consistent index of adjustment and an
+end point in clinical trials in the West [8], but little research has
+characterized QOL issues in Chinese breast cancer patients.
+One study with newly diagnosed Chinese breast cancer pa-
+tients found that income, time since diagnosis, marital status,
+and education were all independently associated with overall
+QOL [13]. Other studies with Chinese and US women have
+observed that younger age was associated with worse QOL in
+breast cancer patients [14–19]. Chinese breast cancer survi-
+vors reported that women who underwent breast conservation
+therapy had better body image compared to women who had
+mastectomy alone [20], consistent with results from studies
+with US women [21]. Patients who undergo chemotherapy
+have been found to report lower quality of life [22], and this
+may be especially true for Chinese cancer patients. Other fac-
+tors, e.g., stage of the disease, were also found to be associated
+with Chinese cancer survivors’ QOL [23–25]. The present
+study therefore investigated how demographic and disease-
+related factors were associated with QOL in both countries.
+This study was a secondary analysis of existing data from
+two intervention studies [26, 27]. The primary goal of this study
+was to compare Chinese breast cancer survivors’ QOL with US
+counterparts. The second goal was to examine how demograph-
+ic and medical factors were associated with QOL across groups.
+We hypothesized that Chinese women would have lower QOL
+compared with the US women (i.e., hypothesis 1). Based on the
+literature reviewed above, we also hypothesized that lower in-
+come and education, younger age, later stage of diagnosis, and
+more aggressive treatment would be associated with worse QOL
+(i.e., hypothesis 2), independent of ethnicity. We finally explored
+whether medical factors differentially influenced QOL depend-
+ing on ethnicity (Chinese vs. US). We hypothesized that having
+undergone chemotherapy prior to the start of radiotherapy (as-
+sessment point) and later stage of diagnosis would have a greater
+influence on QOL among Chinese than among US breast cancer
+survivors (i.e., hypothesis 3).
+Methods
+Participants
+A total of 159 patients (97 Chinese and 62 American) partic-
+ipated in the study. Participants were recruited from two
+Support Care Cancer
+comparable intervention studies conducted in Shanghai,
+China and Houston, USA. All the participants who enrolled
+in these studies were included in this study and met all inclu-
+sion and exclusion criteria of parent studies, which were the
+same criteria for this study. Detailed information on the study
+methods has been published previously [26, 27]. Eligible
+Chinese patients were identified by physicians and research
+nurses at the breast cancer clinic. These patients were sched-
+uled for radiotherapy at Fudan University Shanghai Cancer
+Center (FUSCC) in Shanghai, China. Eligible US patients
+were identified through the Cardiac Arrest Registry to
+Enhance Survival (CARES) database, which is an institutional
+database that keeps track of patient schedules at MD
+Anderson Cancer Center. These patients were undergoing ra-
+diotherapy in the Department of Radiology Oncology, at MD
+Anderson Cancer Center. Inclusion criteria were (1) women
+18 years or older, (2) with stage 0–III breast cancer, and (3)
+completed surgery and/or chemotherapy and had not started
+radiotherapy. Additional inclusion criteria were reading, writ-
+ing, and speaking fluency in Chinese for Chinese women or
+English for US women. The study excluded patients with any
+major psychiatric diagnoses or metastatic disease.
+Procedures
+Patients were recruited and provided written informed consent
+prior to the start of radiotherapy. All patients had completed
+surgery and/or chemotherapy prior to consent. In the Qigong
+intervention study, 123 Chinese patients were approached,
+100 patients consented and were randomized, and 96 complet-
+ed the survey, yielding a response rate of 96 %. In the Yoga
+intervention study, 137 of the US patients were approached,
+81 consented, 71 were randomized, and 61 completed the
+survey, resulting in a response rate of 75.3 %. After patients
+consented to the study and before they were randomized to the
+experimental or control groups, a 45-min battery of question-
+naires was given at baseline to measure QOL and demograph-
+ic information, and medical data was extracted from patient
+charts and electronic medical record. The MD Anderson
+Institutional Review Board approved both studies, and the
+Fudan University IRB approved the Chinese study.
+Measures
+QOL was measured by FACT-B version 4. This measure is
+validated for both Chinese and US breast cancer patients [28,
+29]. Participants respond on a Likert scale ranging from 0 (not
+at all) to 4 (very much). The instrument has a total of 36
+statements asking respondents to rate how true each statement
+is for the last 7 days. One of the items in the social well-being
+subdimension asked about sexual satisfaction and was largely
+skipped by Chinese participants; therefore, this item was ex-
+cluded from the analysis in this paper. The FACT-B consists of
+the Functional Assessment for Cancer Therapy General
+(FACT-G) scale [28], with the addition of breast cancer-
+specific questions. The FACT-G has four subscale scores:
+physical well-being (e.g., BI have nausea.^), functional well-
+being (e.g., BI am able to work, including work at home.^),
+emotional well-being (e.g., BI feel nervous.^), and social/
+family well-being (e.g., BI am satisfied with family communi-
+cation about my illness.^). Responses are summed for a total
+score, with greater scores indicating higher QOL. The BCS
+subscale addresses breast cancer-specific concerns (e.g., BOne
+or both of my arms are swollen or tender.^), with higher scores
+on this dimension indicating fewer concerns and better QOL.
+In this current study, for group comparison, we reported the
+FACT-G subscale and total scores and BCS subscale separate-
+ly so that future studies with non-breast and breast cancer
+survivors can compare the FACT-G score with our report.
+Prior literature demonstrates that the alpha coefficients of the
+whole scale are 0.92 and 0.90 and for each subscale ranges
+from 0.82 to 0.88 and from 0.82 to 0.85 in US and Chinese
+samples, respectively.
+Data analyses
+In the preliminary analyses, descriptive statistics were com-
+puted within each of the cultural samples and cultural group.
+Comparisons of all the variables were conducted with
+ANOVAs or chi-squared tests. Correlation coefficients of all
+variables were computed with Pearson correlations, Spearman
+correlations, or cross-tabulations. For all the analyses below,
+we first used the FACT-G total score and the BCS score as the
+dependent variable. When group differences emerged in the
+FACT-G total score, each subscale of FACT-G was used as a
+dependent variable to further illustrate cultural differences in a
+particular domain of QOL.
+To test hypothesis 1, ANOVAs were performed with cul-
+tural groups as an independent variable. To rule out the pos-
+sibility that the findings were confounded with demographic
+and cancer-related characteristics, ANCOVAs were conducted
+controlling for all the demographic and medical variables in-
+cluding age, disease stage, surgery type (mastectomy vs. con-
+servation breast surgery), chemotherapy (yes vs. no), income,
+and education. When statistically controlling for income, we
+used the relative income compared with the mean within the
+group, rather than the absolute value to adjust for country-
+related differences in income. To test hypothesis 2, regression
+analyses were used with QOL and subscales as dependent
+variables and with all demographic and medical variables
+(age, disease stage, surgery type, chemotherapy, income, and
+education) entered as independent variables. To test hypothe-
+sis 3, ANCOVAs were conducted to examine how disease
+stage and chemotherapy would separately interact with cultur-
+al groups in predicting QOL when controlling for all demo-
+graphic and medical variables. For significant interaction
+Support Care Cancer
+effects, we conducted simple effect analyses to illustrate how
+these variables would be differently associated with QOL
+within each of the two cultural samples [30].
+Results
+Sample characteristics and country comparisons are shown in
+Table 1. Compared with the US sample, the Chinese sample
+was younger, poorer, less educated, and had a higher percent-
+age of women that had undergone chemotherapy, even though
+there were no disease stage differences. ANOVAs for hypoth-
+esis 1 showed that Chinese breast cancer survivors reported
+lower scores for FACT-G total, all FACT-G subscales, and
+BCS than their US counterparts (Table 2). ANCOVA analyses
+revealed that after controlling for covariates including age,
+disease stage, mastectomy, chemotherapy, income, and
+education, the above cultural differences remained significant
+except for BCS and the social well-being (SWB) subscale.
+Regression analyses for hypothesis 2 for the combined
+populations revealed that after controlling for other demo-
+graphic and medical variables, income was positively associ-
+ated with FACT-G total scores (β = 0.31, p = 0.001) and three
+subscales of FACT-G, including physical well-being (PWB;
+β = 0.21, p = 0.03), SWB (β = 0.38, p < 0.001), and functional
+well-being (FWB; β = 0.29, p = 0.002). FACT-G was not
+significantly associated with other factors including age, edu-
+cation, disease stage, mastectomy, and chemotherapy.
+However, age was positively associated with BCS (β = 0.18,
+p = 0.04), and having chemotherapy was negatively associat-
+ed with PWB (β = −0.21, p = 0.04), after controlling for the
+other demographic and medical variables.
+Analyses for hypothesis 3 found significant interactions
+between cultural group and chemotherapy predicting FACT-
+G total scores, F(1, 138) = 6.63, p = 0.01, ηp
+2 = 0.046, even
+Table 1 Demographic and
+cancer-related characteristics of
+the samples
+Total N = 159,
+n (%)
+Chinese
+N = 97, n (%)
+American
+N = 62, n (%)
+F/χ2
+df
+p
+Age
+15.53
+2
+<0.001
+25–45 years
+54 (34.0)
+38 (39.2)
+16 (25.8)
+46–55 years
+61 (38.4)
+43 (44.3)
+18 (29.0)
+56–68 years
+44 (27.7)
+16 (16.5)
+28 (45.2)
+Annual personal income
+15.66
+2
+<0.001
+Below average
+9 (5.7)
+6 (6.2)
+3 (4.8)
+Average
+50 (31.4)
+43 (44.3)
+7 (11.3)
+Above average
+65 (40.9)
+33 (34.0)
+32 (51.7)
+Missing
+35 (22.0)
+15 (15.5)
+20 (32.3)
+Educational attainment
+35.11
+2
+<0.001
+High school or lower
+51 (32.1)
+44 (45.4)
+7 (11.3)
+College
+80 (50.3)
+47 (48.4)
+33 (51.3)
+Graduate degree
+25 (15.7)
+4 (4.1)
+21 (33.9)
+Missing
+3 (1.9)
+2 (2.1)
+1 (1.6)
+Disease stage
+1.11
+3
+0.78
+0–I
+47 (29.5)
+28 (28.9)
+19 (30.7)
+II
+62 (39.0)
+35 (36.1)
+27 (43.5)
+III
+40 (25.2)
+24 (24.7)
+16 (25.8)
+Missing
+10 (6.3)
+10 (10.3)
+0 (0)
+Mastectomy
+2.16
+1
+0.14
+Yes
+79 (49.7)
+53 (54.6)
+26 (41.9)
+No
+79 (49.7)
+44 (45.4)
+35 (56.5)
+Missing
+1 (.6)
+0 (0)
+1 (1.6)
+Chemotherapy
+15.73
+1
+<0.001
+Yes
+22 (13.8)
+92 (94.8)
+45 (72.6)
+No
+137 (86.2)
+5 (5.2)
+17 (27.4)
+The cutoff points of average and below average income are retrieved from government reports for each cultural
+sample, which are $8000 and $1500 (currency rate, 6.34 Yuan = US$1) in the Chinese sample and are $50,000
+and $20,000 in the US sample
+Support Care Cancer
+after controlling for demographic and other medical covariate
+variables. Simple effect analysis demonstrated that Chinese
+breast cancer survivors receiving chemotherapy (M = 71.55,
+SD = 14.52) reported significantly lower FACT-G than those
+who did not (M = 86.20, SD = 12.44), F(1, 138) = 7.73,
+p = 0.006, but such difference did not emerge among
+American breast cancer survivors, F(1, 138) = 1.94, ns (see
+Fig. 1). Subscale analyses revealed that cultural group × che-
+motherapy interaction effect were significant on PWB, F(1,
+138) = 4.00, p = 0.047, ηp
+2 = 0.028, and EWB, F(1,
+138) = 5.95, p = 0.016, ηp
+2 = 0.041. Chinese breast cancer
+survivors who had chemotherapy (MPWB = 19.44, SD = 5.21)
+reported significantly lower PWB than those who did not
+(MPWB = 25.00, SD = 3.32), F(1, 138) = 11.63, p = 0.001.
+However, US breast cancer survivors who had chemotherapy
+(M = 20.50, SD = 2.71) reported better EWB than those who
+did not (M = 18.50, SD = 3.87), F(1, 138) = 4.87, p = 0.03.
+Because the Chinese sample had a significantly higher per-
+centage (94.8 %) undergoing chemotherapy compared with
+the US sample (72.6 %) and only five Chinese women did
+not receive chemotherapy, we also compared QOL among
+those with chemotherapy controlling for other covariates.
+Chinese breast cancer survivors receiving chemotherapy had
+significantly lower FACT-G, F(1, 119) = 11.97, p = 0.001,
+ηp
+2 = 0.091, PWB, F(1, 119) = 5.81, p = 0.018, ηp
+2 = 0.047,
+EWB, F(1, 119) = 9.17, p = 0.003, ηp
+2 = 0.072, and FWB,
+F(1, 119) = 9.53, p = 0.003, ηp
+2 = 0.074, than did their US
+counterparts, and no group differences emerged for SWB,
+F(1, 119) = 3.05, ns, or BCS, F(1, 119) = 1.38, ns.
+The cultural group × disease stage interaction was signifi-
+cant for FACT-G even after controlling for demographic and
+other medical variables, F(2, 136) = 4.32, p = 0.05, ηp
+2 = 0.06;
+see Fig. 2. Simple effect analysis revealed that Chinese breast
+cancer survivors with stage II (M = 66.58, SD = 2.40) had
+significantly lower FACT-G than those with stages 0–I
+(M = 78.86, SD = 12.30), F(2, 136) = 7.50, p = 0.001, but
+such difference did not exist in the US sample, F(2,
+136) = 1.73, ns. The Chinese breast cancer survivors scored
+lower on FACT-G compared to the US women if they were at
+stage II, F(1, 136) = 12.86, p < 0.001, and stage III, F(1,
+136) = 5.05, p = 0.03, but not at stages 0–I, F(1,
+136) = 0.52, ns. Subscale analyses showed that cultural group
+interacted with disease stage on EWB, F(2, 136) = 3.78,
+p = 0.03, ηp
+2 = 0.05, only. Simple effect analyses demonstrat-
+ed that Chinese survivors at stage II (M = 15.97, SD = 4.49)
+displayed significantly lower EWB than those at stages 0–I
+(M = 19.54, SD = 3.04), F(2, 136) = 7.59, p = 0.001, but such
+difference did not exist in the US sample. No significant group
+and disease stage interaction merged for BCS.
+Table 2 Mean, standard
+deviation, and comparison of
+quality of life between Chinese
+and US breast cancer patients
+Chinese (N = 97)
+American (N = 62)
+F
+df
+p
+ηp
+2
+FACT-G (26 items)
+72.45 (15.31)
+83.30 (12.25)
+22.10
+1
+<0.001
+0.123
+PWB (7 items)
+19.73 (5.27)
+22.52 (4.13)
+12.46
+1
+0.001
+0.073
+SWB (6 items)
+19.29 (4.07)
+21.34 (3.58)
+10.54
+1
+0.001
+0.063
+EWB (6 items)
+17.68 (4.46)
+19.92 (3.27)
+11.58
+1
+0.001
+0.069
+FWB (7 items)
+15.75 (5.19)
+19.53 (5.27)
+19.84
+1
+<0.001
+0.112
+BCS (9 items)
+22.30 (4.88)
+24.13 (4.67)
+5.51
+1
+0.020
+0.034
+FWB functional well-being, PWB physical well-being, EWB emotional well-being, SWB social well-being, BCS
+breast cancer-specific concerns
+**
+*
+Fig. 1 Interaction effects between chemotherapy and cultural group on
+FACT-G. *p < 0.05, **p < 0.01
+**
+*
+*
+*
+Fig. 2 Interaction effects between cancer stage and cultural group on
+FACT-G. *p < 0.05, **p < 0.01
+Support Care Cancer
+Discussion
+Although the rates of breast cancer have been rising in Asian
+populations [5], there has been a lack of understanding of the
+QOL among Asian cancer survivors. Furthermore, previous
+studies have not compared Asian breast cancer survivors’
+QOL with Westerners. Studies that have been conducted sep-
+arately, either in the USA or China, are difficult to compare as
+a result of inconsistencies in the time points assessed, tools
+used for assessment, and the population of breast cancer pa-
+tients examined. This is the first study that has compared re-
+sponses on the FACT-B in Chinese and US women with breast
+cancer. Both populations were obtained from a similar group
+of patients and examined at the same time point (before the
+start of radiotherapy).
+This study revealed that Chinese breast cancer survivors
+had lower overall FACT-G total scores compared to US wom-
+en. Furthermore, Chinese women reported lower levels of
+functional, physical, social, and emotional well-being and
+more breast cancer concerns than US women. A difference
+in FACT-G total scores of 5–7 points is indicative of clinically
+significant QOL changes/differences [31]. On average,
+Chinese women were 11 points lower on the FACT-G total
+score compared to the American, which is considered a clin-
+ically significant difference. Moreover, the differences
+remained pronounced in multiple domains of QOL including
+functional, physical, and emotional well-being even after con-
+trolling for age, disease stage, mastectomy, chemotherapy, in-
+come, and education. The more salient differences emerged
+for the functional well-being subscale (ηp
+2 = 0.112), where
+differences were also clinically significant (>3).
+The Chinese sample was poorer, younger, less educated,
+and more likely to have undergone chemotherapy compared
+with the US sample. The finding that Chinese women were
+younger on average than US women is consistent with prior
+research showing that Chinese women are being diagnosed
+with breast cancer at a younger age than US women [32].
+Even after statistically controlling for these variables, the
+Chinese women still had worse quality of life. This suggests
+that perhaps symptom control strategies were not as aggres-
+sive for the Chinese as the US women. Nevertheless, it is still
+possible that income and greater use of chemotherapy could
+be reasons for country differences in QOL. Those who have
+undergone chemotherapy have been found to report lower
+quality of life [22]. It could be possible that Chinese patients
+undergo more aggressive treatment or take drugs that have
+more adverse side effects. Yet, symptom control strategies
+may also be different, and these data were not collected.
+Further investigation is needed.
+The interaction effect also provided some possible expla-
+nations. Chinese patients who underwent chemotherapy were
+at later cancer stages and had a much worse quality of life
+compared to their US peers, whereas Chinese patients who
+did not receive chemotherapy and were at an early cancer
+stage were similar to their US peers. These findings suggest
+that more attention needs to be paid to improve QOL among
+those with chemotherapy and those at more advanced cancer
+stages. We did not find surgery type to be differentially linked
+to QOL. Future studies need to investigate symptom control
+strategies that may have contributed to the country differences
+in QOL.
+Higher income was associated with higher QOL total score
+in both Chinese and US samples, a finding consistent with
+previous studies in Caucasian populations [10, 15, 33]. Past
+research also suggests that younger age and less education are
+associated with poor QOL [22, 34, 35]. We only found an
+association between younger age and worse QOL in the US
+breast cancer survivors. This may be a result of the small
+sample size, relative homogeneity of the samples, the fact that
+the Chinese women were significantly younger and less edu-
+cated than the US women, and confounded by other medical
+and demographic facts known to be associated with QOL.
+Studies in Chinese populations have inconsistently found as-
+sociations with stage of disease and some subscales of the
+FACT-G [13, 36]. In some studies, FACT total score included
+the breast cancer concern subdimension, and others did not
+include this subdimension. In order to easily make the com-
+parisons between this study and other studies reported FACT
+scores, we calculated the FACT-G total separately from the
+BCS scale and reported the four subdimensions and breast
+cancer concerns separately so that future studies can make
+comparisons with our findings.
+Comparison of responses on the FACT-B in Asian and US
+breast cancer patients has not been previously conducted. The
+FACT-B has been used in many studies in US breast cancer
+patients, and even with the differences in the time QOL was
+assessed across studies [15, 19, 37], scores on the FACT-B
+subscale scores were similar to our US sample. A previous
+study validated the FACT-B in Chinese breast cancer inpa-
+tients at an Oncological Hospital in Yunnan providence [29].
+The women in that study scored lower in all FACT-B scales
+compared to Chinese women in our study. The women in our
+study were treated in Shanghai at one of the best hospitals in
+China. If the women in our study have better QOL than
+Chinese women treated in other regions, the differences be-
+tween Chinese women from regional hospitals and US women
+may even be larger.
+Several caveats of the current study are worth mentioning.
+The study examined the country difference in QOL with two
+convenience samples, which limits the generalizability.
+However, the Chinese women in our study reported higher
+QOL than Chinese women in two other studies, suggesting
+that the major conclusion of the study that Chinese women
+had worse QOL could be generalized to Chinese women from
+other regions within China. Second, the small sample size
+limited our analyses of interactions between covariates and
+Support Care Cancer
+cultural groups. There were a smaller number of breast cancer
+survivors without chemotherapy in the analysis for cultural
+group by chemotherapy interaction. In addition, a limited
+number of covariates were examined. Other covariates that
+have been shown to be associated with QOL in both
+Chinese and US populations need to be included as well; these
+factors include marital status, time since diagnosis, co-
+morbidity factors, and social support [23–25, 36]. Other fac-
+tors have also been shown to influence QOL, such as pain,
+fatigue, and anxiety [18]. Future studies should examine the
+relationship between these factors and QOL in both groups.
+We were also not able to extract medical data related to symp-
+tom control strategies used for the women, such as medica-
+tions for nausea and vomiting, fatigue, and sleep disturbances.
+Differences in symptom control strategies may explain some
+of the QOL differences. Finally, although the FACT-B is val-
+idated in Chinese, it may not be completely comparable across
+populations and contain questions that introduce bias into
+study results. Future studies using a mixed paradigm with both
+qualitative and quantitative data may shed light into the cul-
+tural equivalence of the questions.
+In sum, this study demonstrated that Chinese breast cancer
+survivors had worse QOL compared with US counterparts,
+and these differences were clinically significant. Treatment
+and cancer stage may have contributed to group differences.
+However, extra efforts are needed to help improve QOL of
+Chinese breast cancer patients. Future studies are warranted to
+further understand what contributed to country differences in
+QOL and how to design better behavioral and medical inter-
+ventions to improve women’s lives in countries where QOL
+needs to be improved.
+Acknowledgments
+Support was provided in part by the US National
+Cancer Institute (NCI) grants CA108084 and CA121503 (principal in-
+vestigator, Lorenzo Cohen) and the American Cancer Society MRSGT-
+10-011-01-CPPB (principal investigator, Qian Lu). Partial support for
+Lorenzo Cohen was provided by the Richard E. Haynes Distinguished
+Professorship in Clinical Cancer Prevention. Jennifer McQuade is sup-
+ported by an institutional T32 training grant and an ASCO Young
+Investigator Award.
+Compliance with ethical standards
+Financial disclosures
+There are no financial disclosures from any
+authors.
+Conflict of interest
+The authors declare that they have no conflict of
+interest.
+References
+1.
+Ferlay J et al. (2010) Estimates of worldwide burden of cancer in
+2008: GLOBOCAN 2008. Int J Cancer 127:2893–2917
+2.
+Population Division of the Department of Economic and Social
+Affairs of the United Nations Secretariat, World Population
+Prospects: The 2012 Revision, in Total Population - Both Sexes
+2012.
+3.
+Centers of Disease Control and Prevention (2007) Cancer
+Survivors—United States. MMWR 2011 60:269–272
+4.
+Shin HR et al. (2010) Cancer in Asia—incidence rates based on
+data in cancer incidence in five continents IX (1998-2002). Asian
+Pac J Cancer Prev 11(Suppl 2):11–16
+5.
+Shin HR et al. (2010) Recent trends and patterns in breast cancer
+incidence among Eastern and Southeastern Asian women. Cancer
+Causes Control 21:1777–1785
+6.
+Parkin DM et al. (2005) Global cancer statistics, 2002. CA Cancer J
+Clin 55:74–108
+7.
+WHOQOL group (1993) Study protocol for the World Health
+Organization project to develop a Quality of Life assessment instru-
+ment (WHOQOL). Qual Life Res 2:153–159
+8.
+Lemieux J et al. (2011) Quality-of-life measurement in randomized
+clinical trials in breast cancer: an updated systematic review (2001-
+2009). J Natl Cancer Inst 103:178–231
+9.
+Ashing-Giwa KT, Lim J (2010) Predicting physical quality of life
+among a multiethnic sample of breast cancer survivors. Qual Life
+Res 19(6):789–802
+10.
+Ashing-Giwa KT, Lim JW (2009) Examining the impact of socio-
+economic status and socioecologic stress on physical and mental
+health quality of life among breast cancer survivors. Oncol Nurs
+Forum 36:79–88
+11.
+Wang JH-Y et al. (2013) A mixed method exploration of survivor-
+ship among Chinese American and non-Hispanic White breast can-
+cer survivors: the role of socioeconomic well-being. Qual Life Res
+22(10):2709–2721
+12.
+Wang JH-Y et al. (2012) Physical distress and cancer care experi-
+ences among Chinese-American and non-Hispanic White breast
+cancer survivors. Gynecol Oncol 124(3):383–388
+13.
+Cui Y et al. (2004) The long-term impact of medical and socio-
+demographic factors on the quality of life of breast cancer survivors
+among Chinese women. Breast Cancer Res Treat 87:135–147
+14.
+Ganz PA et al. (2003) Breast cancer in younger women: reproduc-
+tive and late health effects of treatment. J Clin Oncol 21:4184–4193
+15.
+Kwan ML et al. (2010) Quality of life among women recently
+diagnosed with invasive breast cancer: the Pathways Study.
+Breast Cancer Res Treat 123:507–524
+16.
+Salonen P et al. (2009) Telephone intervention and quality of life in
+patients with breast cancer. Cancer Nurs 32:177–190 quiz 191-2
+17.
+So WK et al. (2011) Age-related differences in the quality of life of
+Chinese women undergoing adjuvant therapy for breast cancer. Res
+Gerontol Nurs 4:19–26
+18.
+So WK et al. (2010) Anxiety, depression and quality of life among
+Chinese breast cancer patients during adjuvant therapy. Eur J Oncol
+Nurs 14:17–22
+19.
+Wenzel LB et al. (1999) Age-related differences in the quality of life
+of breast carcinoma patients after treatment. Cancer 86:1768–1774
+20.
+Fung KW et al. (2001) The impact of mastectomy, breast-
+conserving treatment and immediate breast reconstruction on the
+quality of life of Chinese women. ANZ J Surg 71:202–206
+21.
+Wainstock JM (1991) Breast cancer: psychosocial consequences for
+the patient. Semin Oncol Nurs 7:207–215
+22.
+Ganz PA et al. (2004) Quality of life at the end of primary treatment
+of breast cancer: first results from the moving beyond cancer ran-
+domized trial. J Natl Cancer Inst 96:376–387
+23.
+Cheng H et al. (2013) Social support and quality of life among
+Chinese breast cancer survivors: Findings from a mixed methods
+study. Eur J Oncol Nurs 17(6):788–796
+24.
+So WK et al. (2013) Associations between social support, prevalent
+symptoms and health-related quality of life in Chinese women un-
+dergoing treatment for breast cancer: A cross-sectional study using
+structural equation modelling. Eur J Oncol Nurs 17(4):442–448
+Support Care Cancer
+25.
+So WK et al. (2009) The symptom cluster of fatigue, pain, anxiety,
+and depression and the effect on the quality of life of women re-
+ceiving treatment for breast cancer: a multicenter study. Oncol Nurs
+Forum 36(4):E205–E214
+26.
+Chandwani KD et al. (2010) Yoga improves quality of life and
+benefit finding in women undergoing radiotherapy for breast can-
+cer. J Soc Integr Oncol 8:43–55
+27.
+Chen Z et al. (2013) Qigong improves quality of life in women
+undergoing radiotherapy for breast cancer: results of a randomized
+controlled trial. Cancer 119:1690–1698
+28.
+Cella DF et al. (1993) The Functional Assessment of Cancer
+Therapy scale: development and validation of the general measure.
+J Clin Oncol 11:570–579
+29.
+Wan C et al. (2007) Validation of the simplified Chinese version of
+the FACT-B for measuring quality of life for patients with breast
+cancer. Breast Cancer Res Treat 106:413���418
+30.
+Aiken LS, West SG (1991) Multiple regression: testing and
+interpreting interactions. SAGE, Newbury Park
+31.
+Cella D et al. (2002) What is a clinically meaningful change on the
+Functional Assessment of Cancer Therapy-Lung (FACT-L)
+Questionnaire? Results from Eastern Cooperative Oncology
+Group (ECOG) Study 5592. J Clin Epidemiol 55:285–295
+32.
+Kwong A, Chu AT (2012) Experience of Southern Chinese: new
+challenges in treating young female breast cancer patients at child-
+bearing age–a call for multi-disciplinary collaboration. Asian Pac J
+Cancer Prev 13:3535–3537
+33.
+Shimozuma K et al. (1999) Quality of life in the first year after
+breast cancer surgery: rehabilitation needs and patterns of recovery.
+Breast Cancer Res Treat 56:45–57
+34.
+Ganz PA, Lee JJ, Siau J (1991) Quality of life assessment. An
+independent prognostic variable for survival in lung cancer.
+Cancer 67:3131–3135
+35.
+Parker PA et al. (2003) Psychosocial and demographic predictors of
+quality of life in a large sample of cancer patients. Psychooncology
+12:183–193
+36.
+Lu W et al. (2007) Impact of newly diagnosed breast cancer on
+quality of life among Chinese women. Breast Cancer Res Treat
+102:201–210
+37.
+Avis NE, Crawford S, Manuel J (2005) Quality of life among youn-
+ger women with breast cancer. J Clin Oncol 23:3322–3330
+Support Care Cancer

subfolder_0/Effect of Bhramari Pranayama on response inhibition.txt

@@ -0,0 +1,376 @@
+Volume 7 | Issue 2 | July-December | 2014
+Official 
+Publication 
+of
+Swami 
+Vivekananda 
+Yoga 
+Anusandhana 
+Samsthana 
+University
+Online full text at
+http://www.ijoy.org.in
+IJ Y
+O
+International Journal of Yoga
+Guest Editorial
+Original Articles
+Comparative immediate effect of different yoga asanas on heart rate and blood pressure in healthy young volunteers
+Effect of trataka on cognitive functions in the elderly
+Effect of Bhramari pranayama and OM chanting on pulmonary function inhealthy individuals: A prospective randomized control trial
+Effect of yogic colon cleansing (Laghu Sankhaprakshalana Kriya) on pain, spinal flexibility, disability and state anxiety in chronic low back pain
+Toward building evidence for yoga
+Contents
+ISSN 
+0973-6131
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+138
+Effect of Bhramari Pranayama on response inhibition: 
+Evidence from the stop signal task
+Sasidharan K Rajesh, Judu V Ilavarasu, Thaiyar M Srinivasan1
+Department of Psychology, 1Division of Yoga and Physical Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, 
+Kempegowda Nagar, Bengaluru, Karnataka, India
+Address for correspondence: Mr. Sasidharan K Rajesh, 
+#19 Eknath Bhavan, No. 19, Gavipuram Circle, Kempgowda Nagar, Bengaluru ‑ 560 019, Karnataka, India. 
+E‑mail: [email protected]
+to be a useful tool for the study of response inhibition 
+in cognitive psychology, cognitive neuroscience, and 
+psychopathology.[1] In SST, subjects act upon a go reaction 
+time  (RT) task. On a random selection of the trials 
+(stop signal trials), a stop signal is presented, instructing 
+them to withhold their go responses.[4] The ability to 
+stop ongoing motor responses in a split second is a vital 
+element of response control and flexibility that relies on 
+frontal‑subcortical network.[5] The stop paradigm is based 
+on the race model where response execution races with 
+the inhibitory process to determine whether a response is 
+inhibited.[6] Further stop signal paradigm allows a sensitive 
+estimate of inhibitory control known as the stop signal 
+RT (SSRT), which reflects the time taken to internally 
+suppress a response.[7] Furthermore, previous studies have 
+shown medication for the treatment of attention deficit 
+hyperactivity disorder (ADHD) enhanced SSRT in healthy 
+volunteers.[8,9] To our knowledge, there is no study to date 
+using this paradigm in yoga based research.
+INTRODUCTION
+Adaptive functioning of behavior on the basis of feedback 
+from the environmental requirements is an important 
+characteristic of executive control. Response inhibition is 
+the hallmark of executive function. It refers to the ability 
+to inhibit inappropriate or irrelevant responses according 
+to dynamic change in environment.[1] Response inhibition 
+deficits have been linked to several psychopathological 
+disorders.[2,3] The Stop Signal Task  (SST) has proved 
+Context: Response inhibition is a key executive control processes. An inability to inhibit inappropriate actions has been linked 
+to a large range of neurologic and neuropsychiatric disorders.
+Aims: Examine the effect of Bhramari Pranayama (Bhpr) on response inhibition in healthy individuals.
+Settings and Design: Thirty‑one male students age ranged from 19-31 years from a residential Yoga University, Bengaluru, India 
+were recruited for this study. We used a randomized self as control within‑subjects design. Participants were counterbalanced 
+randomly into two different experimental conditions (Bhpr and deep breathing (DB)).
+Materials and Methods: Response inhibition has been measured using a standard tool Stop Signal Task (SST). Each session 
+lasted for 50 min with 10 min for the experimental conditions, preceded and followed by 20 min of assessment. The primary 
+outcome measure was stop signal reaction time (SSRT), an estimate of the subject’s capacity for inhibiting prepotent motor 
+responses. Additional measures of interest were the probability of responding on stop signal trials, P (r | s) and mean RT to 
+go stimuli.
+Results: The mean probability of responding on stop signal trials (p (r | s)) during Bhpr and DB are close to 50%, indicating 
+reliable SSRT. Paired sample t‑tests showed a significant decrease (P = 0.024) in SSRT after Bhpr session, while the  DB 
+group did not show any significant change. Further, t‑tests show that the go RT increased significantly after Bhpr (P = 0.007) 
+and no other changes/differences were observed.
+Conclusions: Bhpr enhanced response inhibition and cognitive control in nonclinical participants.
+Key words: Bhramari; response inhibition; stop signal; yoga
+ABSTRACT
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.133896
+Short Communication
+Rajesh, et al.: Bhramari pranayama on response inhibition
+139
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+Yoga in its original form consisted of a system of 
+ethical, psychological, and physical practices; 
+although of ancient origin, it transcends cultures and 
+languages.[10] Yoga lays emphasis on manipulation of breath 
+movement (Pranayama), which contributes to a positive 
+neurophysiologic response.[11] Yogic breathing technique 
+called Bhramari Pranayama (Bhpr), involves producing 
+a vibrating constant pitch sound emulating the buzzing 
+of female bumble bee. The term Bhramari is a Sanskrit 
+word meaning a female bee. In the Bhramari breathing 
+technique, a humming sound resembling that of a female 
+bee is produced. In this Pranayama, one produces a low 
+pitched humming audible sound resembling the sound 
+of a female bee as long as possible, during exhalation. 
+EEG paroxysmal gamma waves were measured during 
+approximately 20 breathing episode of Bhpr in eight 
+subjects. The result shows an increased theta range 
+activity, which is similar to results obtained with other 
+meditation techniques.[12] Further, Bhpr as a therapy shows 
+significantly reduced irritability, depression, and anxiety 
+associated with tinnitus.[13] However, the effect of Bhpr on 
+cognitive function has not been reported. In this study, 
+we examine the effect of yogic breathing Bhpr on SST in 
+healthy individuals.
+MATERIALS AND METHODS
+Subjects
+Thirty‑four undergraduate and graduate male students 
+from a residential Yoga University, Bengaluru, India were 
+recruited for this study. The final sample comprised 
+31 volunteers, because the data for three subjects were 
+excluded due to failure of software. Participants’ age 
+ranged from 19 to 31 years with a mean age of 23.90 years 
+(standard deviation (SD) =3.48). All reported having a 
+normal or corrected vision and normal hearing. Females 
+were excluded because of reported varying SST during 
+phases of the menstrual cycle.[14] Participants were free 
+from medication, smoking, alcohol consumption, and 
+cardiorespiratory ailments by self‑report. Since the 
+handedness effects are not known, all subjects selected were 
+right handed only. The experience of subjects practicing 
+breathing techniques ranges from 6  months–5  years. 
+The approval of the Institutional Ethics Committee was 
+obtained and informed consent was collected. Participants 
+received no monetary compensation for their participation.
+Design and procedure
+This was a randomized self as control within‑subjects 
+design. Participants were counterbalanced randomly into 
+two different experimental conditions (Bhpr and deep 
+breathing (DB)). Each session was on a different day. Half of 
+the subject’s undergone Bhpr session the first day and DB 
+on the next day. For remaining half the order of the sessions 
+reversed. Subjects were counterbalanced to either one of 
+the conditions, to wash out any possible learning effect. 
+The time of day was kept constant for both sessions for 
+an individual (6 am-8 am). Each session lasted for 50 min. 
+The SST was recorded before and after the trial conditions. 
+All subjects had undergone orientation in the experimental 
+conditions (Bhpr and DB) for 15 days before the actual 
+assessment. All subjects received a practice session 1 day 
+prior to the experimental sessions in order to familiarize 
+them with the SST and procedures. During the practice 
+trails, experimenter shows the task on a laptop screen. 
+Volunteers then undertook brief practice, until it was 
+evident to the experimenter that the volunteer was 
+responding appropriately. The experiment was conducted 
+individually in a room under normal fluorescent lighting 
+with a laptop in the research lab. Care was taken that 
+during the experiment no external distractions or noises 
+were present.
+SST
+The stimuli were presented on a laptop using STOP‑IT, 
+which is a free‑to‑use SST program.[7] Participants were 
+seated approximately at 50  cm from the screen. The 
+primary task is to perform a two‑choice RT task in which 
+subjects had to react as quickly and accurately as possible 
+to discriminate between a square and a circle stimulus. 
+The primary task stimulus followed by fixation sign (+) 
+is presented in the center of the computer screen, in 
+white, on a black background. The subject responds 
+with ‘Z’ (for square) and ‘/’  (for circle) on a keyboard 
+with the left and right index finger, respectively. On 
+no‑signal trials (go task), only the primary task stimulus 
+is presented. On stop‑signal trials (Stop Task), an auditory 
+‘stop signal’ beep is presented at a variable delay (stop 
+signal delay, SSD) following the go stimulus. Subjects 
+are instructed to inhibit their responses on the trials with 
+a stop signal beep. Tasks were presented randomly: Go 
+task (75%) and stop task (25%). SSD is initially set at 
+250 ms and is adjusted continuously with dynamically 
+tracking procedure, dependent upon the performance 
+of the participant. Successful inhibitions resulted in an 
+increase of the SSD by 50 ms, whereas failed inhibitions 
+resulted in a reduction of the SSD by 50 ms. This procedure 
+ensured that on average each participant in each session 
+had a probability of successful inhibition approaching 
+50%.[7] A total of 392 trials were presented, divided over 
+six blocks of 64 trials, lasting 3 min each. Subjects had 
+waited for 10 s between blocks before they start the next 
+block. The primary outcome measure is SSRT, an estimate 
+of the subject’s capacity for inhibiting prepotent motor 
+responses. SSRT was calculated by subtracting mean stop 
+signal delay from mean RT to go stimuli (go RT). Additional 
+measures of interest are the probability of responding on 
+stop signal trials, p (r | s) and Go RT.
+Rajesh, et al.: Bhramari pranayama on response inhibition
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+140
+Experimental conditions
+Subjects sat on a comfortable cushion on the floor of the 
+experimental room, in a crossed leg posture keeping the 
+spine erect, with eyes closed condition. On experimental 
+session  (Bhpr), after a deep inhalation, participant 
+exhale strictly through the nasal airways, emulating the 
+buzzing of bumblebees with a constant pitch. On control 
+session (DB), the subjects assumed the Bhpr position, 
+but did not produce the humming sound. Instead, they 
+attempted to manipulate the respiratory rhythm by deep 
+inhalation and exhalation.[12] Both the sessions were of 
+10 min in duration. Each subject performed approximately 
+an average of 20 inhalations and exhalations per session.
+RESULTS
+Statistical analysis was carried out using Statistical 
+Package for Social Sciences (SPSS) version 10.0. Table 1 
+shows the means of the SSRT and go RT and also the 
+p (r | s). The mean probability of responding on stop‑signal 
+trials (p (r | s)) during Bhpr and DB are close to 50%, 
+indicating that the dynamic tracking algorithm worked 
+well in both sessions and produced a reliable SSRT. 
+The data for SSRT and go RT were found to be normally 
+distributed and difference between the means of the two 
+PRE sessions was not significant. Paired sample t‑tests 
+showed a significant decrease (P = 0.024) in SSRT after 
+Bhpr session, while the DP group did not show any 
+significant change [Table 1]. The means in the post session 
+were not significantly different, but the Bhpr group showed 
+a notable lower value. Further, t‑tests show that the Go RT 
+increased significantly after Bhpr (P = 0.007) and no other 
+changes/differences were observed.
+DISCUSSION
+In the present study, we have evaluated the immediate 
+effect of Bhpr on SST. There was a significant reduction 
+in SSRT, suggesting that the practice results in enhanced 
+response inhibition.[1] Further, subject slow down the go 
+responses, indicating subject made a proactive response 
+strategy to achieve a balance between competing goals, 
+suggesting a flexible cognitive control.[15]
+As per our knowledge, there is no previous report 
+specific to BhPr on cognitive function for comparison. 
+We found that, enhancement of inhibitory control is 
+consistent with previous behavioral studies on single dose 
+administration of atomoxetine[8] and methylphenidate[9] 
+in healthy volunteers. Atomoxetine and methylphenidate 
+are widely used stimulant medication for the treatment 
+of ADHD. The mechanism underlying the enhancement 
+is not known. Dynamics of electroencephalogram (EEG) 
+theta activity correspond to executive control demands 
+across different sources of cognitive interference.[16] Theta 
+power enhancement relates to the recruitment of cognitive 
+control. Earlier study has shown resonating and repetitive 
+effects of humming bee sound in the Bhpr breathing 
+technique, increased theta activity.[12] We hypothesize 
+that improvement in response inhibition may be due to 
+enhanced theta activity. Further, it is possible to use this 
+breathing technique as an adjunct for the management 
+of ADHD. More studies are required for the use of this 
+technique in clinical cases.
+The study is limited by the small sample size, and the 
+lasting effect of intervention was not assessed. Future 
+studies should incorporate various assessment methods 
+to capture changes while performing the task and 
+intervention to understand underlying mechanism.
+ACKNOWLEDGEMENT
+We are especially grateful to S‑VYASA Yoga University, Bengaluru 
+for financial support and Prof. Gordon D. Logan for insightful 
+suggestions on design and assessment.
+REFERENCES
+1.	
+Verbruggen F, Logan GD. Response inhibition in the stop‑signal paradigm. 
+Trends Cogn Sci 2008;12:418‑24.
+2.	
+Enticott PG, Ogloff JR, Bradshaw JL. Response inhibition and impulsivity 
+in schizophrenia. Psychiatry Res 2008;157:251‑4.
+3.	
+Aron AR, Poldrack RA. The cognitive neuroscience of response inhibition: 
+Relevance for genetic research in attention‑deficit/hyperactivity disorder. 
+Biol Psychiatry 2005;57:1285‑92.
+4.	
+Logan GD, Cowan WB, Davis KA. On the ability to inhibit simple and choice 
+reaction time responses: A model and a method. J Exp Psychol Hum Percept 
+Perform 1984;10:276‑91.
+5.	
+Aron AR, Behrens TE, Smith S, Frank MJ, Poldrack RA. Triangulating a 
+cognitive control network using diffusion‑weighted magnetic resonance 
+imaging (MRI) and functional MRI. J Neurosci 2007;27:3743‑52.
+6.	
+Band GP, van der Molen MW, Logan GD. Horse‑race model simulations of 
+the stop‑signal procedure. Acta Psychol (Amst) 2003;112:105‑42.
+7.	
+Verbruggen F, Logan GD, Stevens MA. STOP‑IT: Windows executable 
+software for the stop‑signal paradigm. Behav Res Methods 2008;40:479‑83.
+8.	
+Chamberlain SR, Hampshire A, Muller U, Rubia K, Del Campo N, Craig K, 
+Table  1: Bhramari and deep breathing: Mean and standard deviations
+Deep breathing
+Bhramari pranayama
+Pre
+Post
+Pre
+Post
+p (r|s)(%)
+48.58±1.93
+49.68±1.78
+48.96±1.77
+49.47±3.38
+SSRT (ms)
+239.44±30.59
+237.35±38.40
+243.75±40.16
+232.67±43.81*
+Go RT (ms)
+733.88±170.89
+751.81±182.16
+701.67±184.10
+732.24±193.40**
+p (r|s) = Mean probability of responding on stop‑signal trials, SSRT = Mean stop‑signal reaction time, Go RT = Mean reaction time on no‑signal trials. *P<0.05, 
+**P<0.01, t test for paired data comparing “pre” with respective “post” values
+Rajesh, et al.: Bhramari pranayama on response inhibition
+141
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+et al. Atomoxetine modulates right inferior frontal activation during inhibitory 
+control: A pharmacological functional magnetic resonance imaging study. 
+Biol Psychiatry 2009;65:550‑5.
+9.	
+Nandam LS, Hester R, Wagner J, Cummins TD, Garner K, Dean AJ, 
+et  al. Methylphenidate but not atomoxetine or citalopram modulates 
+inhibitory control and response time variability. Biol Psychiatry 2011;69: 
+902‑4.
+10.	 Nagendra HR. Defining yoga. Int J Yoga 2008;1:43‑4.
+11.	
+Jerath R, Edry JW, Barnes VA, Jerath V. Physiology of long pranayamic 
+breathing: Neural respiratory elements may provide a mechanism that 
+explains how slow deep breathing shifts the autonomic nervous system. Med 
+Hypotheses 2006;67:566‑71.
+12.	 Vialatte FB, Bakardjian H, Prasad R, Cichocki A. EEG paroxysmal gamma 
+waves during Bhramari Pranayama: A yoga breathing technique. Conscious 
+Cogn 2009;18:977‑88.
+13.	 Sidheshwar  P, Niladri  KM, Ravishankar  N. Role of self‑induced 
+sound therapy: Bhramari Pranayama in Tinnitus. Audiol Med 2010;8: 
+137‑41.
+14.	 Colzato LS, Hertsig G, van den Wildenberg WP, Hommel B. Estrogen 
+modulates inhibitory control in healthy human females: Evidence from the 
+stop‑signal paradigm. Neuroscience 2010;167:709‑15.
+15.	 Verbruggen F, Logan GD. Proactive adjustments of response strategies in the 
+stop‑signal paradigm. J Exp Psychol Hum Percept Perform 2009;35:835‑54.
+16.	 Nigbur R, Ivanova G, Sturmer B, Theta power as a marker for cognitive 
+interference. Clin Neurophysiol 2011;122:2185‑94.
+How to cite this article: Rajesh SK, Ilavarasu JV, Srinivasan TM. Effect 
+of Bhramari Pranayama on response inhibition: Evidence from the stop 
+signal task. Int J Yoga 2014;7:138-41.
+Source of Support: S-VYASA University, Conflict of Interest: 
+None declared
+Author Help: Reference checking facility
+The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks 
+the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal.
+• 
+The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a 
+single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference. 
+• 
+Example of a correct style
+	
+Sheahan P
+, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy. 
+Otolaryngol Head Neck Surg 2002;127:294-8. 
+• 
+Only the references from journals indexed in PubMed will be checked. 
+• 
+Enter each reference in new line, without a serial number.
+• 
+Add up to a maximum of 15 references at a time.
+• 
+If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct 
+article in PubMed will be given.
+• 
+If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to 
+possible articles in PubMed will be given. 

subfolder_0/Effect of Holistic Module of Yoga and Ayurvedic.txt

@@ -0,0 +1,1081 @@
+Open Journal of Endocrine and Metabolic Diseases, 2013, 3, 90-98 
+http://dx.doi.org/10.4236/ojemd.2013.31014 Published Online February 2013 (http://www.scirp.org/journal/ojemd) 
+Effect of Holistic Module of Yoga and Ayurvedic 
+Panchakarma in Type 2 Diabetes Mellitus—A Pilot Study 
+Barve Vaibhavi, Tripathi Satyam, Patra Sanjibkumar, Nagarathna Raghuram, Nagendra H. Ramarao 
+Division of Life Sciences, SVYASA, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, India 
+Email: [email protected] 
+ 
+Received November 24, 2012; revised December 26, 2012; accepted January 28, 2013 
+ABSTRACT 
+Objective: Ayurveda and Yoga have emerged as beneficial adjuvant in management of diabetes. This pilot study was 
+planned to understand the concepts and assess the effect of a combination of Ayurvedic panchakarma and Yoga. Design: 
+Experimental pilot study with pre post design. Subjects: Twelve patients with type 2 diabetes in age between 40 - 70 
+years (mean 56 ± 9.08) with no cardiac, renal or retinal complications. Settings: Residential Holistic Health Centre of 
+S-VYASA. Intervention: A validated Ayurveda protocol comprising of panchakarma followed by maintenance the- 
+rapy with a specific module of Integrated Approach of Yoga Therapy for Diabetes that included selected physical pos- 
+tures (asanas), pranayama, meditation, lifestyle change and yogic counseling for stress management. All subjects un- 
+derwent a residential program for six weeks followed by therapy at home for 12 weeks. Results were analyzed using 
+paired “t” test. Results: After 6 weeks, Fasting Blood Glucose reduced (p < 0.05) from 129.31 ± 58.11 to 103.54 ± 
+40.74 (19.93%), Post Prandial Blood Glucose from 191.69 ± 76.77 to 152.92 ± 62.06 (20.23%, p < 0.05), Total choles- 
+terol from 209 ± 33.7 to 186.92 ± 23.36 (10.56%, p < 0.05), Triglycerides from 198.25 ± 94.78 to 151.25 ± 43.65 
+(23.71%, p < 0.05), HbA1c reduced (p = 0.014) from 8.79 ± 2.12 to 8.07 ± 1.77 (8.19%) in 6th week and further to 7.63 
+± 2.12 (13.19%, p = 0.001) after 12th week. Oral Hypoglycemic Agent (OHA) drug score reduced from 2.83 ± 0.93 to 1 
+± 1.27 (64.66%, p < 0.001). Symptom score reduced from 2.83 ± 1.02 to 1.66 ± 0.65 (p < 0.001). At baseline guna 
+questionnaire showed six subjects each with rajas and tamas dominance. On post assessments, two subjects shifted from 
+tamas to rajas dominance. Conclusion: This first pilot study has indication of a potentially beneficial effect of combin- 
+ing traditionally recommended Ayurveda panchakarma with maintenance herbs and Yoga, in reducing blood glucose 
+and lipids. Long term RCT is recommended. 
+ 
+Keywords: Ayurveda; Yoga; Diabetes 
+1. Introduction 
+Diabetes mellitus imposes a sizeable burden globally in 
+terms of early mortality, morbidity, and health care costs. 
+The incidence of diabetes worldwide was likely to be 
+2.8% in 2000 and expected to rise to 4.4% by 2030, and 
+above three-quarters of people with diabetes would be 
+living in developing countries [1]. Diabetes mellitus 
+(madhumeha) was known to ancient Indian physicians 
+with detailed description of its clinical features and 
+management protocols [2]. Ayurveda is a comprehensive 
+system of traditional health care, which originated in 
+India approximately three thousand years ago. Its unique 
+holistic approach appears to have become relevant today 
+due to the increasing prevalence of non communicable 
+diseases. This science of life deals with body, mind, and 
+spirit as a single entity with clear understanding of the 
+techniques of managing them. Ancient Ayurveda classics 
+by Charaka, Sushruta, and Vagbhata contain ample 
+literature about Prameha and its treatment. Prameha is a  
+metabolic disorder and is diagnosed mainly with the help 
+of signs and symptoms related to “Mutra” (Urine). 
+Genetic predisposition with sedentary life style, inju- 
+dicious intake of food, and stress are recognized as some 
+of the important etiological factors of Prameha, [3]. The 
+diagnosis and management of diabetes (madhumeha) is 
+based on tridosa (bodily humor) theory which says that 
+kapha (phlegm), pitta (bile) and vata (wind) are the basic 
+pillars of life [4]; balanced functioning of these tridosas 
+is health and imbalance is disease [5]. A disturbance in 
+the doshas precedes the genesis of various pathological 
+states which results to 20 types of Prameha where finally 
+diabetes (madhumeha) is one of the chronic type of 
+Prameha. Thus, the primary aim in prevention, diagnosis 
+and treatment of a disease is to detect the degree of 
+vitiation in these doshas. 
+Several studies have shown the beneficial effects of 
+Ayurveda in T2DM with significant reduction in Glyco- 
+sylated Haemoglobin (HbA1c), Fasting and Post Prandial 
+Copyright © 2013 SciRes.                                                                              OJEMD 
+B. VAIBHAVI  ET  AL. 
+91
+Blood Glucose (FBG, PPBG) levels and lipids [6-8]. A 
+study by Ahmed et al. that treated diabetic rats with the 
+fruit juice of Momordia charantia has reported rege- 
+neration or increase in the number of beta cells [9], 
+which appears to offer some evidence to the additional 
+benefits of Ayurveda because none of the conventional 
+Oral Hypoglycemic Agents (OHA) exhibit this property. 
+Momordia charantia also has exhibited extra-pancreatic 
+effects with improved peripheral glucose utilization [10]. 
+Recent studies [11,12] have described the role of a few 
+herbs like Trigonella foenum graecum and Tinospora 
+cordifolia on activities of enzymes involved in carbo- 
+hydrate and lipid metabolism. In animal based studies, 
+herbs like Curcuma longa have shown reduction in 
+dyslipidemia in diabetics [13] through its effect on lipid 
+peroxidation [14]. 
+Ayurveda being a holistic science, it has to be pra- 
+cticed as a whole science including several steps of 
+management and cannot be given only as one capsule of 
+a proven herbal preparation. Hence it was necessary to 
+review the classical texts and compile them to present a 
+holistic management protocol in the form of flow chart 
+with different steps, which was finally done and sent for 
+validation from various Ayurveda experts [15]. 
+Yoga is also one of the modalities in Complimentary 
+and Alternative Medicine (CAM) which is an integral 
+part of Ayurveda (mentioned in classical texts) [16]. 
+Yoga is found to be very effective as a complimentary 
+treatment for type 2 diabetes in several studies [17-19]. 
+Studies have demonstrated significant reduction in FBG, 
+PPBG [20-22] Glycosylated Haemoglobin (HbA1c) [22], 
+improvement in nerve functions [22], reduction in oral 
+glycemic agents [23] and Body Mass Index (BMI) [24] 
+after the practice of Yoga.  
+Multiple factors involved in the pathogenesis of 
+diabetes demands a multi-modal remedial approach [25]. 
+Although there are many studies that reveal the efficacy 
+of CAM modalities, there are very few studies which 
+report the efficacy of these modalities when used 
+together. Since there are ample evidences that Ayurveda 
+can be a potential complimentary therapy for diabetes 
+[6-8], it would be worthwhile to test its efficacy when 
+combined with Yoga, which is also one of the CAM 
+modalities having large number evidence based studies 
+supporting its effect in type 2 diabetes. 
+Hence this pilot study was planned with an intention of 
+assessing the feasibility and safety of this residential 
+Ayurveda and Yoga therapy before launching a con- 
+trolled study on a larger population. 
+2. Materials and Methods 
+2.1. Subjects 
+Twelve (n = 12) subjects (7 female, 5 male) in age range 
+of 40 - 70 years (mean 56 ± 9.08) with Type 2 Diabetes 
+Mellitus (T2DM) were recruited for the study. The 
+sample size was calculated based on an effect size 
+(Cohen’s effect size, ε = 2.45) obtained from a previous 
+study of changes following the practices of Yoga in DM 
+patients [16]. It was calculated using G*Power software, 
+Version 3.0.10, where the level was 0.05 and power = 
+0.95 and the recommended sample size was twelve. Thus, 
+a sample size of twelve was recruited for the present study. 
+Subjects who satisfied the American Diabetes Association 
+(ADA) criteria for T2DM [26], not practicing Yoga for at 
+least previous three months and willing to participate in 
+the trial were included. Those with cardiac complications 
+and nephropathy were excluded after checking ECG, 
+FBG, blood urea, and creatinin. Those with proliferative 
+retinopathy (screened by an ophthalmologist) and had 
+practiced Yoga in the recent past (three months) were 
+also excluded. Ethical clearance was obtained from 
+institutional ethical committee. Signed informed consent 
+was obtained from all subjects. 
+2.2. Design 
+This was an experimental pilot study with a pre post 
+design in a single group. 
+2.3. Methods 
+All subjects went through a daily routine (Table 1) that 
+included Integrated Approach of Yoga Therapy for Diabetes 
+(IAYTD) along with a progressive plan of panchakarma 
+(purificatory therapy) and maintenance herbs. 
+The protocol had the flexibility for changes in medica- 
+tion or Yoga practices based on their daily response as- 
+sessments. After admission, first week was planned for 
+stabilization of the baseline parameters without any in- 
+tervention. The fasting (12-hr) blood sample was ob- 
+tained via a veni-puncture in the arm with the individual 
+in an upright position and after at least 5 min in a resting 
+state. Supervised intervention with strict adherence to the 
+schedule was followed from the beginning of second to 
+end of fifth week. The clinical progress was monitored 
+daily by one Ayurveda and one allopathic physician; 
+therapies were carried out by certified therapists and 
+documentation was done by the research team. The sub- 
+jects were monitored daily for symptoms scores, medica- 
+tion scores (number of OHA tablets per day), pulse rate, 
+blood pressure, respiratory rate and blood glucose (glu- 
+cometer). Diet was planned based on nutritional and 
+dosha assessments. Post assessments were done in sixth 
+week when the patients continued to remain in the cam- 
+pus attending the same daily routine on their own without 
+instructions by the therapists. After discharge they were 
+given the diet chart, personalized Yoga chart with in- 
+struction DVD, and maintenance medication. Home  
+Copyright © 2013 SciRes.                                                                              OJEMD 
+B. VAIBHAVI  ET  AL. 
+92 
+Table 1. Ayurveda protocol. 
+Ayurveda protocol 
+Treatment plan 
+Drugs used in treatment plan 
+with their dosage and time 
+Appetizer, digestive drugs 
+(Deepana/Paachan) for 3 - 7 
+days 
+Trikatu churna [27] 2 gms twice 
+daily before food 
+Internal oleation for 3 - 7 
+days (Snehapaan) 
+Sarshapa tail [28] 
+30ml/60ml/90ml in increasing 
+dose 
+External oleation with 
+sudation (Abhyanga/Swedan) 
+for 3 days 
+Brihat saindhavadi Taila [29] 
+(external application) 
+Purgation (Virechan) 1 day 
+Trivrit lehyam [30] 30 - 60 gms 
+Post purgation diet 
+restrictions 
+(Samsarjana/Krama ) for 3 - 
+5 days 
+- 
+Palliative therapy (Shamana) 
+to be continued 
+Kathakhadiradi kashaya [31] 15 
+ml twice daily. Amritmehari 
+churna [32] 2 gms twice daily. 
+Shilajatwadi vati [33] 2 tabs 
+thrice daily 
+ 
+practice was monitored up to 12 weeks by regular moti-
+vating phone calls. HbA1c was assessed at the end of 
+twelfth week. 
+2.4. Intervention 
+A validated Ayurveda protocol developed on the basis of 
+classical scriptural references was used which included 
+panchakarma followed by maintenance medication (Ta- 
+ble 2). Along with Ayurveda protocol, the module of 
+Integrated Approach of Yoga Therapy (IAYTD) for dia- 
+betes comprised of Yogasanas, Pranayama, meditation 
+and lectures as used in our two earlier studies in India 
+[23,34] and UK [17] (Table 3). 
+2.5. Outcome Measures 
+Ama, agni and kostha were assessed at baseline using a 
+check list prepared for the purpose of this study based on 
+guidelines in classical texts. Agni was scored on a three 
+point scale 1 = mandagni (less digestive capacity), 2 = mad- 
+hyagni (medium digestive capacity) and 3 = pravaragni 
+(more digestive capacity). The end point of the cleansing 
+procedure was considered to be when ama score reached 
+a balanced score of 1. Koshta (colonic sensitivity) was 
+assessed based on seven questions with three response 
+choices. A total score of 1 to 7 indicates mrudu koshta 
+(more colonic sensitivity), 8 to 18 madhyam koshta (me- 
+dium colonic sensitivity) and 19 to 21 krura koshta (less co- 
+lonic sensitivity). These assessments were done at baseline 
+and daily for assessing the effect of panchakarma procedure. 
+Table 2. Daily schedule of subjects. 
+Daily schedule of subjects 
+Time (hours)
+Duration 
+(minutes)
+Yoga practice 
+5.00 - 5.30 
+30 
+Om meditation 
+5.30 - 6.30 
+60 
+Yoga based special technique 1 
+(physical practices)/kriyas 
+6.30 - 7.30 
+60 
+Bath and wash 
+7.30 - 8.15 
+45 
+Lecture on bhagvadgita/chanting 
+8.15 - 8.45 
+30 
+Breakfast 
+8.45 - 10.00
+75 
+Rest 
+10.00 - 11.00
+60 
+Lecture (on ayurvedic and yogic 
+lifestyle) 
+11.00 - 12.00
+60 
+Pranayama (breathing practices) 
+12.00 - 13.00
+60 
+Yoga based special technique 2 
+(physical practices) 
+13.00 - 14.00
+60 
+Lunch (vegetarian diabetic diet) 
+14.00 - 14.30
+30 
+Deep Relaxation Technique (DRT) 
+14.30 - 16.00
+90 
+Assessments, psychological and 
+yogic counseling 
+16.00 - 17.00
+60 
+Cyclic Meditation (CM) 
+17.00 - 18.00
+60 
+Tuning to nature 
+18.00 - 19.00
+60 
+Divine hymns session (Bhajan) 
+19.00 - 19.45
+45 
+Mind sound resonance technique 
+19.45 - 20.30
+45 
+Dinner ( vegetarian diabetic diet) 
+20.30 - 21.30
+60 
+Cleansing technique for eye 
+(Trataka) 
+21.30 - 22.00
+30 
+Self study 
+22.00 
+- 
+Lights off 
+2.5.1. Symptom Score 
+The average severity of all symptoms documented before 
+and after the 6 weeks was recorded. Severity was scored 
+on a 4-point scale of 0 - 3 (0 = nil, 1-mild not disturbing 
+the daily routine, 2 = moderate-disturbs routine requires 
+symptomatic medication, 3 = severe-require hospital- 
+ization or parenteral medication).  
+2.5.2. Medication Score 
+Number of tables of Oral Hypoglycemic Agent (OHA)/day; 
+1 tablet = the standard strength each for adults quoted in 
+pharmacopeia index e.g. one tablet of Metformin = 500 mg. 
+2.5.3. Guna Assessment 
+The G-Inventory [35] (GI) assessed the shift of guna 
+dominance after the intervention. GI is a measure of the  
+Copyright © 2013 SciRes.                                                                              OJEMD 
+B. VAIBHAVI  ET  AL. 
+Copyright © 2013 SciRes.                                                                              OJEMD 
+93
+ 
+Table 3 Demographic details of the subject 
+Sub no. 
+Name 
+Age 
+(years) 
+Sex 
+(M/F) 
+Duration of 
+DM in years
+**Family H/O 
+DM 
+Creatinine 
+(mg/dl) 
+Urea 
+(mg/dl) 
+Agni 
+Ama
+Kostha
+1 
+SS 
+69 
+M 
+03 
+N 
+1.3 
+30.8 
+1 
+3 
+19 
+2 
+AS 
+48 
+F 
+5.5 
+N 
+0.78 
+29.4 
+3 
+3 
+9 
+3 
+MG 
+55 
+M 
+12 
+N 
+0.90 
+30.3 
+1 
+3 
+9 
+4 
+R 
+68 
+F 
+08 
+N 
+0.7 
+28 
+1 
+3 
+12 
+5 
+H 
+56 
+F 
+15 
+F 
+0.86 
+34.2 
+1 
+3 
+8 
+6 
+TC 
+49 
+F 
+14 
+M/B 
+0.85 
+18.6 
+3 
+2 
+9 
+7 
+BS 
+50 
+F 
+16 
+B/S 
+0.86 
+21.7 
+1 
+3 
+7 
+8 
+AS 
+40 
+M 
+04 
+B 
+0.72 
+22.8 
+1 
+3 
+18 
+9 
+Hu 
+52 
+M 
+07 
+N 
+0.8 
+39.5 
+2 
+3 
+19 
+10 
+A 
+61 
+F 
+11 
+S 
+1.0 
+20.0 
+1 
+3 
+11 
+11 
+S 
+63 
+F 
+25 
+GF 
+1.0 
+23.0 
+2 
+2 
+13 
+12 
+D 
+66 
+M 
+9 
+B 
+1.2 
+19.0 
+1 
+3 
+7 
+**F—Father, M—Mother, B—Brother, S—Sister, GF—Grandfather, GM—Grandmother, N—Nil history. 
+ 
+three gunas (sattva, rajas and tamas) and contains ten 
+questions with three response choices. A total score of 
+above 28 indicates sattva, 24 to 28 rajas and <24 tamas. 
+This test has a test retest reliability of 0.60 with a confi- 
+dence level of 99% and has been validated. Biochemical 
+parameters: these included Fasting (FBG) and Post Pran- 
+dial Blood Glucose (PPBG), HbA1c and lipid profile 
+determined at baseline and at the end of 6th week. HbA1c 
+was repeated at end of 12th week. A semi-auto analyzer 
+was used for the biochemical measurements. Blood Glu- 
+cose was determined by enzymatic oxidation method 
+using glucose peroxidase [36]. HbA1c was estimated by 
+glucose oxidase method and cation-exchange resin me- 
+thod [37]. Cholesterol was determined after enzymatic 
+hydrolysis and oxidation [38]. Triglycerides were deter- 
+mined after enzymatic splitting with lipoprotein lipase. 
+Indicator for the same was generated from 4-aminoanti- 
+pyrine and 4-chlorophenol by hydrogen peroxide under 
+the catalytic action of peroxidase. LDL-VLDL Choles- 
+terol was determined by using Friedewald’s equation 
+[39]. 
+3. Statistical Analysis 
+Data were analyzed using SPSS version 16.0; checked 
+for normal distribution by Shapiro Wilk’s test. As the 
+data were normally distributed for all variables student’s 
+paired samples “t” test was used with a significance 
+value set at 0.05 for two-sided hypothesis testing. 
+4. Results 
+Table 3 gives the demographic characteristics of subjects. 
+The mean age was 56 ± 9.08 years. None had cardiac, 
+renal or retinal complications. There were no drop outs in 
+this study. At baseline, 2 subjects had madhyam ama and 
+10 had pravara ama, while 10 subjects had manda agni 
+and 2 had madhyam agni and 3 subjects had mrudu 
+kostha, 7 had madhyam kostha and 2 had krura kostha. 
+Table 4 shows the results after the intervention.  
+After 6 weeks of intervention, the symptom score re- 
+duced from 2.83 ± 1.02 to 1.66 ± 0.65 (p < 0.001). OHA 
+score reduced (p < 0.001) from 2.83 ± 0.93 to 1 ± 1.27 
+(64.66%). FBG reduced (p < 0.05) from 129.31 ± 58.11 
+to 103.54 ± 40.74 (19.93%). PPBG decreased from 
+191.69 ± 76.77 to 152.92 ± 62.06 (20.23%, p < 0.05). 
+HbA1c reduced (p = 0.014) from 8.79 ± 2.12 to 8.07± 
+1.77 (8.19%) in 6th week. It reduced further to 7.63 ± 
+2.12 (13.19%, p = 0.001) after 12th week. At baseline 
+guna questionnaire showed 6 subjects each with rajas and 
+tamas dominance. On post assessments, two subjects 
+shifted from tamas to rajas dominance. All of them had 
+balanced functioning of agni, ama and kostha at the end 
+of 6 weeks.  
+Lipid profile: Total Cholesterol decreased significantly 
+(p < 0.05) from 209 ± 33.7 to 186.92 ± 23.36 (10.56%). 
+Triglycerides reduced (p < 0.05) from 198.25 ± 94.78 to 
+151.25 ± 43.65 (23.71%). There was non-significant 
+reduction in the levels of LDL, VLDL and HDL. 
+5. Discussion 
+This pilot study on twelve subjects with T2DM has 
+shown significant reduction in FBG, PPBG, HbA1c, TC 
+nd TG along with reduction in oral hypoglycemic 
+a
+ 
+B. VAIBHAVI  ET  AL. 
+94 
+ 
+Table 4. Results after the intervention. 
+Post intervention changes# 
+Variables 
+Pre (1st week) 
+Mean ± SD 
+Post (6th week) 
+Mean ± SD 
+Post2 (12th week) 
+Mean ± SD 
+p-value 
+Medication scores 
+2.83 ± 0.93 
+1 ±1.27*** 
+- 
+0.001 
+Symptom score 
+2.83 ± 1.02 
+1.66 ± 0.65*** 
+- 
+0.001 
+FBG 
+129.31 ± 58.11 
+103.54 ± 40.74* 
+- 
+0.017 
+PPBG 
+191.69 ± 76.77 
+152.92 ± 62.06* 
+- 
+0.013 
+HbA1c 
+8.79 ± 2.12 
+- 
+7.63 ± 2.12*** 
+0.001 
+Total Cholesterol 
+209 ± 33.7 
+186.92 ± 23.36* 
+- 
+0.024 
+Total Triglycerides 
+198.25 ± 94.78 
+151.25 ± 43.65* 
+- 
+0.020 
+LDL 
+129.42 ± 29.63 
+115.25 ± 15.63 
+- 
+0.121 
+VLDL 
+39.65 ± 18.96 
+38.5 ± 33.5 
+- 
+0.907 
+*p < 0.05, **p < 0.01, ***p < 0.001, baseline data compared with the post data using a paired “t” test. Fasting Blood Glucose (FBG), Post Prandial Blood Glu- 
+cose (PPBG), Glycosylated Hemoglobin (HbA1c), Total Cholesterol (TC), Total Triglycerides (TG), Low Density Lipoprotein (LDL), Very Low Density 
+Lipoprotein (VLDL). #Note: These significant values stated are based on single group pre comparison to post. There is no control group which is an imita- 
+tion of this study and that can also effect p-values when compared with control groups in main efficacy study. 
+ 
+medication and balanced functioning of agni, ama and 
+kostha after six weeks of residential intervention using 
+Yoga and Ayurveda.  
+5.1. Comparisons 
+To the best of our knowledge, there are no studies which 
+report the effect of a combination of Yoga and Ayurveda 
+(panchakarma and maintenance therapy) although there 
+are studies on these two therapeutic modalities used 
+independently in comparison to conventional medicine. 
+Kumari et al. [8]. Assessed the effect of panchakarma 
+followed by maintenance ayurvedic herbal therapy in 
+forty two subjects with T2DM, which showed significant 
+reduction in FBG and PPBG by 10.2% and 6.4% 
+respectively after one month of intervention. In one of 
+our earlier Yoga studies we had observed a decrease in 
+FBG and HbA1c by 6.9% and 15.5% after an integrated 
+Yoga protocol in a control study on diabetics in London 
+[17]. Sahay et al. showed that Yoga was effective in 
+reducing TC (by 0.47%) and TG (by 18.03%) [25]. In 
+comparison, the present study has shown reduction in 
+mean values of FBG (19.9%), PPBG (20.2%), HbA1c 
+(13.2%), TC (10.6%), and TG (23.7%). These values 
+(except HbA1c) showed higher magnitude of change 
+than the independent Yoga or Ayurveda studies. There 
+are other studies on Ayurveda in T2DM that have shown 
+encouraging results. Elder et al. randomized 60 adults 
+with newly diagnosed T2DM (baseline HbA1c of 6.0 to 
+8.0) into experimental and control groups. The Ayurveda 
+protocol included Ayurvedic diet, meditation and 
+Ayurvedic herbal supplement (MA 471). The results 
+showed significant difference between groups (ANCOVA) 
+in HbA1c, FBG, TC, LDL and body weight in those who 
+had higher baseline HbA1c [6]. Saxena and Vikram 
+reviewed the accumulated literature on ten herbs with 
+antidiabetic activity and reported that momordica 
+charantia, pterocarpus marsupium and trigonella foenum 
+greacum have beneficial effects in treating T2DM [40]. 
+The results of many other studies on Yoga are also 
+consistent with the outcomes of present study [17]. Yoga 
+nidra (a form of guided relaxation) resulted in decreased 
+FBG, PPBG, in patients with T2DM [41]. Looking at 
+cardiac functions Singh et al. showed that training in 
+Yoga asanas for forty days in 24 T2DM decreased their 
+pulse rate, blood pressure, and Corrected QT interval in 
+addition to decrease in FBG (25.5%), PPBG (27.03%) 
+and HbA1c (13.3%) [42]. A randomized control study 
+that used Nadishodhana Pranayama and Sun Salutation 
+for 5 weeks in twenty T2DM has shown significant 
+decrease in plasma glucose, serum cortisol and serum 
+Malone-Di-Aldehyde (MDA) levels and a significant 
+increase in serum Super Oxide Dismutase (SOD) activity, 
+more prominently in those who has poor glycemic 
+control [43]. 
+5.2. Mechanism 
+According to the present day molecular biological under- 
+standing of T2DM, the etiology is traceable to erratic life 
+style that promotes expression of the diabetes related 
+genes [44]; this results in a series of imbalances [calorie 
+intake-out put = obesity, adipoleptin-nectin = IR; [45] 
+proinflammatory—anti-inflammatory cytokines = tissue 
+Copyright © 2013 SciRes.                                                                              OJEMD 
+B. VAIBHAVI  ET  AL. 
+95
+inflammation [46] resulting in insulin resistance which in 
+turn is responsible for the biochemical changes and the 
+clinical manifestations. Thus, the benefits may be traced 
+to reduction in oxidative stress mediators, modified HPA 
+axis [47], reduction in adipoleptin [48], and pro-inflam- 
+matory cytokines [49] that are known to induce IR. The 
+mechanism described by Yoga and Ayurveda offers a 
+different model of understanding T2DM. Accordingly, 
+diabetes is the effect of erratic life style that has resulted 
+from lack of mastery over the mind and wrong notion 
+about the meaning and purpose of life (prajnaparadha). 
+The flow chart in Table 5 shows the pathogenesis of 
+T2DM. Yoga masters proposed that the human system is 
+made of five levels of subtle bodies [annamaya (physi- 
+cal), pranamaya (vital energy), manomaya (mental), vij- 
+nanamaya (intellectual) and anandamaya (bliss) kosas] 
+[50]. Three gunas (satva, rajas and tamas) that grossify 
+into three doshas (vata, pitta and kapha) constitute the 
+physical body (annamaya kosha). Man is in best of health 
+when there is a balanced functioning of the tridosas 
+which is possible when the mind is in a state of satva 
+(freedom from stress) and established in anandamaya 
+kosha. T2DM, madhumeha [8] is a tridoshaja vyadhi, i.e. 
+there is vitiation of all three dosas which is preceded by 
+imbalance of the three gunas [dominance of tamas and/or 
+rajas]. T2DM, a life style disease (samanya adhija vya- 
+dhi), begins in manomaya kosha. This is due to lack of 
+right knowledge (a function of vijnanamaya kosha) that 
+“I am made of happiness and freedom from all thoughts”. 
+This leads to craving for happiness from outside objects 
+(wealth and fame). Long standing stresses (due to unsat- 
+isfied desires) leads to sleeplessness, irritability, indeci- 
+siveness, depression, and/or frustration (violent negative 
+emotions). The long standing suppressed emotions are 
+characterized by uncontrolled rewinding of thoughts in 
+the mind (yogic definition of stress).This habituated un- 
+controlled speed percolates in to the pranamaya kosha 
+and drains large quantities of prana leading to early aging 
+(DM is an aging disease). This uncontrolled habituated 
+speed results in an imbalance that further settles down in 
+the physical body as structural damage (inflammation = 
+speed at annamaya kosha). This descent (prasava) from a 
+balanced state of functioning of the mind-body complex 
+results in an imbalance of the three doshas. Caraka, the 
+father of Ayurveda, describes T2DM as a disease char- 
+acterized by covering (avarana) of excess kapha over 
+vata that leads to obstruction in the harmonious move- 
+ment of vata, and this obstructed/restricted movement in 
+turn leads to stagnation and unavailability of pitta that is 
+responsible for healthy metabolic processes in tissues. In 
+addition, the obstructed vata gets aggravated and gets 
+vitiated further [51]. Thus, T2DM begins with wrong life 
+style due to adnyana (pragnaparadha) that leads to kapha 
+dosha or tamo guna pradhanaka vihara and ahara (seden-
+tary life- style, day time sleeping, excessive intake of 
+fermented foods, oily foods, excess sweets and meat). 
+This domi- nance of kapha results in agnimandya (im-
+proper func- tioning of digestive fire). This goes on to 
+produce excess ama (endotoxins) which blocks the 
+channels (srotas) thus preventing the balanced flow of 
+vata. The vitiated kapha circulates throughout the body 
+resulting in dhatwagni mandya (poor functioning of di-
+gestive fire at tissue level). It affects the dushya struc-
+tures, the dhatus (tissues). Adipose tissue (medas) is the 
+first dushya to be affected. Then it goes on to affect all 
+other structures of the body including muscular tissue 
+(mansa), intracellular and extra cellular fluids (kleda), 
+vasa (muscle fat), shukra (semen), rakta (blood), majja 
+(marrow tissue), rasa (blood plasma), lasika (fluids & 
+plasma) and ojas (vital substance that maintains immu-
+nity). Mutravaha srotas is the main channel to be affected 
+that leads to madhumeha [52]. 
+The holistic module of management of T2DM is based 
+on measurement of the status of guna, the genetic per-
+sonality type (prakrti), the present state of imbalance of 
+the doshas (vikrti), the status of dushya, srotas, agni and 
+ama at all stages of therapy. 
+It includes manifold techniques that possess the ability 
+to reinstate homeostasis (pratiprasava) through increas- 
+ing the satva guna and balancing the vitiated doshas. The 
+integrated approach to yoga therapy (IAYT) prescribes 
+practices at all the five koshas to arrive at complete mas- 
+tery over the modifications of mind and remain in a state 
+of inner contentment and joyful existence under all cir- 
+cumstances of life. The physical practices begin with 
+cleansing the system of all endotoxins. This is achieved 
+through satkriyas (Yoga) or panchakarma (Ayurveda). 
+The stepwise progression of panchakarma starts with 
+stimulating the excretion of the endotoxins (ama) through 
+Snehana-Abhyangam (external and internal oleation 
+through medicated massage) and swedana (induced 
+sweating) followed by Virechana that helps in dislodging 
+the vitiated doshas (excess kapha and pitta) [8] through 
+purgation. This is followed by sanshamana (soothing 
+relaxation) through herbal therapies for maintenance of 
+balance. Thus, panchakarma removes ama, reduces 
+kapha, clears the avarana (covering), cleanses the srotas, 
+improves agni, promotes normal flow of vata, normalizes 
+pitta and restores dhatwagni that promotes normal func-
+tioning of dhatus. IAYT, a mind body intervention adds 
+on the component of self corrective processes to restore 
+balance at all levels through deep rest. In summary, 
+avoiding the etiological factors (nidan parivarjana) 
+through lifestyle change [by mind mastery through jnana 
+Yoga (right knowledge), raja Yoga, karma Yoga and 
+bhakti Yoga] [55], detoxification through panchakarma,  
+Copyright © 2013 SciRes.                                                                              OJEMD 
+B. VAIBHAVI  ET  AL. 
+Copyright © 2013 SciRes.                                                                              OJEMD 
+96 
+ 
+ 
+ 
+ 
+Table 5. Pathophysiology and management of Type 2 Diabetes Mellitus according to Ayurveda, Yoga and biomedicine. 
+Pathophysiology according to 
+Ayurveda and Yoga [53] 
+Reversing Pathophysiology Ayurveda 
+and Yoga [54] 
+Pathophysiology according to  
+modern [46] 
+Reversing the 
+Pathophysiology 
+modern [46] 
+ 
+ 
+ 
+correct the dosha imbalance and clear the subtle channels 
+through medication, asanas and pranayama forms the 
+basis of this integrated Yoga and Ayurveda model used 
+in this program. Long term regular monitoring is neces-
+sary to prevent return of the imbalance that is genetically 
+determined in T2DM. This is ensured by lifelong regular 
+IAYT and medication.  
+6. Strength of the Study 
+This is the first attempt to test the efficacy of multi mo- 
+dalities of CAM in a residential setting using standard 
+tools of assessment. The development of an integrated 
+module by an exhaustive search of all available texts of 
+Ayurveda and Yoga (16 texts) with a sound conceptual 
+basis for the holistic approach is the major contribution 
+of this study. Rendering the traditional knowledge in an 
+acceptable capsule for the present day elite community of 
+diabetics has been achieved by this pilot study.  
+7. Limitations of the Study 
+Sample size was small and no control group was planned. 
+There is lack of a control group using either of Yoga and 
+Ayurveda, the comparison with other single method 
+study is not very valid. As this was a pilot study and not 
+an efficacy trial the conclusions from the study are only 
+pointers to a larger study and not a proof of concept. 
+8. Implications and Suggestions for Future 
+Work 
+The Yoga and Ayurveda model of etio-pathogenesis of 
+T2DM based on the concepts of imbalance of gunas and 
+doshas offers an opening to subtler dimensions Holistic 
+way of understanding of this disease and may bring about 
+a paradigm shift in diabetes research. This pilot study has 
+prepared the ground for a four armed control study that 
+has been funded by dept. of AYUSH, ministry of health 
+and family welfare, Govt. of Karnataka, India. Statisti-
+cally acceptable sample sizes, with a battery of assess-
+ment of the cognitive functions (subjective and objective), 
+autonomic functions along with biochemical, molecular, 
+genetic, immunological variables has been included in 
+the proposed project.  
+9. Conclusion 
+This pilot study has shown the safety, feasibility and in- 
+dication of a potentially beneficial effect of an integrated 
+Yoga and Ayurveda module in achieving good glycemic 
+control and lipid profile with reduced requirement of 
+B. VAIBHAVI  ET  AL. 
+97
+Oral Hypoglycemic Agents in patients with T2DM. This 
+has prepared the ground for an efficacy trial. 
+10. Acknowledgements 
+We thank the faculty of Susruta Ayurveda College, Ban- 
+galore for their help in preparing the module of Ayurveda 
+protocol. We thank the therapists of S-VYASA for their 
+support in carrying out the study. We thank Dr. Pradhan 
+B. for his support with statistics and Dr. Haldavnekar R. 
+for her continuous support during the study. 
+REFERENCES 
+[1] 
+S. Wild, G. Roglic, A. Green, R. Sicree and H. King, 
+“Global Prevalence of Diabetes: Estimates for the Year 
+2000 and Projections for 2030,” Diabetes Care, Vol. 27, 
+No. 5, 2004, pp. 1047-1053.  
+doi:10.2337/diacare.27.5.1047 
+[2] 
+V. P. Upadhyay and P. Kamla, “Ayurvedic Approach to 
+Diabetes Mellitus and Its Management by Indiginous Re- 
+sources,” In: J. S. Bajaj, Eds., Diabetes Mellitus in Deve- 
+loping Countries, Interprint, New Delhi, 1984, pp. 375-377.  
+[3] 
+B. Tripathi, “Sarangadhara Samhita of Sharangadhara- 
+charya,” In: Chaukhamba Surbharati Prakashana, Vara-
+nasi, 2010, p. 101. 
+[4] 
+G. K. Garde, “Sartha Vaghbhata,” In: Sutrasthana 6th 
+Verse, Raghuvamshi Publishers, Pune, 1996, p. 2. 
+[5] 
+G. K. Garde, “Sartha Vaghbhata,” In: Sutrasthana 7th 
+Verse, Raghuvamshi Publishers, Pune, 1996, p. 2. 
+[6] 
+C. Elder, M. Aickin, V. Bauer, J. Cairns and N. Vuckovic, 
+“Randomized Trial of a Whole-System Ayurvedic Proto- 
+col for Type 2 Diabetes,” Alternative Therapies in Health 
+and Medicine, Vol. 12, No. 5, 2006, pp. 24-30. 
+[7] 
+T. Ila, H. M. Chandola and J. R. Joshi, “Clinical Efficacy 
+of Mehamudgara Vati in Type 2 Diabetes Mellitus,” Ayu, 
+Vol. 32, No. 1, 2011, pp. 30-39.  
+doi:10.4103/0974-8520.85722 
+[8] 
+J. Kumari, C. S. Mehta, V. D. Shukla, A. R. Dave and T. 
+M. Shingala, “A Comparative Clinical Study of Nya- 
+grodhadi Ghanavati and Virechana Karma in the Mana- 
+gement of Madhumeha,” Ayu, Vol. 31, 2010, pp. 300-304. 
+doi:10.4103/0974-8520.77152 
+[9] 
+I. Ahmed, I. Chandranath, A. K. Sharma, E. Adeghate, D. 
+J. Pallot and J. Singh, “Mechanism of Hypoglycemic Ac- 
+tion of Momordica Charantia Fruit Juice in Normal and 
+Diabetic Rats,” The Journal of Physiology, Vol. 520, 1999. 
+[10] I. Ahmed, E. Adeghate, A. K. Sharma, D. J. Pallot and J. 
+Singh, “Effects of Momordica Charantia Fruit Juice on 
+Islet Morphology in the Pancreas of the Streptozotocin- 
+Diabetic rats,” Diabetes Research and Clinical Practice, 
+Vol. 40, No. 3, 1998, pp. 145-151.  
+doi:10.1016/S0168-8227(98)00022-9 
+[11] J. Raju, D. Gupta, A. R. Rao, P. K. Yadava and N. Z. 
+Baquer, “Trigonella Foenum Graecum (Fenugreek) Seed 
+Powder Improves Glucose Homeostasis in Alloxan Dia- 
+betic Rat Tissues by Reversing the Altered Glycolytic, 
+Gluconeogenic and Lipogenic Enzymes,” Molecular and 
+Cellular Biochemistry, Vol. 224, No. 1-2, 2001, pp. 45-51.  
+doi:10.1023/A:1011974630828 
+[12] P. Stanely, M. Prince and V. P. Menon, “Hypoglycemic 
+and Other Related Actions of Tinospora Cordifolia Roots 
+in Alloxan-Induced Diabetic Rats,” Journal of Ethno- 
+pharmacology, Vol. 70, No. 1, 2000, pp. 9-15.  
+doi:10.1016/S0378-8741(99)00136-1 
+[13] A. C. Reddy and B. R. Lokesh, “Studies on Spice Princi- 
+ples as Antioxidants in the Inhibition of Lipid Peroxida- 
+tion of Rat Liver Microsomes,” Molecular and Cellular 
+Biochemistry, Vol. 111, No. 1-2, 1992, pp.117-124. 
+[14] PS. Babu and K. Srinivasan, “Hypolipidemic Action of 
+Curcumin, the Active Principle of Turmeric (Curcuma 
+Longa) in STZ Induced Diabetic Rats,” Molecular and 
+Cellular Biochemistry, Vol. 166, No. 1-2, 1997, pp. 169- 
+175. doi:10.1023/A:1006819605211 
+[15] S. Tripathi, R. Nagarathna, H. R. Nagendra, “Validation 
+of an Integrated Ayurveda-Yoga Module for Residential 
+Treatment of Patients with Type 2 Diabetes Mellitus—A 
+Compilation from Traditional Literature,” International 
+Journal of Applied Mechanics, Vol. 2, No. 5, 2012, pp. 
+921-934.  
+[16] G. K. Garde, “Sartha Vaghbhata,” In: Sutrasthana, Rag- 
+huvamshi Publishers, Pune, 1996, p. 8. 
+[17] R. Monro, J. Powar, R. Nagarathna and P. Dandona, 
+“Yoga Therapy for NIDDM—A Control Trial,” Journal 
+of Complementary Medicine Research, Vol. 6, No. 2, 
+1992, pp. 66-68. 
+[18] S. V. Hegde, P. Adhikari, S. Kotian, V. J. Pinto, S. D’ 
+Souza and V. D’Souza, “Effect of 3-Month Yoga on Oxi- 
+dative Stress in Type 2 Diabetes with or without Compli- 
+cations: A Controlled Clinical Trial,” Diabetes Care, Vol. 
+34, No. 10, 2011, pp. 2208-2010. 
+[19] R. K. Yadav, R. B. Ray, R. Vempati and R. L. Bijlani, 
+“Effect of a Comprehensive Yoga-Based Lifestyle. Modi- 
+fication Program on Lipid Peroxidation,” Indian Journal 
+of Physiology and Pharmacology, Vol. 49, No. 3, 2005, 
+pp. 358-362. 
+[20] V. Malhotra, S. Singh, O. P. Tandon and S. B. Sharma, 
+“The Beneficial Effect of Yoga in Diabetes,” Nepal 
+Medical College, Vol. 7, No. 2, 2005, pp. 145-147. 
+[21] S. Singh, V. Malhotra, K. P. Singh, S. V. Madhu and O. P. 
+Tandon, “Role of Yoga in Modifying Certain Cardiovas- 
+cular Functions in Type 2 Diabetic Patients,” Journal of 
+the Association of Physicians of India, Vol. 52, 2004, pp. 
+203-206.  
+[22] V. Malhotra, S. Singh, O. P. Tandon, S. V. Madhu, A. 
+Prasad and S. B. Sharma, “Effect of Yogasanas on Nerve 
+Conduction in Type 2 Diabetes,” Indian Journal of 
+Physiology and Pharmacology, Vol. 46, No. 3, 2002, pp. 
+298-306. 
+[23] S. C. Jain, A. Uppal, S. O. Bhatnagar and B. Talukdar, “A 
+Study of Response Pattern of Noninsulin Dependent 
+Diabetics to Yoga Therapy,” Diabetes Research and 
+Clinical Practice, Vol. 19, No. 1, 1993, pp. 69-74.  
+doi:10.1016/0168-8227(93)90146-V 
+[24] M. Kosuri and G. Sridhar, “Yoga Practice in Diabetes 
+Improves Physical and Psychological Outcomes,” Meta-
+Copyright © 2013 SciRes.                                                                              OJEMD 
+B. VAIBHAVI  ET  AL. 
+Copyright © 2013 SciRes.                                                                              OJEMD 
+98 
+bolic Syndrome and Related Disorders, Vol. 7, No. 6, 
+2009, pp. 515-517. doi:10.1089/met.2009.0011 
+[25] A. K. Tiwari and J. M. Rao, “Diabetes Mellitus and Mul- 
+tiple Therapeutic Approaches of Phytochemicals: Present 
+Status and Future Prospects,” Current Science, Vol. 83, 
+No. 1, 2002, pp. 30-38. 
+[26] American Diabetes Association, “Standards of Medical 
+Care in Diabetes—2011”, American Diabetes Association 
+Diabetes Care, Vol. 34, No. 1, 2011, pp. S11-S61. 
+[27] G. K. Garde, “Sartha Vaghbhata,” In: Sutrasthana, Rag- 
+huvamshi Publishers, Pune, 1996, p. 35. 
+[28] K. N. Shastri and G. N. Chaturvedi, “Agnivesha’s Cha- 
+raka Samhita, Vidyotini Commentary,” In: Chikitsast-
+hana, Chaukhamba Bharati Academy, Varanasi, 2004, p. 
+235. 
+[29] G. M. Shastri, “Bhavprakash,” In: Chikitsa Prakarana 
+Verse 117-118, Sastu Sahitya Vardhaka Karyalaya, Ah- 
+medabad, 1966, p. 1117. 
+[30] G. K. Garde, “Sartha Vaghbhata,” In: Sutrasthana, Rag- 
+huvamshi Publishers, Pune, 1996, p. 338. 
+[31] D. K. Nishteswar and R. Vidyanath, “Sahasrayogam,” In: 
+Prameha Prakarana, Chawkhamba Samkrit Series Office, 
+Varanasi, 2006, p. 30. 
+[32] D. K. Nishteswar and R. Vidyanath, “Sahasrayogam,” In: 
+Prameha Prakarana, Chawkhamba Samkrit Series Office, 
+Varanasi, 2006. 
+[33] S. Ambikadutta, “Bhaishajyaratnavali,” In: Pradararoga 
+Chikitsa, Chowkhamba Samskrit Academy, Varanasi, 
+2008, p. 1035. 
+[34] B. K. Sahay, “Role of Yoga in Diabetes,” Journal of the 
+Association of Physicians of India, Vol. 55, 2007, pp. 121- 
+126. 
+[35] S. Despande, H. R. Nagendra and R. Nagarathna, “A 
+Randomized Control Trial of the Effect of Yoga on 
+Gunas (Personality) and Health in Healthy Volunteers,” 
+International Journal of Yoga, Vol. 1, No. 1, 2008, pp. 2- 
+10. doi:10.4103/0973-6131.36785 
+[36] P. Trinder, “Analysis of Glucose,” Ann Clin Biochem, 
+Vol. 6, 1969, p. 24. 
+[37] D. M. Nathan, D. E. Singer, K. Hurxthal and J. D. 
+Goodson, “The Clinical Information Value of the Glyco- 
+sylated Hemoglobin Assay,” The New England Journal of 
+Medicine, Vol. 310, No. 6, 1984, pp. 341-346.  
+doi:10.1056/NEJM198402093100602 
+[38] J. D. Artiss and B. Zak, “Measurement of Cholesterol 
+Concentration,” In: N. Rifai, G. R. Warnick and M. H. 
+Dominiczak, Eds., Handbook of Lipoprotein Testing, 
+AACC Press, Washington, 1997, pp. 99-114. 
+[39] W. T. Friedewald, R. I. Levy and D. S. Fredrickson, “Es- 
+timation of the Concentration of Low Density Lipoprotein 
+Cholesterol in Plasma without the Use of Preparatory 
+Centrifuge,” Clinical Chemistry, Vol. 18, 1972, pp. 499- 
+503. 
+[40] A. Saxena and N. K. Vikram, “Role of Selected Indian 
+Plants in Management of Type 2 Diabetes: A Review,” 
+Journal of Alternative and Complementary Medicine, Vol. 
+10, No. 2, 2004, pp. 369-378.  
+doi:10.1089/107555304323062365 
+[41] S. Amita, S. Prabhakar, I. Manoj, S. Harminder and T. 
+Pavan, “Effect of Yoga-Nidra on Blood Glucose Level in 
+Diabetic Patients,” Indian Journal of Physiology and 
+Pharmacology, Vol. 53, No. 1, 2009, pp. 97-101. 
+[42] S. Singh, V. Malhotra, K. P. Singh, S. V. Madhu and O. P. 
+Tandon, “Role of Yoga in Modifying Certain Cardiovas-
+cular Functions in Type 2 Diabetic Patients,” Journal of 
+the Association of Physicians of India, Vol. 52, 2004, pp. 
+203-206. 
+[43] H. H. Mahapure, S. U. Shete and T. K. Bera, “Effect of 
+Yogic Exercise on Super Oxide Dismutase Levels in 
+Diabetics,” International Journal of Yoga, Vol. 1, No. 1, 
+2008, pp. 21-26. doi:10.4103/0973-6131.36792 
+[44] W. F. Paul, M. Jose-Luis, H. H. Anne and J. W. Nicholas, 
+“Gene-Lifestyle Interaction on Risk of Type 2 Diabetes,” 
+Nutrition, Metabolism and Cardiovascular Diseases, Vol. 
+17, No. 2, 2007, pp. 104-124.  
+doi:10.1016/j.numecd.2006.04.001 
+[45] E. Y. Jung, S. K. Young, R. C. Mi and R. Choue, “Ratio 
+of Fat to Energy Intake Independently Associated with 
+the Duration of Diabetes and Total Cholesterol Levels in 
+Type 2 Diabetes,” Nutrition Research and Practice, Vol. 
+5, No. 2, 2011, pp. 157-162.  
+doi:10.4162/nrp.2011.5.2.157 
+[46] A. Fauci, E. Braunwald, D. Kasper, S. Hauser, D. Longo, 
+J. Jameson and J. Loscalzo, “Diabetes Mellitus. Harri- 
+sons’ Principles of Internal Medicine,” McGraw-Hill, 
+Boston, 2008. 
+[47] H. L. Fehm, W. Kern and A. Peters, “The Selfish Brain: 
+Competition for Energy Resources,” Progress in Brain 
+Research, Vol. 153, 2006, pp. 129-140.  
+doi:10.1016/S0079-6123(06)53007-9 
+[48] S. C. Woods, S. C. Benoit and D. J. Clegg, “The Brain- 
+Gut-Islet Connection,” Diabetes, Vol. 55, Suppl. 2, 2006, 
+pp. S114-S121. doi:10.2337/db06-S015 
+[49] J. S. Yudkin, “Adipose Tissue, Insulin Action and Vascu- 
+lar Disease: Inflammatory Signals,” International Journal 
+of Obesity, Vol. 27, Suppl. 3, 2003, pp. S25-S28.  
+doi:10.1038/sj.ijo.0802496 
+[50] S. Lokeswarananda, “Taittireya Upanishad,” The Ramak- 
+rishna Mission Institute of Culture, Kolkatta, 1996. 
+[51] S. A. Dutta, “Sushruta Samhita,” In: Nidanasthana, Chau- 
+khamba Bharati Academy, Varanasi, 2007, pp. 251-252.  
+[52] K. N. Shastri and G. N. Chaturvedi, “Agnivesha’s Cha- 
+raka Samhita,” In: Chikitsasthana, Chaukhamba Bharati 
+Academy, Varanasi, 2004, pp. 228-229. 
+[53] K. N. Shastri and G. N. Chaturvedi, “Agnivesha’s 
+Charaka Samhita Vidyotini Commentary,” In: Chikitsas- 
+thana, Chaukhamba Bharati Academy, Varanasi, 2004, p. 
+243. 
+[54] K. N. Shastri and G. N. Chaturvedi, “Agnivesha’s Cha- 
+raka Samhita,” In: Chikitsasthana, Chaukhamba Bharati 
+Academy, Varanasi, 2004, pp. 234-235 
+[55] R. Nagarathna and H. R. Nagendra, “Integrated Approach 
+of Yoga Therapy for Positive Health,” Swami Vivekan- 
+anda Yoga Prakashana, Bangalore, 2008. 
+ 

subfolder_0/Effect of Mind Sound Resonance Technique.txt

@@ -0,0 +1,602 @@
+Complementary Therapies in Medicine 56 (2021) 102606
+Available online 13 November 2020
+0965-2299/©
+2020
+The
+Author(s).
+Published
+by
+Elsevier
+Ltd.
+This
+is
+an
+open
+access
+article
+under
+the
+CC
+BY-NC-ND
+license
+(http://creativecommons.org/licenses/by-nc-nd/4.0/).
+Effect of Mind Sound Resonance Technique (MSRT – A yoga-based 
+relaxation technique) on psychological variables and cognition in school 
+children: A randomized controlled trial 
+U.S. Anusuya a, Sriloy Mohanty b, Apar Avinash Saoji c,* 
+a Annai College of Naturopathy and Yoga Sciences, Anaikudi Road, Kovilachery, Kumbakonam, Tamil Nadu, India 
+b Center for Integrative Medicine and Research, All India Institute of Medical Sciences, New Delhi, India 
+c Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India   
+A R T I C L E  I N F O   
+Keywords: 
+MSRT 
+Yoga-based relaxation 
+Children 
+Cognition 
+Mind wandering 
+Mindfulness 
+A B S T R A C T   
+Objective: School children undergo stress, which could impact their psychological functions and cognitive abil­
+ities. Yoga practices have been found useful in enhancing psychological functions and performance. The current 
+study was planned to evaluate a yoga-based relaxation technique’s efficacy as an extracurricular activity on 
+psychological state and cognitive function. 
+Design and setting: This study was a parallel-group randomized controlled trial conducted at a government school 
+in south India. 
+Participants: Sixty students with age ranging between 14–16 years (mean age ± SD; 15.3 ± 0.71 years) satisfying 
+the inclusion and exclusion criteria were randomized to experimental and control groups with an allocation ratio 
+of 1:1. 
+Intervention: Experimental group received Mind Sound Resonance Technique (MSRT), whereas the control group 
+performed supine rest (SR) for two-weeks. 
+Outcome measures: Participants were assessed with State trait anxiety inventory - short form, Mind Wandering 
+Questionnaire, State Mindfulness Attention Awareness Scale, and Trail making task at baseline and post- 
+intervention. 
+Results: Experimental group showed a reduction in state anxiety and mind wandering with improvement in state 
+mindfulness and performance in the Trail-making task compared to the control group. 
+Conclusion: Results of the current trial indicate the beneficial role of MSRT in enhancing psychological and 
+cognitive functions in children. Further, large-scale trials are warranted to ascertain the usefulness of the 
+technique.   
+1. Introduction 
+School children face stress, both physical as well as psycho-social. 
+They are subjected to high levels of stress, anxiety and depression 
+arising from peer pressure.1 Studies demonstrate a high level of aca­
+demic stress in high-school students with depressive symptoms.2 Such 
+stress could lead to declined cognitive abilities, impaired verbal pro­
+cessing, and complex problem-solving abilities and could also lead to 
+physical health issues, resulting in decreased academic performance. 
+Studies demonstrate declined cognition and academic performance 
+associated with anxiety in school children.3,4 Also, physical conditions 
+such as tension-type headaches5 and chronic fatigue syndrome 6 were 
+prevalent among students. If not addressed in time, the stress and anx­
+iety among children could lead to a cascade of physical and 
+psycho-social issues, which may impact cognition among children. 
+In science, cognition is referred to all sets of mental abilities and 
+processes related to acquizition and utilization of knowledge. It includes 
+the processes such as attention, memory and working memory, judg­
+ment and evaluation, reasoning and computation, problem-solving and 
+decision making, comprehension and production of language, etc.7 
+Human cognition is conscious and unconscious, concrete, or abstract, as 
+well as intuitive. Cognition helps to generate new knowledge through a 
+* Corresponding author at: Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, 19, Eknath Bhvan, Gavipuram Circle, KG Nagar, 
+Bengaluru, 560019, India. 
+E-mail address: [email protected] (A.A. Saoji).  
+Contents lists available at ScienceDirect 
+Complementary Therapies in Medicine 
+journal homepage: www.elsevier.com/locate/ctim 
+https://doi.org/10.1016/j.ctim.2020.102606 
+Received 14 January 2020; Received in revised form 24 October 2020; Accepted 26 October 2020   
+Complementary Therapies in Medicine 56 (2021) 102606
+2
+mental process and helps to use the knowledge people have in daily life. 
+Several Mind-Body techniques have been used to combat stress and 
+enhance cognitive abilities. Relaxation techniques have a significant 
+impact on human physiology and psychology.8 Yoga has emerged as a 
+popular Mind-body therapy for managing stress and anxiety in the 
+recent past. A study performed in school children demonstrated a pos­
+itive impact of Yoga for anxiety.9 Several studies show the beneficial 
+effects of Yoga to reduce stress and enhance well-being among stu­
+dents.10 There is also a positive impact of specific yoga practices such as 
+yoga breathing on psychological functions in adults.11,31 Yogic practices 
+are also known to restore autonomic balance12 and help reduce the risk 
+of complications of long-standing stress. The practice of Yoga is also 
+found to enhance cognitive abilities in students.13 
+Mind Sound Resonance Technique (MSRT) is one of the yoga-based 
+relaxation techniques that uses mantra to generate resonance, which is 
+used to induce deep relaxation for mind and body. MSRT can be prac­
+ticed for improving well-being, concentration, willpower, and relaxa­
+tion.14 The practice of MSRT has demonstrated to improve stress, 
+anxiety, depression, self-esteem, blood pressure, and heart rate in clin­
+ical and non-clinical populations.15,16 It is also found to decrease state 
+anxiety and improve psychomotor performance.17 A single-session of 
+MSRT positively impacted cognitive performance in University medical 
+students.18 Another study demonstrated that a month-long intervention 
+of MSRT facilitates a reduction in stress, anxiety, fatigue, and psycho­
+logical distress. The relaxation technique also enhanced self-esteem and 
+quality of sleep among female teachers working in primary schools.16 
+Though these studies indicate a positive impact of MSRT, there are no 
+studies to understand the effect of MSRT on psychological functions and 
+cognitive abilities in school children. Hence, the present study was 
+planned to evaluate the impact of a two-week practice of MSRT on 
+psychological factors and cognition of school students. 
+2. Materials and methods 
+2.1. Design and setting 
+The current trial was a single-center randomized controlled trial with 
+two assessment points, i.e., baseline and two-weeks. The study consisted 
+of two groups, i.e., experimental and control, in which the allocation of 
+subjects was done with a 1:1 ratio. Experimental group received guided 
+relaxation sessions of MSRT for 30 min/day, six days/week for two 
+weeks. Beyond the guided sessions at school, subjects were asked not to 
+perform the practice at home to maintain practice uniformity. The 
+Control group continued their routine activities, along with supine rest 
+(SR), for a similar duration of MSRT. The study was executed at a gov­
+ernment school in Tamilnadu, India. The trial was not registered in the 
+clinical trial registry. 
+2.2. Participants 
+The subjects were recruited from a pool of eighth and ninth-grade 
+students of a government school in Tamilnadu, India, based on the in­
+clusion and exclusion criteria. Sixty healthy school going children with 
+equal gender distribution were allocated to either of the groups with an 
+allocation ratio of 1:1. The inclusion criteria were; healthy children 
+regardless of their gender, aged between 14–16 years with no history of 
+any illness for at least six months before the study. Unwilling subjects 
+and the ones could not comprehend and follow the instructions given by 
+the instructor were excluded. Written informed consent was obtained 
+from the participant and their guardians after explaining the steps of the 
+study. They also underwent systemic health checkup by a trained 
+physician, who otherwise had no role in the study. The sample size was 
+not calculated a priori. All eligible 60 students satisfying inclusion and 
+exclusion criteria from grade eighth and ninth were recruited for the 
+study. 
+2.3. Randomization 
+Eligible subjects were identified and were stratified based on their 
+gender. Then subjects from each stratum were randomly divided into 
+two groups, i.e., experimental and control groups. A computer-based 
+program generated the random numbers with an allocation ratio of 
+1:1 by a statistician who had no role in the study. Further, to maintain 
+concealment, serial number specific opaque sealed envelopes were made 
+by the same statistician. Authors enrolled the patients and allotted in 
+groups to them. The current study was a non-blinded trial. However, the 
+outcome assessors were blinded to group allocation. 
+2.4. Ethical considerations 
+The study’s protocol was reviewed and approved by the Institutional 
+Ethics Committee of the Swami Vivekananda Yoga Anusandhana 
+Samsthana, Bengaluru. Written Informed consent was obtained from the 
+participants and their legal guardians after a briefing about the protocol. 
+It was ensured that the participants and the guardians understood the 
+implications of signing the consent form; all the details were explained 
+to them in their vernacular language. A participant information sheet 
+(PIS) in the colloquial language was also provided to all the eligible 
+participants before randomization. PIS document provides detail on the 
+purpose of this study, assessments and procedures involved, risks, and 
+benefits of participation in the trial. 
+2.5. Intervention 
+2.5.1. Experimental group 
+The study group received the advanced yogic technique called MSRT 
+done in a supine position, with closed eyes. MSRT involves experiencing 
+with closed eyes the internal vibrations and resonance developed while 
+chanting the syllables A, U, M, Om, and Maha-Mrityunjaya Mantra.14,17 
+The intervention was given by an institutionally trained yoga therapist 
+for 30 min every day for two weeks at school. The participants were 
+asked to appreciate the resonance all over the body during loud (Ahata: 
+heard) and mental chanting (Anahata: unheard). This is done alter­
+nately, starting from Ahata (loud) ’A’ followed by Anahata(mental) ’A’ 
+repeated three times. Similar repetitions of all other chants follow this. 
+2.5.2. Control group 
+Participants in the control group practiced SR for the same duration, 
+i.e., 30 min in Shavasana, as described in the Hatha Yoga Pradipika with 
+closed eyes and palms facing roof.19 A teacher supervised the sessions. 
+All subjects, irrespective of their group allocation, were advised to 
+follow their routine day to day schedule and not practice at home to 
+maintain homogeneity of intervention. 
+2.5.3. Environment of the therapy room 
+A suitable environment for the practice of MSRT was created to avoid 
+disturbance due to external sound or light. The MSRT sessions were 
+conducted in a dimly lit yoga hall, which had sufficient space to 
+accommodate all the participants, and it was made sure that the in­
+structor’s voice was audible to everyone. 
+2.5.4. Outcome measures 
+The outcome measures were planned to assess the psychological 
+function and cognition in children. Since the study was an exploratory 
+one, no primary endpoint was decided. The four instruments used were 
+State anxiety inventory-short form (STAI-SF), State mindfulness atten­
+tion awareness scale (SMAAS), Mind wandering questionnaire (MWQ), 
+and Trail making test (TMT). Data were obtained at baseline and at the 
+end of two-weeks. The instruments were administered in their original 
+English versions since all the study participants were comfortable with 
+English. 
+STAI-SF is a six-item short version for assessing state anxiety from the 
+U.S. Anusuya et al.                                                                                                                                                                                                                             
+Complementary Therapies in Medicine 56 (2021) 102606
+3
+original Spielberg’s State-Trait Anxiety inventory. The participants were 
+asked to respond to each question on a Likert scale ranging from 1 to 4.20 
+SMAAS is a reliable and valid tool to assess state mindfulness. The 
+questionnaire contains five questions to be answered on a scale of 1 (not 
+at all) to 6 (very much). MWQ is a reliable and validated five-item 
+self-rated questionnaire, in which subjects filled responses on a scale 
+of 1 (almost never) to 6 (almost always).21 TMT was used to evaluate 
+changes in attention and working memory.22 The tool consists of two 
+parts: TMT "A" involved subjects drawing lines connecting 25 consecu­
+tive circled numbers in a numerical sequence (i.e., 1–2–3, etc.) as rapidly 
+as possible. In TMT "B," the subjects were directed to draw lines to 
+connect 12 consecutive circled numbers and 12 following letters in an 
+alternate numeric and alphabetic sequence (i.e., 1-A-2-B, etc.) as rapidly 
+as possible. Time (in seconds) taken for completing the tasks was noted 
+using a stopwatch. The score on each part represents the amount of time 
+required to complete the task.23 The errors committed during task 
+completion were scored accurately. 
+Cronbach’s alphas for the scales were as follows: STAI-SF = 0.82; 
+SMAAS = 0.92; MWQ = 0.85; and TMT = 0.89. 
+2.5.5. Data analysis 
+The data were extracted using the questionnaires/tools’ manuals and 
+arranged in JASP statistical package version 0.11.1 (JASP Team, 2019). 
+We performed an analysis of covariance (ANCOVA) using the baseline 
+values as covariates. 
+3. Results 
+A schematic representation of the trial profile is depicted in Fig. 1. 
+Sixty participants from grades 8 and 9 with a mean age (±SD) of 15.03 ±
+0.71 years completed the study with an allocation ratio of 1:1. There 
+were no dropouts in the current trial. The participants’ socioeconomic 
+status was assessed using the Kuppuswamy and Udai Pareekh’s scale 
+adapted by the Govt. of India.24 The demographic data from the whole 
+study population are presented in Table 1. 
+A one-way analysis of covariates (ANCOVA) was performed to 
+determine the significant differences between groups in the post values, 
+controlling for the baseline values, age, and gender as covariates. Sta­
+tistically significant changes were observed in STAI-SF scores (p =
+0.0308) SMAAS scores (p = 0.0017); MWQ scores (p < 0.001) and each 
+component of TMT scores (p < 0.001). The details of the same are 
+depicted in Table 2. 
+We performed within-group analyses using paired samples t-test. 
+Significant reductions were observed in the STAI-SF and MWQ scores, 
+with improvements in SMAAS scores and performance in the TMT in the 
+experimental group. In the control group, however, only two variables 
+changed significantly. MWQ scores increased significantly (p = 0.049), 
+indicating increased mind wandering, which increased the time taken in 
+TMT task B significantly (p = 0.01). Thus, there was deterioration in 
+performance in the control group. The within-group changes in experi­
+mental and control groups are indicated in Table 3, respectively. 
+4. Discussion 
+This study was conducted to assess the effect of a two-week session of 
+Fig. 1. Trial profile.  
+Table 1 
+Demographic Characteristics of the participants at baseline.   
+Experimental 
+Group 
+Control 
+Group 
+Total 
+Age (years) 
+15.13 ± 0.63 
+14.93 ± 0.78 
+15.03 ± 0.71 
+Gender 
+Male: 15 
+Male: 15 
+Male: 30 
+Female: 15 
+Female: 15 
+Female: 30 
+Socioeconomic status 
+High: 01 
+High: 03 
+High: 04 
+Middle: 19 
+Middle: 17 
+Middle: 36 
+Lower: 09 
+Lower: 11 
+Lower: 20 
+Educational Status 
+Grade 8th :15 
+Grade 8th : 15 
+Grade 8th: 30 
+Grade 9th:15 
+Grade 9th : 15 
+Grade 9th: 30 
+State of anxiety at 
+baseline 
+Normal: 15 
+Normal: 12 
+Normal: 27 
+Anxious: 15 
+Anxious: 18 
+Anxious: 33  
+U.S. Anusuya et al.                                                                                                                                                                                                                             
+Complementary Therapies in Medicine 56 (2021) 102606
+4
+MSRT on psychological functions and cognition in school children. The 
+study results revealed a reduction in anxiety and mind wandering with 
+increased state mindfulness, awareness, attention, and working memory 
+in school children. This is the first study assessing the effect of MSRT in 
+school children to the best of our knowledge. Our findings indicate 
+enhanced psychological functions and cognition among children 
+following a two-week intervention period compared to the control 
+group, which continued to perform their routine activities and SR for 30 
+min. 
+Our findings concur with previous studies conducted with the MSRT 
+and other yogic relaxation/meditation techniques. In an earlier study 
+conducted on effects of MSRT, a single session of MSRT was found to be 
+beneficial in enhancing the performance in cognitive tasks that demand 
+sustained attention, concentration, visual scanning, and activation and 
+inhibition of rapid responses, psychomotor speed, mental flexibility, and 
+speed of information processing, when compared to SR for the same 
+duration .18 Ten days of MSRT was applied to patients with generalized 
+anxiety, in which Bhargav et al. could demonstrate reduced anxiety and 
+enhanced cognitive abilities.17 An earlier randomized controlled trial 
+showed a reduction in anxiety in patients with chronic neck pain by the 
+practice of MSRT for ten days compared to SR.25 The possible mecha­
+nism involved in reducing stress, anxiety and the improvement in the 
+psychological variables assessed could be attributed to parasympathetic 
+dominance resulting from om chanting and mantra chanting. An fMRI 
+study performed on chanting of OM was found to have a similar effect to 
+that of vagal stimulation,26 which could have led to a state of para­
+sympathetic dominance. Reduction of anxiety through the practice of 
+MSRT, as seen in an earlier study,17 could also be attributed to enhanced 
+performance in the TMT, as anxiety can impact cognition negatively.3,4 
+A systematic review mentioned that yoga and meditation interven­
+tion nurture mindfulness and may be a feasible and effective building 
+resilience method in childhood and adolescence.27 
+Enhanced 
+mindfulness was associated with reduced anxiety and mind-wandering 
+in an earlier study with Yoga breathing.11 Mind-wandering is related 
+to low mood and depression,28 a reduction of the same may have 
+contributed to enhanced cognitive abilities. Earlier studies on medita­
+tion practices are shown to have increased mindfulness and reduced 
+mind-wandering.29,30 In all the trials mentioned above, the common 
+limitation was the short duration of the intervention (ranging from a 
+single session to a maximum of one week). In the current experiment, 
+the length of the intervention was comparatively extended than the 
+other trials (for two-weeks). 
+Clinically, the data we gathered in the current study indicate a trend 
+towards reduced anxiety and mind-wandering and improved mindful­
+ness and performance in the cognitive tasks. Both the trends are sig­
+nificant in the learning abilities, especially in school-children. The 
+results warrant further inquiry into the impact of MSRT in school- 
+children. 
+Since the study was conducted at the school, there were no dropouts 
+throughout the study. Though we used the robust design of RCT, a 
+relatively small sample size and lack of objective measures to determine 
+the possible mechanism of action of MSRT are amongst the limitation of 
+the study. There was also no follow-up, and so, it is not known whether 
+improvements in task performance and self-efficacy sustained. Studies 
+with an extended follow-up period and robust objective assessment tools 
+to assess the effects of MSRT may be planned to ascertain the impact and 
+the underlying mechanisms of action. 
+5. Conclusion 
+The current study suggests that training in MSRT may enhance 
+psychological functions and cognitive abilities in school children. 
+Incorporating MSRT as a regular practice in schools may help enhance 
+the psychological well-being and cognitive functions of school children. 
+Research involving human participants 
+The study was approved by the institutional ethics committee and 
+have therefore been performed in accordance with the ethical standards 
+laid down in the 1964 Declaration of Helsinki and its later amendments. 
+Informed consent 
+All the participants who participated and their legal guardians pro­
+vided a written informed consent. 
+CRediT authorship contribution statement 
+U.S. Anusuya: Data curation, Investigation, Project administration, 
+Writing - original draft, Writing - review & editing. Sriloy Mohanty: 
+Conceptualization, Data curation, Formal analysis, Methodology, Vali­
+dation, Writing - original draft, Writing - review & editing. Apar 
+Table 2 
+Changes between the experimental and control groups following two-week 
+assessment duration.  
+Outcome 
+Adj. R2 
+F 
+p 
+Cohen’s d 
+MWQ 
+0.50 
+15.93 
+< 0.0001 
+−1.936 
+SMAAS 
+0.21 
+4.99 
+0.0017 
+0.998 
+STAI 
+0.11 
+2.88 
+0.0308 
+−0.573 
+TMT- A 
+0.80 
+61.86 
+< 0.0001 
+−0.702 
+TMT-B 
+0.87 
+105.75 
+<0.0001 
+−0.801 
+TMT- Total Time 
+0.69 
+34.94 
+<0.0001 
+−1.302 
+TMT Executive function 
+0.72 
+38.92 
+<0.0001 
+−0.571 
+MWQ: Mind Wandering Questionnaire, SMAAS: State Mindfulness Attention 
+Awareness Scale, STAI-SF: State trait anxiety inventory - short form; TMT: Trail 
+making task. 
+The results are obtained from fitting ANCOVA model in which post test result 
+taken as dependent variable & pre-test result, group(experimental and control), 
+age and gender(male and female) taken as independent variables. 
+Table 3 
+Changes within the experimental and control groups before and following the two-week assessment duration.  
+Variable 
+Experimental Group 
+(n = 30; df = 29) 
+Control Group 
+(n = 30; df = 29)  
+Pre 
+Post 
+t 
+Pre 
+Post 
+T 
+MWQ Score 
+3.65 ± 9.86 
+2.51 ± 0.96*** 
+5.500 
+3.76 ± 0.66 
+4.10 ± 0.58* 
+−2.053 
+SMAAS Scores 
+4.04 ± 1.45 
+5.00 ± 0.92** 
+−2.995 
+4.11 ± 0.90 
+3.87 ± 1.27 
+0.954 
+STAI- SF Scores 
+39.56 ± 9.74 
+33.22 ± 7.14*** 
+3.658 
+42.55 ± 10.46 
+38.89 ± 10.52 
+1.427 
+TMT A (Sec) 
+30.40 ± 4.03 
+28.20 ± 3.85*** 
+4.826 
+34.07 ± 5.84 
+34.70 ± 5.79 
+−1.208 
+TMT B (Sec) 
+65.50 ± 9.77 
+61.30 ± 9.11*** 
+7.290 
+73.73 ± 9.70 
+76.57 ± 10.50** 
+−2.746 
+TMT Total time 
+95.90 ± 12.21 
+89.50 ± 11.91*** 
+8.222 
+105.43 ± 19.42 
+111.27 ± 13.50 
+−1.970 
+TMT Executive Function 
+35.10 ± 8.63 
+33.10 ± 7.35** 
+2.906 
+39.67 ± 9.24 
+41.87 ± 10.27 
+−1.677 
+Paired samples t-test. * = p < 0.05, **= p < 0.01, *** = p < 0.001. 
+MWQ: Mind Wandering Questionnaire, SMAAS: State Mindfulness Attention Awareness Scale, STAI-SF: State trait anxiety inventory - short form; TMT: Trail making 
+task. 
+U.S. Anusuya et al.                                                                                                                                                                                                                             
+Complementary Therapies in Medicine 56 (2021) 102606
+5
+Avinash Saoji: Conceptualization, Data curation, Formal analysis, 
+Investigation, Methodology, Project administration, Supervision, Vali­
+dation, Visualization, Writing - original draft, Writing - review & 
+editing. 
+Declaration of Competing Interest 
+The authors report no declarations of interest. 
+References 
+1 Oppenheimer CW, Hankin BL, Young J. Effect of parenting and peer stressors on 
+cognitive vulnerability and risk for depression among youth. J Abnorm Child Psychol. 
+2018;46(3):597–612. https://doi.org/10.1007/s10802-017-0315-4. 
+2 Liu Y, Lu Z. Chinese high school students’ academic stress and depressive symptoms: 
+gender and school climate as moderators. Stress Health. 2012;28(4):340–346. 
+https://doi.org/10.1002/smi.2418. 
+3 McDonald AS. The prevalence and effects of test anxiety in school children. Educ 
+Psychol. 2003;21(1):89–101. https://doi.org/10.1080/01443410124641. 
+4 Seipp B, McDonald AS. Anxiety and academic performance: a meta-analysis of 
+findings. Educ Psychol. 2007;21(1):89–101. https://doi.org/10.1080/ 
+08917779108248762. 
+5 Goto M, Yokoyama K, Nozaki Y, et al. Characteristics of headaches in Japanese 
+elementary and junior high school students: a school-based questionnaire survey. 
+Brain Dev. 2017;39(9):791–798. https://doi.org/10.1016/j.braindev.2017.05.010. 
+6 Shi J, Shen J, Xie J, Zhi J, Xu Y. Chronic fatigue syndrome in Chinese middle-school 
+students. Med (United States). 2018;97(4). https://doi.org/10.1097/ 
+MD.0000000000009716. e9716. 
+7 Wessinger CM, Clapham E. Cognitive neuroscience: an overview. Encyclopedia of 
+neuroscience. Elsevier; 2009:1117–1122. https://doi.org/10.1016/B978-008045046- 
+9.00299-0. 
+8 Jacobs GD. The physiology of mind-body interactions: The stress response and the 
+relaxation response. J Altern Complement Med. 2001;7(Suppl 1):S83–92. 
+9 Bazzano AN, Anderson CE, Hylton C, Gustat J. Effect of mindfulness and yoga on 
+quality of life for elementary school students and teachers: results of a randomized 
+controlled school-based study. Psychol Res Behav Manage. 2018;11:81–89. https:// 
+doi.org/10.2147/PRBM.S157503. 
+10 Saoji AA. Yoga: a strategy to cope up stress and enhance wellbeing among medical 
+students. N Am J Med Sci. 2016;8(4):200–202. https://doi.org/10.4103/1947- 
+2714.179962. 
+11 Saoji AA, Raghavendra BR, Madle K, Manjunath NK. Additional practice of yoga 
+breathing with intermittent breath holding enhances psychological functions in yoga 
+practitioners: a randomized controlled trial. Explore (NY). 2018;14(5):379–384. 
+https://doi.org/10.1016/j.explore.2018.02.005. 
+12 Saoji AA, Raghavendra BR, Manjunath NK. Immediate effects of yoga breathing with 
+intermittent breath retention on the autonomic and cardiovascular variables 
+amongst healthy volunteers. Indian J Physiol Pharmacol. 2018;62(1):41–50. 
+13 Saoji AA, Raghavendra BR, Rajesh SK, Manjunath N. Immediate effects of yoga 
+breathing with intermittent breath holding on response inhibition among healthy 
+volunteers. Int J Yoga. 2020. https://doi.org/10.4103/ijoy.IJOY_65_16. 
+14 Nagendra H. Mind sound resonance technique. Swami Vivekananda Yoga Prakashana; 
+2001. 
+15 Mohanty S, Metri K, R. N, Nagendra HR. Immediate effect of mind sound resonance 
+technique (Msrt- a yogic relaxation technique) on cognitive function in type 2 
+diabetes. Work Pap. 2015. Published online. 
+16 Rao M, Metri KG, Raghuram N, Hongasandra NR. Effects of mind sound resonance 
+technique (yogic relaxation) on psychological states, sleep quality, and cognitive 
+functions in female teachers: a randomized, controlled trial. Adv Mind Body Med. 
+2017;31(1):4–9. 
+17 Bhargav H, Metri K, Dhansoia V. Immediate effect of mind sound resonance 
+technique on state anxiety and cognitive functions in patients suffering from 
+generalized anxiety disorder: a self-controlled pilot study. Int J Yoga. 2015;8(1):70. 
+https://doi.org/10.4103/0973-6131.146069. 
+18 Saoji A, Mohanty S, Vinchurkar SA. Effect of a single session of a yogic meditation 
+technique on cognitive performance in medical students: a randomized crossover 
+trial. J Relig Health. 2017;56(1):141–148. https://doi.org/10.1007/s10943-016- 
+0195-x. 
+19 Muktibodhananda S. Hatha yoga pradipika: Light on hatha yoga. 2nd ed. Yoga 
+Publication Trust; 2002. 
+20 Marteau TM, Bekker H. The development of a six-item short-form of the state scale of 
+the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol. 1992;31(3): 
+301–306. https://doi.org/10.1111/j.2044-8260.1992.tb00997.x. 
+21 Mrazek MD, Phillips DT, Franklin MS, Broadway JM, Schooler JW. Young and 
+restless: validation of the Mind-Wandering Questionnaire (MWQ) reveals disruptive 
+impact of mind-wandering for youth. Front Psychol. 2013;4:560. https://doi.org/ 
+10.3389/fpsyg.2013.00560. 
+22 Bhatia T, Shriharsh V, Adlakha S, Bisht V, Garg K, Deshpande SN. The trail making 
+test in India. Indian J Psychiatry. 2007;49(2):113–116. https://doi.org/10.4103/ 
+0019-5545.33258. 
+23 Tombaugh TN, Rees L, McIntyre N. Normative data for the trail making test. Personal 
+communication cited in Spreen and Strauss. A compendium of neuropsychological tests: 
+Administration, norms and commentary. 2nd ed. 1998. 
+24 Wani RT. Socioeconomic status scales-modified Kuppuswamy and Udai Pareekh’s 
+scale updated for 2019. J Fam Med Prim Care. 2019;8(6):1846–1849. https://doi.org/ 
+10.4103/jfmpc.jfmpc_288_19. 
+25 Yogitha B, Nagarathna R, John E, Nagendra HR. Complimentary effect of yogic 
+sound resonance relaxation technique in patients with common neck pain. Int J Yoga. 
+2010;3(1):18–25. https://doi.org/10.4103/0973-6131.66774. 
+26 Kalyani BG, Venkatasubramanian G, Arasappa R, et al. Neurohemodynamic 
+correlates of “OM” chanting: a pilot functional magnetic resonance imaging study. Int 
+J Yoga. 2011;4(1):3–6. https://doi.org/10.4103/0973-6131.78171. 
+27 Greenberg MT, Harris AR. Nurturing mindfulness in children and youth: current state 
+of research. Child Dev Perspect. 2012;6(2):161–166. https://doi.org/10.1111/j.1750- 
+8606.2011.00215.x. 
+28 Mason MF, Norton MI, Van Horn JD, Wegner DM, Grafton ST, Macrae CN. 
+Wandering minds: the default network and stimulus-independent thought. Science. 
+2007;315(5810):393–395. https://doi.org/10.1126/science.1131295. 
+29 Garland EL, Hanley A, Farb NA, Froeliger BE. State mindfulness during meditation 
+predicts enhanced cognitive reappraisal. Mindfulness (N Y). 2015;6(2):234–242. 
+https://doi.org/10.1007/s12671-013-0250-6. 
+30 Hasenkamp W, Wilson-Mendenhall CD, Duncan E, Barsalou LW. Mind wandering 
+and attention during focused meditation: a fine-grained temporal analysis of 
+fluctuating cognitive states. Neuroimage. 2012;59(1):750–760. https://doi.org/ 
+10.1016/j.neuroimage.2011.07.008. 
+31 Saoji Apar Avinash, Raghavendra BR, Manjunath NK. Effects of yogic breath 
+regulation: A narrative review of scientific evidence. J. Ayurveda Integr. Med. 2019;10 
+(1):50–58. https://doi.org/10.1016/j.jaim.2017.07.008. 
+U.S. Anusuya et al.                                                                                                                                                                                                                             

subfolder_0/Effect of Needling at CV-12 (Zhongwan) on Blood Glucose Levels in Healthy Volunteers_.txt

@@ -0,0 +1,353 @@
+RESEARCH ARTICLE
+Effect of Needling at CV-12 (Zhongwan) on
+Blood Glucose Levels in Healthy Volunteers:
+A Pilot Randomized Placebo Controlled Trial
+Sriloy Mohanty 1, A. Mooventhan 2,*, Nandi Krishnamurthy Manjunath 2
+1 Department of Naturopathy, S-VYASA University, Bangalore, Karnataka, India
+2 Department of Research and Development, S-VYASA University, Bangalore,
+Karnataka, India
+Available online 20 September 2016
+Received: May 30, 2016
+Revised: Aug 20, 2016
+Accepted: Aug 24, 2016
+KEYWORDS
+acupuncture;
+blood glucose;
+Zhongwan
+Abstract
+Introduction: Acupuncture, a key part of traditional Chinese medicine, is used to relieve symp-
+toms of diabetes mellitus. The aim of this study was to evaluate the effect of needling CV-12
+(Zhongwan) on blood glucose levels in healthy volunteers.
+Materials and methods: Thirty-six individuals were recruited and randomized into either the
+acupuncture group or the placebo control group. The participants in the acupuncture
+group were needled at CV-12 (4 cun above the center of the umbilicus), and those in the pla-
+cebo control group were needled at a nonexisting “sham” point on the right side of the
+abdomen (1 cun beside the CV-12)da nonacupuncture point. For both groups, the needle
+was retained for 20 minutes without stimulation. Assessments were performed prior to and af-
+ter the intervention. Statistical analysis was performed using the Statistical Package for the
+Social Sciences, version 16.
+Results: The result of this study showed a mild reduction in random blood glucose (RBG) levels
+in the acupuncture group and a mild increase in RBG levels in the placebo control group.
+However, these changes were not statistically significant both within and between groups.
+This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://
+creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any me-
+dium, provided the original work is properly cited.
+* Corresponding author. Department of Research and Development, S-VYASA University, #19, Eknath Bhavan, Kavipuram Circle,
+Kempegowda Nagar, Bengaluru 560019, Karnataka, India.
+E-mail: [email protected] (A. Mooventhan).
+pISSN 2005-2901
+eISSN 2093-8152
+http://dx.doi.org/10.1016/j.jams.2016.08.002
+Copyright ª 2016, Medical Association of Pharmacopuncture Institute.
+Available online at www.sciencedirect.com
+Journal of Acupuncture and Meridian Studies
+journal homepage: www.jams-kpi.com
+J Acupunct Meridian Stud 2016;9(6):307e310
+Conclusion: The result of this study suggests that although 20 minutes of needling at CV-12
+without stimulation produced a mild reduction in RBG levels in healthy volunteers, it did
+not produce a statistically significant result.
+1. Introduction
+Diabetes
+is
+a
+major
+public
+health
+problem
+that
+is
+approaching epidemic proportions globally. The number of
+people with diabetes is likely to increase up to 380 million
+by 2025. Almost 80% of total adults with diabetes are from
+developing countries. India leads the global top 10 coun-
+tries in terms of the highest number of people with dia-
+betes, and there is a growing incidence of diabetes at a
+younger age [1].
+Acupuncture at CV-12 (Zhongwan) has been widely used
+in traditional Chinese medicine to relieve symptoms of
+diabetes. Previous studies using electroacupuncture on only
+CV-12 [2] and combining this with CV-4 (Guanyuan) [3,4],
+SP-6 (Sanyinjiao), and ST-36 (Housanli) have produced a
+hypoglycemic effect [2e4] with normalized insulin sensi-
+tivity, ameliorating both insulin resistance and hyper-
+insulinemia [3] in diabetic rats.
+In
+a
+human
+study,
+CV-12din
+combination
+with
+acupuncture points such as CV-4, CV-6 (Qihai), CV-10 (Xia-
+wan), ST-24 (Huaroumen), ST-25 (Tianshu), TE-5 (Wailing),
+SP-15 (Daheng), and KI-13 (Qixue)dwas shown to decrease
+blood glucose levels and improve insulin resistance with no
+adverse effects in obese Type 2 diabetic volunteers [5].
+Other studies have focused on single needling at CV-12
+[2], ST-36 [6], BL20 (Pishu) [7], and GB 26 (Daimai) [8] in a
+rat model; however, there is lack of studies on human
+volunteers. Hence, the aim of this study aims was to eval-
+uate the effect of single point acupuncture at CV-12 on
+blood glucose levels in healthy human volunteers.
+2. Materials and methods
+2.1. Participants
+A total of 36 healthy volunteers whose ages ranged from 18
+years to 24 years were recruited from a residential college
+based on the following inclusion and exclusion criteria. The
+inclusion criteria called for male and female volunteers
+who were 18 years and above, and were willing to partici-
+pate in the study. The exclusion criteria were as follows:
+individuals with a history of any systemic and mental
+illness, regular use of medication for any diseases, needle
+phobia, chronic smoking, and alcoholism. The study pro-
+tocol was approved by the institutional ethics committee,
+and a written informed consent was obtained from each
+participant.
+2.2. Study design
+This is a pilot randomized placebo-controlled trial, in which
+all participants were randomly assigned into either the
+acupuncture group or the placebo control group. The
+acupuncture group received needling at CV-12 and the
+placebo
+control
+group
+received
+needling
+at
+a
+non-
+acupuncture point for 20 minutes. Data assessment was
+performed prior to and after the intervention.
+2.3. Randomization
+All participants were allotted with random numbers. The
+first volunteer was allocated to a group on the basis of a flip
+of a coin, then the next volunteer was assigned to the
+opposite group, in a randomization ratio of 1:1. Thus, all
+members of the group had an equal chance to be in either
+group. This randomization was performed by one of the
+authors, who was involved in intervention but was not
+involved in any part of the investigation.
+2.4. Blinding/masking
+All participants were blind to the acupuncture (CV-12) and
+the placebo control points. The investigator who assessed
+the blood glucose was blind to the acupuncture and placebo
+control groups.
+2.5. Assessments
+2.5.1. Random blood glucose
+The random blood glucose (RBG) level was assessed be-
+tween 10:30 and 11:30 A.M. using a portable ACCU-CHEK,
+Performa Nano machine (Roche Diagnostics India Pvt. Ltd,
+Mumbai, India). Assessments were performed prior to and
+after the intervention for both groups.
+2.6. Intervention
+2.6.1. Acupuncture group
+The participants received traditional Chinese medicine-
+style of acupuncture. Needling was performed at CV-12 (4
+cun above the center of the umbilicus) [9] at a depth of 0.5
+cun. The participants were informed about the procedure,
+sensations of needle insertion, and response sought. The
+needle was left out without any stimulation. We used 0.5-
+cun filiform locally manufactured cupper needle with
+0.38 mm diameter and 13 mm length. The participants
+received only one session of acupuncture for a duration of
+20 minutes. The participants did not receive any treat-
+ments other than acupuncture. Needling was administered
+by one of the authors who is institutionally qualified with 2
+years’ experience in clinical acupuncture.
+2.6.2. Placebo control group
+The participants in this group received needling in the right
+side of the abdomen 1 cun lateral to CV-12 where there is
+no known acupuncture point.
+308
+S. Mohanty et al.
+2.7. Data analysis
+All data were checked for normality using Kolmogor-
+oveSmirnov and ShapiroeWilk tests. Statistical analysis was
+performed using Student paired t test (within groups) and
+analysis of variance (between groups) was carried out using
+Statistical Package for the Social Sciences (SPSS) for Win-
+dows, Version 16.0, Chicago, SPSS Inc.
+3. Results
+Of 41 volunteers, five did not meet the inclusion criteria
+and were subsequently excluded from the study. All
+recruited participants (n Z 36) were randomly divided into
+either the acupuncture (n Z 18) or the placebo control
+group (n Z 18). Needling was performed at CV-12 and at
+the right side of the abdomen 1 cun lateral to CV-12 in the
+acupuncture and placebo control groups, respectively.
+Baseline and posttest assessments were done prior to and
+after the intervention. Demographic (Table 1) and the
+baseline blood glucose levels (Fig. 1) were comparable, and
+there were no significant changes between the groups.
+Even though the result of this present study showed mild
+reduction in RBG levels in the acupuncture group and mild
+increase in the placebo control group, these changes were
+not statistically significant both within and between groups
+(Fig. 1).
+4. Discussion
+CV-12 is known as the stomach control point in Korean
+medicine and is located on the abdominal wall associated
+with the pancreas. Although it is located on the Conception
+Vessel Meridian, it is considered a therapeutic point for
+diseases of the digestive organs such as the stomach,
+pancreas, and spleen [10]. For example, electric stimula-
+tion at the CV-12 was used for treatment of diabetic rats
+[2,10].
+The results of this present study showed that a 20-
+minute single session needling at CV-12 acupuncture point
+without any stimulation (manual or electrical) produced a
+mild reduction in RBG levels in healthy volunteers. At the
+same time a 20-minutes single session of needling at the
+placebo control point produced a mild increase in RBG
+levels in healthy individuals. However, these changes were
+not statistically significant.
+Only one session was administered on CV-12 to check for
+the immediate effect on RBG. This may not be sufficient to
+produce
+significant
+changes.
+Needling
+was
+performed
+without stimulation, however, including either manual,
+electrical, laser, or catgut embedding stimulation, which
+might have produced a more significant effect in reducing
+RBG. It should be noted that in previous studies on elec-
+troacupuncture at CV-12 alone in diabetic rats [2] and in
+combination with other acupuncture points in diabetic rats
+[3,4] and human studies [5], laser irradiation on CV-12 along
+with other points in metabolic syndrome [9], and catgut
+embedding in CV-12 along with other acupuncture points in
+diabetic rats [11] have been shown to reduce blood glucose
+[2e5,11] and fasting insulin [9,11].
+001As healthy individuals have normal physiological
+functions and do not have abnormally elevated blood
+glucose/reduced insulin levels, CV-12 might have not
+influenced the blood glucose levels. In previous studies, the
+hypoglycemic effect of CV-12 alone [2] and in combination
+with other acupuncture points were reported mainly in
+diabetic rats [3,4,11], and in diabetic patients but not in
+healthy individuals [5]. Hence, we expect needling at CV-12
+to be effective in participants with high blood glucose
+levels; however, this needs to be confirmed in further
+studies.
+4.1. Strength of the study
+This is the first randomized placebo controlled study to
+evaluate the effect of CV-12 on RBG levels in healthy vol-
+unteers. Both the participants and the investigator were
+blind to the acupuncture and placebo control groups.
+4.2. Limitations of this study
+Sample size was not calculated based on the previous study.
+The present study evaluated only the immediate effect
+without stimulation and did not evaluate its short-term or
+long-term effect with or without stimulation. Assessment of
+variables such as fasting blood glucose, postprandial blood
+Table 1
+Demographic variables of acupuncture (n Z 18)
+and placebo control groups (n Z 18).
+Variables
+Acupuncture
+group
+Placebo control
+group
+Age (y)
+19.61 
 1.975
+19.22 
 1.517
+Sex
+9 males/9 females 9 males/9 females
+Height (cm)
+161.78 
 11.855
+164.00 
 9.628
+Weight (kg)
+54.94 
 8.003
+56.28 
 8.372
+Body mass index
+(kg/m2)
+21.40 
 3.520
+20.90 
 2.288
+All values are expressed as mean 
 standard deviation, except
+for values of sex.
+Figure 1
+Baseline and post-test random blood glucose levels
+of acupuncture (n Z 18) and placebo groups (nZ18).
+Effect of Needling at CV-12 in RBG Levels
+309
+glucose, glycosylated hemoglobin, and insulin levels was
+not performed. Hence, long-term studies with either
+manual or electric stimulation are required in a larger
+sample size, and more variables such as fasting blood
+glucose, postprandial blood glucose, HbA1C, and insulin
+levels should be measured in order to better understand
+the effect of CV-12 on blood glucose levels.
+5. Conclusion
+The result of this present study suggests that 20 minutes of
+needling at CV-12 without stimulation produces a mild
+reduction in RBG levels in healthy volunteers; however, it
+did not produce a statistically significant result.
+Disclosure statement
+The authors declare that they have no conflicts of interest
+and no financial interests related to the material of this
+manuscript.
+Acknowledgments
+The authors thank Robert Mazure, Integrated Holistic Ther-
+apies, London, UK, for his help in editing the manuscript.
+References
+[1] Tabish SA. Is diabetes becoming the biggest epidemic of the
+twenty-first century? Int J Health Sci (Qassim). 2007;1:5e8.
+[2] Chang SL, Lin JG, Chi TC, Liu IM, Cheng JT. An insulin-
+dependent hypoglycaemia induced by electroacupuncture at
+the Zhongwan (CV12) acupoint in diabetic rats. Diabetologia.
+1999;42:250e255.
+[3] Zheng YH, Ding T, Ye DF, Liu H, Lai MH, Ma HX. Effect of low-
+frequency
+electroacupuncture
+intervention
+on
+oxidative
+stress and glucose metabolism in rats with polycystic ovary
+syndrome. Zhen Ci Yan Jiu. 2015;40:125e130.
+[4] Peplow PV, McLean GT. Repeated electroacupuncture: an
+effective treatment for hyperglycemia in a rat model. J Acu-
+punct Meridian Stud. 2015;8:71e76.
+[5] Yang Y, Liu Y. BO’s abdominal acupuncture for obese type-2
+diabetes mellitus. Zhongguo Zhen Jiu. 2015;35:330e334.
+[6] Lee YC, Li TM, Tzeng CY, Chen YI, Ho WJ, Lin JG, et al.
+Electroacupuncture at the zusanli (ST-36) acupoint induces a
+hypoglycemic effect by stimulating the cholinergic nerve in a
+rat model of streptozotocine-induced insulin-dependent dia-
+betes mellitus. Evid Based Complement Alternat Med. 2011.
+http://dx.doi.org/10.1093/ecam/neq068.
+[7] Cornejo-Garrido J, Becerril-Cha
+´vez F, Carlı
+´n-Vargas G, Ordo-
+n
+˜ez-Rodrı
+´guez JM, Abrajan-Gonza
+´lez Mdel C, de la Cruz-
+Ramı
+´rez
+R,
+et
+al.
+Antihyperglycaemic
+effect
+of
+laser
+acupuncture treatment at BL20 in diabetic rats. Acupunct
+Med. 2014;32:486e494.
+[8] Li YY, Hu H, Liang CM, Wang H. Effects of electroacupuncture
+stimulation of “Daimai” (GB 26) on body weight, blood glucose
+and blood lipid levels in rats with metabolism syndrome. Zhen
+Ci Yan Jiu. 2014;39:202e206.
+[9] El-Mekawy HS, ElDeeb AM, Ghareib HO. Effect of laser
+acupuncture combined with a dieteexercise intervention on
+metabolic syndrome in post-menopausal women. J Adv Res.
+2015;6:757e763.
+[10] Kim MS, Sung B, Ogay V, Choi CJ, Kim MS, Kang DI, et al. Novel
+circulatory connection from the acupoint Zhong Wan (CV12) to
+pancreas. J Korean Pharmacopunct Inst. 2008;11:13e19.
+[11] Zhang H, Guo H, Zhang YC, Liu M, Ai K, Su YM, et al. Effect of
+acupointecatgut-embedding intervention on type II diabetic
+rats. Zhen Ci Yan Jiu. 2014;39:358e361, 381.
+310
+S. Mohanty et al.

subfolder_0/Effect of Trataka on cognitive functions in the elderly.txt

@@ -0,0 +1,779 @@
+Volume 7 | Issue 2 | July-December | 2014
+Official 
+Publication 
+of
+Swami 
+Vivekananda 
+Yoga 
+Anusandhana 
+Samsthana 
+University
+Online full text at
+http://www.ijoy.org.in
+IJ Y
+O
+International Journal of Yoga
+Guest Editorial
+Original Articles
+Comparative immediate effect of different yoga asanas on heart rate and blood pressure in healthy young volunteers
+Effect of trataka on cognitive functions in the elderly
+Effect of Bhramari pranayama and OM chanting on pulmonary function inhealthy individuals: A prospective randomized control trial
+Effect of yogic colon cleansing (Laghu Sankhaprakshalana Kriya) on pain, spinal flexibility, disability and state anxiety in chronic low back pain
+Toward building evidence for yoga
+Contents
+ISSN 
+0973-6131
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+96
+Effect of trataka on cognitive functions in the elderly
+Shubhada Talwadkar, Aarti Jagannathan, Nagarathna Raghuram
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samasthana, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Aarti Jagannathan, 
+Swami Vivekananda Yoga Anusandhana Samasthana 19, Gavipuuram, 
+ 
+Kempegowda Nagar ‑ 560 019, Bengaluru, Karnataka, India. 
+ 
+E‑mail: [email protected]
+Original Article
+functions, as well as various other complex cognitive 
+functions.[5‑7] Varied treatment options have been 
+propagated for cognitive impairment in the elderly 
+such as oral medications,[8] cognitive interventions,[9] 
+diet,[10] etc., Many experts have suggested that mentally 
+challenging activities (e.g. crossword puzzles and brain 
+teasers) may be helpful for patients with mild cognitive 
+impairment.[11] Physical activity (PA), aimed at improving 
+cardiorespiratory health, has been proposed to be a 
+good, practical, and powerful candidate to overcome 
+cerebral and behavioral declines.[12] Yoga practices also 
+have shown various health benefits including the ability 
+to improve cognition and thereby preventing cognitive 
+impairments and dementia.[13]
+Many scientific studies have proven that yoga is effective 
+to improve various cognitive functions such as remote 
+memory, mental balance, attention and concentration, 
+attention span, processing speed, attention alternation 
+ability, delayed and immediate recall, executive functions, 
+verbal retention, and recognition tests in the healthy young 
+subjects.[14,15] Very few studies have looked at the effect of 
+yoga in the elderly population. For example, relaxation 
+INTRODUCTION
+In normal aging, decreased ability to retrieve information 
+can cause memory lapses that sometimes impair the ability 
+to perform activities of daily living.[1] These changes are 
+largely the result of decline in frontal lobe function, 
+which is measured as executive functions (the ability 
+to organize, plan, and focus on a topic).[2] Age‑related 
+decline in cognitive abilities varies considerably 
+across individuals and across cognitive domains. 
+Various cognitive domains show different degrees of 
+susceptibilities to aging.[3] Changes in the brain due to 
+aging occur earliest in the prefrontal cortex (PFC).[4] The 
+PFC is associated with memory, attention, executive 
+Background: Trataka, a type of yoga practice is considered to improve cognitive functions. The aim of this study was to test 
+the effect of trataka on cognitive functions of the elderly.
+Materials and Methods: Elderly subjects were recruited based on inclusion and exclusion criteria (n = 60) and randomly divided 
+using randomized block design into two groups: Trataka and wait list control group. Trataka (a visual cleansing technique) 
+was given for a period of 1 month (26 days). The subjects in both groups were assessed on day 1 (pre‑ and postintervention 
+in trataka group and after quiet sitting in control group) and on day 30 on Digit Span Test, Six Letter Cancellation Test (SLCT), 
+and Trail Making Test‑B (TMT‑B).
+Results: Friedman’s test and Wilcoxon signed‑rank test showed that at the 2nd follow‑up there was significant improvement 
+in digit span scores (z = −3.35, P < 0.01) in the trataka group. SLCT scores (t = 5.08, P < 0.01) and TMT‑B scores (t = −4.26, 
+P < 0.01) improved immediately after the practice of trataka (when baseline compared to first follow‑up). At 1 month follow‑up, 
+trataka group showed significantly better performance in the SLCT test compared to baseline (t = −3.93, P < 0.01) and TMT‑B 
+scores (t = 7.09, P < 0.01). Repeated measure analysis of variance (RM ANOVA) results also reiterated that there was significant 
+interaction effect at the end of 1 month of trataka intervention as compared to control group on TMT‑B and SLCT scores.
+Conclusions: The results of this study establish that Trataka can be used as a technique to enhance cognition in the elderly.
+Key words: Cognitive functions; elderly; trataka.
+ABSTRACT
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.133872
+Talwadkar, et al.: Trataka for cognitive functions
+97
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+response training is seen to improve reaction time on 
+simple attention/psychomotor tasks in older adults.[16] 
+Another cross‑sectional study comparing the cognitive 
+performance of 20 meditators (long‑term practitioners of 
+Vihangam yoga meditation) and 20 non‑meditators in the 
+geriatric age group showed that Vihangam yogis performed 
+better on all the tests of attention except for the digit 
+backward test.[17]
+The above review depicts that the number of published 
+literature in the last decade on effectiveness of yoga on 
+cognitive functions of the elderly is limited. Although 
+there are no published scientific studies, authentic 
+traditional texts of yoga describe the benefits of trataka 
+on a whole range of physiological and cognitive 
+functions.[18,19] It is observed to be most effective on the 
+ajna chakra[20] (the vortice of vital energy in the forehead) 
+and the brain.[21] Ajna chakra is described as the “eye 
+of knowledge”, and it is said that with the activation of 
+this chakra, the intelligence, concentration, and memory 
+improve and the mind becomes strong and steady.[22] It 
+is proposed that the practice of Trataka may activate 
+this chakra,[23] and thus may improve attention, memory, 
+and concentration.[24,25] In the above context, the aim of 
+this study was to test the effect of trataka on cognitive 
+functions of the elderly. Effect of trataka was studied 
+as against wait list control group; in improving short 
+term memory, attention, concentration, and executive 
+functions.
+MATERIALS AND METHODS
+Participants were recruited from old age homes in Goa and 
+from individuals staying in and around Ponda and Margao 
+areas in Goa. The approval from Institutional Ethics 
+Committee of Swami Vivekananda Yoga Anusandhana 
+Samasthana (SVYASA) was obtained.
+A total of 136 subjects were screened usinginclusion and 
+exclusion criteria. Those who were 60-80 years of age 
+and had minimum of fifth grade education were included 
+in the study. Further those subjects who had  (a) Any 
+neurological disorder,  (b) any psychiatric disorder, 
+and (c) had received yoga training in last 3 months were 
+excluded from the study. The above exclusion criteria 
+and abnormality in hearing and vision were examined 
+by a trained and qualified clinician. Based on this 
+screening procedure, 75 subjects were found suitable 
+for the study. As 15 of them declined to give consent to 
+participate, the remaining 60 subjects were considered 
+for the study and written informed consent was taken 
+from them.
+The sample size calculation estimated that 27 participants 
+in each group was required to detect a clinically significant 
+difference equivalent to an effect size of 0.75 (Cohen’s d) 
+in total memory score between the groups. A sample of 
+27 had 80% power to detect this difference with an alpha 
+of 0.05 for a between‑groups analysis. To account for a 
+dropout of about 10%, a sample of 30 patients in each 
+group was decided. Hence, it was decided to recruit a 
+total of 60 healthy elderly sample for the study using 
+purposive sampling. The CONSORT diagram of the flow 
+of participants and the sociodemographic data of the 
+participants has been provided in Figure 1 and Table 1, 
+respectively.
+A randomized block design was used in the study where 
+subjects were divided into four blocks  (two old ages 
+homes comprising of one block each and two blocks of 
+individual elderly participants from Ponda area of Goa), 
+a sample of approximately 15 subjects comprised of one 
+block. The lottery method of manual randomization was 
+conducted due to the small number of blocks (n = 4). Two 
+blocks were randomized into trataka group (intervention 
+group) and two blocks were randomized into wait list 
+control group.
+For the intervention group, assessments were conducted 
+on day 1 before intervention, immediately after trataka 
+intervention on day 1, and after 1  month of trataka 
+intervention. In the wait list control group, data was 
+taken on day 1 before the quite sitting and after 30 min 
+of quite sitting and at the end of 1 month. The variables 
+used in this study were:  (a) Working memory  (Digit 
+Span Forward and Backward Test[26]), (b) attention and 
+concentration  (Six Letter Cancellation Test, SLCT[27]), 
+and  (c) executive functions  (Trail Making Test B, 
+TMT‑B[28]). For SLCT and TMT‑B, the standard procedure 
+for translation was used; translated and back translated 
+from Roman to Devnagiri to Roman. The tests were 
+translated into Devnagiri for the ease of application of the 
+tests to the local population in Goa. The Digit Span (DS) 
+is a subtest in Wechsler Adult Intelligence Scale‑third 
+edition (WAIS‑III)[29] and has been standardized for use 
+in an Indian population. The SLCT which measures 
+cognitive functions such as selective and focused 
+attention, concentration, visual scanning as well as 
+activation and inhibition of rapid responses has been 
+employed to assess cognitive impairments in alcoholic 
+Table  1: Socio‑demographic details of the subjects 
+(n=55)
+Variable
+Mean  (SD)/n  (%)
+t value/
+chi‑square
+P value
+Trataka 
+(n=31)
+Control 
+(n=24)
+Age (years)
+67.7 (7.4) 71.2 (6.6)
+−1.83
+0.07
+Educational status (years) 11.8 (3.6) 11.6 (3.8)
+0.15
+0.88
+Gender
+Male
+8 (25.8)
+9 (37.5)
+0.87
+0.35
+Female
+23 (74.2)
+15 (62.5)
+SD = Standard deviation
+Talwadkar, et al.: Trataka for cognitive functions
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+98
+cirrhotic patients,[30] and to evaluate target detection 
+deficits in patients who have undergone frontal 
+lobectomy surgery.[31] This test has also been evaluated 
+for its reliability and validity based on standard criteria 
+and has standard norms for the Indian population. TMT‑B 
+is one of the most popular neuropsychological tests and 
+is included in most test batteries, is a measure of visual 
+scanning, complex attention, psychomotor speed mental 
+flexibility, and executive functions. The TMT is sensitive 
+to a variety of neurological impairments.[32,33] Adequate 
+test‑retest reliability has been found for both Part A and 
+Part B of the TMT in the healthy control group (r = 0.46 
+and 0.44, respectively), as calculated using Pearson’s 
+correlation coefficients.[34]
+The intervention of trataka included set of procedures 
+including eye exercises and gazing at the candle 
+flame with focused attention followed by defocussing. 
+Breathing and chanting were also included in the practice 
+that promotes internal awareness and focusing on the 
+Figure 1: The CONSORT (consolidated standards of reporting trials, Altman et al., 2001) diagram of flow of participants through each stage of the randomized trial 
+activity followed by defocusing. Each session was of 
+30 min duration [Table 2]. Classes were conducted on 
+everyday basis, except for Sundays and attendance was 
+also recorded. Data of only those participants who had 
+completed a minimum of 75% and above class attendance 
+was analyzed.
+The data at baseline was assessed for normality using 
+Shapiro‑Wilk test. As the data was found to be normal 
+for TMT‑B (trataka, statistics = 0.931, P = 0.05; control, 
+statistics = 0.929, P = 0.09) and SLCT (trataka = 0.957, 
+P = 0.24; control statistics = 0.946, P = 0.22) parametric 
+tests such as paired sample t‑tests, independent sample 
+t‑test, and Repeated measure analysis of variance (RM 
+ANOVA) were used to analyze the data. In case of the 
+Digit Span Test, the data was not found to be normally 
+distributed (trataka statistics = 0.845, P = 0.00; control 
+statistics = 0.931, P = 0.72). There were no outliers in 
+the data; however the data had distinct two peaks at the 
+higher and lower range of scores. If we had divided the 
+Talwadkar, et al.: Trataka for cognitive functions
+99
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+digit span scores using the median values into two groups, 
+we could have possibly got two independent normal 
+distributions. However, as we did not have any rationale 
+for dividing the group based on the median values, 
+nonparametric tests such as Mann‑Whitney, Wilcoxon 
+signed rank test, and Friedman’s test were used to analyze 
+the Digit Span Test scores. Bonferroni adjustment was 
+conducted as there were multiple comparisons to analyze 
+the time effect.
+RESULTS
+Out of the 60 subjects, 55 subjects completed the first 
+follow‑up on day 1  (postintervention). However, only 
+48 subjects completed the second follow‑up, which was 
+conducted at the end of 1 month (trataka group n = 26, 
+wait list control n = 22).
+There were no group differences at baseline in all three 
+outcome variables. Both the groups were comparable at 
+baseline, on all outcome variables. On Mann‑Whitney 
+tests, there was no significant difference between trataka 
+and wait list control group in Digit Span Test scores at 
+the first follow‑up. When compared to wait list control 
+group at the second follow‑up a possible trend towards 
+significance could be observed in the trataka group. When 
+compared within group (Friedman’s test and Wilcoxon 
+signed rank test), digit span scores improved at the first 
+follow‑up in trataka group, but the difference was not 
+significant. At the second follow‑up, there was significant 
+improvement in digit span scores (z = −3.35, P < 0.01). 
+While in control group, scores decreased at the first and 
+the second follow‑up, but there were no any significant 
+changes [Figure 2].
+When compared between groups (independent sample 
+t‑test), there was no significant difference between the 
+trataka and wait list control group at first and second 
+follow‑up in SLCT scores. However, with respect to 
+time effect  (paired sample t‑test), selective as well as 
+sustained attention and concentration (measured using 
+SLCT scores) was seen to improve immediately after 
+the practice of trataka (when baseline compared to first 
+follow‑up) (t = 5.08, P < 0.01). Wait list control group 
+also performed better (may be because of retest effect), 
+but the improvement was not significant. At 1 month 
+follow‑up, trataka group showed significantly better 
+performance in the SLCT test compared to baseline 
+(t = −3.93, P < 0.01). Whereas, scores of wait list control 
+group came back to the baseline scores at the second 
+follow‑up.
+On the independent sample t‑test, at the first follow‑up, 
+there was no significant difference in TMT‑B scores 
+between trataka and wait list control group. However at the 
+second follow‑up, there was a trend towards significance. 
+Trataka group performed significantly better at the first 
+follow‑up (paired sample t‑test) (t = −4.26, P < 0.01) 
+in TMT B test  (indicative of executive functions). In 
+contrast, in the wait list control group there was increase 
+in time taken to complete the task (suggestive of poor 
+performance) and the change was not significant. At the 
+second follow‑up, only trataka group showed significantly 
+improved (statistics = 7.09, P = 0.00) performance when 
+compared to the baseline scores.
+The traditional analysis that is used to detect treatment 
+outcomes in randomized longitudinal clinical trials was 
+used; RM ANOVA. RM ANOVA results showed that 
+the executive functions in both the groups improved 
+over time  (occasion effect). Though there was no 
+significant group effect, trataka group showed significant 
+improvement in TMT‑B scores over a month period 
+of the study as compared to the wait list control 
+group (f = 6.67, P < 0.01; interaction effect) [Table 3]. 
+Table  2: Details of trataka practice
+Name of the practice
+Duration
+Starting prayer
+1 min
+Preparatory eye exercises
+9 mins
+Up and down or vertical movements‑10 rounds
+30 secs
+Simple palming
+1 min
+Right and left or horizontal movements‑10 rounds
+30 secs
+Simple palming
+1 min
+Diagonal movements‑right up‑left down‑10 rounds
+30 secs
+Press and release palming
+1 min
+Diagonal movements‑left up‑right down‑10 rounds
+30 secs
+Press and release palming
+1 min
+Rotational movements‑clockwise‑10 rounds
+30 secs
+Constant pressure palming
+1 min
+Rotational movements‑anticlockwise‑10 rounds
+30 secs
+Constant pressure palming
+1 min
+Jyoti trataka
+Effortless gazing or focusing
+4 mins
+‘A’kara chanting
+1 min
+Intensive focusing
+4 mins
+‘U’kara chanting
+1 min
+Break
+1 min
+De‑focussing
+4 mins
+Bhramari
+1 min
+Silence
+4 mins
+Closing prayer
+1 min
+Figure 2: Changes in median digit span scores across timeline in trataka and 
+wait list control group (Friedman’s test)
+
+
+
+
+
+%DVHOLQH
+VWIROORZXS
+QGIROORZXS
+'LJLWVSDQWHVW
+7UDWDND*URXS
+&RQWURO*URXS
+Talwadkar, et al.: Trataka for cognitive functions
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+100
+With respect to SLCT scores, there was a trend towards 
+better improvement (f = 3.11, P = 0.05) in trataka group as 
+compared to the wait list control group over the 1 month 
+period of the study (interaction effect) [Table 3].
+For the convenience of conducting intervention, half 
+of the subjects in the trataka group were provided the 
+intervention in the morning and the remaining half 
+were provided the intervention in the evening. Baseline 
+analysis showed that there were significant differences 
+in TMT‑B and SLCT scores between the morning group 
+and the evening group, with scores higher in the evening 
+group than morning group. Hence, post hoc test was 
+conducted to check if there was any significant interaction 
+effect (group X time) after controlling for baseline scores 
+using analysis of covariance (ANCOVA). Results show that 
+there was no significant difference between groups (people 
+who practiced in the morning as compared to people 
+who practiced in the evening) over the study period after 
+controlling for baseline differences.
+DISCUSSION
+In this study on elderly subjects, trataka intervention 
+improved cognitive functions  (short‑term memory 
+and working memory, selective and focused attention, 
+concentration, visual scanning as well as activation and 
+inhibition of rapid responses and executive functions) 
+when compared to wait list control group at the end of 
+1 month. Trataka practice involves various steps like 
+preparatory eye exercises, focusing, defocusing, chanting, 
+and silence during relaxation. Each component or all 
+of them together could have been responsible for the 
+improvement in the cognitive functions. Preparatory 
+eye exercises improve the stamina of the eye muscles 
+and avoid eye strain. The degree of optical illusion is 
+observed to reduce post a set of yoga practices that includes 
+trataka (involving both focusing and defocusing of the 
+gaze and attention).[35] Dharana or focusing improves 
+concentrative attention  (“desha‑bandhashchittasya 
+dharanam”; Patanjali’s Yoga Sutras, Chapter III, Verse 1).[36] 
+Focused attention (FA) is the attention which is restricted 
+to a specific focus[37] such as the breath or the candle 
+flame (trataka). Receptive attention is a kind of attention 
+which is “objectless” and the goal is simply to keep attention 
+fully “readied” in the present moment of experience 
+without orienting, directing, or limiting it in any way. 
+Research studies have shown that intense FA meditation 
+effects cortical engagement, as reflected by a concomitant 
+reduction in event related desynchronization  (ERD) 
+to target tones in the beta (13-30 Hz) frequency band. 
+Reductions in beta ERD after practice of external tasks is 
+due to the decreased cognitive efforts.[38] There is enhanced 
+processing of task‑related auditory inputs during FA 
+meditation. FA meditation training is thought to improve 
+one’s ability to remain vigilant and monitor distractors 
+without losing focus. It is proposed that these mental 
+training‑related effects might be produced by a reduction 
+in cortical noise and/or by an enhancement of the rhythmic 
+mode of attention.
+The second stage of trataka, the phase of defocussing is 
+akin to the stage of dhyana effortless attention (“tatra 
+pratyayaikatanata dhyanam”; Patanjali’s Yoga Sutras, 
+Chapter III, Verse 2).[39] When dharana becomes effortless, 
+it takes the form of dhyana, which is defined as the 
+uninterrupted spontaneous flow of the mind toward the 
+chosen object. Vigilance and attention are not required 
+during dhyana, which is the actual phase of meditation.[40] 
+Though there are different forms of meditation all of them 
+lead to calm yet alert mind.[41] At a more advanced level 
+of training in FA meditation which could be considered 
+a state of dhyana, the regulative attention skills are 
+invoked less frequently, and the ability to sustain focus 
+thus becomes progressively “effortless”.[38] Dhyana 
+is associated with reduced sympathetic activity and 
+increased vagal tone.[42] The defocussed phase of trataka 
+could be similar to the benefits of dhyana phase of 
+meditation. Multiple studies show that meditation may 
+affect multiple pathways that could play a role in brain 
+aging and mental fitness.[13] For example, meditation may 
+reduce stress‑induced cortisol secretion and this could 
+have neuroprotective effects potentially via elevating 
+levels of brain derived neurotrophic factor  (BDNF). 
+Meditation processes are linked to gamma‑aminobutyric 
+acid  (GABA) ergic cortical inhibition, a mechanism 
+implicated in improved cognitive performance and 
+enhanced emotional regulation.[43] Further, meditation 
+may potentially strengthen neuronal circuits and enhance 
+cognitive reserve capacity. Brain regions associated with 
+attention, interception, and sensory processing are thicker 
+in meditation practitioners including the PFC and right 
+anterior insula.[44] Advanced meditators have higher 
+melatonin levels (that blocks the build‑up of beta‑amyloid 
+plaque, a hallmark feature of Alzheimer’s disease)[45] than 
+nonmeditators.[46]
+The results suggest that long‑term practice of trataka and 
+not just 1 day practice is required to improve short‑term 
+Table  3: RMANOVA for TMT‑B and SLCT scores
+Variable
+Mean (SD)
+F
+P value
+Baseline
+1st follow up
+2nd follow up
+TMT B
+Trataka 170.58 (92.43) 151.45 (88.0) 111.27 (71.63) 6.67
+0.003
+Control 187.96 (79.77) 191.70 (91.98) 151.76 (80.67)
+SLCT
+Trataka 23.88 (10.07)
+31.48 (14.68)
+31.04 (13.31) 3.11
+0.05
+Control 24.96 (12.71)
+29.33 (14.61)
+26.23 (13.53)
+TMT-B = Trail making test‑B; SLCT = Six letter cancellation test; SD = Standard 
+deviation
+Talwadkar, et al.: Trataka for cognitive functions
+101
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+memory. Similar study done on elderly subjects showed 
+that, at the 3  month follow‑up, yoga group improved 
+in semantic memory, short‑term primary memory, and 
+short‑term working memory.[47] So, the result of our study 
+is consistent with the results of earlier study. The only 
+difference is that our study period was only of 1 month; 
+still we could show significant improvement in the trataka 
+group. Thus, we can make a statement from our results 
+that first time yoga participants, if provided with 1 month 
+trataka intervention, can improve their executive, memory, 
+and cognitive functioning. This claim however needs to 
+be tested in larger samples.
+In a study done on the healthy aging adults, it was seen 
+that performance on a simple attention task improved after 
+5‑week relaxation response training program; whereas, no 
+improvement was seen in complex tasks of attention.[16] 
+In another study, net scores on the six‑letter cancellation 
+task were significantly higher after a session of Dharana.[48] 
+These results are in consistence with our results, as we 
+also observed increased SLCT scores immediately after 
+Trataka practice. Since Trataka is a type of dharana practice 
+that involves focused attention on a specified object, this 
+further strengthens that the results are valid and obtained 
+correctly.
+There could be various other possible reasons for finding 
+differences over the 1 month period. The group was at a 
+stage when cognitive decline was a reality. All the aging 
+individuals  (after the age of 60  years) develop some 
+degree of decline in cognitive capacity as time progresses. 
+Studies show that 16.8% of aged people have some form 
+of cognitive decline without the symptoms of dementia.[49] 
+If the study was done on healthy young subjects, then we 
+might not have got the significant difference, because of 
+‘ceiling effect’.
+Another reason for the significant result could be that 
+majority of the participants of the study had never been 
+exposed to trataka or any yoga intervention earlier. A few 
+of the participants, who had earlier learnt yoga, had either 
+discontinued or had not practiced it for the past 3 months. 
+In such a case, we believe that the effect of trataka was 
+pronounced as there was no previous or past effect of any 
+similar intervention.
+The fact that we got significant results to show that trataka 
+practice for 1 month is effective in improving cognitive 
+functions shows that the scales used in this study were 
+sensitive enough to tap the cognitive improvement in the 
+elderly after the trataka intervention. Three tests used in 
+this study were Digit Span Test, TMT‑B, and SLCT. Though 
+not developed specifically to test the effect of trataka, these 
+widely used tests have shown that they can tap significant 
+changes post yoga intervention.
+Studies have time and again discussed the importance 
+of the prolonged practice of yoga.[50‑52] We assessed the 
+cognitive functions immediately after one session of 
+trataka and after 1 month of continuous daily practice. The 
+results pronounced that there was no significant difference 
+between groups at the end of one session (first follow‑up); 
+however, significant group and time differences including 
+interaction effects were observed at the end of 1 month 
+of intervention. Hence, we believe that our study results 
+validate earlier quoted studies which advocate prolonged 
+duration (number of days) of practice of yoga/trataka for 
+desirable effects.
+The design of the study, that is, randomized block 
+design (RBD) was the main strength of the study. RBD 
+eliminates any bias in treatment assignment, specifically 
+selection bias and confounding. It maximizes statistical 
+power, especially in subgroup analyses. Another strength 
+of the study was that the intervention was provided 
+to the sample that needed the intervention, aging 
+individuals (after the age of 60), as they often develop 
+some degree of decline in cognitive capacity.
+In spite of its strong methodology, the results of the 
+study need to be understood in the context that the 
+sampling was done only in two old age homes in Goa. 
+Further the sample size was small. The total sample size 
+was 60 based on earlier sample size calculations and 
+post attrition, the sample size for analysis was reduced 
+to 48. The results of the current study showed that 
+there was a trend towards significance in the trataka 
+group in the between group analysis  (group effect) 
+for some outcome variables. In this context, a larger 
+sample size could have depicted significant differences 
+between groups. Also, only three outcome variables 
+were used in the study. Age‑related cognitive decline 
+can be seen in different cognitive domains (e.g. speed 
+of processing, spatial ability, reasoning, etc.) and 
+varies individually. Further studies can be conducted 
+to test the effect of trataka on different neurological test 
+batteries.
+CONCLUSION
+The results of this study establish that trataka can be 
+used as a technique to enhance cognition in the elderly. 
+The trataka intervention is easy to learn, implement, and 
+adhere. Further trataka, after the initial few sessions, can 
+be practiced independently by the participant to achieve 
+desired results. For researchers, this study could provide 
+a substantial base for conducting future trials to test the 
+efficacy of trataka in controlled experiments.
+REFERENCES
+1.	
+Squire LR. Memory and Brain. New York: Oxford Univ Pr; AQ7 1987.
+Talwadkar, et al.: Trataka for cognitive functions
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+102
+2.	
+Schacter DL. Stories of Elders, Searching for Memory: The Brain, the Mind, 
+and the Past. New York: Basic Books; 1997. p. 280‑AQ9 308.
+3.	
+Hughes TF. Promotion of cognitive health through cognitive activity in the 
+aging population. Aging Health 2010;6:111‑21.
+4.	
+Smith EE, Jonides J. Storage and executive processes in the frontal lobes. 
+Science 1999;283:1657‑61.
+5.	
+Gray JR, Braver TS, Raichle ME. Integration of emotion and cognition in 
+the lateral prefrontal cortex. Proc Natl Acad Sci USA 2002;99:4115‑20.
+6.	
+Miyake A, Friedman NP, Emerson MJ, Witzki AH, Howerter A, Wager TD. 
+The unity and diversity of executive functions and their contributions to 
+complex “Frontal lobe” tasks: A latent variable analysis. Cogn Psychol 
+2000;41:49‑100.
+7.	
+West RL. An application of prefrontal cortex function theory to cognitive 
+aging. Psychol Bull 1996;120:272‑92.
+8.	
+Panza F, Frisardi V, Capurso C, D’Introno A, Colacicco AM, Chiloiro R, 
+et al. Effect of donepezil on the continuum of depressive symptoms, mild 
+cognitive impairment, and progression to dementia. J Am Geriatr Soc 
+2010;58:389‑90.
+9.	
+Simon SS, Yokomizo JE, Bottino CM. Cognitive intervention in amnestic 
+Mild Cognitive Impairment: A systematic review. Neurosci Biobehav Rev 
+2012;36:1163‑78.
+10.	 Roberts RO, Geda YE, Cerhan JR, Knopman DS, Cha RH, Christianson TJ, 
+et al. Vegetables, unsaturated fats, moderate alcohol intake, and mild cognitive 
+impairment. Dement Geriatr Cogn Disord 2010;29:413‑23.
+11.	
+Wilson RS, Barnes LL, Aggarwal NT, Boyle PA, Hebert LE, Mendes de 
+Leon CF, et al. Cognitive activity and the cognitive morbidity of Alzheimer 
+disease. Neurology 2010;75:990‑6.
+12.	 Abou‑Dest A, Albinet CT, Boucard G, Audiffren M. Swimming as a positive 
+moderator of cognitive aging: A cross‑sectional study with a multitask 
+approach. J Aging Res 2012;2012:273185.
+13.	 Xiong GL, Doraiswamy PM. Does meditation enhance cognition and brain 
+plasticity? Ann N Y Acad Sci 2009;1172:63‑9.
+14.	 Chattha R, Nagarathna R, Padmalatha V, Nagendra HR. Effect of yoga on 
+cognitive functions in climacteric syndrome: A randomized control study. 
+BJOG 2008;115:991‑1000.
+15.	 Prakash R, Dubey I, Abhishek P, Gupta SK, Rastogi P, Siddiqui SV. Long‑term 
+Vihangam Yoga meditation and scores on tests of attention. Percept Mot Skills 
+2010;110:1139‑48.
+16.	 Galvin JA, Benson H, Deckro GR, Fricchione GL, Dusek JA. The relaxation 
+response: Reducing stress and improving cognition in healthy aging adults. 
+Complement Ther Clin Pract 2006;12:186‑91.
+17.	 Prakash R, Rastogi P, Dubey I, Abhishek P, Chaudhury S, Small BJ. Long‑term 
+concentrative meditation and cognitive performance among older adults. 
+Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 2012;19:479‑94.
+18.	 Niranjanananda SS, Gheranda S. Commentary on the Yoga Teachings of 
+Maharshri Gheranda. Yoga Publications Trust: Munger, India, 2012.
+19.	 Muktibodhananda S, Saraswati SS. Hatha Yoga Pradipika. Yoga Publications 
+Trust: Munger; 2000.
+20.	 Gharote ML, Parimal D, Jha VK. Hatharatnavali‑a treatise on hathayoga. 
+Lonavala: The Lonavla Yoga Institute; 2002.
+21.	 Niranjanananda SS. Dharana darshan‑yogic, Tantric and Upanishadic 
+Practices of Concentration and Visualizations. 2nd ed. Munger, Bihar: Yoga 
+Publications Trust; 2003.
+22.	 Redmond L. Chakra meditation: Tranformation Through the Seven Energy 
+Centres of the Body. Canada: Sounds True; 2010.
+23.	 Niranjanananda SS. Yoga Darshan‑vision of the Yoga Upanishads. Munger: 
+Yoga Publications trust; 2002.
+24.	 Nagendra HR, Nagrathana R. Promotion of Positive Health. Bangalore: Swami 
+Vivekananda Yoga Prakashana; 2001.
+25.	
+Niranjanananda SS. Dharana darshan‑yogic, Tantric and Upanishadic Practices of 
+Concentration and Visualizations. 2nd ed. Munger: Yoga Publications Trust; 2003.
+26.	 Wechsler DA. Wechsler Adult Intelligence Scale‑third edition. San Antonio: 
+The Psychological Corporation; 1997.
+27.	 Diller L, Ben YY, Gerstman LJ, Goodin R, Gordon W, Weinberg J. 
+Studies in scanning behavior in hemiplegia. Rehabilitation Monograph 
+No. 50, Studies in cognition and rehabilitation in hemiplegia. New York: 
+New York University Medical Center, Institute of Rehabilitation 
+Medicine; 1974.
+28.	 Reitan RM, Wolfson D. The Halstead–ReitanNeuropsycholgical Test 
+Battery: Therapy and Clinical Interpretation. Tucson: Neuropsychological 
+Press; 1985.
+29.	 Wechsler DA. Wechsler Adult Intelligence Scale. 3rd ed. San Antonio: The 
+Psychological Corporation; 1997.
+30.	 Kapczinski F, Curran HV, Przemioslo R, Williams R, Fluck E, Fernandes C, et al. 
+Cognitive impairments of alcoholic cirrhotic patients: Correlation with 
+endogenous benzodiazepine receptor ligands and increased affinity of platelet 
+receptors. J Neurol Neurosurg Psychiatry 1996;60:676‑80.
+31.	 Richer F, Decary A, Lapierre MF, Rouleau I, Bouvier G, Saint‑Hilaire JM. 
+Target detection deficits in frontal lobectomy. Brain Cogn 1993;21:203‑11.
+32.	 Lezak MD. Neuropsychological Assessment. 3rd ed. New York: Oxford 
+University Press; 1995.
+33.	 Spreen O, Strauss E. A  Compendium of Neuropsychological Tests: 
+Administration, Norms and Commentary. 2nd ed. New York: Oxford University 
+Press; 1998.
+34.	 Matarazzo JD, Wiens AN, Matarazzo RG, Goldstein SG. Psychometric and 
+clinical test‑retest reliability of the Halstead impairment index in a sample 
+of healthy, young, normal men. J Nerv Ment Dis 1974;188:37‑49.
+35.	 Telles S, Nagarathna R, Vani PR, Nagendra HR. A combination of focusing 
+and defocusing through yoga reduces optical illusion more than focusing 
+alone. Indian J Physiol Pharmacol 1997;41:179‑82.
+36.	 Taimini IK. The Science of Yoga. Madras: The Theosophical Publishing 
+House; 2005. p. 275‑8.
+37.	 Jha AP, Krompinger J, Baime MJ. Mindfulness training modifies subsystems 
+of attention. Cogn Affect Behav Neurosci 2007;7:109‑19.
+38.	 Lutz A, Slagter HA, Rawlings NB, Francis AD, Greischar LL, Davidson RJ. 
+Mental training enhances attentional stability: Neural and behavioral evidence. 
+J Neurosci 2009;29:13418‑27.
+39.	 Taimini IK. The science of yoga. Madras: The Theosophical Publishing 
+House; 2005. p. 278‑80.
+40.	 Telles S, Naveen KV, Balkrishna A. Meditation and attention: A comment on 
+a recent article. Percept Mot Skills 2010;111:918‑20.
+41.	 Telles S, Raghavendra BR, Naveen KV, Manjunath NK, Kumar S, 
+Subramanya P. Changes in autonomic variables following two meditative 
+states described in yoga texts. J Altern Complement Med 2013;19:35‑42.
+42.	 Telles S and Bhat RR Neurophysiological Changes in Meditation Correlated 
+with Descriptions from the Ancient Texts. 2011. p. 56-9.
+43.	 Guglietti CL, Daskalakis ZJ, Radhu N, Fitzgerald PB, Ritvo P. 
+Meditation‑related increases in GABAB modulated cortical inhibition. 
+Brain Stimul 2013;6:397‑402.
+44.	 Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. 
+Meditation experience is associated with increased cortical thickness. 
+Neuroreport 2005;16:1893‑7.
+45.	 Feng Z, Zhang JT. Protective effect of melatonin on beta‑amyloid‑induced 
+apoptosis in rat astroglioma c6 cells and its mechanism. Free Radic Biol Med 
+2004;37:1790‑801.
+46.	 Solberg EE, Holen A, Ekeberg O, Osterud B, Halvorsen R, Sandvik L. The 
+effects of long meditation on plasma melatonin and blood serotonin. Med 
+Sci Monit 2004;10:CR96‑101.
+47.	 Manjunath NK. Yoga and geriatric care: An evaluation of positive health 
+indicators. Phd Thesis submitted to Swami Vivekananda Yoga Anusandhana 
+Samasthana (SVYASA), Bangalore, India; 2005.
+48.	 Kumar S, Telles S. Meditative states based on yoga texts and their 
+effects on performance of a letter‑cancellation task. Percept Mot Skills 
+2009;109:679‑89.
+49.	 Graham JE, Rockwood K, Beattie BL, Eastwood R, Gauthier S, 
+Tuokko H, et al. Prevalence and severity of cognitive impairment with and 
+Talwadkar, et al.: Trataka for cognitive functions
+103
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+How to cite this article: Talwadkar S, Jagannathan A, Raghuram N. 
+Effect of trataka on cognitive functions in the elderly. Int J Yoga 
+2014;7:96-103.
+Source of Support: Study conducted as part of the MD degree in 
+‘Yoga and Rehabilitation, at SVYASA University, Bengaluru, Conflict of 
+Interest: None declared
+without dementia in an elderly population. Lancet 1997;349:1793‑6.
+50.	 Chaya MS, Kurpad AV, Nagendra HR, Nagaratna R. The effect of long term 
+combined yoga practice on the basal metabolic rate of healthy adults. BMC 
+Complement Altern Med 2006;6:28.
+51.	 Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN. Yoga therapy 
+as an add‑on treatment in the management of patients with schizophrenia:A 
+randomized controlled trial. Acta Psychiatr Scand 2007;116:226‑32.
+52.	 Gangadhar BN, Nagendra HR, Thirthalli J, Subbakrishna DK, Muralidhar D, 
+Varambally S, et al. Efficacy of Yoga as an Add‑on Treatment in Schizophrenia. 
+Project report submitted under Scheme for Extra Mural Research (EMR) to 
+Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH), 
+New Delhi; 2010.

subfolder_0/Effect of Yoga Based Lifestyle Intervention on Patients with Knee Osteoarthritis A Randomized Controlled Trial.txt

@@ -0,0 +1,1082 @@
+ORIGINAL RESEARCH
+published: 08 May 2018
+doi: 10.3389/fpsyt.2018.00180
+Frontiers in Psychiatry | www.frontiersin.org
+1
+May 2018 | Volume 9 | Article 180
+Edited by:
+Mardi A. Crane-Godreau,
+Department of Microbiology &
+Immunology, Geisel School of
+Medicine at Dartmouth, United States
+Reviewed by:
+Alejandro Magallares,
+Universidad Nacional de Educación a
+Distancia (UNED), Spain
+Karin Meissner,
+Ludwig-Maximilians-Universität
+München, Germany
+*Correspondence:
+Singh Deepeshwar
+[email protected]
+Specialty section:
+This article was submitted to
+Psychosomatic Medicine,
+a section of the journal
+Frontiers in Psychiatry
+Received: 21 February 2018
+Accepted: 18 April 2018
+Published: 08 May 2018
+Citation:
+Deepeshwar S, Tanwar M, Kavuri V
+and Budhi RB (2018) Effect of Yoga
+Based Lifestyle Intervention on
+Patients With Knee Osteoarthritis: A
+Randomized Controlled Trial.
+Front. Psychiatry 9:180.
+doi: 10.3389/fpsyt.2018.00180
+Effect of Yoga Based Lifestyle
+Intervention on Patients With Knee
+Osteoarthritis: A Randomized
+Controlled Trial
+Singh Deepeshwar*, Monika Tanwar, Vijaya Kavuri and Rana B. Budhi
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India
+Objective:
+To investigate the effect of integrated approach of yoga therapy (IAYT)
+intervention in individual with knee Osteoarthritis.
+Design: Randomized controlled clincial trail.
+Participants: Sixty-six individual prediagnosed with knee osteoarthritis aged between
+30 and 75 years were randomized into two groups, i.e., Yoga (n = 31) and Control (n
+= 35). Yoga group received IAYT intervention for 1 week at yoga center of S-VYASA
+whereas Control group maintained their normal lifestyle.
+Outcome measures: The Falls Efficacy Scale (FES), Handgrip Strength test (left hand
+LHGS and right hand RHGS), Timed Up and Go Test (TUG), Sit-to-Stand (STS), and right
+& left extension and flexion were measured on day 1 and day 7.
+Results: There were a significant reduction in TUG (p < 0.001), Right (p < 0.001), and
+Left Flexion (p < 0.001) whereas significant improvements in LHGS (p < 0.01), and right
+extension (p < 0.05) & left extension (p < 0.001) from baseline in Yoga group.
+Conclusion:
+IAYT practice showed an improvement in TUG, STS, HGS, and
+Goniometer test, which suggest improved muscular strength, flexibility, and functional
+mobility.
+CTRI
+Registration
+Number:
+http://ctri.nic.in/Clinicaltrials,
+identifier
+CTRI/2017/10/
+010141.
+Keywords: knee osteoarthritis, integrative approach of yoga therapy (IAYT), handgrip strength (HGS), goniometer,
+falls efficacy scale (FES)
+INTRODUCTION
+Osteoarthritis (OA) is the most common form of arthritis and leading cause of disability and loss of
+functions in the elderly population. It can affect any joints, but the knee is one of the most affected
+parts of the body in humans. There are several risk factors for OA such as obesity, smoking, intra-
+articular fractures, chondrocalcinosis, crystals in joint fluid/cartilage, female gender, prolonged
+immobilization, joint hypermobility, instability, peripheral neuropathy, prolonged occupational,
+or sports stress (1). The prevalence of knee osteoarthritis increases with age (2). Approximately
+41.1% of males and 56.5% of females suffer from OA (3). Over 40% of adults between 50 and 75
+years are affected with knee OA worldwide (4). The prevalence of knee OA in India is estimated to
+be 28.7% (5). A total of 11 COPCORD (Community Oriented Program for Control of Rheumatic
+Disorders) reports of knee OA data showed differences between rural (3.3%) and urban (5.5%)
+population of India (6, 7).
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+Symptoms of OA present as pain in and around the joints,
+morning stiffness, restricted joint movements associated with
+muscle weakness. Knee OA is associated with disrupted sleep,
+depression, increased sedentary behavior, less physical activity,
+obesity and decreased the quality of life (8). Bilateral knee
+osteoarthritis impaired the balance and increased the risk of fall,
+particularly in people with moderate knee osteoarthritis (9).
+Non-pharmacological
+interventions
+such
+as
+exercise,
+Yoga, integrated approach of yoga therapy (IAYT), Tai-Chi,
+physiotherapy, acupressure, naturopathy, and massage therapy
+showed improvements in quality of life along with a reduction
+in pain, improved physical functions, psychological balance in
+patients with knee OA (10–14). These non-pharmacological
+rehabilitation interventions have focused mainly on practices
+for Knee OA that produces only small to moderate benefits
+with the limited durability of effects on the symptoms of knee
+OA (15). These interventions provided substantial benefits, but
+are underutilized, and the efficacy and safety remain poorly
+defined. In few earlier studies, yoga showed promising changes
+in reducing pain, morning stiffness, and increased flexibility,
+muscular strength and overall quality of life in knee OA patients
+(16–19).
+Yoga, a mind-body intervention, originated in India. Different
+schools of yoga (such as Iyengar yoga, IAYT, hatha yoga, etc.)
+developed a therapeutical intervention for knee OA. A pilot study
+was conducted on nine participants, using modified Iyengar
+yoga postures (90-min classes once in a week for 8 weeks) as a
+treatment modality and showed potential reductions in pain and
+disability caused by knee OA (20). Few other studies compared
+yoga therapy with different interventions such as traditional
+stretching and strengthening exercises or no structured group
+exercise for 6 weeks and showed functional changes and
+improvement in the quality of life in traditional practice
+and yoga-based approach (21). Ebnezar et al. investigated
+transcutaneous electrical stimulation and ultrasound treatment
+followed by IAYT intervention (40 min) and reported that IAYT
+is better than physiotherapy exercises for reducing pain, morning
+stiffness, state and trait anxiety, blood pressure and pulse rate in
+OA patients (18). This study was limited to numerical pain scale
+and state and trait anxiety (STAI 1&2). Meta-analyses of yoga for
+musculoskeletal problems suggest that yoga is helpful for chronic
+pain and low back problems in older women population (16).
+Studies on aerobic exercises including physical activities, yoga,
+and Tai Chi, have long been a rehabilitation intervention for
+treating patients with OA in decreasing pain, joint tenderness and
+improving functional status (22). Most of these studies indicate
+the long-term effect of yoga on symptoms of OA. There are
+very few studies reporting the immediate impact of yoga on
+patients with knee OA and self-efficacy. Also, limited data are
+available to support the efficacy of IAYT intervention for OA
+management. Few studies have methodological issues related to
+their design such as small sample size, wide-ranging age group
+due to unavailability of similar age group participants, whereas
+other studies have a long-term intervention, high attrition rate,
+etc.
+Hence, the present study intended to investigate the
+immediate effect of 1-week integrated approach of yoga therapy
+(IAYT) intervention in older adults with knee OA. We
+hypothesized that a brief intervention of yoga practice may have
+a positive effect on, (i) Falls Efficacy Scale (FES), (ii) handgrip
+strength (HGS), (iii) Timed up and Test (TUG), (iv) Sit to Stand
+(STS), and (v) knee extension and flexion.
+MATERIALS AND METHODS
+Participants
+A total of 66 participants (50 female and 16 male) aged 30–
+75 years (60.2 ± 8.2 years), were recruited from Arogyadhama,
+a home-based health center, S-VYASA, Bangalore and the
+nearby area between April 2015–July 2015. The sample size was
+calculated with G-Power software by fixing the alpha at 0.05
+powered at 0.8 and an effect size of 0.71 based on the mean and
+SD of an earlier study (18). The inclusion criteria were, patients
+suffering from knee OA for more than 3 months (diagnosed by
+a physician), fully ambulant, literate, and willing to participate
+in the study. Patients with rheumatoid arthritis, autoimmune
+diseases, malignancies, knee surgery or knee-arthroscopy, and
+knee pain caused by congenital dysplasia were excluded. The
+flow chart of study participants from enrollment to completion
+is given in Figure 1.
+Prospective participants were informed about the trial
+through media reports and advertisements in local newspapers
+and University magazine. The CONSORT Flow diagram of the
+trial is given in Figure 1 and the demographic details collected
+for all participants (age, gender, duration of OA complaints, BMI,
+education, and Occupation) are given in Table 1.
+Ethical Consideration
+The
+research
+study
+was
+approved
+by
+the
+Institutional
+Review
+Board
+(IRB)
+of
+the
+S-VYASA
+University
+(No.
+SVYASA/MSc/IRB/10/21) and conducted under the guidance
+of senior doctors and therapists of the University. All subjects
+were informed about the trial, and written informed consent was
+obtained from the participants of this study.
+Design
+Recruited participants were randomly divided into two groups,
+i.e., Yoga group with the intervention of integrative approach
+for yoga therapy (IAYT) and Control group without any form
+of yoga intervention. The study set-up was completely a yoga-
+based lifestyle where all participants in yoga group followed
+intervention of IAYT treatment for 6 days. All assessments
+and treatment plans for participants were discussed with senior
+doctor and therapist. All participants in both groups continued
+their medication as per the requirements. It was not possible
+to mask the yoga intervention from the subjects. However, the
+investigators who collected primary and secondary outcomes
+were blind to the intervention (23).
+Intervention
+Integrated Approach of Yoga Therapy (IAYT)
+IAYT module for arthritis was developed using a holistic
+approach to health management at physical, mental, emotional,
+and intellectual levels (24). The practices were yoga postures
+Frontiers in Psychiatry | www.frontiersin.org
+2
+May 2018 | Volume 9 | Article 180
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+FIGURE 1 | CONSORT Flow diagram of study participants.
+(asana), yoga breathing (pranayama), relaxation techniques,
+meditation and lectures on yogic lifestyle, devotional sessions,
+and stress management through yogic counseling. The yogic
+practices for knee OA included simple yogic movements and
+postures that provided stretching, flexibility, strengthening weak
+muscles and relaxation of body and mind (24). Yogic breathing
+helps participants to achieve a slow rhythmic pattern of breathing
+with slowing down the breathing pattern, deep inhalation, and
+longer exhalation as the foundation (25). Cyclic meditation,
+Om meditation and devotional sessions (prayers) are part of
+meditation to control the surge of negative emotions. Lectures
+and individual yogic counseling for stress management were
+effectively focused on knee pain (26).
+Cleansing techniques (Kriyäs) were used to help clean and
+refresh the optical path, respiratory tract, and gastrointestinal
+tract. All participants practiced intense candlelight gazing
+Frontiers in Psychiatry | www.frontiersin.org
+3
+May 2018 | Volume 9 | Article 180
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+TABLE 1 | Characteristics of the study participants (n = 66).
+Participants
+Yoga (n = 31)
+Control (n = 35)
+Gender—50 Females (75%)
+Males
+6 (61.83 ± 9.1 years)
+10 (60.13 ± 8.6 years)
+Females
+25 (59.8 ± 8.2 years)
+25 (59.4 ± 9.4 years)
+Duration of pain, in years;
+mean (SD)
+2–16 years; 11.52
+(4.01)
+2–14 years; 12.31
+(5.36)
+BMI (mean; SD)
+28.15 (5.80)
+30.02 (4.15)
+Education: n (%)
+(<6 years)
+22 (71%)
+19 (54%)
+(>6 and 12 years)
+7 (22%)
+12 (34%)
+(>12 years)
+2 (7%)
+4 (11%)
+Occupation: n (%)
+Housewife
+18 (58%)
+24 (69%)
+Govt. Employee
+2 (5%)
+1 (3%)
+Private Employee
+7 (20%)
+8 (23%)
+Retired
+5 (17)
+2 (5%)
+(Tr¯
+at
+.aka), nasal cleansing with water and catheter (Jala and sutra
+neti), frontal brain cleansing breath (Kap¯
+alabh¯
+ati), vomiting with
+lukewarm saline water (Vamana dhauti), partial colon cleansing
+(Laghu´
+sankha Praksh¯
+alana) (27). These techniques were done
+everyday twice (morning and evening) during the intervention
+period of 7 days. The summarized yoga practices for knee OA are
+given in Table 2.
+Outcome Measures
+All participants were assessed for primary and secondary
+outcomes twice, at baseline (day 1) and end of study period, day 7.
+Primary Outcomes
+(i) Timed up and go Test (TUG)—TUG is an easy and low-cost
+test developed to assess the functional mobility of patients during
+everyday activities. The test comprises the following sequence of
+movements: to stand up from a standard chair, walk 3 m, turn,
+walk back to the chair and sit down again. The time taken by
+patients to complete the sequence of this movement is recorded
+and compared before and after treatment (28). The internal
+consistency (Cronbach’s alpha) was 0.74.
+(ii) Sit-to-Stand (STS)—Participants were instructed to stand
+up five times from a chair without using the support of their
+arms, as fast as possible. The test was repeated twice as this
+improved the reliability of the test, and the average time will be
+calculated in seconds (29). The correlation coefficients of intra-
+session reliability and test-retest reliability were 0.95 and 0.99,
+respectively. The convergent validity of the five-repetition sit-to-
+stand test was supported by significant correlation with a one-
+repetition maximum of the loaded sit-to-stand test, isometric
+muscle strength, scores of Gross Motor Function Measure, and
+gait function (r or rho = 0.40–0.78) (30).
+(iii) Goniometer test for flexibility and range of motion—
+Participants were seated on a chair with legs stretched in front
+called Right and Left Extension. The goniometer was placed on
+the knee and was asked to bend the leg at the knee as far as
+they could, Right and Left Flexion, and the degree of the bend
+was measured with the goniometer. The average range of motion
+(ROM) of the knee is 120–150◦(31). The data analysis revealed
+that the inter-tester reliability (r = 0.98; ICC = 0.99) and validity
+(r = 0.97–0.98; ICC = 0.98–0.99) were high (32). An overall
+mean score was calculated for each participant.
+Secondary Outcomes
+(i) Handgrip Strength Test (HGS)—Handgrip strength of both
+hands right handgrip strength (RHGS) and left handgrip strength
+(LHGS) were assessed using a handgrip dynamometer. Subjects
+were tested in 6 trials, 3 for each hand alternately, with a gap of
+10 s between trials (33).
+(ii) Falls Efficacy Scale (FES)—FES is an instrument to
+measure fear of falling, based on the operational definition of
+this fear as “low perceived self-efficacy at avoiding falls during
+essential, non-hazardous activities of daily living.” FES is a 10-
+item rating scale with test–retest reliability (r = 0.71), used to
+assess confidence in performing daily activities without falling
+(34). Each item is rated from 1 = extreme confidence, to 10 =
+no confidence at all. Participants who reported avoiding activities
+because of fear of falling had higher FES scores, representing
+lower self-efficacy or confidence than those not reporting fear of
+falling.
+Procedure
+All recruited participants were randomized in two groups,
+i.e., Yoga group (n = 31; 59.8 ± 10.21 years) and Control
+group (n = 35; 61.07 ± 9.17 years), using systematic
+sampling method. The data collected of 66 participants on
+Day 1 and Day 7 were extracted with the help of the
+therapist from rheumatology department. There were no
+dropouts in this study, and all collected data were observed
+carefully. The data were tabulated and no missing values were
+found.
+Data were obtained from participants as per the stipulated
+instructions in the manuals of questionnaires and tests.
+DATA ANALYSIS
+Statistical
+analysis
+was
+carried
+out
+using
+the
+Statistical
+Package for the Social Science (SPSS version 20.00, IBM
+Corp.,
+USA).
+The
+scores
+were
+assessed
+for
+between-
+group
+differences
+in
+the
+change
+of
+outcome
+measures,
+i.e., Timed up and test (TUG), Sit to stand test (STS),
+Handgrip strength test (HGS), Extension and Flexion, and
+Falls Efficacy Scale (FES) after the 1-week intervention of
+IAYT.
+Within
+Group
+and
+Between-Group
+comparisons
+were
+performed for exploratory reasons and are given in Table 3.
+Test of normality showed no significant difference in age,
+duration of osteoarthritis and socio-economic status between
+the
+groups.
+Repeated
+measures
+of
+Analysis
+of
+Variance
+(ANOVA) were performed for each outcome measures with
+two factors: (1) Groups: Yoga and Control; and (2) number
+of assessments: Pre and Post. Repeated measures of ANOVA
+were carried out separately followed by post-hoc analysis
+Frontiers in Psychiatry | www.frontiersin.org
+4
+May 2018 | Volume 9 | Article 180
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+TABLE 2 | Yoga practices module for knee OA.
+S. No.
+Practices
+Practice name (Sanskrit and English)
+Duration of practice
+1.
+Breathing practices
+Hands in and out Breathing
+5 rounds (2 min)
+Hands Stretch Breathing
+5 rounds (2 min)
+Ankle Stretch Breathing
+5 rounds (2 min)
+2.
+Loosening practices in standing
+Twisting
+5 rounds (2 min)
+Side bending
+5 rounds (2 min) on each side
+3.
+Loosening practices in sitting
+Knee Cap Tightening
+5 rounds (2 min) each, both legs
+Passive Patella Movement (Up and Down, In and Out, Rotation)
+10 rounds (4 min) both legs
+Knee bending
+5 rounds (2 min) each, both legs
+4.
+Loosening practices in Supine
+Folded Leg Lumber Stretch (Left, Right, Both)
+5 rounds (2 min)
+Cycling
+5 rounds (2 min) both legs
+Straight Leg Raising (Left, Right and Both)
+5 rounds (2 min)
+5.
+Yoga Posture- Sitting
+Paschimottasana (Seated forward bend Pose)
+3 rounds (3 min)
+Bh¯
+un
+. aman¯
+asana (Earth Salutation Pose)
+3 rounds (3 min)
+6.
+Yoga Posture-Prone
+Bhuja ˙
+ng¯
+asana (Cobra Pose)
+3 rounds (3 min)
+Salabh¯
+asana (Locust Pose)
+3 rounds (1 min)
+Vipareetkarani (Inverted Pose)
+2 min
+7.
+Yoga posture- Supine
+Setubandh¯
+asana (Bridge Pose)
+2 rounds (1 min)
+Markat
+. ¯
+asana (Lumbar Stretch Pose)
+2 rounds (1 min)
+Sav¯
+asana (Corpse Pose)
+5 min
+8.
+Relaxation Techniques
+Instant Relaxation Technique
+2 min
+Quick Relaxation Technique
+5 min
+Deep Relaxation Technique
+10 min
+9.
+Kriyas (Cleansing techniques)
+Jalaneti (Nasal Cleansing with Water)
+30 min
+Vamanadhouti (Internal Cleansing by Water)
+15 min
+Tr¯
+at
+.aka (Candle Light Gazing)
+10 min
+Kap¯
+alabh¯
+ati (Frontal Brain Cleansing)
+5 min
+10.
+Pr¯
+an
+. ayama (Yoga Breathing)
+Vibh¯
+ag¯
+ıyaPr¯
+an
+. ayama (Sectional Breathing)
+3 rounds (3 min)
+N¯
+ad¯
+ı´
+suddh¯
+ı (Alternate Breathing)
+9 rounds (3 min)
+Brah¯
+amar¯
+ı (Humming Bee Breathing)
+9 rounds (3 min)
+Bhastrik¯
+a (Bellows Breathing)
+9 rounds (3 min)
+11.
+Cooling Pr¯
+an
+. ayama
+´
+S¯
+ıtali (Rolling Tongue Breathing)
+9 rounds (3 min)
+´
+Sitk¯
+ar¯
+ı (Folded Tongue Breathing)
+9 rounds (3 min)
+Sadant¯
+a (Clenched Teeth Breathing)
+9 rounds (3 min)
+12.
+Meditation
+N¯
+ad¯
+anusandh¯
+ana (A,U,M and A-U-M Kara chanting)
+10 min
+Om Meditation
+10 min
+Cyclic Meditation
+30 min
+Mind Sound Resonance Technique
+10 min
+with Bonferroni correction, for two-time points of all the
+outcome measures. All comparisons were made between
+pre and post mean values of each outcome measure. If the
+p-value was p ≤0.05, the results were considered statistically
+significant.
+RESULTS
+The demographic data of recruited participants are given in
+Table 1. The repeated measures of ANOVA were performed for
+each outcome measure with two factors, i.e., groups (Yoga and
+Frontiers in Psychiatry | www.frontiersin.org
+5
+May 2018 | Volume 9 | Article 180
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+TABLE 3 | Comparison of change in primary and secondary outcomes in IAYT and control groups.
+Variables
+Within group
+Between-Group (p-value)
+2-Way repeated measures of ANOVA
+Yoga group
+Control group
+F group (p-value) F time (p-value) F interaction (p-value)
+Before
+After
+Before
+After
+PRIMARY OUTCOMES
+Timed Up and Go Test (TUG)
+19.16 ± 5.99
+15.57 ± 5.23***
+18.56 ± 6.41
+19.02 ± 5.19*
+0.014
+2.500
+35.413$$$
+8.842$$
+Sit-to-Stand (STS)
+18.35 ± 6.25
+14.22 ± 4.65***
+19.28 ± 5.69
+18.06 ± 5.71
+0.004
+4.72$
+30.973$$$
+9.092$$
+Goniometer -
+177.58 ± 3.63
+179.36 ± 2.14*
+178.17 ± 3.25
+176.21 ± 3.05
+NS
+0.912
+6.298$
+1.142
+(i) Right Extension
+(ii) Right Flexion
+45.52 ± 13.03
+37.23 ± 11.28***
+46.22 ± 13.40
+44.54 ± 14.32
+0.026
+2.38$
+28.910$$$
+12.671$$$
+(iii) Left Extension
+176.52 ± 4.49
+179.32 ± 1.90***
+175.84 ± 4.22
+176.20 ± 5.19
+0.035
+0.887
+12.429$$
+7.927$$
+(iv) Left Flexion
+46.39 ± 15.47
+39.84 ± 12.55***
+47.89 ± 16.24
+45.43 ± 15.12*
+NS
+1.96
+31.435$$$
+6.488$
+SECONDARY OUTCOMES
+Falls Efficacy Scale (FES)
+39.13 ± 10.36
+41.58 ± 11.18
+37.53 ± 11.05
+36.21 ± 13.14
+NS
+0.258
+2.180
+2.081
+Hand Grip Strength (HGS)-
+(i) Right Hand Grip Strength (RHGS)
+22.42 ± 6.28
+23.67 ± 6.05
+24.51 ± 7.35
+24.34 ± 5.75
+NS
+0.886
+0.937
+1.779
+(ii) Left Hand Grip Strength (LHGS)
+21.11 ± 6.32
+22.55 ± 6.88**
+22.11 ± 6.01
+20.2 ± 6.32
+NS
+0.821
+7.625$$
+1.082
+*p < 0.05; **p < 0.01; ***p < 0.001 significant difference before and after yoga intervention.
+$ < 0.05; $$ < 0.01; $$$ < 0.001 showed main effect or interaction effect in 2-way repeated measures ANOVA.
+Frontiers in Psychiatry | www.frontiersin.org
+6
+May 2018 | Volume 9 | Article 180
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+Control) and times of assessment (Pre and Post). The primary
+and secondary outcome scores of within-group analysis are
+shown in Table 3. The 2-way ANOVA results showed that there
+was a significant interaction between “group” and “time” of (i)
+TUG (F = 8.84; p < 0.01), (ii) STS (F = 9.09; p < 0.01), and
+(iii) Goniometer (a) Right Flexion (F = 12.67; p < 0.001), (b)
+Left Extension (F = 7.93; p < 0.01), and (c) Left Flexion (F
+= 6.49; p < 0.05). Post-hoc analysis with Bonferroni correction
+showed significant decrease in TUG (p < 0.001), STS (p < 0.001),
+increased Right & Left Flexion (p < 0.001) and Right (p < 0.05)
+& Left (p < 0.001) extension in primary outcomes.
+Whereas in the secondary outcomes, handgrip strength showed
+significant increase in LHGS (p < 0.01) in yoga group after 1 week
+IAYT intervention and no changes falls efficacy score. In Control
+group, we observed there was no relief of symptoms. After 1
+week, we observed that the Control group had a significant
+increase in TUG (p < 0.05) and a decrease in Left Flexion
+(p < 0.05) suggesting worsened symptoms after 1 week with
+conventional treatment alone. Between group analysis showed
+there was significant difference in post assessments of TUG (p
+< 0. 05), STS (p < 0.01), Right Flexion (p < 0.05), Left Extension
+(p < 0.05) of Yoga and Control group as shown in Figures 2A–C.
+DISCUSSION
+The results of the present study of the 1-week integrated
+approach of yoga therapy (IAYT) demonstrated significant
+improvements in TUG and STS tests in the Yoga group and
+no changes were observed in Control group. Yoga group
+participants reported significantly shorter time taken to perform
+different physical tests after 1-week yoga intervention which
+suggest better functional performance. The TUG test assesses
+multiple components of balance and mobility (35). The STS
+movement is one function people frequently use as they change
+from a sitting position to a standing position. STS requires
+forward movement of the center of mass while still seated
+(in preparation to stand), acceleration of the center-of-mass
+both in the anterior, posterior, and vertical plane, push offand
+stabilization once standing is achieved (36, 37). This movement
+is defined as a transitional movement to the upright posture
+requiring movement of the center of mass from a stable position
+to a less stable position over extended lower extremities (38).
+The HGS is a reliable measurement when standardized methods
+and calibrated equipment are used, even when there are different
+assessors or different brands of dynamometers (39, 40). Grip
+strength is related to the predictive of other health conditions.
+In the present study, right and left handgrip strength showed
+improvement after 1 week IAYT intervention. Previous studies
+reported that handgrip strength is positively related to normal
+bone mineral density in postmenopausal women (41), and can be
+used as a screening tool for women at risk of osteoporosis (42).
+Additionally, in the present study, Yoga group patients
+showed that there was a significant decrease in knee pain and
+stiffness, and significant improvement in mobility, measured
+through right and left leg extension and flexion test. These
+results are consistent with previous findings of Schilke et al.
+were 10 patients with knee pain, have undergone 8 weeks of
+the isokinetic muscle-strength-training program and showed
+a significant decrease in pain and stiffness. There was also a
+significant decline in arthritis activity after intervention and an
+increase in all strength measures of right-left flexion and left-leg
+extension across the training period (14).
+One study on rheumatoid arthritis (RA) patients aged 18
+years and older, underwent 8 weeks of yoga (two 60-min
+classes and one home practice/wk) reported higher physical
+component summary (PCS), walking capacity, positive affect
+and lower center for epidemiologic studies depression scale.
+Improvements were also shown in SF-36 health-related quality
+of life, role physical (work and daily activity impairment
+due to physical health), pain, general health, vitality, and
+mental health scale (43). Yoga showed a reduction in pain,
+depression and more significant improvement in life satisfaction
+after intervention (44). Yoga is mind-body interventions, that
+impart stress management with physical activity may be well
+suited for osteoarthritis and rheumatoid arthritis. Another
+therapeutic intervention of Iyengar yoga in patients with knee
+OA, EMG biofeedback showed a significant reduction in pain
+and improvement in functional ability (19). This suggests that
+yoga along with conventional therapy provides better results
+in chronic knee osteoarthritis regarding pain and functional
+disability. In a comparison of conventional therapy and add-
+on yoga for 56 patients of knee rehabilitation after total knee
+arthroplasty showed that there was a significant change for
+pain, stiffness and functional subscales of Western Ontario and
+McMaster Universities OA Index (WOMAC) Scale in both the
+groups (45). This indicates that yoga asana protocol works better
+than physiotherapy alone. The practice of yoga is doable, easy to
+follow, safe and most important is useful for patients with knee
+OA. There is evidence that Tai-Chi and yoga are safe and showed
+significant reduction of pain and improvement of physical
+function and quality of life in patients (46). The physical posture
+(hatha yoga) practice also helps to reduce pain and symptoms
+of OA and increase scores of daily activities, sports, spare-time
+activities, and quality of life (17). The practice of yoga effects
+on knee OA reported positive outcomes on symptoms including
+pain, flexibility, functional disability, anxiety, and quality of life
+(20). Earlier studies indicated subsided pain intensity in walking
+scale and improvement in WOMAC and quality of life after yoga
+practice. The resting pain and morning stiffness were studied in a
+former study, and the current study is a continuation of the same
+intervention (i.e., IAYT). The present study reported reduction
+in Time Up and Go test, Sit To Stand test. These results show that
+yoga practice improves muscular strength, better movement, and
+flexibility.
+The possible mechanism of yoga therapy-related changes in
+symptoms of OA is not known. The multifactorial approach
+of yoga therapy includes physical postures (asanas), breathing
+practices (pranayama), meditation (dhyana), spiritual and
+emotional cultures discourses may help to the amelioration of
+OA symptoms. Yoga therapy intervention may increase cartilage
+proteoglycan content and prevent cartilage degeneration (47).
+This is helpful for the strengthening of periarticular muscles (i.e.,
+quads and hamstrings) that normally contract to stabilize the
+Frontiers in Psychiatry | www.frontiersin.org
+7
+May 2018 | Volume 9 | Article 180
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+FIGURE 2 | Comparison between yoga and control groups after intervention. (A) Time Up and Go Test(TUG) and Sit To Stand (STS). (B) Right and left extension
+assessed with Goniometer. (C) Right and left flexion assessed with Goniometer. *p < 0.05, **p < 0.01.
+Frontiers in Psychiatry | www.frontiersin.org
+8
+May 2018 | Volume 9 | Article 180
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+knee joint pain. Also, yoga practice may prevent synovial fluid
+volume deterioration by stretching and strengthen different parts
+of the body, massaging and bringing fresh blood to the internal
+organs while rejuvenating the nervous system and lubricating the
+joints, muscles, and ligaments. It is purported to have different
+effects on the nervous and circulatory systems, coordination and
+concentration and calming effect on the body. This also suggests
+that yoga practice helps in reducing several psychological factors
+such as stress, anxiety, depression, mood disturbances, and
+enhance self-esteem and quality of life (43) in individuals with
+chronic pain and arthritic conditions (48). It can be concluded
+that yoga can be used as a complementary treatment along with
+conventional treatment to improve the situation of people with
+knee osteoarthritis.
+There are several limitations to this study such as very
+short duration of yogic intervention, confounding variables
+such as diet, controlled environment, small sample size, etc.
+Another limitation was no standard self-reported measure of
+osteoarthritis symptoms was used. Further, sample was not
+balanced by gender, so the outcome of the study cannot be
+generalized and future study can be planned with equal number
+of both the gender. Additionally, placebo is reported to be
+effective for OA, especially for subjective outcomes such as pain,
+stiffness, self-reported function, and physician global assessment
+and in the current study no placebo group was taken. Hence,
+the placebo effect on the outcome cannot be ruled out in
+this study and further study can be planned with placebo
+group. The strength of the present study is its cost-effectiveness
+and use of non-invasive intervention and assessments. This
+study comprises intensive lifestyle modification program with
+self-corrective practice. The IAYT intervention could be used as
+an add-on treatment of alternative and complementary therapy
+for osteoarthritis.
+CONCLUSION
+In summary, the previous evidence and present study suggest that
+yoga is an acceptable and safe intervention, which may result in
+clinically relevant improvements in pain and functional outcome
+associated with a range of musculoskeletal conditions such as
+muscular dystrophy, osteoarthritis, rheumatoid arthritis, etc. The
+present study would suggest that 1 week of IAYT may be useful
+in decreasing pain and increasing functional mobility in these
+patients over time.
+AUTHOR CONTRIBUTIONS
+SD helped in trial design, allocated participants, collected the
+data, analysed, interpreted data, and wrote the manuscript; MT
+performed the literature search and evaluated the outcomes
+(blind assessor); VK data analysis; assisted in manuscript
+compilation and RB editing; assisted in manuscript compilation
+and correspondence.
+ACKNOWLEDGMENTS
+The authors would like to thank Yoga therapy center in
+Bengaluru for providing participants and support for the conduct
+of this study. The authors would also like to thank Dr. Vijay
+Kumar for his guidance and support.
+REFERENCES
+1. Mahajan A, Verma S, Tandon V. Osteoarthritis. J Assoc Phys India (2005)
+53:634–41.
+2. Cheung C, Wyman JF, Savik K. Adherence to a yoga program in older
+women with knee osteoarthritis. J Aging Phys Act. (2016) 24:181–8.
+doi: 10.1123/japa.2015-0048
+3. Dunlop DD, Song J, Semanik PA, Chang RW, Sharma L, Bathon
+JM, et al. Objective physical activity measurement in the osteoarthritis
+initiative: are guidelines being met? Arthritis Rheum. (2011) 63:3372–82.
+doi: 10.1002/art.30562
+4. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older
+adults: a review of community burden and current use of primary
+health
+care.
+Ann
+Rheum
+Dis.
+(2001)
+60:91–7.
+doi:
+10.1136/ard.6
+0.2.91
+5. Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee
+osteoarthritis in India and related factors. Indian J Orthop. (2016) 50:518–22.
+doi: 10.4103/0019-5413.189608
+6. Chopra A. The WHO-ILAR COPCORD Bhigwan (India) model: foundation
+for a future COPCORD design and data repository. Clin Rheumatol. (2006)
+25:443–7. doi: 10.1007/s10067-006-0273-7
+7. Haq SA, Davatchi F. Osteoarthritis of the knees in the COPCORD
+world. Int J Rheum Dis. (2011) 14:122–9. doi: 10.1111/j.1756-185X.2011.
+01615.x
+8. Meiring RM, Frimpong E, Mokete L, Pietrzak J, Van Der Jagt D, Tikly M,
+et al. Rationale, design and protocol of a longitudinal study assessing the
+effect of total knee arthroplasty on habitual physical activity and sedentary
+behavior in adults with osteoarthritis. BMC Musculoskelet Disord. (2016)
+17:281. doi: 10.1186/s12891-016-1141-5
+9. Khalaj N, Abu Osman NA, Mokhtar AH, Mehdikhani M, Wan Abas WAB.
+Balance and risk of fall in individuals with bilateral mild and moderate
+knee osteoarthritis. PLoS ONE (2014) 9:e92270. doi: 10.1371/journal.pone.
+0092270
+10. Ebnezar J, Bali Y, Nagarathna R, Nagendra H. Effect of an integrated
+approach of yoga therapy on quality of life in osteoarthritis of the
+knee joint: a randomized control study. Int J Yoga (2011) 4:55–63.
+doi: 10.4103/0973-6131.85486
+11. Ferreira GE, Robinson CC, Wiebusch M, Viero CC, de M, da Rosa LHT, Silva
+MF. The effect of exercise therapy on knee adduction moment in individuals
+with knee osteoarthritis: a systematic review. Clin Biomech. (2014) 30:521–7.
+doi: 10.1016/j.clinbiomech.2015.03.028
+12. Field T. Knee osteoarthritis pain in the elderly can be reduced by massage
+therapy, yoga and tai chi: a review. Complement Ther Clin Pract. (2016)
+22:87–92. doi: 10.1016/j.ctcp.2016.01.001
+13. Glickman-Simon R, Wallace J. Acupuncture for knee osteoarthritis,
+chasteberry for premenstrual syndrome, probiotics for irritable bowel
+syndrome, yoga for hypertension, and trigger point dry needling for plantar
+fasciitis. Explore (2015):11:157–61. doi: 10.1016/j.explore.2014.12.009
+14. Schilke JM, Johnson GO, Housh TJ, O’Dell JR. Effects of muscle-strength
+training on the functional status of patients with osteoarthritis of the knee
+joint. Nurs Res. (1996) 45:68–72.
+15. Robbins L, Kulesa MG. The state of the science in the prevention
+and management of osteoarthritis: experts recommend ways to increase
+nurses’ awareness and knowledge of osteoarthritis. HSS J. (2012) 8:151–8.
+doi: 10.1007/s11420-012-9272-1
+16. Cheung C, Wyman JF, Resnick B, Savik K. Yoga for managing knee
+osteoarthritis in older women: a pilot randomized controlled trial. BMC
+Complement Altern Med. (2014) 14:160. doi: 10.1186/1472-6882-14-160
+Frontiers in Psychiatry | www.frontiersin.org
+9
+May 2018 | Volume 9 | Article 180
+Deepeshwar et al.
+Yoga Based Lifestyle Intervention for Osteoarthritis
+17. Ghasemi GA, Golkar A, Marandi SM. Effects of hata yoga on knee
+osteoarthritis. Int J Prev Med. (2013) 4(Suppl 1):S133–8.
+18. Nagarathna R, Nagendra H, Ebnezar J, Yogitha B. Effect of integrated
+yoga therapy on pain, morning stiffness and anxiety in osteoarthritis of
+the knee joint: a randomized control study. Int J Yoga (2012) 5:28–36.
+doi: 10.4103/0973-6131.91708
+19. Nambi GS, Shah AAK. Additional effect of iyengar yoga and EMG biofeedback
+on pain and functional disability in chronic unilateral knee osteoarthritis. Int
+J Yoga (2013) 6:123–7. doi: 10.4103/0973-6131.113413
+20. Kolasinski SL, Garfinkel M, Tsai AG, Matz W, Van Dyke A, Schumacher HR.
+Iyengar yoga for treating symptoms of osteoarthritis of the knees: a pilot study.
+J Altern Complement Med. (2005) 11:689–93. doi: 10.1089/acm.2005.11.689
+21. Bukowski E, Conway A, Glentz L, Kurland K, Galantino M. The effect of
+iyengar yoga and strengthening exercises for people living with osteoarthritis
+of the knee: a case series. Int Q Community Health Educ. (2006) 26:287–305.
+doi: 10.2190/IQ.26.3.f
+22. Brosseau L, Pelland L, Wells G, Macleay L, Lamothe C, Michaud G, et al.
+Efficacy of Aerobic exercises for osteoarthritis (part II): a meta-analysis. Phys
+Ther Rev. (2004) 9:125–45. doi: 10.1179/108331904225005061
+23. Rao RM, Nagendra HR, Raghuram N, Vinay C, Chandrashekara S, Gopinath
+KS, et al. Influence of yoga on postoperative outcomes and wound healing in
+early operable breast cancer patients undergoing surgery. Int J Yoga (2008)
+1:33–41. doi: 10.4103/0973-6131.36795
+24. Nagarathna R, Nagendra H. Yoga for Arthritis. 2nd ed. Bangalore: Swami
+Vivekananda Yoga Prakashan (2001).
+25. Nagendra HR. Pranayama:The Art and Science 3rd ed. Bangalore: Swami
+Vivekananda Yoga Prakashan (1998).
+26. Tekur P, Chametcha S, Hongasandra RN, Raghuram N. Effect of yoga on
+quality of life of CLBP patients: a randomized control study. Int J Yoga (2010)
+3:10–7. doi: 10.4103/0973-6131.66773
+27. Nagarathna R, Nagendra HR. Integrated Approach of Yoga Therapy for Positive
+Health. 1st ed. Bangalore: Swami Vivekananda Yoga Prakashan (2008).
+28. Oliveira AM, Peccin MS, Silva KN, Teixeira LE, Trevisani VF. Impact
+of exercise on the functional capacity and pain of patients with knee
+osteoarthritis: a randomized clinical trial. Rev Bras Reumatol. (2012) 52:876–
+82. doi: 10.1590/S0482-50042012000600006
+29. Andersson EI, Lin CC, Smeets RJ. Performance tests in people with chronic
+low back pain: responsiveness and minimal clinically important change. Spine
+(2010) 35:E1559–63. doi: 10.1097/BRS.0b013e3181cea12e
+30. Wang TH, Liao HF, Peng Y.-C. Reliability and validity of the five-repetition
+sit-to-stand test for children with cerebral palsy. Clin Rehabil. (2012) 26:664–
+71. doi: 10.1177/0269215511426889
+31. Kappetijn O, van Trijffel E, Lucas C. Efficacy of passive extension mobilization
+in addition to exercise in the osteoarthritic knee: an observational
+parallel-group study. Knee (2014) 21:703–9. doi: 10.1016/j.knee.2014.
+03.003
+32. Gogia PP, Braatz JH, Rose SJ, Norton BJ. Reliability and validity of goniometric
+measurements at the knee. Phys Ther. (1987) 67:192–5.
+33. Skelton DA, Young A, Greig CA, Malbut KE. Effects of resistance training on
+strength, power, and selected functional abilities of women aged 75 and older.
+J Am Geriatr Soc. (1995) 43:1081–7.
+34. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling.
+J Gerontol. (1990) 45:P239–43.
+35. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional
+mobility for frail elderly persons. J Am Geriatr Soc. (1991) 39:142–8.
+36. Herman T, Giladi N, HausdorffJM. Properties of the ‘Timed Up and
+Go’ Test: more than meets the eye. Gerontology (2011) 57:203–10.
+doi: 10.1159/000314963
+37. Janssen WGM, Bussmann HBJ, Stam HJ. Determinants of the sit-to-stand
+movement: a review. Phys Ther. (2002) 82:866–79. doi: 10.1093/ptj/82.9.866
+38. Vander Linden DW, Brunt D, McCulloch MU. Variant and invariant
+characteristics of the sit-to-stand task in healthy elderly adults. Arch Phys Med
+Rehabil. (1994) 75:653–60.
+39. Mathiowetz V. Comparison of Rolyan and Jamar dynamometers for
+measuring grip strength. Occup Ther Int. (2002) 9:201–9.
+40. Smidt N, van der Windt DA, Assendelft WJ, Mourits AJ, Devillé WL,
+de Winter AF, et al. Interobserver reproducibility of the assessment of
+severity of complaints, grip strength, and pressure pain threshold in patients
+with lateral epicondylitis. Arch Phys Med Rehabil. (2002) 83:1145–50.
+doi: 10.1053/apmr.2002.33728
+41. Kärkkäinen M, Rikkonen T, Kröger H, Sirola J, Tuppurainen M, Salovaara
+K, et al. Physical tests for patient selection for bone mineral density
+measurements
+in
+postmenopausal
+women.
+Bone
+(2009)
+44:660–5.
+doi: 10.1016/j.bone.2008.12.010
+42. Di
+Monaco
+M,
+Di
+Monaco
+R,
+Manca
+M,
+Cavanna
+A.
+Handgrip
+strength is an independent predictor of distal radius bone mineral
+density in postmenopausal women. Clin Rheumatol. (2000) 19:473–6.
+doi: 10.1007/s100670070009
+43. Moonaz SH, Bingham CO, Wissow L, Bartlett SJ. Yoga in sedentary adults
+with arthritis: effects of a randomized controlled pragmatic trial. J Rheumatol.
+(2015) 42:1194–202. doi: 10.3899/jrheum.141129
+44. Park J, McCaffrey R, Newman D, Cheung C, Hagen D. The effect of Sit “n”
+Fit Chair Yoga among community-dwelling older adults with osteoarthritis.
+Holist Nurs Pract. (2014) 28:247–57. doi: 10.1097/HNP.0000000000000034
+45. Bedekar N, Shyam A, Sancheti P, Prabhu A, Sancheti K. Comparative
+study
+of
+conventional
+therapy
+and
+additional
+yogasanas
+for
+knee
+rehabilitation after total knee arthroplasty. Int J Yoga (2012) 5:118–22.
+doi: 10.4103/0973-6131.98226
+46. Uhlig T. Tai Chi and yoga as complementary therapies in rheumatologic
+conditions.
+Best
+Pract
+Res
+Clin
+Rheumatol.
+(2012)
+26:387–98.
+doi: 10.1016/j.berh.2012.05.006
+47. Otterness
+IG,
+Eskra
+JD,
+Bliven
+ML,
+Shay
+AK,
+Pelletier
+JP,
+Milici
+AJ.
+Exercise
+protects
+against
+articular
+cartilage
+degeneration
+in
+the
+hamster.
+Arthritis
+Rheum.
+(1998)
+41:2068–76.
+doi: 10.1002/1529-0131(199811)41:11<2068::AID-ART23>3.0.CO;2-L
+48. Sharma M. Yoga as an alternative and complementary approach for arthritis:
+a systematic review. J Evid Based Complement Altern Med. (2014) 19:51–8.
+doi: 10.1177/2156587213499918
+Conflict of Interest Statement: The authors declare that the research was
+conducted in the absence of any commercial or financial relationships that could
+be construed as a potential conflict of interest.
+Copyright © 2018 Deepeshwar, Tanwar, Kavuri and Budhi. This is an open-access
+article distributed under the terms of the Creative Commons Attribution License (CC
+BY). The use, distribution or reproduction in other forums is permitted, provided
+the original author(s) and the copyright owner are credited and that the original
+publication in this journal is cited, in accordance with accepted academic practice.
+No use, distribution or reproduction is permitted which does not comply with these
+terms.
+Frontiers in Psychiatry | www.frontiersin.org
+10
+May 2018 | Volume 9 | Article 180

subfolder_0/Effect of Yoga as an Add-on Therapy in the Modulation of Heart Rate Variability in Children with Duchenne Muscular Dystrophy.txt

@@ -0,0 +1,308 @@
+Int J Yoga. 2019 Jan-Apr; 12(1): 55–61.
+doi: 10.4103/ijoy.IJOY_12_18
+PMCID: PMC6329227
+PMID: 30692784
+Effect of Yoga as an Add-on Therapy in the Modulation of Heart Rate
+Variability in Children with Duchenne Muscular Dystrophy
+Dhargave Pradnya,  Atchayaram Nalini,  Raghuram Nagarathna,  Trichur R Raju,  Ragupathy Sendhilkumar,
+Adoor Meghana,  and Talakad N Sathyaprabha
+Physiotherapy Center, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
+Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
+Vivekananda Yoga Research Foundation, Bengaluru, Karnataka, India
+Department of Neurophysiology, National Institute of Mental Health and Neurosciences, Bengaluru,
+Karnataka, India
+Address for correspondence: Dr. Talakad N. Sathyaprabha, Department of Neurophysiology, National
+Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru - 560 029, Karnataka, India. E-mail:
+[email protected]
+Received 2018 Feb; Accepted 2018 May.
+Copyright : © 2018 International Journal of Yoga
+This is an open access journal, and articles are distributed under the terms of the Creative Commons
+Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the
+work non-commercially, as long as appropriate credit is given and the new creations are licensed under the
+identical terms.
+Abstract
+Background:
+Duchene muscular dystrophy (DMD) is a progressive muscular disorder. Cardiac disorder is the
+second-most common cause of death in children with DMD, with 10%–20% of them dying of cardiac
+failure. Heart rate variability (HRV) is shown to be a predictor of cardio-autonomic function.
+Physiotherapy (PT) is advised for these children as a regular treatment for maintaining their functional
+status. The effect of yogic practices on the cardio-autonomic functions has been demonstrated in
+various neurological conditions and may prove beneficial in DMD.
+Materials and Methods:
+In this study, 124 patients with DMD were randomized to PT alone or PT with yoga intervention.
+Home-based PT and yoga were advised. Adherence was serially assessed at a follow-up interval of 3
+months. Error-free, electrocardiogram was recorded in all patients at rest in the supine position. HRV
+parameters were computed in time and frequency domains. HRV was recorded at baseline and at an
+interval of 3 months up to 1 year. Repeated-measures ANOVA was used to analyze longitudinal
+follow-up and least significant difference for post hoc analysis and P < 0.05 was considered
+statistically significant.
+Results:
+In our study, with PT protocol, standard deviation of NN, root of square mean of successive NN, total
+power, low frequency, high-frequency normalized units (HFnu), and sympathovagal balance improved
+at varying time points and the improvement lasted up for 6–9 months, whereas PT and yoga protocol
+1
+2
+3
+4
+1
+4
+4
+1
+2
+3
+4
+showed an improvement in HFnu during the last 3 months of the study period and all the other
+parameters were stable up to 1 year. Thus, it is evident that both the groups improved cardiac functions
+in DMD. However, no significant difference was noted in the changes observed between the groups.
+Conclusion:
+The intense PT and PT with yoga, particularly home-based program, is indeed beneficial as a
+therapeutic strategy in DMD children to maintain and/or to sustain HRV in DMD.
+Keywords: Duchene muscular dystrophy, heart rate variability, physiotherapy, yoga
+Introduction
+Duchenne muscular dystrophy (DMD) is a steadily progressive primary muscle disease and is the most
+common form of neuromuscular disorder with an X-linked recessive pattern of inheritance that
+ultimately leads to loss of ambulation and death at a young age.[1,2] The incidence of DMD is
+approximately 15.9–19.5/100,000 live births.[3,4] In India, DMD has been found to account for 30% of
+all reported forms of muscular dystrophies.[5] Respiratory failure and cardiac involvement are the most
+common causes of death in children with DMD,[6] but with advancement in respiratory support
+techniques, cardiac disorders remain an important problem in the late stages of the disease. Research in
+this field reveals that there is an involvement of myocardium before the onset of clinically apparent
+cardiomyopathy in DMD.[7] However, it has been observed that, in a routine management of DMD
+children, assessment of cardiac function is not considered until the clinical manifestations are detected.
+Nonrecognition of cardiac impairment and treatment at the early stages can lead to poor outcomes.
+Hence, recognition and management of the cardiac autonomic dysfunction is an important strategy for
+prolonged life expectancy and better quality of life in children with DMD.
+Heart rate variability (HRV) assessment is an economical, noninvasive, and sensitive procedure for
+investigating autonomic neurocardiac regulation.[8] HRV also provides a novel approach to the clinical
+diagnosis and prognostic measures. Several authors have used HRV to assess cardiac neural regulation.
+[9,10,11] Short-term HRV analysis is a good tool to investigate DMD children for evidence of cardiac
+autonomic dysfunction.[12] Our previous study demonstrated the need for routine assessment of
+cardiac functions using HRV measures, and short-term HRV analysis showed significant difference in
+the cardio-autonomic parameters among the DMD children than the healthy volunteers.[12]
+Apart from medical management, physiotherapy (PT) in the form of physical exercise is considered as
+one of the vital rehabilitation strategies for the maintenance of physical function. The role of exercise
+has been studied in the modulation of cardiac functions and found that training induces a resting
+bradycardia accompanied by increased cardiac vagal modulation in healthy individuals.[13]
+Yoga being the adjuvant therapy is considered as a simple practice that can be followed even at home
+with prior training. Practicing yoga has shown improvement in cardio-autonomic functions in normal
+individuals of different age groups.[14,15,16] Improvement in cardio-autonomic functions in healthy
+volunteers using different yoga modules and physical exercise has been documented.[17] However, the
+effect of yoga therapy to modulate HRV in DMD children has not been studied.
+Materials and Methods
+Subjects
+This study was conducted at the National Institute of Mental Health and Neurosciences (NIMHANS).
+Approval for this study was obtained from the Institutional Ethics Committee. Two hundred children
+were screened, and 124 children with genetically confirmed DMD, in the age group of 5–10 years, who
+were self-ambulant or required minimal assistance for walking, were recruited after obtaining written
+assent and consent. Our cohort were drug naive at the time of evaluation and were recruited for the
+study after genetic testing which was available within 3–4 weeks after clinical examination. Children
+who had muscular dystrophy other than DMD, nonambulant children, and children/parents not willing
+to participate in the study were excluded from the study.
+Study design
+Age matched randomized controlled repeated measure design.
+The patients were paired for age and randomly allocated to Group 1 (PT only) and Group 2 (yoga and
+PT [Y and PT]) using a computer-generated random table.
+Assessment
+HRV was used as the assessment tool in this study. Artifact-free, electrocardiograms were obtained for
+all patients in the supine position. Recordings were analyzed for time and frequency domain parameters
+according to the Taskforce report on HRV.[8] HRV parameters were computed in time and frequency
+domains. Time domain measures include the standard deviation of NN (SDNN) interval and root of
+square mean of successive NN (RMSSD) interval. Frequency domain consisted of total power (TP),
+low frequency (LF), and high frequency (HF) power values. The ratio of LF/HF power values was
+determined using the customized software. HRV assessments were done at the first presentation and
+sequentially at intervals of 3, 6, 9, and 12 months. All participants were given a compliance notebook
+to maintain exercise performance to make sure that children were practicing yoga and PT at home. Log
+books were reviewed on every visit.
+Intervention
+All children received the standard approved therapy of oral prednisolone at 0.75 mg/kg/day from the
+day of diagnosis and this was continued during the entire study period.
+Physiotherapy
+PT exercise was taught to children and parents in the Physiotherapy Department of NIMHANS. They
+were made to practice it under the supervision of physiotherapists initially for a period of 1 week. Once
+they learned the exercises, they were advised to carry it out at their homes. PT exercises were
+performed twice daily by the participants, morning and evening for 45 min per session, and were
+continued during the entire study period. Details of PT exercises are summarized in Table 1.
+Table 1
+Physiotherapy exercises
+Yoga
+Similarly, yoga practice was taught to the children and their parents by a trained, accredited yoga
+therapist. They were made to perform the yoga under the supervision of the yoga therapist for 1 week.
+Once they learned, they were advised to practice yoga in their homes. Children in this group performed
+yoga in the morning and PT exercises in the evening, each session lasting for 45 min, and was
+continued during the entire study period. Detail of yoga practices is summarized in Table 2.
+Table 2
+Yoga practices
+Open in a separate window
+Data extraction
+All the data were documented in a standardized pro forma and later decoded.
+Data analysis
+Basic demographic details were analyzed using descriptive statistics. Groups were compared using
+independent sample t-test for continuous variables. HRV data were square root transformed to produce
+normal distributions. Values are expressed in (mean [standard deviation]). Level of significance was
+kept at <0.05. RM ANOVA was used to analyze longitudinal follow-up and least significant difference
+for post hoc analysis.
+Results
+The age of the children participated in this study ranged from 5 to 10 years. The mean age at
+presentation was 7.9 ± 1.5 years. Mean height was 118.2 ± 8.4 cm (95–147 cm). Mean weight was 20.6
+± 4.3 kg (11–32 kg). Mean age at onset of DMD was 2.8 ± 0.6 years (1.5–4.0 years). Mean duration of
+illness was 5.1 ± 1.5 years (1–8 years). At the end of the study, 45 children completed the scheduled
+assessments in PT group and 43 children completed in Y and PT group. Details are explained in
+CONSORT diagram [Figure 1].
+Open in a separate window
+Figure 1
+CONSORT flow diagram
+At baseline, DMD children showed significantly lower mean NN (PT: 606.1 ± 77.1 and Y and PT:
+605.7 ± 78.5), higher average heart rate (PT: 100.4 ± 12.0 and Y and PT: 100.8 ± 13.0), and
+significantly reduced HF and HF normalized units (HFnu). The sympathovagal balance (SVB) was
+tilted toward sympathetic limb in DMD children. The time and frequency domain findings of HRV
+were similar in both the two study groups.
+After the PT protocol, SDNN, RMSSD, TP, LF, HFnu, and SVB improved at varying time points and
+the improvement lasted up for 6–9 months. Whereas the combined protocol of PT and yoga showed an
+improvement in HFnu during the last 3 months of the study period and all the other parameters were
+stable up to 1 year. When compared age wise with baseline values up to 1 year, in PT group, there was
+no significant change in any of the HRV parameters, while, Y and PT group showed a significant
+improvement in HFnu in 5–6 years’ group and mean NN and average HR in 7–8 years. However, no
+significant difference was observed between PT and Y and PT groups in other parameters. We
+observed that PT group demonstrated improvement in HRV parameters, but these effects were not long
+lasting, whereas Y and PT combination is more helpful in improving cardiac function between 5–8
+years of age. Detailed data are provided in Tables 3 and 4.
+Table 3
+Comparison of serial evaluation of heart rate variability values in the two study groups
+Table 4
+Age-wise difference between baseline and 1 year for heart rate variability values in the two
+study groups
+Open in a separate window
+Strengths
+Discussion
+This study was conducted to know the added effect of yoga in the modulation of HRV among the
+children with DMD. The HRV measures were used to assess the sympathetic and parasympathetic
+nervous activities. In HRV measures, the HF component of the HRV indicates the vagal activity. In a
+given point of time, any rise in the HF power, especially HFnu, indicates a vagal dominance. Similarly,
+increased LF power indicates increased sympathetic activity. The LF-HF ratio indicates overall SVB.
+High LF-HF ratio denotes increased sympathetic activity and a low LF-HF ratio indicates increased
+parasympathetic activity.[18] In this study, the baseline HRV findings were showing predominant
+sympathetic overactivity (increased SVB and reduced HF; HFnu) along with decreased mean NN.
+Subsequently, the PT intervention showed noteworthy changes in HRV parameters. The
+parasympathetic domination was very obvious during the intervention and lasted up to 6–9 months.
+However, the added benefit of yoga showed further improvement in parasympathetic regulation
+(HFnu). The age-wise improvement toward vagal balance was significant in our study. There was an
+additional long-lasting improvement in autonomic modulation in 5–8 years of age of DMD children
+with Y and PT group. All these findings confirm that DMD children have autonomic dysfunction and
+these can be modulated by the interventions and stringent follow-ups. We also proved that yoga as an
+adjuvant therapy has an additional benefit in enhancing the neuro-cardiac autonomic controls.
+Studies showed that skeletal muscle training can be beneficial in patients with DMD.[19,20,21] Despite
+the lack of studies addressing the use of yoga exercises as a complementary therapy for DMD patients,
+there have been several other clinical studies of yoga on healthy volunteers. A study on healthy adults
+aimed to find out the effect of yoga practice on HRV and showed increase in certain HRV parameters
+such as mean RR interval, SDNN, HF power, and HFnu.[22] There was also reduction in the resting
+heart rate, LF power, and LF/HF ratio. Several other studies on the effect of yoga on HRV exhibited an
+increase in the parasympathetic tone which is reflected through the HRV measures.[14,23] To our
+knowledge, the present study is the first to address and confirm the safety and efficacy of yogic
+exercises along with PT in children with DMD. The yogic exercises used in the present study are
+distinctive and were aimed at improving the muscular strength. Each school of yoga has various
+physical postures (asanas), breathing practices (pranayama), and meditation as their components. In our
+study, we used Sakthivikasaka (a practice aimed to improve the overall muscular function), selected
+asanas, pranayama, and meditation (guided meditation). Although the effect of Sakthivikas has not
+been studied, it can be considered as a practice equivalent to performing moderate-intensity exercise.
+Since yoga comprises both physical activity in the form of sakhivikasakas and asanas and pranayama,
+it has advantage in the modulation of HRV through mechanisms similar to practicing physical exercises
+in addition to practicing pranayama and meditation.
+The possible beneficiary effect of interventions on DMD may be due to several mechanisms. It
+includes a reduction in the catecholamine, angiotensin II, and an increased bioavailability of nitric
+oxide.[24] Complex neurophysiological mechanism, mediated through limbic, hypothalamic medullary
+axis and the medullary cardiovascular center, is thought to be the reason for improvements in the HRV
+after the practice of slow pranayamas.[18] On the other hand, HF yoga breathing practices such as
+Kapalabhathi are found to enhance sympathetic activity by reducing the vagal tone.[25] Overall
+relaxation and calming the mind through physical and breathing practices is the primary goal of yogic
+practices. Finally, we could see that yoga does have a positive effect on skeleton muscle as well as
+neuro-cardiac beneficiary with probable above-discussed mechanisms.
+Strengths and limitations of our study
+To our knowledge, this is the first study involving DMD children, with follow-up for 1 year,
+with large samples, to study the effect of yoga. It was a longitudinal, prospective, age-matched, two-
+group randomized study, with controlled RM design. The DMD being a progressive disease,
+performing exercise and yoga might have reduced the deleterious effects on such patients. The primary
+objective of the study was to show that yoga and exercises can be performed by patients with DMD.
+Although there was 30.6% and 27.4% dropout in yoga and exercise groups, this study showed that
+yoga exercises are feasible, harmless, and can actually improve HRV in DMD children.
+Limitation
+This study was not blinded for assessments and interventions.
+Conclusion
+Since modulation of HRV is an indicator of stable cardiac function and assessment of cardiac function
+using HRV measure and therapeutic measures, we advised that combined PT and yoga can be initiated
+as one of the rehabilitation strategies in children with DMD. This can also be a home-based PT, and
+yoga programs appear to be beneficial and cost-effective in the management of patients with DMD if
+started early.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+References
+1. Siciliano G, Tessa A, Renna M, Manca ML, Mancuso M, Murri L, et al. Epidemiology of
+dystrophinopathies in North-West Tuscany: A molecular genetics-based revisitation. Clin Genet.
+1999;56:51–8. [PubMed] [Google Scholar]
+2. Parsons EP, Bradley DM, Clarke AJ. Newborn screening for Duchenne muscular dystrophy. Arch
+Dis Child. 2003;88:91–2. [PMC free article] [PubMed] [Google Scholar]
+3. Mendell JR, Shilling C, Leslie ND, Flanigan KM, al-Dahhak R, Gastier-Foster J, et al. Evidence-
+based path to newborn screening for Duchenne muscular dystrophy. Ann Neurol. 2012;71:304–13.
+[PubMed] [Google Scholar]
+4. Moat SJ, Bradley DM, Salmon R, Clarke A, Hartley L. Newborn bloodspot screening for Duchenne
+muscular dystrophy: 21 years experience in Wales (UK) Eur J Hum Genet. 2013;21:1049–53.
+[PMC free article] [PubMed] [Google Scholar]
+5. Das S, Sarala D. Diagnosis of muscular dystrophies: The changing concepts. Neurol India.
+1998;46:165–76. [PubMed] [Google Scholar]
+6. Canet E, Praud JP, Bureau M. Chest wall diseases and dysfunction in children. In: Chernick V, Boat
+T, editors. Kendig's Disorders of the Respiratory Tract in Children. 6th ed. Philadelphia: Saunders;
+1998. pp. 787–815. [Google Scholar]
+7. Nigro G, Comi LI, Politano L, Bain RJ. The incidence and evolution of cardiomyopathy in
+Duchenne muscular dystrophy. Int J Cardiol. 1990;26:271–7. [PubMed] [Google Scholar]
+8. Malik Heart rate variability: Standards of measurement, physiological interpretation and clinical use.
+Task Force of the European Society of Cardiology and the North American Society of Pacing and
+Electrophysiology. Circulation. 1996;93:1043–65. [PubMed] [Google Scholar]
+9. Abhishekh HA, Nisarga P, Kisan R, Meghana A, Chandran S, Raju T, et al. Influence of age and
+gender on autonomic regulation of heart. J Clin Monit Comput. 2013;27:259–64. [PubMed]
+[Google Scholar]
+10. Meghana A, Sriranjini SJ, Sathyaprabha T, Sanjib S, Prathyusha V, Satishchandra P, et al.
+Autonomic function in reflex and non-reflex epilepsy – An exploratory study. Acta Neurol Scand.
+2016;133:459–65. [PubMed] [Google Scholar]
+11. Udupa K, Sathyaprabha TN, Thirthalli J, Kishore KR, Lavekar GS, Raju TR, et al. Alteration of
+cardiac autonomic functions in patients with major depression: A study using heart rate variability
+measures. J Affect Disord. 2007;100:137–41. [PubMed] [Google Scholar]
+12. Dhargave P, Nalini A, Abhishekh HA, Meghana A, Nagarathna R, Raju TR, et al. Assessment of
+cardiac autonomic function in patients with Duchenne muscular dystrophy using short term heart rate
+variability measures. Eur J Paediatr Neurol. 2014;18:317–20. [PubMed] [Google Scholar]
+13. Sandercock GR, Bromley PD, Brodie DA. Effects of exercise on heart rate variability: Inferences
+from meta-analysis. Med Sci Sports Exerc. 2005;37:433–9. [PubMed] [Google Scholar]
+14. Telles S, Sharma SK, Balkrishna A. Blood pressure and heart rate variability during yoga-based
+alternate nostril breathing practice and breath awareness. Med Sci Monit Basic Res. 2014;20:184–93.
+[PMC free article] [PubMed] [Google Scholar]
+15. Raghuraj P, Ramakrishnan AG, Nagendra HR, Telles S. Effect of two selected yogic breathing
+techniques of heart rate variability. Indian J Physiol Pharmacol. 1998;42:467–72. [PubMed]
+[Google Scholar]
+16. Vempati RP, Telles S. Yoga-based guided relaxation reduces sympathetic activity judged from
+baseline levels. Psychol Rep. 2002;90:487–94. [PubMed] [Google Scholar]
+17. Patil SG, Mullur LM, Khodnapur JP, Dhanakshirur GB, Aithala MR. Effect of yoga on short-term
+heart rate variability measure as a stress index in subjunior cyclists: A pilot study. Indian J Physiol
+Pharmacol. 2013;57:153–8. [PubMed] [Google Scholar]
+18. Pal GK. Yoga and heart rate variability. Int J Clin Exp Physiol. 2015;2:2–9. [Google Scholar]
+19. Grange RW, Call JA. Recommendations to define exercise prescription for Duchenne muscular
+dystrophy. Exerc Sport Sci Rev. 2007;35:12–7. [PubMed] [Google Scholar]
+20. Jansen M, van Alfen N, Geurts AC, de Groot IJ. Assisted bicycle training delays functional
+deterioration in boys with Duchenne muscular dystrophy: The randomized controlled trial “no use is
+disuse” Neurorehabil Neural Repair. 2013;27:816–27. [PubMed] [Google Scholar]
+21. Routledge FS, Campbell TS, McFetridge-Durdle JA, Bacon SL. Improvements in heart rate
+variability with exercise therapy. Can J Cardiol. 2010;26:303–12. [PMC free article] [PubMed]
+[Google Scholar]
+22. Muralikrishnan K, Balakrishnan B, Balasubramanian K, Visnegarawla F. Measurement of the effect
+of Isha yoga on cardiac autonomic nervous system using short-term heart rate variability. J Ayurveda
+Integr Med. 2012;3:91–6. [PMC free article] [PubMed] [Google Scholar]
+23. Krishna BH, Pal P, Pal GK, Balachander J, Jayasettiaseelon E, Sreekanth Y, et al. Effect of yoga
+therapy on heart rate, blood pressure and cardiac autonomic function in heart failure. J Clin Diagn Res.
+2014;8:14–6. [PMC free article] [PubMed] [Google Scholar]
+24. Oliveira NL, Ribeiro F, Alves AJ, Teixeira M, Miranda F, Oliveira J, et al. Heart rate variability in
+myocardial infarction patients: Effects of exercise training. Rev Port Cardiol. 2013;32:687–700.
+[PubMed] [Google Scholar]
+25. Telles S, Singh N, Balkrishna A. Heart rate variability changes during high frequency yoga
+breathing and breath awareness. Biopsychosoc Med. 2011;5:4. [PMC free article] [PubMed]
+[Google Scholar]
+Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow
+Publications

subfolder_0/Effect of a diet enriched with fresh coconut saturated fats on plasma lipids and erythrocyte fatty acid composition in normal adults.txt

@@ -0,0 +1,760 @@
+Full Terms & Conditions of access and use can be found at
+http://www.tandfonline.com/action/journalInformation?journalCode=uacn20
+Download by: [Cornell University Library]
+Date: 18 May 2017, At: 09:36
+Journal of the American College of Nutrition
+ISSN: 0731-5724 (Print) 1541-1087 (Online) Journal homepage: http://www.tandfonline.com/loi/uacn20
+Effect of a Diet Enriched with Fresh Coconut
+Saturated Fats on Plasma Lipids and Erythrocyte
+Fatty Acid Composition in Normal Adults
+Rokkam Shankar Nagashree MSc, N. K. Manjunath, M. Indu, M. Ramesh, V.
+Venugopal, P. Sreedhar, N. Pavithra & Hongasandra R. Nagendra
+To cite this article: Rokkam Shankar Nagashree MSc, N. K. Manjunath, M. Indu, M. Ramesh, V.
+Venugopal, P. Sreedhar, N. Pavithra & Hongasandra R. Nagendra (2017): Effect of a Diet Enriched
+with Fresh Coconut Saturated Fats on Plasma Lipids and Erythrocyte Fatty Acid Composition in
+Normal Adults, Journal of the American College of Nutrition, DOI: 10.1080/07315724.2017.1280713
+To link to this article:  http://dx.doi.org/10.1080/07315724.2017.1280713
+Published online: 16 May 2017.
+Submit your article to this journal 
+View related articles 
+View Crossmark data
+Effect of a Diet Enriched with Fresh Coconut Saturated Fats on Plasma Lipids
+and Erythrocyte Fatty Acid Composition in Normal Adults
+Rokkam Shankar Nagashree, MSca, N. K. Manjunatha, M. Indub, M. Ramesha, V. Venugopala, P. Sreedhara, N. Pavithrab,
+and Hongasandra R. Nagendraa
+aSwami Vivekananda Yoga Anusandhana Samsthana, Department of Yoga and Life Sciences, Bengaluru, India; bSt. John’s Research Institute, Division of
+Nutrition, Bengaluru, India
+ARTICLE HISTORY
+Received 8 November 2016
+Accepted 5 January 2017
+ABSTRACT
+Objective: The objective of this study was to compare the effects of increased saturated fatty acid (SFA)
+(provided by fresh coconut) versus monounsaturated fatty acid (MUFA) intake (provided by a combination
+of groundnuts and groundnut oil) on plasma lipids and erythrocyte fatty acid (EFA) composition in healthy
+adults.
+Material and Methods: Fifty-eight healthy volunteers, randomized into 2 groups, were provided
+standardized diet along with 100 g fresh coconut or groundnuts and groundnut oil combination for
+90 days in a Yoga University. Fasting blood samples were collected before and after the intervention
+period for the measurement of plasma lipids and EFA profile.
+Results: Coconut diet increased low-density lipoprotein (LDL) and high-density lipoprotein (HDL) levels
+significantly. In contrast, the groundnut diet decreased total cholesterol (TC), mainly due to a decrease in
+HDL levels. There were no differences in the major SFA of erythrocytes in either group. However, coconut
+consumption resulted in an increase in C14:0 and C24:0 along with a decrease in levels of C18:1 n9 (oleic
+acid). There was a significant increase in levels of C20:3 n6 (dihomo-gamma linolenic acid, DGLA).
+Conclusions: Consumption of SFA-rich coconut for 3 months had no significant deleterious effect on
+erythrocytes or lipid-related factors compared to groundnut consumption. On the contrary, there was an
+increase in the anti-atherogenic HDL levels and anti-inflammatory precursor DGLA in erythrocyte lipids.
+This suggests that coconut consumption may not have any deleterious effects on cardiovascular risk in
+normal subjects.
+Abbreviations: SFA, saturated fatty acid; MCSFA, medium-chain saturated fatty acids; MUFA, monounsaturated fatty
+acid; HDL, high-density lipoprotein; TC, total cholesterol; TG , triglycerides; CAD, coronary artery disease; PUFA, poly-
+unsaturated fatty acid; DGLA, dihomo-g-linolenic acid; VCO, virgin coconut oil; WHO, World Health Organization;
+FAO, Food and Agriculture Organization
+KEYWORDS
+Coconut; saturated fat;
+plasma lipid; erythrocyte
+fatty acid; MUFA; gas
+chromatography; groundnut
+Introduction
+Consumption of saturated fat is believed to increase the risk of
+coronary artery disease mainly because of its effects on increas-
+ing plasma total cholesterol (TC) levels. As early as the 1950s,
+Keys et al. [1,2] and later Dietschy [3] and Hegsted et al. [4]
+worked out equations that showed how dietary fatty acids influ-
+enced plasma cholesterol levels. These equations suggested that
+saturated fatty acids (SFAs) increased TC levels, whereas poly-
+unsaturated fatty acids (PUFAs) decreased them and monoun-
+saturated fats (MUFAs) were largely considered as neutral [5].
+These studies were the basis of dietary recommendations that
+advised reduced consumption of all types of SFAs [6].
+Nearly one third of the world’s population depends on coco-
+nut to some degree for their food [7]. Indian diets are relatively
+low in fat; however, inclusion of fresh/dry coconut in the daily
+diet is a common practice in many parts of the country. India
+is the third largest producer of coconuts in the world [8] and
+more than half of this (52%) is consumed in raw form as either
+fresh or dry coconut [9]. Studies on the effect of coconut oil
+consumption on plasma lipids are contradictory, with some
+studies showing deleterious effects and others showing neutral
+effects. However, there are almost no studies conducted on the
+health effects of fresh coconut consumption. Fresh coconuts
+contain 40%–50% moisture and, in addition to SFAs, they are
+rich in fiber and protein and a number of vitamins, minerals,
+and electrolytes [10]. Furthermore, the coconut SFA composi-
+tion is unique in that it consists of over 50% of medium-chain
+SFAs (MCSFAs) [11], whose properties and metabolism appear
+to differ from longer chain SFAs commonly found in animal
+products [12]. MCSFAs are rapidly oxidized in the liver to Ace-
+tyl coenzyme A (acetyl CoA) and do not enter or alter the lipid
+pool in the liver, thus remaining neutral with respect to regula-
+tion of TC or low-density lipoprotein (LDL) levels [13].
+The current study was therefore undertaken to study the
+effects of daily consumption of fresh coconut on plasma lipids
+CONTACT Rokkam Shankar Nagashree
+[email protected]
+Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana,
+Eknath Bhavan, Gavipuram Circle, Kempegowda Nagar, Bengaluru - 560018, Karnataka, India.
+© 2017 American College of Nutrition.
+JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
+https://doi.org/10.1080/07315724.2017.1280713
+and erythrocyte fatty acid composition in healthy young men
+and women.
+Materials and methods
+The study was carried out on 58 healthy adults who were
+recruited following advertisement of the study at Swami Vive-
+kananda Yoga Anusandhana Samstha University. Sample size
+was calculated using SPSS software, Version 10 (IBM), where
+the alpha was 0.05 and the power was 0.95. The effect size was
+0.570 and the sample size was 27. Subjects were aged 23.8 §
+4.8 years and had no known metabolic, endocrine, or hemato-
+logical diseases; were not on any medications; and had high
+physical activity levels. Subjects were nonsmokers and tee-
+totalers residing on a residential campus of a university. The
+study protocol was approved by the institutional ethics com-
+mittee. This study has been registered with the Clinical Trial
+Registry of India (CTRI/2016/07/007071). Signed informed
+consent was obtained from the volunteers.
+The subjects were randomized into 2 groups—the coconut
+group (C) and the groundnut group (G). Randomization was
+done using a computer-generated random number table (www.
+randomizer.org). All subjects received a balanced diet based on
+yogic principles of food (sativic, rajasic, and tamasic) blended
+with modern medical nutrition (calorie requirements, composi-
+tion of a balanced meal) and consumed this standard meal plus
+intervention for a period of 90 days. Details of the diet are pro-
+vided in Table 1. In addition to this standard meal, group C
+consumed 100 g (444 kcal) of fresh coconut per day and group
+G consumed 45 g (256 kcal) of groundnuts and 22 g (198 kcal)
+of groundnut oil per day. A combination of groundnut and oil
+was used to make the 2 study interventions isocaloric and to
+ensure similar macronutrient compositions. Group C con-
+sumed 2689 kcal, 392 g of carbohydrates (58.3%), 77 g of pro-
+teins (11.4%), and 90 g (30.3%) of fat and group G consumed
+2699 kcal, 384 g of carbohydrates (57%), 89 g protein (13%),
+and 90 g fats per day (30%).
+Subjects were trained and requested to abstain from con-
+suming anything other than the food and snacks provided by
+the project kitchen, set up exclusively for the study.
+Anthropometry
+Subjects’ weight, height, waist and hip measurements, and body
+mass index (BMI; weight in kilograms divided by height in
+square meters) were determined. Body weight was measured
+using a digital scale, height was measured with a stadiometer,
+and waist and hip circumferences were assessed using a stan-
+dard tape measure, performed by the same person.
+Biochemical data and fatty acid analysis
+Lipid profile was measured soon after sample collection using a
+fully automated biochemistry analyzer (Mindray BS 390
+Shenzhen, China). Blood samples for erythrocyte fatty acid
+analysis were collected into EDTA tubes and centrifuged with
+HiSep lymphocyte separation media (LSM 1077) at 1550 rpm
+for 15 min. Erythrocytes were separated, washed 3 times with
+phosphate-buffered saline, and centrifuged at 1400 rpm for
+10 min at 4
C and stored at ¡80
C until analysis.
+Fatty acid profile of rbs through gas chromatography
+Fatty acids in 300 mL erythrocytes were extracted using a chlo-
+roform: methanol (1:2) mixture and transmethylated with 2%
+concentrated H2SO4 in methanol. The different fatty acids were
+separated using gas chromatography–flame ionization detec-
+tion (Varian 3800; Varian, Palo Alto, CA; fused silica column–
+fatty acid methyl ester (FAME), Varian 50 m, 0.2 mm capillary
+column) with nitrogen as the carrier gas and quantified using
+C17 as an internal standard. The total fatty acid content of the
+samples was calculated and each identified fatty acid was
+expressed as a percentage of total fatty acids.
+Fatty acids profile of the meals
+The fatty acid profile of coconut and groundnut meal for one
+person for a whole day was obtained through gas chromatogra-
+phy–flame ionization detection. Coconut meal contained 58%
+SFA and 18% MUFA compared to 22% SFA and 41% MUFA
+in the groundnut meal (Table 2).
+Data analysis
+Statistical analysis was done using SPSS Version 10 (IBM).
+Each variable was first assessed for normality of distribution
+using the Kolmogorov-Smirnov test. When the data were nor-
+mally distributed with equal variance, parametric statistical
+tests were selected for analysis. Within-group analysis was
+done using a paired sample t test comparing the data collected
+on day 90 with the respective day 1 values for each variable
+Table 1. Diet composition of standard meal.
+Food Group
+No. of Exchanges Portion (g) Quantity(g) Energy(kcal)
+Cereals and millets
+12
+30
+360
+1200
+Pulses
+3
+30
+90
+300
+Milk and its products
+3
+100
+300
+210
+Roots and tubers
+1
+100
+100
+80
+Green leafy vegetables
+2
+100
+200
+90
+Other vegetables
+3
+100
+300
+90
+Fruits
+2
+100
+200
+80
+Jaggery/honey
+3
+5
+15
+60
+Fat
+3
+5
+15
+135
+Total
+2245
+Table 2. Macronutrient and fatty acid composition of the 2 diets.
+Coconut Group
+Groundnut Group
+Energy (kcal/day)
+2689
+2699
+Carbohydrates (%)
+58.3 (392 g/d)
+57 (384 g/d)
+Protein (%)
+11.4 (77 g/d)
+13 (89 g/d)
+Fat (%)
+30.3 (90 g/d)
+30 (90 g/d)
+Fatty acid composition (%)
+MCSFAs
+39 (11.8%)
+0
+Total SFAs
+58 (17.5%)
+22 (6.6%)
+MUFAs
+18 (5.4%)
+41 (12.3%)
+PUFAs
+24 (7.4%)
+37 (11.1%)
+MCSFA D medium-chain saturated fatty acid, SFA D saturated fatty acid, MUFA D
+monounsaturated fatty acid, PUFA D polyunsaturated fatty acid.
+2
+R. S. NAGASHREE ET AL.
+separately. Chi-square test was performed when the data were
+nonparametric in nature. The between-group comparisons
+were done to understand the significant differences between
+groups C and G at baseline as well as at day 90 using an inde-
+pendent sample t test.
+Results
+Table 2 provides details of the diet composition of the 2 groups.
+Both groups consumed similar amounts of macronutrients;
+however, the fatty acid compositions of the 2 diets were very
+different. Group C consumed 17.5% as SFA, of which 11.8%
+came from MCSFA, whereas group G consumed only 6.6% as
+SFA, with no MCSFA. The MUFA as well as PUFA intake in
+group G was double that of group C.
+Physical activity levels of subjects in both groups were com-
+parable (x2
+1
+ð Þ D 1:16; p D 0:466Þ. Table 3 shows that the
+baseline characteristics of the 2 groups were similar. A significant
+decrease in weight was observed in group C; however, no changes
+were observed in either BMI or in waist–hip ratio in either group.
+The effect of coconut consumption on plasma lipids is pre-
+sented in Table 4. It was seen that consumption of coconut for
+90 days resulted in an increase in both LDL as well as high-den-
+sity lipoprotein (HDL) levels, although TC levels did not
+increase significantly. On the other hand, groundnut consump-
+tion for the same period resulted in a decrease in TC levels that
+was mainly due to a significant decrease in HDL levels. No
+changes were observed in any of the other lipids.
+Erythrocyte fatty acid composition before and after the inter-
+vention is detailed in Table 5. No significant changes were
+observed in the major SFA composition in either group, although
+significant changes were seen in minor fatty acids in both groups.
+In the coconut group, an increase was seen in all of the minor
+SFAs—14:0 and 24:0—whereas in the groundnut group, there
+was a decrease in 14:0 and a corresponding increase in 22:0 and
+24:0. There was also a decrease in total n-3 PUFAs in the ground-
+nut group. A significant increase was seen in the levels of 20:3 n-6
+(dihomo-g-linolenic acid, DGLA) accompanied by a decrease in
+the main MUFA (18:1 n-9) in the coconut group.
+Discussion
+In this carefully controlled diet study, we seek to shed light on
+the impact of SFAs from fresh coconut (C) in comparison to
+MUFAs from a groundnut and groundnut oil combination (G)
+on some well-accepted indices of cardiovascular disease (CVD)
+risk. The most important finding of the present study was that
+despite much higher intakes of SFAs in the coconut group, the
+effects on plasma TC and triglycerides were minimal. There
+was a significant increase in LDL levels in the coconut group,
+which is in line with a number of studies with coconut oil sup-
+plementation [14,15]. This has been generally attributed to
+either increased LDL synthesis or reduced LDL clearance. On
+the other hand, a number of studies have reported beneficial
+effects of virgin coconut oil on LDL and have attributed it to
+the presence of high levels of polyphenols such as caffeic acid
+[16], which play a key role in scavenging free radicals [17]. In
+the current study, despite the use of fresh coconut rich in poly-
+phenols, we observed an increase in LDL levels. However, it
+was also seen that there was no significant increase in TC levels,
+suggesting that this increase in LDL was well within physiologic
+variability in the current study population of normal men and
+women.
+Groundnut was used as the control in this study because it is
+a rich source of MUFA and is more commonly consumed than
+Table 3. Basic characteristics of the 2 groups before and after dietary intervention.
+Variables
+Coconut Group (n D 27)
+Groundnut Group (n D 31)
+Age (years)
+23 § 4.1
+24.65 § 5.5
+Gender (male/female)
+15/12
+16/15
+Day 1
+Day 90
+Day 1
+Day 90
+Mean § SD
+Mean § SD
+Mean § SD
+Mean § SD
+Weight (kg)
+59.8 § 10.2
+59.1 § 9.6
+56.78 § 7.3
+56.2 § 7.9
+BMI
+21.6 § 2.2
+21.4 § 2.1
+21.0 § 2.0
+20.80 § 1.9
+Waist–hip ratio
+0.82 § 0.07
+0.79 § 0.12 0.82 § 0.06
+0.81 § 0.06
+BMI D body mass index.
+p < 0.05, paired sample t test; day 90 values compared to respective day 1 values.
+Table 4. Biochemical measures recorded in both coconut and groundnut groups
+on days 1 and 90.a
+Coconut Group
+Groundnut Group
+Variable
+Day 1
+Day 90
+Day 1
+Day 90
+TG (mg/dl)
+78.1 § 34.2
+79.7 § 25.3
+78.7 § 32.1
+70.1 § 24.8
+LDL (mg/dl)
+85.9 § 20.1 97.96 § 23.8
+81.84 § 19.3 79.97 § 21.0
+HDL (mg/dl)
+42.9 § 9.6
+46.74 § 11.4
+43.61 § 10.3 41.19 § 10.3
+TC (mg/dl)
+150.5 § 22.6 157.6 § 27.9
+144.45 § 20.1 133.8 § 19.3
+TG/HDL
+1.9 § 1
+1.8 § 0.8
+1.9 § 1
+1.8 § 0.9
+apo-B/apo-A1
+0.63 § 0.16
+0.63 § 0.17
+0.63 § 0.16
+0.63 § 0.17
+TG D triglycerides, LDL D low density lipoprotein, HDL D high density lipoprotein,
+TC D total cholesterol, apo-A D apolipoprotein A, apo-B D apolipoprotein B.
+aValues are group mean § standard deviation.
+p < 0.05.p < 0.01.p < 0.001. Comparing day 90 values with day 1 values
+using paired sample t test.
+Table 5. Fatty acid profile of erythrocytes recorded in both coconut and ground-
+nut groups on days 1 and 90.a
+Coconut Group
+Groundnut Group
+Fatty Acid
+Day 1
+Day 90
+Day 1
+Day 90
+12:0
+0.01 § 0.04
+0.06 § 0.34
+0.09 § 0.31
+0.06 § 0.26
+14:0
+0.09 § 0.26
+0.43 § 0.55
+0.32 § 0.52
+0.11 § 0.33
+16:0
+24.5 § 2.1
+24.0 § 1.2
+24.6 § 1.8
+24.4 § 3.5
+18:0
+18.3 § 1.4
+18.0 § 1.23
+18.1 § 1.8
+18.2 § 1.5
+18:1
+13.4 § 1.5
+12.7 § 1.3
+13.6 § 1.7
+13.7 § 1.6
+18:2 n-6
+13.9 § 1.3
+14.3 § 1.4
+13.6 § 0.94
+13.4 § 1.5
+20:3 n-6
+1.63 § 0.33
+1.79 § 0.43
+1.60 § 0.31
+1.60 § 0.40
+20:4 n-6
+14.4 § 2.1
+14.4 § 1.5
+14.4 § 2.5
+14.1 § 3.1
+22:0
+0.68 § 0.54
+0.92 § 0.85
+0.63 § 0.52
+0.96 § 0.49
+22:04
+4.47 § 1.12
+4.35 § 1.12
+4.7 § 0.93
+4.66 § 1.13
+24:0
+2.8 § 1.1
+3.2 § 0.78
+2.7 § 1.0
+3.5 § 0.82
+22:5 n-6
+2.6 § 1.3
+2.8 § 0.7
+2.5 § 1.1
+2.5 § 0.72
+22:5 n-3
+1.1 § 0.58
+1.0 § 0.38
+1.1 § 0.55
+0.96 § 0.53
+22:6 n-3
+1.7 § 0.66
+1.6 § 0.55
+1.7 § 0.64
+1.6 § 0.72
+Total SFA
+46.5 § 3.5
+46.7 § 2.4
+46.5 § 3.5
+47.3 § 5.6
+Total MUFA
+13.4 § 1.5
+12.7 § 1.3
+13.6 § 1.8
+13.7 § 1.6
+Total PUFA
+40.0 § 4.1
+40.4 § 2.4
+39.8 § 4.2
+38.9 § 6.6
+Total n-6
+37.0 § 3.6
+37.7 § 2.3
+36.9 § 3.5
+36.4 § 5.7
+Total n-3
+2.9 § 1.1
+2.7 § 0.81
+2.8 § 1.1
+2.5 § 1.2
+SFA D saturated fatty acid, MUFA D monounsaturated fatty acid, PUFA D polyun-
+saturated fatty acid.
+aValues are group mean § standard deviation.
+p < 0.05.p < 0.01.p < 0.001. Comparing day 90 values with day 1 values
+using paired sample t test.
+JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
+3
+olive oil in India. We have enough evidence from several epide-
+miologic studies that dietary MUFAs have a positive impact on
+CVD risk factors by promoting a healthy blood lipid profile,
+improving blood pressure, and decreasing inflammation and
+oxidative stress [18,19]. MUFAs are also reported to improve
+insulin sensitivity [19]. In the present study, there was a signifi-
+cant decrease in TC levels in the groundnut group; however,
+this appeared to be mainly due to a decrease in HDL levels
+(Table 4). In contrast, the coconut group showed a significant
+increase in HDL levels, which could be attributed to the high
+MCSFA content of the diet [20].
+Research from the past 30 years has shown that increased
+levels of circulating HDL cholesterol are associated with a
+reduced risk of coronary heart disease events, and HDL par-
+ticles have properties that could provide protection against the
+development of atherosclerosis [21–23]. Low levels of HDL
+(<40 mg/dl) are not only an independent risk factor for CVD
+[21] but are considered a higher risk factor than elevated levels
+of LDL, mainly because HDL has important anti-atherogenic
+effects like reverse cholesterol transport, inhibition of LDL oxi-
+dation, and antiplatelet and anti-inflammatory actions [24].
+Supplementation of as little as 2 g of coconut oil (8 weeks)
+increased HDL levels significantly without harmful effects on
+LDL or TC [25]. Older studies have shown that lauric and myr-
+istic acids increase HDL levels [26,27]. Green and Pittman pro-
+posed that a lower rate of Cholesteryl ester transfer protein
+(CETP)-mediated transfer of lauric or myristic acid–rich cho-
+lesteryl esters from HDL compared to longer chain saturated
+fatty acids results in this increase in HDL levels [28].
+However, increased HDL levels do not always ensure protec-
+tion against atherosclerosis. It is not the level of HDL that
+determines the innate ability for cholesterol efflux from macro-
+phages [29]. Therefore, alternative markers have been proposed
+to better reflect cardiovascular risk, such as the TC: HDL ratio
+or TG: HDL or apolipoprotein ratios [30]. A recent review of
+coconut oil studies points to this flaw; that is, in earlier research
+the effect of coconut consumption on the ratio of TC or TG to
+HDL was often not studied [31]. In the current study, there was
+no significant change in the TG: HDL ratio in either group.
+Therefore, it appears that daily consumption of 100 g of coco-
+nut providing 16% as SFA does not have any deleterious effects
+on plasma lipid profile.
+The effect of dietary changes in fat intake are reflected well
+in erythrocyte membrane fatty acid composition. Long-term fat
+quality is best reflected in the fatty acid composition of adipose
+tissue [32]. However, a number of studies confirm that erythro-
+cytes fatty acid composition can serve as a reliable biomarker of
+medium- to long-term dietary changes [33]. The results of the
+current study show that daily consumption of coconut for 3
+months had no deleterious effect on erythrocyte fatty acid com-
+position compared to consumption of groundnut. Though the
+dietary intake of SFAs was 2.6 times higher in the coconut
+group compared to the groundnut group (58 g vs 22 g; Table 2),
+there was no change in the levels of major SFAs such as pal-
+mitic (16:0) and stearic (18:0) acid. This is logical because SFA
+composition is more an index of de novo lipogenesis, and it is
+likely that increasing intakes of dietary SFAs could result in a
+downregulation of de novo fatty acid synthesis [34]. However,
+significant changes were seen in minor fatty acids in both
+groups. In the coconut group, an increase was seen in minor
+saturated fatty acids C14:0 and C24:0. In the groundnut group,
+there was a decrease in C14:0 and a corresponding increase in
+C22:0 and C24:0.
+The differences in the intakes of MUFAs (18 g vs 41 g),
+however, appear to be reflected in the erythrocytes because
+there was a significant decrease in oleic acid (18:1 n-9) lev-
+els at the end of the intervention period in the coconut
+group. Although there were no changes in the total PUFA
+content in both groups, it was interesting to note that the
+levels of DGLA (20:3 n-6) were significantly increased in
+the coconut group. DGLA is also a substrate for both cyclo-
+oxygenase as well as lipoxygenase, leading to the formation
+of the 1-series prostaglandins and the 3-series leukotrienes,
+respectively [35]. These molecules have been shown to be
+anti-inflammatory in nature and also play a role in reducing
+risk of thrombosis [36]. Taken together, it appears that con-
+sumption of high SFAs from coconut does not have any
+deleterious effects on erythrocyte fatty acids.
+Recently, there have been some questions raised about die-
+tary recommendations to reduce SFA consumption. A meta-
+analysis of prospective epidemiologic studies in 2010 shows
+that there is a lack of significant evidence on SFA intake and
+CVD/coronary heart disease risk [37]. The 2010 Joint World
+Health Organization/Food and Agriculture Organization rec-
+ommendations continue to reiterate the previous recommenda-
+tion to reduce SFAs to less than 10% of total calories [6]. This
+needs to be better understood in regard to coconut saturated
+fats. Even long-term coconut oil studies confirm that there is
+no change in lipid-related cardiovascular risk factors and events
+after 2 years of coconut oil consumption [38]. A recent study
+has also suggested that PUFA-rich oils such as soybean oil
+might be more deleterious to metabolic health compared to
+SFA-rich coconut oil [39]. The current study shows that con-
+sumption of fresh coconut, which is commonly consumed as
+part of the daily diet in many parts of India, does not have any
+deleterious effects on blood lipids or erythrocyte fatty acids but
+may have some beneficial effects such as increasing levels of the
+anti-atherogenic HDL as well as the anti-inflammatory fatty
+acid DGLA.
+Recent advances in nutritional science now allow assessment
+of critical questions about the health effects of SFAs. Our find-
+ings contradict the perspective that dietary saturated fat per se
+is harmful and emphasize the importance of considering the
+source of dietary SFAs. This is one of the first studies on fresh
+coconut that supports the beneficial effects of coconut.
+Conclusion
+Fresh coconut, though rich in SFAs in comparison to a combi-
+nation of groundnut and groundnut oil when used over a
+period of 90 days, had no significant deleterious effect on eryth-
+rocyte fatty acid composition and did not deleteriously change
+lipid-related cardiovascular risk factors. On the whole, this
+study suggests that regular consumption of 100 g of coconut,
+containing high levels of SFAs, does not have any harmful
+effect on plasma lipids and erythrocyte fatty acid composition.
+The results of this work have particular relevance in suggesting
+that individuals wishing to use fresh coconut in their diets can
+4
+R. S. NAGASHREE ET AL.
+do so safely, but more studies need to be conducted with larger
+sample sizes.
+Acknowledgments
+The authors thank the SVYASA project kitchen, especially the man-
+ager and staff of the kitchen for working together to share the main
+kitchen space and endless hours of tasty food preparation. In addition,
+we are grateful for the efforts of student volunteers of SVYASA for
+working toward study-related tasks. St. John’s Research Institute and
+“Anveshana” molecular biology lab at SVYASA is gratefully acknowl-
+edged for analyzing all of our samples. Lastly, the authors thank the
+research participants for their time and dedication in making this
+study possible.
+References
+1. Keys A, Mickelsen O, Miller E, Chapman C: The relation in man
+between cholesterol levels in the diet and in the blood. Science 112
+(2899):79–81, 1950.
+2. Keys A, Anderson JT, Grande F: Serum cholesterol response to
+changes in the diet. Metabolism 14:776–787, 1965.
+3. Dietschy JM: Dietary fatty acids and the regulation of plasma low den-
+sity lipoprotein. J Nutr 128:444S–448S, 1998.
+4. Hegsted DM, McGandy RB, Myers ML, Stare FJ: Quantitative effects
+of dietary fat on serum cholesterol in man. Am J Clin Nutr 17(5):281–
+295, 1965.
+5. Ramprasath VR, Jones PJH, Buckley DD, Woollett LA, Heubi JE:
+Decreased plasma cholesterol concentrations after PUFA-rich diets
+are not due to reduced cholesterol absorption/synthesis. Lipids
+47:1063–1071, 2012.
+6. Food and Agriculture Organization of the United Nations (FAO):
+“Fats and Fatty Acids in Human Nutrition. Report of an Expert Con-
+sultation.” Author, 2010.
+7. Ramaswamy L: Coconut flour—a low carbohydrate, gluten free flour.
+Int J Ayurvedic Herb Med 3:1426–1436, 2014.
+8. Shahikumar HM, Chandrashekar S: An analysis of production and
+marketing of coconut in Tumkur district, India. Int J Curr Res Acad
+Rev 2:167–175, 2014.
+9. Moideenkutty C: Consumption pattern of coconut. Indian Coconut J
+52:122, 2005.
+10. Gopalan C, Sastri BVR, Balasubramanian SC: “Nutritive Value of
+Indian Foods.” Hyderabad, India: National Institute of Nutrition,
+ICMR, 2012.
+11. Vasudevan DM: Lipid profile in blood and in plaque material from
+diseased coronary artery. Indian Coconut J October 2010:17–21, 2010.
+12. Uragoda GC: Coconut fats. Ceylon Med J 51(2), 2006.
+13. Sabitha P, Vasudevan DM: Lipid profile and antioxidant enzymes in
+coconut oil. Indian Coconut J 2010.
+14. Tholstrup T, Ehnholm C, Jauhiainen M, Petersen M, Høy C-E, Lund
+P, Sandstr€
+om B: Effects of medium-chain fatty acids and oleic acid on
+blood lipids, lipoproteins, glucose, insulin, and lipid transfer protein
+activities. Am J Clin Nutr 79:564–569, 2004.
+15. Assuncao ML, Ferreira HS, dos Santos AF, Cabral CR, Florencio TMMT:
+Effects of dietary coconut oil on the biochemical and anthropometric pro-
+files of women presenting abdominal obesity. Lipids 44:593–601, 2009.
+16. Seneviratne KN, Sudarshana DM: Variation of phenolic content in
+coconut oil extracted by two conventional methods. Int J Food Sci
+Technol 43:597–602, 2008.
+17. Mahayothee B, Koomyart I, Khuwijitjaru P, Prasong Siriwongwilai-
+chat MN, M€
+uller J: Phenolic compounds, antioxidant activity, and
+medium chain fatty acids profiles ofcoconut water and meat at differ-
+ent maturity stages. Int J Food Prop 19:2041–2051, 2016.
+18. Davis C, Bryan J, Hodgson J, Murphy K: Definition of the Mediterra-
+nean diet: a literature review. Nutrients 7:9139–9153, 2015.
+19. Gillingham LG, Harris-Janz S, Jones PJH: Dietary monounsaturated
+fatty acids are protective against metabolic syndrome and cardiovas-
+cular disease risk factors. Lipids 46:209–228, 2011.
+20. Khoramnia A, Ebrahimpour A, Ghanbari R, Ajdari Z, Lai O: Improve-
+ment of medium chain fatty acid content and antimicrobial activity of
+coconut oil via solid-state fermentation using a Malaysian Geotrichum
+candidum. Biomed Res Int 2013:7–9, 2013.
+21. Hausenloy DJ, Yellon DM: Targeting residual cardiovascular risk:
+raising high-density lipoprotein cholesterol levels. Postgrad Med J
+84:590–598, 2008.
+22. Ali KM, Wonnerth A, Huber K, Wojta J: Cardiovascular disease risk
+reduction by raising HDL cholesterol—current therapies and future
+opportunities. Br J Pharmacol 167:1177–1194, 2012.
+23. Barter P: HDL-C: role as a risk modifier. Atherosclerosis 12:267–270,
+2011.
+24. Eren E, Yilmaz N, Aydin O: High density lipoprotein and its dysfunc-
+tion. Open Biochem J 6:78–93, 2012.
+25. Thompson-Felty C, Johnston CS, Ryder A: Coconut oil supplementa-
+tion an innovative strategy for cardiovascular disease risk reduction.
+FASEB J 30:904–919, 2016.
+26. Mensink RP, Zock PL, Kester ADM, Katan MB: Effects of dietary fatty
+acids and carbohydrates on the ratio of serum total to HDL cholesterol
+and on serum lipids and apolipoproteins: a meta-analysis of 60 con-
+trolled trials. Am J Clin Nutr 77:1146–1155, 2003.
+27. Temme EH, Mensink RP, Hornstra G: Effects of medium chain fatty
+acids (MCFA), myristic acid, and oleic acid on serum lipoproteins in
+healthy subjects. J Lipid Res 38:1746–1754, 1997.
+28. Green SR, Pittman RC: Comparative acyl specificities for transfer and
+selective uptake of high-density-lipoprotein cholesteryl esters. J Lipid
+Res 32:457–467, 1991.
+29. Rodrigues A, Burke MF, Jafri K, French BC, Phillips JA, Mucksavage
+ML, Wilensky RL, Mohler ER, Rothblat GH, Rader DJ: Cholesterol
+efflux capacity, high-density lipoprotein function, and atherosclerosis.
+N Engl J Med 364(2):127–135, 2011.
+30. Di Angelantonio E, Sarwar N: Major lipids, apolipoproteins, and risk
+of vascular disease. J Am Med Assoc 302:1993–2000, 2009.
+31. Eyres L, Eyres MF, Chisholm A, Brown RC: Coconut oil consumption
+and cardiovascular risk factors in humans. Nutr Rev 74:267–280,
+2016.
+32. Arab L: Biomarkers of fat and fatty acid intake. J Nutr 133
+(Suppl):925S–932S, 2003.
+33. Caspar-Bauguil S, Garcia J, Galinier A, P
+eriquet B, Ferri
+eres J,
+Allenbach S, Morin N, H
+ericotte P, Salvayre R, Baudet M: Positive
+impact of long-term lifestyle change on erythrocyte fatty acid profile
+after acute coronary syndromes. Arch Cardiovasc Dis 103(2):106–114,
+2010.
+34. Papackova Z, Cahova M: Fatty acid signaling: the new function of
+intracellular lipases. Int J Mol Sci 16:3831–3855, 2015.
+35. Wang X, Lin H, Gu Y: Multiple roles of dihomo-g-linolenic acid
+against proliferation diseases. Lipids Health Dis 11:25, 2012.
+36. Yeung J, Tourdot B, Adili R, Green A, Freedman C, Fernandez-
+Perez P, Yu J, Holman T, Holinstat M: 12(S)-HETrE, a 12-lipoxy-
+genase oxylipin of dihomo-g-linolenic acid, inhibits thrombosis
+via Gas signaling in platelets. Arterioscler Thromb Vasc Biol
+36:2068–2077, 2016.
+37. Siri-tarino PW, Sun Q, Hu FB, Krauss RM: Meta-analysis of prospec-
+tive cohort studies evaluating the association of saturated fat with car-
+diovascular disease. Am J Clin Nutr 91:535–546, 2010.
+38. Vijayakumar M, Vasudevan DM, Sundaram KR, Krishnan S, Vaidya-
+nathan K, Nandakumar S, Chandrasekhar R, Mathew N: A random-
+ized study of coconut oil versus sunflower oil on cardiovascular risk
+factors in patients with stable coronary heart disease. Indian Heart J
+68:498–506, 2016.
+39. Deol P, Evans JR, Dhahbi J, Chellappa K, Han DS, Spindler S, Sladek
+FM: Soybean oil is more obesogenic and diabetogenic than coconut
+oil and fructose in mouse: potential role for the liver. PLoS One 10:
+e0132672, 2015.
+JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
+5

subfolder_0/Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint A randomized control study.txt

@@ -0,0 +1,384 @@
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+1/9
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A
+randomized control study
+John Ebnezar, Raghuram Nagarathna, [...], and Hongasandra Ramarao Nagendra
+Abstract
+Aim:
+This study was designed to evaluate the efficacy of addition of integrated yoga therapy to therapeutic exercises in osteoarthritis
+(OA) of knee joints.
+Materials and Methods:
+This was a prospective randomized active control trial. A total of t participants with OA of knee joints between 35 and 80 years
+(yoga, 59.56 ± 9.54 and control, 59.42 ± 10.66) from the outpatient department of Dr. John's Orthopedic Center, Bengaluru,
+were randomly assigned to receive yoga or physiotherapy exercises after transcutaneous electrical stimulation and ultrasound
+treatment of the affected knee joints. Both groups practiced supervised intervention (40 min per day) for 2 weeks (6 days per
+week) with followup for 3 months. The module of integrated yoga consisted of shithilikaranavyayama (loosening and
+strengthening), asanas, relaxation techniques, pranayama, meditation and didactic lectures on yama, niyama, jnana yoga,
+bhakti yoga, and karma yoga for a healthy lifestyle change. The control group also had supervised physiotherapy exercises. A
+total of 118 (yoga) and 117 (control) were available for final analysis.
+Results:
+Significant differences were observed within (P < 0.001, Wilcoxon's) and between groups (P < 0.001, Mann–Whitney U-test) on
+all domains of the Short Form-36 (P < 0.004), with better results in the yoga group than in the control group, both at 15  day
+and 90  day.
+Conclusion:
+An integrated approach of yoga therapy is better than therapeutic exercises as an adjunct to transcutaneous electrical stimulation
+and ultrasound treatment in improving knee disability and quality of life in patients with OA knees.
+Keywords: Knee disability, osteoarthritis, SF-36, yoga
+INTRODUCTION
+Osteoarthritis (OA) is the second most common rheumatological problem in India and has a prevalence rate of 22–39%.[1] It is
+characterized primarily by articular cartilage degeneration and a secondary periarticular bone response.[2,3] Worldwide
+prevalence rate of OA is 20% for men, 41% for women, and it causes pain or dysfunction in 20% of the elderly.[4] Relieving
+pain stiffness and improving physical functions are the important goals of the present day therapy.[5,6]
+The management of OA is still far from optimal, because the medications currently available provide limited symptomatic relief
+and are fraught with a number of side-effect.[7] It is increasingly recognized that a key outcome measure for any health-care
+intervention for OA is the change in health-related quality of life (QOL).[8,9] Although OA itself is not a life-threatening
+disease, QOL can significantly deteriorate with pain and loss of mobility causing dependence and disability.[10] Health-related
+QOL may be measured by disease-specific and generic health status questionnaires. Western Ontario and McMaster Universities
+Osteoarthritis Index Score (WOMAC) is used to measure specific functional disability and SF-36 is used to measure general health
+status that includes assessment of emotional functioning, energy level, and social functioning in addition to functional disability
+th
+th
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+2/9
+assessment. Aglamiş et al[11] Foley et al,[12] and Diracoglu et al.[13] observed greater increases in the SF-36 after the exercise
+program of various durations for patients with OA knees. Kirkley et al.[14] showed that in patients assigned to arthroscopic
+surgery, there was no improvement with health-related QOL. In a study by Tekur et al.[15] the role of yoga in the improvement
+of QOL of patients with chronic low backache was discussed, and she showed that in the yoga group, there was significant
+improvement in the scores of WHOQOL (WHO's Quality of life) brief on all domains. In a study by Sudheer et al.[16] about the
+role of yoga about QOL in normal volunteers, 28% in physical, 16% in psychological, 10.17% in social, and 8.8% in the
+environmental domain changed significantly after shifting to the control intervention in the second week.
+There are no studies that have looked at disability and QOL measures in patients with OA knees after integrated yoga therapy
+involving loosening, strengthening, asanas, etc. Hence, this study was planned with an aim to assess the effects of the integrated
+approach of yoga therapy on QOL using a generic health-status tool involving SF-36 in patients with OA knee.
+MATERIALS AND METHODS
+A total of t patients with OA knees from the outpatient department of Dr John's Orthopedic Center, Bengaluru, were recruited
+for the study. A sample size of 250 was obtained on G power software by fixing the alpha at 0.05 powered at 0.8 and an effect
+size of 0.379 considering the mean and SD of an earlier study.[17] A total of t of both genders in the age group of 35–80 years
+(59.56 ± 8.18) in the yoga group and (59.42 ± 10.66) control group with OA knees (one or both joints) satisfying theAmerican
+College of Rheumatology (ACR) Guidelines[18] for diagnosis were included. The inclusion criteria were (i) persistent pain for 3
+months prior to recruitment, (ii) moderate-to-severe pain on walking, (iii) Kellegren and Lawrence[19] radiologic grading of II-
+IV in X-rays taken within 6 months prior to entry, and (iv) those fully ambulant, literate, and willing to participate in the study.
+Those with (i) grade I changes in -ray, (ii) acute knee pain, (iii) secondary osteoarthritis due to rheumatoid arthritis, gout, septic
+arthritis, tuberculosis, tumor, trauma, or hemophilia, and (iv)those with major medical or psychiatric disorders were excluded.
+The study was approved by the institutional review board (IRB) and ethical committee of SVYASA (Swami Vivekananda Yoga
+Anusandhana Samsthana) University. Signed informed consent was obtained from all the participants.
+Design
+This was a prospective randomized parallel active control study on patients with OA knees in the age range of 35-80 years.
+Patients attending the outpatient department of Dr John's Orthopedic Center who satisfied the inclusion criteria were recruited
+for the study. After the initial screening for selection criteria, they were assigned to either the yoga group or control group. A
+computer-generated random number table (www.randomization.com) was used for randomization. Numbered envelopes were used
+to conceal the sequence until the intervention was assigned. Both groups were given the conventional physiotherapy using
+transcutaneous electrical stimulation and ultrasound for 15 days.
+Both groups had supervised practices at the center for 40 min daily (6 days/week) after physiotherapy (20 min) for 2 weeks. The
+yoga classes were conducted in the basement of the hospital where one hall is exclusively dedicated for yoga therapy. The study
+group was taught integrated yoga and the control group was taught the non-yogic physiotherapy exercises by certified therapists.
+After this, they were asked to practice daily at home for the next 3 months. Compliance was supervised by telephone calls once
+in 3 days and a weekly review was conducted once a week for 3 months. The daily review cards were checked for the regularity
+and doubts if any were clarified. The evaluation was conducted by the senior research fellow. All patients were asked to tick the
+practices daily after the home practice in the diary provided for the purpose; at every visit their clinical progress and therapy
+received on the day were documented. All assessments were carried out on 1 , 15 , and 90  days.
+Blinding and masking
+As this was an interventional study, double blinding was not possible. The answer sheets of the questionnaires were coded and
+analyzed only after the study was completed. Here, the statistician who did the randomization, data analysts, and the researcher
+who carried out the assessments were blinded to the treatment status of the subjects.
+st
+th
+th
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+3/9
+Intervention for the yoga group
+The daily routine practiced at the center in the yoga group included 40 min of integrated yoga therapy practice after 20 min of
+physiotherapy with transcutaneous electrical stimulation and ultrasound for 2 weeks [Table 1]. The integrated yoga therapy
+practice included shithilikaranavyayamas (loosening practices), saktivikasaka (strengthening practices) followed by yogasanas
+and relaxation techniques with devotional songs. Later patients were advised to continue the integrated yoga therapy practice for
+40 min at home for the next 10 weeks.
+Table 1
+Yoga module for osteoarthritis knees
+The concept used to develop a specific module of an integrated approach of yoga therapy for knee pain was taken from the
+traditional yoga scriptures (patanjali yoga sutras, yoga vasishtha, and upanishads) that highlight a holistic lifestyle for positive
+health at physical, mental, emotional, and intellectual levels.[20] Yoga is defined as the mastery over the modifications of mind
+(chittavrittinirodhah—definition of yoga by patanjali). It helps to remove the unnecessary surges of neuromuscular activation
+resulting from heightened stress responses that may contribute to aging.[21] The daily routine included a 40 min practice as
+follows:
+Yogic sukshmavyayamas (loosening and strengthening practices): These are safe, rhythmic, repetitive stretching
+movements synchronized with breathing. These practices mobilize the joints and strengthen the periarticular muscles.
+Relaxation techniques: Three types of guided relaxation techniques were interspersed between the physical practices of
+sukshmavyayamas and asanas.
+Asanas (physical postures): Asanas are featured by effortless maintenance in the final posture by internal awareness. We
+selected asanas in standing, supine and prone positions that would relax and strengthen the knee joints.
+Pranayama: The practice of voluntary regulated breathing while the mind is directed to the flow of breath is called
+Pranayama. These practices promote autonomic balance through mastery over the mind.[22]
+Meditation: Patanjali defines meditation (dhyana) as effortless flow of a single thought like OM in the mind without
+distractions (pratyayaekataanatadhyanam). This has been shown to offer physiological benefits through alertful rest to
+the mind body complex.[23]
+Lectures and counseling: Yogic concepts of health and disease, yama, niyama, bhakti yoga, Jnana yoga, and karma yoga were
+presented in the theory classes. These sessions were aimed at understanding the need for lifestyle change, weight management,
+and prevent early aging by yogic self-management of psychosocial stresses.
+Intervention for the control group
+The daily routine practiced at the center in the control group included 40 min of therapeutic exercises after 20 min of
+physiotherapy with transcutaneous electrical stimulation and ultrasound for 2 weeks [Table 2]. These therapeutic exercises
+included loosening and strengthening practices for all the joints of the upper and lower limbs, brief period of rest, specific knee
+practices, and supine rest followed by light music. Later patient was advised to continue the therapeutic exercise practice of 40
+min at home for the next 12 weeks.
+Table 2
+Control module for OA knees
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+4/9
+Outcome variables
+Short Form 36) was used to assess QOL after the intervention in both groups on day 15 and 90. SF-36 is one of the popularly
+used self-evaluation questionnaire for the assessment of general.[24] It contains 36 questions aimed at assessment of the
+participant's health under eight major categories: physical functioning, role limitations due to physical health, role limitations
+due to mental health, energy or fatigue, emotional well-being, social functioning, pain, and general health. The scores are then
+averaged accordingly under those headings.[25]
+The increase in scores indicates better for domains physical functioning, role of limitations in physical health, role of limitations
+in emotional problems, social functioning, pain reduction, general health, and for domains fatigue and emotional well-being the
+decrease in scores indicates better QOL. The internal consistency of the SF-36 Health Survey Questionnaire as determined by
+Cronbachs was high and ranged from 0.72-0.94.
+Statistical methods
+The data were analyzed using SPSS Version 16. The baseline values of the two groups were checked for normal distribution by
+Shapiro–Wilk's test. Baseline matching was checked by the Mann–Whitney test. Wilcoxon's signed ranks test and MannWhitney
+U-test were used for assessing ‘within’ and ‘between’ groups differences, respectively.
+Tables 1 and 2 show the interventions of both study and control groups. Table 3 shows the baseline characteristics which were
+similar between groups on all variables (P > 0.05, Mann–Whitney test for pre values).
+Table 3
+Demographic data
+RESULTS
+The trial profile of the study is shown in Figure 1. There were seven dropouts in the study group and eight in the control group. 
+Table 4 shows the results within the yoga group of 15  and 90  day. Table 5 shows the results within the control group of 15
+and 90  day, and Table 6 shows the results between the yoga and control groups.
+Figure 1
+Trial profile of the study
+Table 4
+Results of variations of several parameters in SF-36 before and after integrated yoga therapy
+Table 5
+Results of variations of several parameters in SF-36 before and after therapeutic exercises
+th
+th
+th
+th
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+5/9
+Table 6
+Results of SF-36 variables between groups (yoga and control groups)
+Quality of life
+Between and within group differences were highly significant on all domains of the SF-36 (P < 0.001) with better improvement
+in the yoga group than the control group on 15  day and 90  day.
+Physical functioning
+This measures all the physical activities including bathing or dressing. In the yoga group, the physical function (P < .001)
+increased from 12.03 ± 9.94 to 39.32 ± 11.24 and further to 67.50 ± 9.09 and in the control group from 12.82 ± 10.81 to 24.95
+± 13.93 and further to 50.94 ± 14.76 on 15  day and 90  days, respectively.
+Role limitation in physical health
+This measures problems with work or other daily activities as a result of physical health. The role limitation in physical health
+(P < 0.001) improved by increase of scores from 52.33 ± 29.59 to 86.44 ± 15.55 in the yoga group and 35.47 ± 36.14 to 58.33
+± 44.52 in the control group on the 15th and 90th days, respectively, with significantly better results in the yoga group than the
+control group (P = 0.001, Mann–Whitney U test).
+Role limitation due to emotional health
+This evaluates problems with work or other daily activities due to physical and emotional problems. The role limitation due to
+emotional health (P < 0.001) improved from 56.17 ± 22.93 to 86.41 ± 17.59 in the yoga group and from 31.02 ± 26.86 to
+58.75 ± 38.94 in the control group on the 15th and 90th days, respectively, with significantly better results in the yoga group
+than the control group (P = 0.001, Mann-Whitney U test).
+Energy and fatigue level
+These levels are evaluated by finding out whether a person feels tired and worn out or feels full of pep and energy all the time.
+The energy and fatigue level improved in both groups (P <0.001, Wilcoxon's) with reduction of scores from 66.36 ± 5.66 to
+50.10 ± 6.30 and further to 36.35 ± 6.08 in the yoga group and from 64.91 ± 5.41 to 58.97 ± 5.6 and to 53.20 ± 6.8 in the
+control group on 15  and 90  days, respectively, with significantly better results in the yoga group than the control group (P =
+0.001, Mann–Whitney U test).
+Emotional well-being
+This evaluates whether a person has problems or no problems with work or other daily activities as a result of emotional
+problems. In the yoga group, the emotional well-being (P < 0.001, Wilcoxon's) improved with reduction in scores from 63.10 ±
+7.17 to 48.88 ± 7.01 and to 34.33 ± 5.46 and in the control group from 62.46 ± 6.61 to 57.43 ± 5.78 to 52.27 ± 5.91 on the
+15  and 90  days, respectively, with significantly better results in the yoga group than the control group (P = 0.001, Mann–
+Whitney U test).
+th
+th
+th
+th
+th
+th
+th
+th
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+6/9
+Social functioning
+This evaluates whether the social activities are limited due to physical and emotional problems. In the yoga group, the emotional
+well-being (P <.001,Wilcoxon's) increased from 50.50 ± 6.82 to 57.83 ± 6.89 and to 64.04 ± 8.92 and in the control group from
+51.92 ± 9.37 to (52.67 ± 9.40) and to 57.15 ± 10.42 on the 15  and 90  days, respectively, with significantly better results in
+the yoga group than the control group (P = 0.001, Mann–Whitney test).
+Pain
+This measures the severity of pain that limits the activities. Well-being on scores of pain improved in both groups (P < 0.001,
+Wilcoxon's) from 11.54 ± 11.55 to 47.88 ± 11.33 and to 73.77 ± 12.67 in the yoga group and in the control group from 11.68
+± 9.11 to 30.21 ± 9.09 and to 46.93 ± 11.22 on the 15  and 90  days, respectively, with significantly better results in the yoga
+group than the control group (P = 0.001, Mann–Whitney test).
+General health
+This evaluates the personal health of the individual. The general health increased in both groups (P < 0.001). It increased from
+36.91 ± 6.94 to 59.31 ± 12.24 to 77.47 ± 20.91 in the yoga group from 36.99 ± 11.08 to 48.75 ± 9.26 to 60.12 ± 12.57 in the
+control group on the 15  and 90  days, respectively, with significantly better results in the yoga group than the control group (P
+= 0.001, Mann–Whitney U test).
+DISCUSSION
+This randomized two armed parallel control trial on 250 participants included patients of both genders (F = 175) in age 35–80
+years with osteoarthritis of knees. Results showed significantly better improvement in the yoga group than the control group on
+all variables (P < 0.001, Mann–Whitney U test) of SF 36.
+In a randomized controlled study on magnetic pulse treatment for knee osteoarthritis by Piptone et al. assessment of the patients
+at week 6 revealed a statistically significant improvement in pain and disability of the WOMAC questionnaire (Western Ontario
+and McMaster Universities) and EuroQol score (EuroQol or EQ-5D is a standardized measure of health status developed by the
+EuroQol group in order to provide a simple, generic measure of health for clinical and economic appraisal) in the active
+treatment group.[26]
+Pain reduction
+The reduction in pain observed in our study points to the beneficial effect of yoga as an add-on therapy to conventional
+physiotherapy practices.
+In pilot studies on OA knees involving yoga, Kolasinski et al.[27] Ranjita et al.[28] showed a better reduction of pain in the yoga
+group than the control group. In our study, we added yoga after the standard physiotherapy and the degree of changes appears to
+be similar in all the three yoga studies (37-47%). This may point to the efficacy of yoga when used with or without a session of
+physiotherapy before the practice of yoga.
+Similar effects of pain reduction ha been observed by Garfinkel et al.[29] in a randomized controlled trial on yoga for carpal
+tunnel syndrome. Tekur et al.[15] studied the efficacy of the integrated approach of yoga therapy in patients with chronic low
+back pain and documented 48.8% reduction in Numerical Rating Scale scores in the yoga group. Garfinkel et al.[30] studied the
+effects of Iyengar yoga in patients with OA hands and found a better reduction in the pain during activity. Yogitha et al.[31]
+showed a reduction in pain and tenderness in patients with common neck pain after integrated yoga. In a study by Aglamiş et al.
+[11] there was a significant group differences in all domains of SF-36 (P < 0.004), while there were no group difference in
+WOMAC domains (P > 0.004). Baker et al.[32] found increases in the SF-36 physical function, physical role, social and mental
+health scores and physical performance scores and decreases in the WOMAC pain after a 4-month strength exercise program.
+Foley et al.[12] stated that after a 6-week exercise program physical performance increased, the WOMAC score did not change,
+th
+th
+th
+th
+th
+th
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+7/9
+and the physical component of the SF-12 increased after hydrotherapy. Diracoglu et al.[13] observed increases in the SF-36
+physical function, physical role, and vitality scores and the WOMAC physical function scores and physical performance in a
+kinesthetic group is greater than in a strength group after an 8 week exercise program. In a study by Kirkley et al.[14] in patients
+assigned to arthroscopic surgery there was no improvement with respect to physical function, pain, or health-related than those
+were assigned to the control group. In a study conducted at our center by Rangaji et al.[33] on the role of IAYT in the treatment
+of osteoporosis, he showed that in the comparison between the groups, the exercise group showed a significant difference in
+physical functioning component of SF-36 than the yoga group.
+This study has revealed a statistically significant improvement in respect of all the domains of the SF 36 score with significantly
+better improvements in the yoga and control groups.
+Mechanisms
+Several factors would have contributed to the beneficial effects observed in both groups in this study. As noted in several earlier
+studies physiotherapy intervention may increase the blood glow. Better results in the yoga group could be due to its stress
+reducing effect since yoga is meant to bring about better emotional stability. Yoga is defined as ‘samtvam yoga’ in
+Bhagavadgita[34] which refers to ‘the balanced state of mind under any demanding life situation, be physical or psychological
+(sheetaushnasukhaduhkheshusamah)’. This emotional stability is achieved by the multifactorial approach of yoga that includes
+safe physical practices (asanas), breathing techniques (pranayama), meditation (dharana and dhyana), and introspective
+corrections in one's cognitive errors by inputs at intellectual (jnana yoga) and emotional level (bhakti yoga).[35] This may have
+contributed to better health behavior and improved QOL.
+Strengths of the study
+Good sample size, randomized control design, active supervised intervention for the control group for the same duration as the
+experimental group and follow up for 3 months with good compliance (6% dropouts) are the strengths of this study. The result
+of this study that has shown marked differences between groups on all variables offers strong evidence for incorporating this
+module of IAYT for knees by the clinicians.
+Suggestions for future work
+A longer follow-up of ≥12 months is necessary to check for long-term efficacy and long-term acceptability. Studies using MRI
+and biochemical variables may throw light on the mechanisms.
+CONCLUSIONS
+Adjunctive program of the integrated approach of yoga therapy for OA knees improves all components of QOL on SF36. IAYT
+offers a good value addition as a nonpharmacological intervention in improving QOL in patients with OA knees.
+Footnotes
+Source of Support: Nil
+Conflict of Interest: None declared
+Article information
+Int J Yoga. 2011 Jul-Dec; 4(2): 55–63.
+doi:  10.4103/0973-6131.85486
+PMCID: PMC3193655
+John Ebnezar, Raghuram Nagarathna,  Yogitha Bali, and Hongasandra Ramarao Nagendra
+1
+1
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+8/9
+Department of Orthopaedics, Dr. John's Orthopaedic Centre, Karnataka, Bengaluru, India
+Division of Life Sciences, Swami Vivekananda Yoga Research Foundation (SVYASA), Karnataka, Bengaluru, India
+Address for correspondence: Dr. John Ebnezar, Department of Orthopaedics, Dr. John's Orthopaedic Centre, Bilekahalli, Bannerghatta Road, Bengaluru,
+Karnataka, India. E-mail: [email protected]
+Copyright : © International Journal of Yoga
+This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits
+unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
+This article has been cited by other articles in PMC.
+Articles from International Journal of Yoga are provided here courtesy of Medknow Publications
+REFERENCES
+1. Chopra A, Patil J, Bilampelly V, Relwani J, Tandle HS. Prevalence of rheumatic disease in rural population in Western India: A WHO-ILAR-
+COPCORD study. J Assoc Physicians India. 2001;49:240–6. [PubMed]
+2. Felson DT. An update on the pathogenesis and epidemiology of osteoarthritis. Radiol Clin North Am. 2004;42:1–9. [PubMed]
+3. Felson DT, Lawrence RC, Dieppe PA, Hirsch R, Helmick CG, Jordan JM, et al. Osteoarthritis: New insights.Part 1: The disease and its risk
+factors. Ann Intern Med. 2000;133:635–46. [PubMed]
+4. Lawrence JS, Bremmer JM, Bier F. Osteoarthrosis.Prevalence in the population and relationship between symptoms and x-ray changes. Ann
+Rheum Dis. 1966;25:1–24. [PMC free article] [PubMed]
+5. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology
+Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:1905–15. [PubMed]
+6. Pendleton A, Arden N, Dougados M, Doherty M, Bannwarth B, Bijlsma JW, et al. EULAR recommendations for the management of
+osteoarthritis: Report of task force standing committee for International Clinical Studies including Therapeutic Trials (ESCISIT) Ann Rheum Dis.
+2000;59:936–44. [PMC free article] [PubMed]
+7. Brazier JE, Harper R, Munro J, Walters SJ, Snaith ML. Generic and condition-specific outcome measures for people with osteoarthritis of the
+knee. Rheumatology (Oxford) 1999;38:870–7. [PubMed]
+8. Patrick DL, Deyo RA. Generic and disease-specific measures in assessing health status and quality of life. Med Care. 1989;27:217–32. [PubMed]
+9. Baker K, McAlindon T. Exercise for knee osteoarthritis. Curr Opin Rheumatol. 2000;12:456–63. [PubMed]
+10. Maly MR, Costigan PA, Olney SJ. Determinants of self report outcome measures in people with knee osteoarthritis. Arch Phys Med Rehabil.
+2006;87:96–104. [PubMed]
+11. Aglamiş B, Toraman NF, Yaman H. Change of quality of life due to exercise training in knee osteoarthritis: SF-36 and Womac. J Back
+Musculoskeletal Rehab. 2009;22:43–8. [PubMed]
+12. Foley A, Halbert J, Hewitt T, Crotty M. Does hydrotherapy improve strength and physical function in patients with osteoarthritis – a
+randomized controlled trial comparing a gym based and hydrotherapy based strengthening programme. Ann Rheum Dis. 2003;62:1162–7.
+[PMC free article] [PubMed]
+13. Diracoglu D, Aydin R, Baskent A, Celik A. Effects of kinesthesia and balance exercises in knee osteoarthritis. J Clin Rheumatol. 2005;11:303–
+10. [PubMed]
+14. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, et al. A randomized trial of arthroscopic surgery for osteoarthritis
+of the knee. N Eng J Med. 2008;359:1097–107. [PubMed]
+15. Tekur P, Singhpow C, Nagarathna HR, Raghuram N. Effect of short term intensive yoga program on pain, functional disability, and spinal
+flexibility in chronic low back pain: A randomized control study. J Altern and Complement Med. 2008;14:637–44. [PubMed]
+1
+8/12/2014
+Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193655/
+9/9
+16. Deshpande S, Nagendra HR, Nagarathna R, Sudheer D, Nagendra HR, Nagarathna R. Effect of yoga on gunas (Personality) and health in normal
+healthy volunteers. Int J Yoga. 2008;2:13–21. [PMC free article] [PubMed]
+17. Bookman AA, Williams KS, Shainhouse JZ. Effect of topical diclofenac solution for relieving symptoms of primary osteoarthritis of the knee: A
+randomized controlled trial. CMAJ. 2004;171:333–8. [PMC free article] [PubMed]
+18. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development of criteria for the classification and reporting of
+osteoarthritis.Classification of the osteoarthritis of the knee. Arthritis Rheum. 1986;29:1039–49. [PubMed]
+19. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16:494–502. [PMC free article] [PubMed]
+20. Nagarathna R, Nagendra HR. Bangalore: Swami Vivekananda Yoga Prakashana; 2000. Yoga for promotion of positive health.
+21. Nagarathna R, Nagendra HR. Bangalore: Swami Vivekananda Yoga Prakashana; 2001. Yoga for Arthritis.
+22. Telles S, Nagarathna R, Nagendra HR. Breathing through a particular nostril can alter metabolism and autonomic activities. Indian J Physiol
+Pharmacol. 1994;38:133–7. [PubMed]
+23. Telles S, Nagarathna R, Nagendra HR. Autonomic changes during Om meditation. Indian J Physiol Pharmacol. 1995;39:418–20. [PubMed]
+24. Ware JE, Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I.Conceptual framework and item selection. Med Care.
+1992;30:473–83. [PubMed]
+25. Jenkinson C, Layte R, Wright L, Coulter A. Oxford, U.K: Health services research unit, dept of public health and primary care, University of
+Oxford; 1996. The U.K. SF-36: An analysis and interpretation manual.
+26. Pipitone N, Scott DL. Magnetic pulse treatment for knee osteoarthritis: a randomised, double-blind, placebo-controlled study. Curr Med Res
+Opin. 2001;17:190–6. [PubMed]
+27. Kolasinski SL, Garfinkel M, Tsai AG, Matz W, Van Dyke A, Schumacher HR. Iyengar yoga for treating symptoms of osteoarthritis of the
+knees: A pilot study. J Altern Complement Med. 2005;11:689–93. [PubMed]
+28. Ranjita R. Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru. Karnataka: 2008. Effect of yoga on pain, mobility, gait, and balance
+in patients with osteoarthritis of the knee.
+29. Garfinkel MS, Singhal A, Katz WA, Allan DA, Reshetar R, Schumacher HR., Jr Yoga-based intervention for carpal tunnel syndrome.A
+randomized trial. JAMA. 1998;280:1601–3. [PubMed]
+30. Garfinkel MS, Schumacher R, Husain A, Levy M, Reshetar RA. Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands.
+J Rheumatol. 1994;21:2341–3. [PubMed]
+31. Yogitha B, Nagarathna R, John E, Nagendra H. Complimentary effect of yogic sound resonance relaxation technique in patients with common
+neck pain. Int J Yoga. 2010;3:18–25. [PMC free article] [PubMed]
+32. Baker KR, Nelson ME, Felson DT, Layne JE, Sarno R, Roubenoff R. The efficacy of home based progressive strength training in older adults
+with knee osteoarthritis: A randomized controlled trial. J Rheumatol. 2001;28:1655–65. [PubMed]
+33. Rangaji . Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru. Karnataka: 2010. Role of IAYT in the treatment of osteoporosis.
+34. Goyandaka J. 19th ed. Gorakhpur: Gita press publications; 2004. Srimadbhagavadgita tattvavivecani.
+35. Nagendra HR, Nagarathna R. An integrated approach of yoga therapy for bronchial asthma: a 3-54-month prospective study. J Asthma.
+1986;23:123–37. [PubMed]

subfolder_0/Effect of holistic yoga program on anxiety symptoms in adolescent girls with polycysti.txt

@@ -0,0 +1,1111 @@
+ 
+ 
+ 
+Journal of Alternative and Complementary Medicine: http://mc.manuscriptcentral.com/jaltcompmed 
+ 
+ 
+ 
+THE EFFECTS OF A HOLISTIC YOGA PROGRAM ON 
+ENDOCRINE PARAMETERS IN ADOLESCENTS WITH 
+POLYCYSTIC OVARIAN SYNDROME: A RANDOMIZED 
+CONTROL TRIAL 
+ 
+ 
+Journal: Journal of Alternative and Complementary Medicine 
+Manuscript ID: JACM-2011-0868.R2 
+Manuscript Type: Original Articles 
+Date Submitted by the Author: 25-Jan-2012 
+Complete List of Authors: Ram, Nidhi; SVYASA, Divison of Yoga and Life Sciences 
+Venkatram, Padmalatha 
+Raghuram, Nagarathna; SVYASA, Divison of yoga and life sciences 
+Ram, Amritanshu; SVYASA, Divison of yoga and life sciences 
+Keywords: endocrinology, mind/body, Ob/Gyn, yoga 
+Abstract: 
+THE EFFECTS OF A HOLISTIC YOGA PROGRAM ON ENDOCRINE 
+PARAMETERS IN ADOLESCENTS WITH POLYCYSTIC OVARIAN SYNDROME: 
+A RANDOMIZED CONTROL TRIAL  
+ 
+ 
+Authors: Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R  
+ABSTRACT:  
+Objective: To compare the effects of a holistic yoga program with the 
+conventional exercise program in adolescent Polycystic Ovarian Syndrome 
+(PCOS).  
+Design: Prospective randomized active control trial  
+Setting: Ninety adolescent (15-18years) girls from a residential college in 
+Andhra Pradesh, who satisfied the Rotterdam criteria were randomized into 
+two groups.  
+Intervention: The yoga group practiced a holistic yoga module while the 
+control group practiced a matching set of physical exercises (1 hour/day, 
+for 12 weeks).  
+Outcome Measure: Anti-Mullerian Hormone (AMH-primary outcome), LH, 
+FSH, testosterone, prolactin, Body Mass Index (BMI), hirsutism and 
+menstrual frequency were measured at inclusion and after 12 weeks.  
+Results: Mann-Whitney test on difference score shows that changes in AMH 
+(Y= - 2.51, C= - 0.49, p=0.006), LH and LH/FSH ratio (LH: Y= - 4.09, 
+C=3.00, p=0.005; LH/FSH: Y= - 1.17, C= 0.49, p= 0.015) were 
+significantly different between the two intervention groups. Also changes in 
+testosterone (Y= - 6.01, C= 2.61, p=0.014) and mFG score (Y= -1.14, C= 
++0.06, p=0.002) were significantly different between the two groups. On 
+the other hand, changes in FSH and prolactin post intervention were non-
+significantly different between the two groups. Also, body weight and BMI 
+Mary Ann Liebert Inc., 140 Huguenot Street, New Rochelle, NY 10801
+Journal of Alternative and Complementary Medicine
+showed non-significantly different changes between the two groups while 
+changes in menstrual frequency were significantly different between the 
+two groups (Y=0.89, C= 0.49, p=0.049).  
+Conclusion: Holistic yoga program for 12 weeks is significantly better than 
+physical exercise in reducing AMH, LH and Testosterone, mFG score for 
+hirsutism and improving menstrual frequency with non significant changes 
+in body weight, FSH and prolactin in adolescent PCOS.  
+Clinical Trial Registration: REFCTRI-2008 000291  
+Key Words: adolescent PCOS, AMH, endocrine parameters, yoga    
+  
+ 
+ 
+Page 1 of 24
+Mary Ann Liebert Inc., 140 Huguenot Street, New Rochelle, NY 10801
+Journal of Alternative and Complementary Medicine
+1
+2
+3
+4
+5
+6
+7
+8
+9
+10
+11
+12
+13
+14
+15
+16
+17
+18
+19
+20
+21
+22
+23
+24
+25
+26
+27
+28
+29
+30
+31
+32
+33
+34
+35
+36
+37
+38
+39
+40
+41
+42
+43
+44
+45
+46
+47
+48
+49
+50
+51
+52
+53
+54
+55
+56
+57
+58
+59
+60
+Original Article
+Effects of a Holistic Yoga Program on Endocrine Parameters
+in Adolescents with Polycystic Ovarian Syndrome:
+A Randomized Controlled Trial
+Ram Nidhi, MSc, Venkatram Padmalatha, MBBS, Raghuram Nagarathna, MBBS, MD,
+and Ram Amritanshu, MSc
+Abstract
+Objectives: The objectives of this trial were to compare the effects of a holistic yoga program with the con-
+ventional exercise program in adolescent polycystic ovarian syndrome (PCOS).
+Design: This was a prospective, randomized, active controlled trial.
+Setting: Ninety (90) adolescent (15–18 years) girls from a residential college in Andhra Pradesh who satisfied the
+Rotterdam criteria were randomized into two groups.
+Intervention: The yoga group practiced a holistic yoga module, while the control group practiced a matching set
+of physical exercises (1 hour/day, for 12 weeks).
+Outcome measures: Anti-mu
+¨ llerian hormone (AMH-primary outcome), luteinizing hormone (LH), follicle-
+stimulating hormone (FSH), testosterone, prolactin, body–mass index (BMI), hirsutism, and menstrual frequency
+were measured at inclusion and after 12 weeks.
+Results: Mann-Whitney test on difference score shows that changes in AMH (Y = - 2.51, C = - 0.49, p = 0.006),
+LH, and LH/FSH ratio (LH: Y = - 4.09, C = 3.00, p = 0.005; LH/FSH: Y = - 1.17, C = 0.49, p = 0.015) were signifi-
+cantly different between the two intervention groups. Also, changes in testosterone (Y = - 6.01, C = 2.61, p = 0.014)
+and Modified Ferriman and Gallway (mFG) score (Y = - 1.14, C = + 0.06, p = 0.002) were significantly different
+between the two groups. On the other hand, changes in FSH and prolactin postintervention were nonsignifi-
+cantly different between the two groups. Also, body weight and BMI showed nonsignificantly different changes
+between the two groups, while changes in menstrual frequency were significantly different between the two
+groups (Y = 0.89, C = 0.49, p = 0.049).
+Conclusions: A holistic yoga program for 12 weeks is significantly better than physical exercise in reducing
+AMH, LH, and testosterone, mFG score for hirsutism, and improving menstrual frequency with nonsignificant
+changes in body weight, FSH, and prolactin in adolescent PCOS.
+Introduction
+P
+olycystic ovarian syndrome (PCOS) is a highly prev-
+alent female endocrine disorder with estimates ranging
+from 2.2% to as high as 26%,1,2 depending on the diagnostic
+criteria used and the ethnicity of the population studied. In a
+recent survey, a 9.13% prevalence of PCOS was found in south
+Indian adolescent girls.3
+In recent years, excessive production of anti-mu
+¨llerian
+hormone (AMH) has been implicated in the etiology of
+PCOS. AMH is emerging as a diagnostic and screening tool
+for PCOS.4 Several studies have shown highly increased
+AMH levels in the serum, granulosa cells (75 times higher),5
+and the follicular fluid of women with PCOS.5,6 AMH, a local
+inhibitor
+of
+follicle-stimulating
+hormone
+(FSH)
+action,7
+shows positive correlation with luteinizing hormone (LH)8
+and negative correlation with FSH.8–10 Dysregulation of
+AMH function due to aberrant sensitivity to FSH leads to
+accumulation of small antral follicles and failed ovulation
+trigger. There is a positive correlation between AMH and
+follicle number.6,9,11,12 Serum AMH levels correlate posi-
+tively with androgen levels in PCOS.7 There are no effective
+therapies for PCOS, although metformin and weight reduc-
+tion have shown some benefits.13 Two (2) studies observed a
+small reduction in AMH levels after prolonged treatment
+with metformin.4,14 Of nonconventional therapies, one study
+Svyasa University, Division of Yoga and Life Sciences, Bangalore, India.
+THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
+Volume 18, Number 00, 2012, pp. 1–8
+ª Mary Ann Liebert, Inc.
+DOI: 10.1089/acm.2011.0868
+1
+ACM-2011-0868-ver9-Nidhi_1P
+Type: research-article
+ACM-2011-0868-ver9-Nidhi_1P.3d
+06/25/12
+12:46pm
+Page 1
+on obese women with PCOS showed no change in AMH
+levels after a 20-week-long weight loss program, although
+there was improvement in reproductive function.15
+There are studies suggesting that chronic stimulation of
+sympathetic activity, a result of stressful lifestyle, can induce
+dysregulation of the hypothalamus–pituitary–ovarian axis
+(HPO axis) in women with PCOS.16 This points to the need
+for stress management–based lifestyle changes that reduce
+sympathetic tone and influence the HPO axis.
+Yogic lifestyle, a form of holistic mind–body medicine
+developed thousands of years ago, is known to reduce
+stress17 and sympathetic tone.18 Hence, it is hypothesized
+that a holistic yoga program would be more effective in re-
+ducing the AMH levels apart from improving all other
+manifestations of PCOS in comparison to a conventional
+exercise program.
+There is a lack of randomized controlled trials analyzing the
+efficacy of lifestyle intervention in PCOS, and to date there is
+no published study on yoga in PCOS. Yogic lifestyle change
+may contribute to a reduction/normalization of sympathetic
+nervous system/hypothalamo-pituitary axis (HPA) activation
+and therefore have beneficial effects on the endocrine system
+in PCOS. Many women with PCOS show psychologic
+distress, which may aggravate hormonal disturbances via
+chronic SNS and/or HPA-axis activation. Thus, the present
+study was designed to investigate the effect of yoga on AMH,
+other endocrine measures, and clinical parameters in adoles-
+cent PCOS in comparison to the physical exercise program.
+Materials and Methods
+Participants
+The study was carried out on adolescent girls aged 15 to 18
+years from a residential college in Anantapur, Andhra
+Pradesh, India. Those who satisfied the Rotterdam criterion
+(two thirds of the features) for PCOS were included in the
+study. The following were the definitions of the three features.
+ Oligo/amenorrhea: absence of menstruation for 45 days
+or more and/or less than eight menses per year.19
+ Clinical hyperandrogenism: Modified Ferriman and
+Gallway (mFG) score of 6 or higher.1 Biochemical
+hyperandrogenism: Serum testosterone level of > 82 ng/
+dL in the absence of other causes of hyperandrogenism.
+ Polycystic ovaries: presence of > 10 cysts, 2–8 mm in
+diameter, usually combined with increased ovarian
+volume of > 10 cm3, and an echo-dense stroma in pelvic
+ultrasound scan.20
+Exclusion
+criteria
+were
+use
+of
+oral
+contraceptives/
+hormone treatment/insulin-sensitizing agents within the
+previous 6 weeks, smoking, hyperprolactinemia, thyroid
+abnormalities, nonclassic adrenal hyperplasia, prior experi-
+ence of yoga, and those who did not consent for the study.
+The study was approved by the Institutional Ethical Com-
+mittee of Swami Vivekananda Yoga Anusandhana Samsthana
+(SVYASA) University. Signed informed consent was obtained
+from the college authorities, the student, and one of the parents.
+Outcome measures
+We have used AMH as the primary outcome measure since
+it is emerging as the most sensitive diagnostic and screening
+tool for PCOS.4 The secondary outcome measures were chan-
+ges in LH, FSH, testosterone, prolactin, mFG score, body–mass
+index (BMI), and menstrual frequency between the groups.
+Power calculation
+Effect size of 0.61 was obtained by using the postintervention
+mean difference between the two groups divided by the corre-
+sponding pooled standard deviation for testosterone from the
+study by Tang et al. on obese PCOS women that compared
+6 months of metformin and lifestyle modification with a
+placebo.21 A sample size of 86 with 43 subjects in each arm was
+calculated keeping this effect size of 0.61, with type1 error at 0.05
+and power at 0.8. The actual recruitment was extended to 90.
+Design
+This was a prospective, randomized, active interventional
+controlled trial in which 90 participants were randomly di-
+vided into two study arms: one arm practiced yoga and the
+other arm practiced conventional physical exercises for the
+same duration.
+Methods
+All women students of standard 11 and 12 attended an
+interactive introductory lecture where the purpose and de-
+sign of the study were elucidated. They were asked to report
+1 week later after obtaining the signed consent from their
+parents. After obtaining the written consent, a clinical ex-
+amination was performed. All girls with oligomenorrhea
+and/or hirsutism (as per the abovementioned definitions)
+were asked to come for an ultrasound scan and blood tests.
+Those who satisfied the Rotterdam criteria for PCOS were
+then randomly assigned to two groups by a statistician using
+a computer-generated random number table by the pre-
+labeled sealed-envelope method. On the basis of a random
+number table, participants were assigned to two interven-
+tions. Anthropometric measurements (BMI, waist and hip
+circumference), endocrine parameters, details of menstrual
+frequency, diet pattern, and stress history were documented.
+Two (2) different halls in the college premises were allot-
+ted for yoga and control group practices. Both groups
+practiced their respective set of practices, 1 hour daily, 7 days
+a week for 12 weeks (total 90 sessions), under the supervision
+of trained instructors. The daily routine in the class consisted
+of lecture (5 minutes) followed by physical practices (40
+minutes), pranayama (5 minutes), and relaxation (10minutes).
+The instructors maintained the register of daily attendance
+and the reason for absence, if any, for both of the groups.
+Blinding and masking
+Double blinding was not possible as this was an inter-
+ventional study. The medical officer, ultrasonologist, and the
+laboratory staff were blind to the groups. Also, the statisti-
+cian who did the randomization and the final analysis was
+blind to the source of the data.
+Assessments
+Abdominal ultrasound scanning of the pelvis with special
+attention to the ovaries was carried out by a certified post-
+graduate medical ultrasonologist using a Philips HD 11XE
+ultrasound system. Vaginal ultrasound scanning was not
+acceptable to the girls or the parents.
+2
+NIDHI ET AL.
+ACM-2011-0868-ver9-Nidhi_1P.3d
+06/25/12
+12:46pm
+Page 2
+A fasting sample of venous blood (10 mL) was drawn in the
+morning (6:00 am–8:00 am) at the hostel premises. The samples
+were packed in ice (3–4C) and transported to the laboratory
+within 6 hours. Serum was separated by centrifugation and
+stored at - 20C until it was analyzed at certified laboratories.
+Hormone estimates including total testosterone, LH, FSH,
+and prolactin were done by fully automated bidirectionally
+interfaced chemiluminescent immunoassay. Thyroid-stimu-
+lating hormone was measured by ultrasensitive sandwich
+chemiluminescent immunoassay. Serum AMH levels were
+assessed by using a second-generation enzyme immunoas-
+say (AMH-EIA kit; Immunotech, a Beckman Coulter Com-
+pany,
+Marseilles,
+France).
+The
+intra-
+and
+interassay
+coefficients of variation were 5.1% and 6.6%, respectively for
+AMH, 3.8% and 4.3% for FSH, 4.9% and 6.5% for LH, and
+4.0% and 5.6% for testosterone.
+Intervention
+The specific modules of intervention were developed by a
+team of experts that included a physiatrist, a gynecologist,
+and yoga therapy physician. Care was taken to match the
+lectures, practical classes, and the type of relaxation tech-
+nique used in the two modules.
+Yoga intervention
+The concepts for the intervention were taken from tradi-
+tional yoga scriptures (Patanjali yoga sutras, Upanishads, and
+Yoga Vasishtha) that highlight a holistic approach to health
+management at physical, mental, emotional and intellectual
+levels.22 The practices consisted of asanas (yoga postures),
+pranayama, relaxation techniques, meditation, and lectures on
+yogic lifestyle and stress management through yogic coun-
+seling. The details of the protocol are given in Table 1. All
+girls received at least one session (about one hour each) of
+individualized counseling that was aimed at cognitive re-
+structuring based on yoga philosophy.
+Control intervention
+Table 1 shows the hour-long module of practices for the
+control group that consisted of a set of physical movements,
+nonyogic safe breathing exercises, followed by supine rest
+(without instructions) that were matched with the yoga
+module. One (1) individualized counseling session was en-
+sured for each student in the control group also. Care was
+taken by the counselors not to introduce any of the yogic
+concepts during these sessions.
+Data analysis
+All statistical analyses were performed using SPSS version
+17.0. The Kolmogorov–Smirnov test was used to check for
+normal distribution. Because the hypothesis was to compare
+the changes after yoga with that of exercise and the data were
+not normally distributed, nonparametric analysis was done by
+using the Mann-Whitney U test to compare difference scores (D
+Table 1. Matched Practices Between Yoga and Control Groups
+Yoga group
+Time
+Control group
+Time
+Group lecture
+8 min
+Group Lecture
+15 min
+Lectures, in the form of cognitive restructuring
+based on the spiritual philosophy
+underlying yogic concepts.
+Lectures on conventional modern
+medical concepts about a healthy
+lifestyle including diet, exercise.
+Surya Namaskara (Sun Salutation)
+10 min
+Brisk walk
+15 min
+Prone asanas
+Prone exercises
+Cobra pose (Bhujangasana)
+1 min
+Prone head lift
+1 min
+Locust pose (Salabhasana)
+1 min
+Prone leg rising
+1 min
+Bow pose (Dhanurasana)
+1 min
+Tiger leg stretch
+1min
+Standing asanas
+Standing exercises
+Triangle pose (Trikonasana)
+1 min
+Spread-leg side bending
+1 min
+Twisted angle pose (Parsva-konasana)
+1 min
+Spread-leg twisted bending
+1 min
+Spread-leg intense stretch (Prasarita padottanasana)
+1 min
+Spread-leg forward bend
+1 min
+Supine asanas
+Supine exercises
+Inverted pose (Viparita Karni)
+1 min
+Straight-leg raising
+1 min
+Shoulder stand (Sarvangasana)
+1 min
+Straight-leg supine twist
+1 min
+Plough pose (Halasana)
+1 min
+Cycling (clockwise–counterclockwise)
+bended-knee crunches
+1 min
+Sitting asanas
+Sitting exercises
+Sitting forward stretch (Paschimottanasana)
+1 min
+Spread-leg forward bend
+1 min
+Fixed-angle pose (Baddha-konasana)
+1 min
+Spread-leg alternate-toe touching
+1 min
+Garland pose (Malasana)
+1 min
+Squat pose
+1 min
+Guided relaxation (Savasana)
+10 min
+Supine rest
+10 min
+Breathing techniques (Pranayama)
+Normal breathing
+8 min
+Sectional breathing (Vibhagiya-Pranayama)
+4 min
+Forceful exhalation (Kapala Bhati)
+2 min
+Right-nostril breathing (Suryanuloma Viloma)
+2 min
+Alternate-nostril breathing (Nadi suddhi)
+2 min
+OM meditation (OM Dhyana)
+10 min
+YOGA EFFECTS ON ENDOCRINE PARAMETERS IN ADOLESCENT PCOS
+3
+ACM-2011-0868-ver9-Nidhi_1P.3d
+06/25/12
+12:46pm
+Page 3
+change) between the two groups wherein difference score was
+calculated by subtracting pre from post values for each variable.
+Results
+Figure 1 describes the trial profile. The recruitment was
+carried out between December 2009 and January 2011. Of 986
+girls who agreed to clinical examination, 154 girls with oligo-
+menorrhea and/or hirsutism (as per the abovementioned
+definitions) were asked to come for ultrasound and biochem-
+ical investigations. After the laboratory evaluations, 90 girls
+who satisfied Rotterdam criteria of PCOS were randomized
+into two groups. Of these, there were a total of 18 dropouts: 8 in
+the yoga group and 10 in the control group because of less than
+75% attendance. The reasons (not confirmed) given for with-
+drawal were (1) sick leave and (2) unexpected events in the
+family. The final analysis was done on 72 participants: 37 in the
+yoga group and 35 in the control group.
+Table 2 shows the demographic data. Of the 90 girls re-
+cruited, 82.2% (74/90) were of normal weight (BMI = 18.5–23)
+and only 17.78% (16/90) were overweight (BMI > 23), 31.11%
+(28/90) had mFG score ‡ 6, and 34.44% (31/90) girls had LH/
+FSH ‡ 2. Maximum 66.67% (60/90) numbers of the girls had
+their menstrual cycle length between 60 and 90 days. Only
+45.56% (41/90) of the girls complained about the presence of
+acne, while 54.44% (49/90) of the girls had no acne.
+The baseline values were not significantly different be-
+tween the yoga and control groups for all the variables in-
+cluding age, BMI, menstrual frequency, serum FSH, serum
+LH, LH/FSH ratio, serum prolactin, total testosterone, and
+serum AMH (Table 2).
+Mann-Whitney test on difference score shows that changes
+in AMH were significantly different between the two inter-
+vention groups (Y = - 2.51, C = - 0.49, p = 0.006). Similarly,
+changes in LH and LH/FSH ratio were also significantly
+different between the yoga and control groups (LH: Y = - 4.09,
+C = 3.00, p = 0.005; LH/FSH: Y = - 1.17, C = 0.49, p = 0.015).
+Also, changes in testosterone were significantly different be-
+tween the two groups (Y = - 6.01, C = 2.61, p = 0.014). On the
+other hand, changes in FSH and prolactin after the 3 months
+of intervention were nonsignificantly different between the
+two groups (FSH: p = 0.474, prolactin: p = 0.982) (Table 3).
+The changes in the means between the groups were sig-
+nificantly different (Y = - 1.14, C = + 0.06, p = 0.002) for mFG
+score. Both body weight and BMI showed nonsignificantly
+different changes between the two groups (weight: p = 0.882,
+BMI: p = 0.910). Changes in menstrual frequency were sig-
+nificantly
+different
+between
+the
+two
+groups
+(Y = 0.89,
+C = 0.49, p = 0.049).
+Discussion
+This is the first randomized controlled trial comparing the
+effect of a holistic yoga program with physical exercise on
+adolescent PCOS, and to the authors’ knowledge this is the
+first study proving the efficacy of a holistic therapy on en-
+docrine parameters and menstrual frequency independent of
+weight loss, within a short duration of 12 weeks.
+The baseline mean AMH (6.01 ng/mL) in our population
+was comparable to earlier observations that ranged from 3.3
+to 15.3 ng/mL15,23 in normal weight and obese adult PCOS.
+As this is the first study of AMH in adolescent PCOS, more
+studies in different races and age groups may help in de-
+fining the cutoff values for the diagnosis of PCOS.
+After 3 months of intervention, there was better reduction
+( p = 0.006) in AMH levels after yoga (mean change 2.51) than
+physical exercise (0.49). A well-designed randomized con-
+trolled trial by Carlsen et al.23 on 50 women with PCOS
+undergoing 26 weeks of diet, lifestyle, metformin, and an-
+drogen suppression by dexamethasone showed no signifi-
+cant change in AMH levels and on the contrary observed an
+anomalous increase in AMH levels (12.6 ng/mL to 14.1 ng/
+mL) in the group who were given dexamethasone. Thus, a
+decrease in AMH after yoga, a nonsignificant change after a
+20-week weight-reduction program,15 and an increase after
+dexamethasone therapy23 is noteworthy. Thus, it is interest-
+ing to note that yoga therapy seems to offer better changes in
+AMH than physical exercises or dexamethasone within a
+short duration (3 months) which is similar to the effect with
+metformin (6 months).
+FIG. 1.
+Trial profile.
+4
+NIDHI ET AL.
+ACM-2011-0868-ver9-Nidhi_1P.3d
+06/25/12
+12:46pm
+Page 4
+The baseline mean value for LH (9.7 mIU/mL) and FSH
+(5.8 mIU/mL) in the current study’s population was lower
+than a similar adolescent population of girls with PCOS from
+Italy by De Leo et al.24 These differences between the study
+groups could be due to ethnicity, BMI, and/or the timing of
+hormonal assessment in relation to the menstrual cycle.
+After 3 months of intervention, the current study showed
+reduction in LH (actual mean change: Y = - 4.09, C = 3.00,
+p = 0.005) and LH/FSH ratio (actual mean change: LH/FSH:
+Y = - 1.17, C = 0.49, p = 0.015). This is similar to De Leo’s
+study24 on the effect of metformin for 6 months in obese
+teenage girls with PCOS. Although there was noteworthy
+change after yoga, it is difficult to arrive at a conclusion with
+certainty because of nonuniformity in the timing of hormonal
+assessment in the current study’s population.
+The results of increased menstrual frequency noted in both
+yoga and control groups in the current study were compa-
+rable to that reported by Tang et al. in their 6 months’ trial
+through metformin and lifestyle modification.21
+The mFG score to define clinical hyperandrogenism is
+variable, ranging from 3 to 8. On the basis of a South Asian
+study by Chen et al.,1 the current study used a score of 6 as
+the upper normal limit. Accordingly, only a small proportion
+(31.11 %) of girls had hirsutism. The reduction in mFG scores
+in the yoga group was similar to the observation by Ganie
+et al. after 12 weeks of metformin therapy in 82 adolescent
+and young women with PCOS.25
+Although it is known that a high androgen level is one of
+the characteristic features in women with PCOS, the baseline
+testosterone value in the current study group was well
+within the normal range ( < 82 ng/dL). Since none of the girls
+in this study had high testosterone levels, there was no need
+to perform a 17-OHP test (to exclude the possibility of con-
+genital adrenal hypertrophy) before inclusion in the study.
+Wabitsch et al. observed much higher values (102.8 ng/dL)
+of testosterone than those in the current group, which could
+be due to higher BMI of girls in their study.26 Although the
+baseline value of testosterone was well within the normal
+range in the present study’s population, unlike many earlier
+studies, a further decrease in its level after yogic intervention
+may explain the significant reduction in mFG scores.
+The possible mechanisms of action of yoga to explain the
+above results are discussed below.
+In the current study’s control group, the reduction ob-
+served in FSH, prolactin, and AMH with improvement in
+menstrual frequency adds evidence to the clinical benefits of
+conventional exercises and lifestyle change, which is similar
+to what has been observed in earlier studies.15 Thomson et al.
+also observed that AMH expression may not be related to
+weight reduction, although there were clinical benefits
+traceable to weight reduction. The result of the current study
+also seems to point to a similar conclusion, as a significant
+reduction in AMH was found, although 82% of the girls were
+in normal weight range and showed a nonsignificant change
+in weight after the intervention in both groups.
+The other factor that may influence the AMH levels seems
+to be the serum androgen levels. Eldar-Geva et al. observed
+that AMH is more elevated in hyperandrogenic compared
+with normoandrogenic women with PCO despite compara-
+ble numbers of small follicles.27 Thus, the yoga’s effect on
+AMH may be related to the reduction in the androgen levels
+in the girls in the current study.
+Several studies have shown that women with PCOS
+suffer with anxiety28 and depression.29 The beneficial effects
+of yoga on stress-related disturbances are seen in anxiety.30
+Cortisol levels are positively associated with stress and
+anxiety.31 Yoga has also been shown to reduce cortisol
+levels both in health32 and disease33 pointing to its effect on
+the HPA axis. Furthermore, the increase in AMH after
+dexamethasone observed by Carlsen et al. may point to the
+relation between high cortisol levels, AMH, and HPA
+axis.23
+Thus, it appears that the beneficial effects of yoga in PCOS
+could be mediated through both HPA and HPO axes based
+on the observation that chronic stimulation of sympathetic
+activity (HPA axis) can induce dysregulation of the HPO
+axis in PCOS.16 There are some studies on other non-
+pharmacologic therapies like acupuncture that have shown
+beneficial effects on HPO axis. Electro-acupuncture restored
+regular ovulation with reduction in LH/FSH ratio in more
+than one third of anovulatory PCOS women.34
+Table 2. Demographics of 90 Girls Recruited
+Variables
+Yoga group
+(n = 45)
+mean (SD)
+Control group
+(n = 45)
+mean (SD)
+Age, years
+16.22 (1.13)
+16.22 (0.93)
+Height, m
+1.54 (0.06)
+1.56 (0.05)
+Weight, kg
+48.42 (6.80)
+50.99 (7.25)
+BMI, kg/m2
+20.36 (2.06)
+21.10 (2.98)
+No. of girls with
+BMI < 23a
+39 (86.7%)
+35 (77.8%)
+No. of girls with
+BMI ‡ 23a
+6 (13.3%)
+10 (22.2%)
+mFG Score
+4.60 (2.02)
+4.20 (2.13)
+No. of girls with
+mFG score < 6a
+30 (66.7%)
+32 (71.1%)
+No. of girls with
+mFG score ‡ 6a
+15 (33.3%)
+13 (28.9%)
+FSH, mIU/mL
+5.70 (1.91)
+5.80 (2.43)
+LH, mIU/mL
+11.19 (8.11)
+8.29 (6.30)
+LH/FSH ratio
+2.45 (4.27)
+1.46 (0.87)
+No. of girls with
+LH/FSH ‡ 2a
+21 (46.7%)
+10 (22.2%)
+No. of girls with
+LH/FSH < 2a
+24 (53.3%)
+35 (77.8%)
+Prolactin, mg/mL
+9.76 (3.37)
+9.63 (3.92)
+Total testosterone, ng/dL
+39.11 (21.58)
+32.43 (18.18)
+AMH, ng/mL
+6.45 (3.91)
+5.57 (2.79)
+Menstrual frequency
+in months
+1.41 (0.84)
+1.47 (0.87)
+No. of girls with cycle
+length of 45–60 daysa
+9 (20%)
+10 (22.2%)
+No. of girls with cycle
+length of 60–90 daysa
+31 (68.9%)
+29 (64.4%)
+No. of girls with cycle
+length of > 90 daysa
+5 (11.1%)
+6 (13.3%)
+No. of girls with
+presence of acnea
+16 (35.6%)
+25 (55.6%)
+No. of girls with
+absence of acnea
+29 (64.4%)
+20 (44.4%)
+aVariables = frequency (% values) are reported.
+SD, standard deviation; BMI, body–mass index; mFG, Modified
+Ferriman and Gallway; FSH, follicle-stimulating hormone; LH,
+luteinizing hormone; AMH, anti-mu
+¨llerian hormone.
+YOGA EFFECTS ON ENDOCRINE PARAMETERS IN ADOLESCENT PCOS
+5
+ACM-2011-0868-ver9-Nidhi_1P.3d
+06/25/12
+12:46pm
+Page 5
+This study was on a captive adolescent population with a
+highly selective age group, which raises the question of
+generalizability of the conclusions of this study.
+It could be speculated that a third arm in the randomized
+controlled trial with a pure control group may have been
+more informative. However, a study by Vigorito et al. on
+exercise intervention in young females with PCOS that used
+a pure control group (with no medications throughout the
+study) had shown nonsignificant changes in weight, BMI,
+and endocrine measures.35 Also, another study by Piltonen
+et al.4 studying females with PCOS in six different age
+range groups concluded that serum AMH levels are two- to
+threefold higher in women with PCOS than in normal
+women in all age groups (between 25 and 35 years).
+Therefore, it is theorized that the addition of a pure control
+group may not have added value to the conclusions of this
+study.
+Other limitations of the study were that LH and FSH
+measurements were not carried out at the same phase of the
+menstrual cycle and that cortisol levels were not measured.
+The present study provides the scientific evidence for the
+treatment of PCOS through yogic lifestyle modification that
+may have an effect on HPO and HPA axes. Yoga not only
+addresses the problems of PCOS but also is likely to prevent
+the long-term sequelae such as cardiovascular disease, dia-
+betes, and so on. Furthermore, yoga as a self-corrective
+therapy is potentially more cost-effective and enduring.
+Hence, the authors recommend yoga as both a primary
+intervention and/or as adjunct to standard medical care.
+This study in Asian population points to some unusual
+racial differences (normal baseline values for testosterone
+and BMI) that need to be confirmed by further studies.
+Studies in other cultures using yoga from other schools
+may throw light on the benefits of this nonpharmacologic
+modality of management of PCOS. Future studies may be
+designed to include longer duration of follow-up to observe
+the changes in ovarian volume and follicular size. Also, fu-
+ture studies may include objective and subjective measures
+of stress that may help in understanding the mechanisms.
+Conclusions
+Twelve (12) weeks of a holistic yoga program in adoles-
+cent PCOS is significantly better than a physical exercise
+program in decreasing AMH, LH, testosterone, and mFG
+scores and increasing menstrual frequency, with no change
+in body weight, FSH, or prolactin.
+Acknowledgments
+We are thankful to the Central Council for Research in
+Yoga and Naturopathy (C.C.R.Y.N.), Ministry of Health,
+Government of India, New Delhi for funding this project. We
+would like to place on record our gratitude for the support
+provided by the Vice Chancellor, SVYASA University. We
+gratefully acknowledge the cooperation of the staff and ad-
+ministration of Sri Sai College in recruiting the students and
+carrying out the study. We are also grateful to Dr. S. Jonna,
+Director of Satyam Diagnostic Labs for his assistance with
+ultrasound; Dr Sheela Kashi, Director, Suhruda Laboratory,
+directors of Thyrocare Laboratories and Religare Labora-
+tories for their assistance with blood assays. We thank many
+others involved in the interviews, database construction, and
+data entry. We extend our gratitude to Dr. Ravi Kulkarni for
+his help in the statistical analysis. We are thankful to all the
+yoga teachers, and the physical trainers who conducted the
+classes for this project and the girls for their cooperation
+during the study. Clinical Trial Registration: REFCTRI-2008
+000291.
+Table 3. Comparison of Change Scores Between Groups After the Intervention
+Variables
+Groups
+Pre mean – SD
+Post mean – SD
+Diff score mean – SD
+Change score Mann-Whitney
+Wt (kg)
+Y
+48.24 – 6.53
+48.28 – 6.75
+0.04 – 1.34
+0.882
+C
+51.83 – 7.66
+52.62 – 6.97
+0.79 – 4.13
+BMI (kg/m2)
+Y
+20.39 – 2.00
+20.41 – 2.07
+0.02 – 0.56
+0.910
+C
+21.39 – 3.20
+21.70 – 2.88
+0.32 – 1.75
+mFG score
+Y
+4.51 – 2.12
+3.38 – 1.80
+1.14 – 1.44
+0.002*
+C
+4.03 – 2.23
+4.09 – 2.06
+0.06 – 1.51
+FSH (mIU/mL)
+Y
+5.97 – 1.87
+5.58 – 1.90
+0.40 – 2.27
+0.474
+C
+5.76 – 2.50
+5.45 – 1.73
+0.31 – 2.70
+LH (mIU/mL)
+Y
+11.94 – 8.32
+7.84 – 6.13
+4.09 – 9.99
+0.005*
+C
+7.26 – 5.18
+10.26 – 8.66
+3.00 – 7.48
+LH/FSH ratio
+Y
+2.59 – 4.67
+1.42 – 0.91
+1.17 – 4.83
+0.015**
+C
+1.33 – 0.82
+1.82 – 1.35
+0.49 – 1.15
+Prl (mg/mL)
+Y
+9.61 – 3.29
+8.73 – 5.08
+0.88 – 5.07
+0.982
+C
+10.00 – 4.19
+8.35 – 4.49
+1.64 – 4.67
+TT (ng/dL)
+Y
+39.55 – 21.40
+33.55 – 19.93
+6.01 – 15.88
+0.014**
+C
+29.48 – 15.27
+32.09 – 16.46
+2.61 – 13.14
+AMH (ng/mL)
+Y
+6.25 – 3.79
+3.73 – 2.25
+2.51 – 2.92
+0.006*
+C
+4.79 – 2.33
+4.30 – 2.88
+0.49 – 2.20
+Mens freq
+Y
+1.49 – 0.87
+2.38 – 0.64
+0.89 – 0.66
+0.049**
+C
+1.49 – 0.89
+1.97 – 0.79
+0.49 – 0.98
+Y, yoga (n = 37); C, control (n = 35); Wt, weight; BMI, body–mass index; mFG, Modified Ferriman Gallway Score; FSH, follicle-stimulating
+hormone; LH, luteinizing hormone; Prl, prolactin; TT, total testosterone; AMH, anti-mu
+¨llerian hormone; Mens freq, menstrual frequency.
+*Significance at < 0.01 level.
+**Significance at < 0.05 level.
+6
+NIDHI ET AL.
+ACM-2011-0868-ver9-Nidhi_1P.3d
+06/25/12
+12:46pm
+Page 6
+Disclosure Statement
+It is declared that none of the authors involved in this
+study have any conflict of interest and that all authors of this
+article have contributed to their fullest capacities.
+References
+1. Chen X, Yang D, Mo Y, et al. Prevalence of polycystic ovary
+syndrome in unselected women from southern China. Eur J
+Obstet Gynecol Reprod Biol 2008;139:59–64.
+2. Michelmore KF, Balen AH, Dunger DB, Vessey MP. Poly-
+cystic ovaries and associated clinical and biochemical
+features in young women. Clin Endocrinol (Oxf) 1999;51:
+779–786.
+3. Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R.
+Prevalence of polycystic ovarian syndrome in Indian ado-
+lescents. J Pediatr Adolesc Gynecol 2011;24:223–227.
+4. Piltonen T, Morin-Papunen L, Koivunen R, et al. Serum anti-
+Mullerian hormone levels remain high until late reproduc-
+tive age and decrease during metformin therapy in women
+with polycystic ovary syndrome. Hum Reprod 2005;20:
+1820–1826.
+5. Pellatt L, Hanna L, Brincat M, et al. Granulosa cell produc-
+tion of anti-Mullerian hormone is increased in polycystic
+ovaries. J Clin Endocrinol Metab 2007;92:240–245.
+6. Cook CL, Siow Y, Brenner AG, Fallat ME. Relationship
+between serum mu
+¨llerian-inhibiting substance and other
+reproductive hormones in untreated women with polycystic
+ovary syndrome and normal women. Fertil Steril 2002;77:
+141–146.
+7. Franks S. Polycystic ovary syndrome. NEJM 1995;333:
+853–861.
+8. Bungum L, Jacobsson AK, Rose
+´n F, et al. Circadian variation
+in concentration of anti-Mu
+¨llerian hormone in regularly
+menstruating females: Relation to age, gonadotrophin and
+sex steroid levels. Hum Reprod 2011;26:678–684.
+9. Pigny P, Merlen E, Robert Y, et al. Elevated serum level of
+anti-mullerian hormone in patients with polycystic ovary
+syndrome: Relationship to the ovarian follicle excess and
+to the follicular arrest. J Clin Endocrinol Metab 2003;88:
+5957–5962.
+10. La Marca A, Pati M, Orvieto R, et al. Serum anti-mullerian
+hormone levels in women with secondary amenorrhea.
+Fertil Steril 2006;85:1547–1549.
+11. Fallat ME, Siow Y, Marra M, et al. Anti Mullerian-inhibiting
+substance in follicular fluid and serum: A comparison of
+patients with tubal factor infertility, polycystic ovary syn-
+drome, and endometriosis. Fertil Steril 1997;67:962–965.
+12. Laven JS, Mulders AG, Visser JA, et al. Anti-Mullerian
+hormone serum concentrations in normoovulatory and an-
+ovulatory women of reproductive age. J Clin Endocrinol
+Metab 2004;89:318–323.
+13. Norman RJ, Noakes M, Wu R, et al. Improving reproduc-
+tive performance in overweight/obese women with effec-
+tive weight management. Hum Reprod Update 2004;10:
+267–280.
+14. Fleming R, Harborne L, MacLaughlin DT, et al. Metformin
+reduces serum mullerian-inhibiting substance levels in
+women with polycystic ovary syndrome after protracted
+treatment. Fertil Steril 2005;83:130–136.
+15. Thomson RL, Buckley JD, Moran LJ, et al. The effect of
+weight loss on anti-Mu
+¨llerian hormone levels in overweight
+and obese women with polycystic ovary syndrome and re-
+productive impairment. Hum Reprod 2009;24:1976–1981.
+16. Diamanti-Kandarakis E. PCOS in adolescents. Best Pract Res
+Clin Obstet Gynaecol 2009;24:173–183.
+17. Sahajpal P, Ralte R. Impact of induced yogic relaxation
+training (IYRT) on stress-level, self-concept and quality of
+sleep among minority group individuals. J Indian Psychol
+2000;18:66–73.
+18. Manjunath NK, Telles S. Effects of sirsasana (headstand)
+practice on autonomic and respiratory variables. Indian
+J Physiol Pharmacol 2003;47:34–42.
+19. Kumarapeli V, Seneviratne RD, Wijeyaratne CN, et al. A
+simple screening approach for assessing community preva-
+lence and phenotype of polycystic ovary syndrome in a
+semiurban population in Sri Lanka. Am J Epidemiol
+2008;168:321–328.
+20. Franks S, Gharani N, Waterworth D, et al. The genetic basis
+of
+polycystic
+ovary
+syndrome.
+Hum
+Reprod
+1997;12:
+2641–2648.
+21. Tang T, Glanville J, Hayden CJ, et al. Combined lifestyle
+modification and metformin in obese patients with poly-
+cystic ovary syndrome: A randomized, placebo-controlled,
+double-blind multicentre study. Hum Reprod 2006;21:80–89.
+22. Nagendra HR, Nagarathna R. Breath-the Bridge-Breathing
+Practices. RN, ed. Bangalore, India: Swami Vivekananda
+Yoga Prakashan, 2004.
+23. Carlsen SM, Vanky E, Fleming R. Anti-Mu
+¨llerian hormone
+concentrations in androgen-suppressed women with poly-
+cystic ovary syndrome. Hum Reprod 2009;24:1732–1738.
+24. De Leo V, Musacchio MC, Morgante G, et al. Metformin
+treatment is effective in obese teenage girls with PCOS. Hum
+Reprod 2006;21:2252–2256.
+25. Ganie MA, Khurana ML, Eunice M, et al. Comparison of
+efficacy of spironolactone with metformin in the manage-
+ment of polycystic ovary syndrome: An open-labeled study.
+J Clin Endocrinol Metab 2004;89:2756–2762.
+26. Wabitsch M, Hauner H, Heinze E, et al. Body fat distribution
+and steroid hormone concentrations in obese adolescent
+girls before and after weight reduction. J Clin Endocrinol
+Metab 1995;80:3469–3475.
+27. Eldar-Geva T, Margalioth EJ, Gal M, et al. Serum anti-
+Mullerian hormone levels during controlled ovarian hyper-
+stimulation in women with polycystic ovaries with and
+without hyperandrogenism. Hum Reprod 2005;20:1814–
+1819.
+28. Benson S, Hahn S, Tan S, et al. Prevalence and implications
+of anxiety in polycystic ovary syndrome: Results of an In-
+ternet-based
+survey
+in
+Germany.
+Hum
+Reprod
+2009;
+24:1446–1451.
+29. Kerchner A, Lester W, Stuart SP, Dokras A. Risk of de-
+pression and other mental health disorders in women with
+polycystic ovary syndrome: A longitudinal study. Fertil
+Steril 2009;91:207–212.
+30. Telles S, Gaur V, Balkrishna A. Effect of a yoga practice
+session and a yoga theory session on state anxiety. Percept
+Mot Skills 2009;109:924–930.
+31. Van Eck M, Berkhof H, Nicolson N, Sulon J. The effects of
+perceived stress, traits, mood states, and stressful daily
+events on salivary cortisol. Psychosom Med 1996;58:447–458.
+32. Kamei T, Toriumi Y, Kimura H, et al. Decrease in serum
+cortisol during yoga exercise is correlated with alpha wave
+activation. Percept Mot Skills 2000;90(3 pt 1):1027– 1032.
+33. Vadiraja HS, Raghavendra RM, Nagarathna R, et al. Effects
+of a yoga program on cortisol rhythm and mood states in
+early breast cancer patients undergoing adjuvant radio-
+therapy: A randomized controlled trial. 2009;8:37–46.
+YOGA EFFECTS ON ENDOCRINE PARAMETERS IN ADOLESCENT PCOS
+7
+ACM-2011-0868-ver9-Nidhi_1P.3d
+06/25/12
+12:46pm
+Page 7
+34. Stener-Victorin E, Waldenstrom U, Tagnfors U, et al. Effects of
+electro-acupuncture on anovulation in women with polycystic
+ovary syndrome. Acta Obstet Gynecol Scand. 2000;79:180–188.
+35. Vigorito C, Giallauria F, Palomba S, et al. Beneficial effects of
+a three-month structured exercise training program on car-
+diopulmonary 10 functional capacity in young women with
+polycystic
+ovary
+syndrome.
+J
+Clin
+Endocrinol
+Metab.
+2007;92:1379–1384.
+Address correspondence to:
+Ram Nidhi, MSc
+#19, Eknath Bhavan
+Gavipuram Cirlce Kempegowdanagar
+Bangalore 560 019
+India
+E-mail: [email protected]
+8
+NIDHI ET AL.
+ACM-2011-0868-ver9-Nidhi_1P.3d
+06/25/12
+12:46pm
+Page 8

subfolder_0/Effect of integrated yoga therapy on nerve conduction velocity in type -2 diabetics a cross sectional clinical study.txt

@@ -0,0 +1,712 @@
+EFFECT OF INTEGRATED YOGA THERAPY ON NERVE CONDUCTION
+VELOCITY IN TYPE -2 DIABETICS A CROSS SECTIONAL CLINICAL STUDY
+C Nagraj1
+N K Manjunath2
+H R Nataraj3
+1Research fellow, S-VYASA Bengaluru, 2Associate professor, S-VYASA Bengaluru,
+3Research associate, Jindal nature cure institute, Bengaluru, Karnataka, India
+INTRODUCTION
+Notably, there is growing evidence that yoga
+practices may aid in the prevention and
+management of DM 2. By attenuating the
+symptoms and signs of those with clinical
+DM 2, with improved glycaemic control,
+improve lipid profile and reduce insulin
+resistance and thus improve its prognosis. A
+study of effect of forty days of yoga done in
+twenty-four type 2 DM cases provides
+metabolic 
+and 
+clinical 
+evidence 
+of
+improvement in glycaemic control and
+autonomic functions. There was a significant
+decrease in fasting blood glucose level,
+postprandial blood glucose and glycosylated
+hemoglobin. Also the pulse rate, systolic and
+diastolic 
+blood 
+pressure 
+decreased
+significantly. Four uncontrolled studies
+targeting adults with diabetes.[i,ii] and/or
+other chronic conditions,[iii,iv] demonstrated
+Research Study
+International Ayurvedic Medical Journal
+ISSN:2320 5091
+ABSTRACT
+Background: Type 2diabetes mellitus comprises an array of dysfunctions resulting from the
+combination of resistance to insulin action and inadequate insulin secretion. It is characterized by
+hyperglycemia and associated with micro vascular i.e., retinal, renal, possibly neuropathic,
+macro vascular i.e., coronary, peripheral vascular, and neuropathic i.e., (autonomic, peripheral)
+complications. Yoga has been shown to reduce the hyperglycemia and thereby reducing the
+underlying nerve damages in diabetics. Objectives: To observe the nerve conduction velocity
+variation among practitioners and non practitioners of yoga. And propose yoga as a better
+method to manage neuropathies in type 2 diabetics. Materials and methods: Across sectional
+clinical study was conducted among type 2 Diabetic patients, two groups i.e. yoga practitioners
+and non yoga practitioners were made with a sample size of 30 in each group and yoga group
+was prescribed with different yogic practices and both group analyzed for nerve conduction
+velocity and data analyzed using Independent t-test.Results: Results were encouraging and
+Independent sample t-test showed significantly higher means in yoga group for nerve conduction
+velocity in right (P= 0.004), and left wrist (P=0.017). Mann-Whitney test showed similarly
+significantly higher mean in
+yoga group for the variable F-wave in right hand
+(P=0.004).Conclusion: People practicing yoga seems to have better nerve conduction parameters
+compare to control group, hence yoga can be used as useful supporting palliative treatment for
+managing diabetes mellitus type 2 induced nerve damage. Keywords: Yoga therapy, Type 2
+Diabetes, Nerve conduction velocity
+EFFECT OF INTEGRATED YOGA THERAPY ON NERVE CONDUCTION
+VELOCITY IN TYPE -2 DIABETICS A CROSS SECTIONAL CLINICAL STUDY
+C Nagraj1
+N K Manjunath2
+H R Nataraj3
+1Research fellow, S-VYASA Bengaluru, 2Associate professor, S-VYASA Bengaluru,
+3Research associate, Jindal nature cure institute, Bengaluru, Karnataka, India
+INTRODUCTION
+Notably, there is growing evidence that yoga
+practices may aid in the prevention and
+management of DM 2. By attenuating the
+symptoms and signs of those with clinical
+DM 2, with improved glycaemic control,
+improve lipid profile and reduce insulin
+resistance and thus improve its prognosis. A
+study of effect of forty days of yoga done in
+twenty-four type 2 DM cases provides
+metabolic 
+and 
+clinical 
+evidence 
+of
+improvement in glycaemic control and
+autonomic functions. There was a significant
+decrease in fasting blood glucose level,
+postprandial blood glucose and glycosylated
+hemoglobin. Also the pulse rate, systolic and
+diastolic 
+blood 
+pressure 
+decreased
+significantly. Four uncontrolled studies
+targeting adults with diabetes.[i,ii] and/or
+other chronic conditions,[iii,iv] demonstrated
+Research Study
+International Ayurvedic Medical Journal
+ISSN:2320 5091
+ABSTRACT
+Background: Type 2diabetes mellitus comprises an array of dysfunctions resulting from the
+combination of resistance to insulin action and inadequate insulin secretion. It is characterized by
+hyperglycemia and associated with micro vascular i.e., retinal, renal, possibly neuropathic,
+macro vascular i.e., coronary, peripheral vascular, and neuropathic i.e., (autonomic, peripheral)
+complications. Yoga has been shown to reduce the hyperglycemia and thereby reducing the
+underlying nerve damages in diabetics. Objectives: To observe the nerve conduction velocity
+variation among practitioners and non practitioners of yoga. And propose yoga as a better
+method to manage neuropathies in type 2 diabetics. Materials and methods: Across sectional
+clinical study was conducted among type 2 Diabetic patients, two groups i.e. yoga practitioners
+and non yoga practitioners were made with a sample size of 30 in each group and yoga group
+was prescribed with different yogic practices and both group analyzed for nerve conduction
+velocity and data analyzed using Independent t-test.Results: Results were encouraging and
+Independent sample t-test showed significantly higher means in yoga group for nerve conduction
+velocity in right (P= 0.004), and left wrist (P=0.017). Mann-Whitney test showed similarly
+significantly higher mean in
+yoga group for the variable F-wave in right hand
+(P=0.004).Conclusion: People practicing yoga seems to have better nerve conduction parameters
+compare to control group, hence yoga can be used as useful supporting palliative treatment for
+managing diabetes mellitus type 2 induced nerve damage. Keywords: Yoga therapy, Type 2
+Diabetes, Nerve conduction velocity
+EFFECT OF INTEGRATED YOGA THERAPY ON NERVE CONDUCTION
+VELOCITY IN TYPE -2 DIABETICS A CROSS SECTIONAL CLINICAL STUDY
+C Nagraj1
+N K Manjunath2
+H R Nataraj3
+1Research fellow, S-VYASA Bengaluru, 2Associate professor, S-VYASA Bengaluru,
+3Research associate, Jindal nature cure institute, Bengaluru, Karnataka, India
+INTRODUCTION
+Notably, there is growing evidence that yoga
+practices may aid in the prevention and
+management of DM 2. By attenuating the
+symptoms and signs of those with clinical
+DM 2, with improved glycaemic control,
+improve lipid profile and reduce insulin
+resistance and thus improve its prognosis. A
+study of effect of forty days of yoga done in
+twenty-four type 2 DM cases provides
+metabolic 
+and 
+clinical 
+evidence 
+of
+improvement in glycaemic control and
+autonomic functions. There was a significant
+decrease in fasting blood glucose level,
+postprandial blood glucose and glycosylated
+hemoglobin. Also the pulse rate, systolic and
+diastolic 
+blood 
+pressure 
+decreased
+significantly. Four uncontrolled studies
+targeting adults with diabetes.[i,ii] and/or
+other chronic conditions,[iii,iv] demonstrated
+Research Study
+International Ayurvedic Medical Journal
+ISSN:2320 5091
+ABSTRACT
+Background: Type 2diabetes mellitus comprises an array of dysfunctions resulting from the
+combination of resistance to insulin action and inadequate insulin secretion. It is characterized by
+hyperglycemia and associated with micro vascular i.e., retinal, renal, possibly neuropathic,
+macro vascular i.e., coronary, peripheral vascular, and neuropathic i.e., (autonomic, peripheral)
+complications. Yoga has been shown to reduce the hyperglycemia and thereby reducing the
+underlying nerve damages in diabetics. Objectives: To observe the nerve conduction velocity
+variation among practitioners and non practitioners of yoga. And propose yoga as a better
+method to manage neuropathies in type 2 diabetics. Materials and methods: Across sectional
+clinical study was conducted among type 2 Diabetic patients, two groups i.e. yoga practitioners
+and non yoga practitioners were made with a sample size of 30 in each group and yoga group
+was prescribed with different yogic practices and both group analyzed for nerve conduction
+velocity and data analyzed using Independent t-test.Results: Results were encouraging and
+Independent sample t-test showed significantly higher means in yoga group for nerve conduction
+velocity in right (P= 0.004), and left wrist (P=0.017). Mann-Whitney test showed similarly
+significantly higher mean in
+yoga group for the variable F-wave in right hand
+(P=0.004).Conclusion: People practicing yoga seems to have better nerve conduction parameters
+compare to control group, hence yoga can be used as useful supporting palliative treatment for
+managing diabetes mellitus type 2 induced nerve damage. Keywords: Yoga therapy, Type 2
+Diabetes, Nerve conduction velocity
+C  Nagraj et;aAl: Effect of Integrated Yoga Therapy on Nerve Conduction Velocity In Type -2 Diabetics A Cross Sectional Clinical
+Study
+120
+www.iamj.in                             IAMJ: Volume 1; Issue 6; Nov– Dec2013
+significant positive changes in blood lipid
+levels following yoga-based interventions
+that ranged from 8 days to 3 months,
+[v] in
+duration.
+Yoga and nerve conduction: A study with
+yogic intervention has shown that yoga
+asana have a beneficial effect on glycaemic
+control and improve nerve function in mild
+to moderate type 2 diabetes with sub-clinical
+neuropathy.[vi]
+Aims and Objectives: Hence the present
+study is conducted with an objective of
+nerve 
+conduction 
+variation 
+among
+practitioners and non practitioners of yoga.
+And to propose yoga as a better method to
+manage neuropathies in type 2 Diabetics.
+Materials and Methods:
+Recruitment was done through public
+announcements made at different yoga
+therapy centers and advertisements. Those
+volunteers who fulfilled the inclusion
+criteria were selected for the study. The
+signed informed consent of subjects was
+obtained before the data recording.
+Study Design
+Subjects belonging to two groups (yoga and
+non yoga) were assessed under standard
+experimental conditions. Since this was a
+two group comparative study with onetime
+assessment, the present study followed a
+cross sectional design.
+The two groups were:
+1. The patients with type two Diabetes, on
+allopathic 
+medication 
+with 
+yoga
+relearning.
+2.
+The patients with type two Diabetes, on
+allopathic medication
+Selection Criteria
+A
+Inclusion Criteria
+
+HbA1c >7
+
+Fasting Bold Glucose < 270 mg/dl
+
+Subject with history of type 2dm who
+have been on diet and exercise.
+
+Willing to participate by giving a written
+informed consent.
+
+Medication-
+any 
+anti-diabetic
+medication.
+
+Women and men between 40-70 years
+(married or singles)
+
+Those who are not practicing yoga since
+last 3months (for non yoga group).
+
+Those who are practicing yoga since last
+6 months (for yoga group).
+
+Patients with the history of DM Type-2
+for minimum of 1 year.
+B Exclusion Criteria
+
+Renal dysfunction
+
+Congestive heart failure.
+
+BMI < 20 or > 40
+
+Hypersensitive to Metformin
+
+Women of child bearing
+
+Uncontrolled hypertension
+
+Alcohol abuse
+
+Type I DM
+
+Retinopathy requiring laser therapy
+
+Recent myocardial infarction less than 3
+months.
+Outcome measures:
+Primary outcome measures
+
+Motor nerve conduction velocity.
+
+Sensory nerve conduction velocity
+
+F- wave: F-waves reflect the antidromic
+conduction of the compound neural
+volley to the ventral spinal cord, and the
+postsynaptic activation of a portion of
+the muscle fibers in the innervated
+muscle. [vii]
+
+Amplitudes: Peak amplitude driven by
+maximal stimulation reflects the number
+C  Nagraj et;aAl: Effect of Integrated Yoga Therapy on Nerve Conduction Velocity In Type -2 Diabetics A Cross Sectional Clinical
+Study
+121
+www.iamj.in                             IAMJ: Volume 1; Issue 6; Nov– Dec2013
+of responding fibers and the synchrony
+of their activity. [viii]
+Nerve
+Conduction 
+Velocity 
+Testing
+(NCV)
+Definition
+A nerve conduction study is a test that
+measures the movement of an impulse
+through a nerve after the deliberate stimula-
+tion of the nerve. The time it takes to travel
+to the other end of the nerve is measured. [ix]
+Recording procedure:
+Subjects have reported to the laboratory with
+prior appointment which was taken with the
+consent. They were made to understand the
+nature of the test and they were asked to sit
+on a comfortable chair and electrodes were
+placed on their palms and median nerve was
+stimulated in various places, through an
+electrical 
+stimulator 
+with 
+appropriate
+amount of current. Then actual values of
+NCV viz, motor nerve conduction velocity,
+sensory nerve conduction velocity, and F-
+wave were noted for further analysis.
+The nerve conduction velocity was recorded
+using RMS.EMG.EP.MARK- machine of
+recorders and Medicare systems pvt. Ltd
+company, haryana. The equipment has an
+inbuilt amplifier with digital filters along
+with electrical stimulator. These filters are
+mathematical filters that can distinguish
+random, background electrical signals from
+the actual signal produced by an activated
+nerve.
+Before placing electrodes in place it is very
+important to apply gel on the points where
+electrodes are to be placed, then electrodes
+are placed in the belly and tendon method
+that is, active electrode was placed on the
+belly of adductor brevis muscle and refer-
+ence electrode was placed on tendon of the
+same muscle just below the thumb finger.
+Then grounding was placed around 3 cm
+away from the active electrode i.e. middle of
+the palm.
+Analysis
+The analysis of the nerve signal involves the
+study of the movement of the signal through
+the nerve from one point to another. Using
+characteristics such as the speed of the im-
+pulse, and the shape, wavelength, and height
+of the signal wave, an examiner can assess
+whether the nerve is functional or defective.
+Data Extraction
+The measurement for motor nerve conduc-
+tion study includes the onset latency, dura-
+tion, and amplitude of CMAP and nerve
+conduction velocity. The onset latency is the
+time in milli seconds from the stimulus arti-
+fact to the first negative deflection of
+CMAP. For the better visualization of the
+take off the latency should be measured at a
+higher gain than the one used for the CMAP
+amplitude measurement. The onset latency
+is a measure of conduction in the fastest
+conducting motor fibers. It also includes
+neuromuscular transmission time and the
+propagation time along the muscle mem-
+brane which constitutes residual latency.
+The amplitude of CMAP is measured from
+baseline to the negative peak (base to peak)
+the amplitude correlates with the number of
+nerve fibers. The duration of CMAP is
+measured from the onset to the negative or
+positive peak or the final return of waveform
+to the baseline. Duration correlated with the
+density of small fibers. The area under the
+CMAP can also be measured. However it
+needs computer analysis.
+Motor nerve conduction velocity is calcu-
+lated by measuring the distance in millime-
+ter between two points of stimulation, which
+is divided by the latency difference in milli-
+C  Nagraj et;aAl: Effect of Integrated Yoga Therapy on Nerve Conduction Velocity In Type -2 Diabetics A Cross Sectional Clinical
+Study
+122
+www.iamj.in                             IAMJ: Volume 1; Issue 6; Nov– Dec2013
+second. The nerve conduction velocity is
+expressed as m/s. Measurement of latency
+between the two points of stimulation elimi-
+nates the effect of residual latency.
+Conduction Velocity= D/PL-DL M/S
+Where PL is The Proximal Latency and DL is
+the Distal Latency in ms, and D is the distance
+between proximal and distal stimulation in mm.
+Plan of Analysis
+The data were analyzed by using Statistical
+Package for Social Sciences (SPSS) version
+10.0. Following statistical steps were fol-
+lowed for all types of variables.
+
+Descriptive statistics
+
+Measures of central tendency and dis-
+persion
+
+Tests for normal distribution: Box
+whisker plot, stem and leaf plot
+
+Test for variance: F test
+
+Inferential statistics
+
+Data type : Ratio scale
+
+Mann-Whitney test was done in case of
+non-parametric data and independent t-
+test was done in case of parametric data.
+INTERVENTION
+Patients in group II were practicing a par-
+ticular format of yoga practices (prescribed
+by their Diabetologist and yoga therapist)
+[Table -1] one hour per day, for the period
+of 6 months.
+RESULTS
+Data were found to be normally distributed
+except for the following variables: in yoga
+group, nerve conduction velocity in right
+hand elbow, nerve conduction velocity in
+left hand elbow, and f-wave in right hand.
+Hence non-parametric test (Mann Whitney
+test) was performed on these variables and
+also f-wave in left hand, which being the
+counterpart of f-wave in right hand. For re-
+maining variables parametric test was per-
+formed (independent sample t-tests). Vari-
+ances were found to be equal for all pa-
+rameters in parametric tests. [Table-2]
+Nerve Conduction Velocity in Right hand
+Wrist (p=0.004) and Nerve Conduction Ve-
+locity in Left hand Wrist (p=0.017) were
+found to be statistically significant across
+yoga and non yoga groups. Higher means
+were observed for yoga group. Also there
+was a significantly higher means noticed in
+yoga group as compared to non yoga group,
+F-Wave in Right hand (p=0.004). [Table-3]
+DISCUSSION
+The result of this cross sectional two group
+comparative study on 60 patients with dia-
+betes type 2 have showed statistically sig-
+nificant difference in nerve conduction vari-
+ables nerve conduction velocity in right
+hand wrist  (p=0.004) and nerve conduction
+velocity in left hand wrist (p=0.017) be-
+tween yoga and non yoga groups. Higher
+means were observed for yoga group. Also
+there was a significantly higher means no-
+ticed in yoga group as compared to non yoga
+group, f-wave in right hand(p=0.004). Dif-
+ferences in all other parameters were found
+to be statistically insignificant. In addition to
+the DCCT,[x] three much smaller but long-
+term prospective studies have confirmed that
+maintained near-normal glycaemia prevents
+the development and retard the progression
+of DPN as assessed electro-physiologically.
+These include the Stockholm Diabetes
+Intervention Study (7.5 years), [xi] and 10
+years), [xii] the Oslo Study (8 years), [xiii] and,
+in type 2 diabetes, the Kumamato Study (6
+years). [xiv] Thus these results are suggestive
+of efficiency of yoga to reduce the nerve
+damage occurred due to hyperglycemic
+condition.The observed differences found in
+the nerve conduction parameters seems to
+C  Nagraj et;aAl: Effect of Integrated Yoga Therapy on Nerve Conduction Velocity In Type -2 Diabetics A Cross Sectional Clinical
+Study
+123
+www.iamj.in                             IAMJ: Volume 1; Issue 6; Nov– Dec2013
+support some of the existing ideas that yoga
+asana have a beneficial effect on glycaemic
+control and improve nerve function in mild
+to moderate Type 2 diabetes with sub-
+clinical neuropathy.[xv]
+CONCLUSION
+People practicing yoga seems to have better
+nerve 
+conduction 
+parameters 
+hence
+suggesting yoga as a useful means for
+managing diabetes mellitus type 2 induced
+nerve damage.
+CORRESPONDING AUTHOR
+C Nagraj
+Research fellow, S-VYASA Bengaluru
+Source of support: Nil
+Conflict of interest: None Declared
+REFERENCES
+i ) Divekar M, Bhat M, Mulla A. Effect of yoga therapy in diabetes and obesity. J Diabet Assoc
+India 1978; 17:75-8.
+ii) Shembakar A, Kate S. Yogic exercise in the management of diabetes mellitus. J Diabet Assoc
+India 1980; 20:167-71.
+iii)  Khare K, Jain D. Effect of yoga on plasma glucose and serum fructosamine level in NIDDM.
+In: Yoga Mimamsa; 1999. p. 1-9.
+iv ) Koertge J, Weidner G, Elliott-Eller M, Scherwitz L, Merritt-Worden TA, Marlin R, et al.
+Improvement in medical risk factors and quality of life in women and men with coronary artery
+disease in the Multicenter Lifestyle Demonstration Project. Am J Cardiol 2003; 91:120-22.
+v ) Ornish D. Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle
+Demonstration Project. Am J Cardiol 1998:82:26
+vi ) Malhotra V, Singh S, Tandon OP, Madhu SV, Prasad A, Sharma SB Effect of Yoga asanas
+on nerve conduction in type 2 diabetes. Indian J Physiol Pharmacol. 2002 Jul; 46 3):298-306.
+vii ) Kohara N, Kimura J, Kaji R, Goto Y, Ishii J, Takiguchi M, Nakai M: F-wave latency serves
+as the most reproducible measure in nerve conduction studies of diabetic polyneuropathy:
+multicentre analysis in healthy subjects and patients with diabetic polyneuropathy. Diabetologia
+43:915–921, 2000
+viii ) Veves A, Malik RA, Lye, RH, Masson EA, Sharma AK, Schady W, Boulton AJM: The
+relationship between sural nerve morphometric findings and measures of peripheral nerve
+function in mild diabetic neuropathy. Diabet Med 8:917–921, 1991
+ix ) Mosby's Manual of Diagnostic and Laboratory Tests, 1998
+x ) DCCT Research Group: The effect of intensive diabetes therapy on the development and
+progression of neuropathy. Ann Int Med 122:561–568, 1995
+xi ) Reichard P, Nilsson BY, Rosenqvist CL: The effect of long-term intensified insulin
+treatment on the development of microvascular complications of diabetes. N Engl J Med
+329:304–309, 1993
+xii Reichard P, Pihl M, Rosenqvist U, Sule J: Complications of IDDM are caused by elevated
+blood glucose levels, the Stockholm Diabetes Intervention study at 10 year follow-up.
+Diabetologia 39:1383–1488, 1996
+C  Nagraj et;aAl: Effect of Integrated Yoga Therapy on Nerve Conduction Velocity In Type -2 Diabetics A Cross Sectional Clinical
+Study
+124
+www.iamj.in                             IAMJ: Volume 1; Issue 6; Nov– Dec2013
+xiii ) Amthor KF, Dahl-Jorgensen K, Berg TJ, Sandvik L, Hanssen KF: The effect of 8 years of
+strict glycaemic control on peripheral nerve function in IDDM patients: the Oslo study.
+Diabetologia 37:579–586, 1994
+xiv ) Ohkubo Y, Kishikawa H, Araki E, Miyata T, Isami S, Motoyoshi S, Kojima Y, Furuyoshi N,
+Shichiri M: Intensive insulin therapy prevents the progression of diabetic microvascular
+complications in Japanese patients with non-insulin-dependent diabetes: a randomized
+prospective 6-year study. Diabetes Res Clin Pract 28:103–117, 1995
+xv ) Malhotra V, Singh S, Tandon OP, Madhu SV, Prasad A, Sharma SB Effect of Yoga asana on
+nerve conduction in type 2 diabetes. Indian J Physiol Pharmacol. 2002 Jul; 46(3):298-306.
+LIST OF TABLES :Table-1 List of Yoga Practices Prescribed For Group-II
+Sl.no
+Name of the practice
+Number of Repetitions
+Breathing practices
+1
+Shashankasana breathing
+5
+2
+Tiger breathing
+5
+Shithili karana vyayama
+1
+Jogging
+3mins
+2
+Forward and backward bending
+11 rounds
+3
+Side bending
+11 rounds
+4
+Dhanurasana swing
+11 rounds
+5
+Uddiyana
+11 rounds
+6
+Surya namaskar 12 rounds
+3 rounds
+YOGASANA
+1
+Parivritta trikonasana
+1 mins
+2
+Pada hastasana
+3 mins
+3
+Ardha chakrasana
+3 mins
+4
+Ardha matsyendrasana
+3 mins
+5
+Ushtrasana
+3 mins
+6
+QRT
+3 mins
+Kriyas
+1
+Jalaneti
+1/week
+2
+Sutranet
+1/week
+C  Nagraj et;aAl: Effect of Integrated Yoga Therapy on Nerve Conduction Velocity In Type -2 Diabetics A Cross Sectional Clinical
+Study
+125
+www.iamj.in                             IAMJ: Volume 1; Issue 6; Nov– Dec2013
+3
+Vamana dhouti
+1/week
+4
+Laghu 
+shankha
+prakshalana
+1/week
+Pranayama
+1
+Vibhagiya pranayama
+11 rounds
+2
+Nadi shudhi
+9 rounds
+3
+Bhramari
+9 rounds
+Meditation
+5mins
+Table: 2 Motor nerve conduction velocities recorded at wrist, elbow and axilla in both yoga
+and non yoga group.
+Variable
+(m/s)
+Yoga
+Non-yoga
+p-value
+Mean(m/
+s)
+Std .dev (m/s)
+Mean(m/s)
+Std .dev(m/s)
+MNC_RT_W
+53.7053
+7.46156
+48.0407
+7.03811
+.004
+MNC_LT_W
+52.6873
+6.71670
+48.3497
+6.95866
+.017
+MNC_RT_ELⱡ
+62.4690
+11.63628
+66.1430
+8.75384
+.280
+MNC_LT_ELⱡ
+57.6677
+12.70624
+63.2080
+11.20706
+.066
+Table: 3 Sensory nerve conduction velocity of median nerve in right and left hand.
+Variable
+Yoga
+Non-yoga
+p-value
+Mean(m/s)
+Std. dev(m/s)
+Mean(m/s)
+Std. dev(m/s)
+SNC_RT
+51.3627
+6.85947
+48.3190
+10.50064
+.189
+SNC_LT
+52.5860
+8.04264
+48.5060
+9.30390
+.074
+Table: 3 f-wave recorded from median nerve in left and right hand.
+Variable
+Yoga
+Non-yoga
+p-value
+Mean(m/s)
+St. dev (m/s)
+Mean(m/s)
+St. dev(m/s)
+FW_RTⱡ
+30.3140
+3.65324
+33.1017
+3.94996
+.004
+FW_LTⱡ
+31.0700
+3.91277
+32.6500
+3.29375
+.143
+Table: 4 Demographic data
+Non Yoga
+yoga
+Male
+Female
+17
+13
+23
+7
+Mean Age
+53.3
+55.36

subfolder_0/Effect of pranayama and meditation as an add-on therapy in rehabilitation of patients with Guillain-Barré syndrome.txt

@@ -0,0 +1,704 @@
+1
+Disability & Rehabilitation, 2012; Early Online: 1–6
+© 2012 Informa UK, Ltd.
+ISSN 0963-8288 print/ISSN 1464-5165 online
+DOI: 10.3109/09638288.2012.687031
+Objective: To study the add-on effects of pranayama and 
+meditation in rehabilitation of patients with Guillain-Barré 
+syndrome (GBS). Patients and Method: This randomized 
+control pilot study was conducted in neurological 
+rehabilitation unit of university tertiary research hospital. 
+Twenty-two GBS patients, who consented for the study and 
+satisfied selection criteria, were randomly assigned to yoga 
+and control groups. Ten patients in each group completed 
+the study. The yoga group received 15 sessions in total over a 
+period of 3 weeks (1 h/session), one session per day on 5 days 
+per week that consisted of relaxation, Pranayama (breathing 
+practices) and Guided meditation in addition to conventional 
+rehabilitation therapeutics. The control group received usual 
+rehabilitation care. All the patients were assessed using 
+Pittsburgh Sleep Quality Index, Numeric pain rating scale, 
+Hospital anxiety and Depression scale and Barthel index 
+score. Mann–Whitney U test and Wilcoxon’s signed rank test 
+were used for statistical analysis. Results: Quality of sleep 
+improved significantly with reduction of PSQI score in the 
+yoga group (p = 0.04). There was reduction of pain scores, 
+anxiety and depression in both the groups without statistical 
+significance between groups (pain p > 0.05, anxiety p > 0.05 
+and depression p > 0.05). Overall functional status improved 
+in both groups without significant difference (p > 0.05). 
+Conclusions: Significant improvement was observed in quality 
+of sleep with yogic relaxation, pranayama, and meditation in 
+GBS patients.
+Keywords:  Guillain-Barré syndrome, yoga
+Background
+Guillain-Barré Syndrome (GBS) is an inflammatory, 
+demyelinating disease affecting multiple peripheral nerves. 
+The disease onset is acute or sub acute in nature. The 
+clinical features include flaccid ascending symmetrical limb 
+weakness/paralysis, absence of deep tendon reflexes, cranial 
+nerve palsies, autonomic nervous system disturbances, pain 
+and paraesthesia [1,2]. It has an annual incidence varying 
+from 0.16 to 4 cases per 100 000 populations [3–5]. There 
+are four clearly defined subtypes of GBS: AIDP (acute 
+inflammatory 
+demyelinating 
+polyradiculoneuropathy), 
+AMAN (acute motor axonal neuropathy), AMSAN (acute 
+motor and sensory axonal neuropathy) and Miller–Fisher 
+syndrome [6]. In general the disease outcome is expected to 
+be good. Wide variations are observed during the long term 
+RESEARCH PAPER
+
+“Effect of pranayama and meditation as an add-on therapy in 
+rehabilitation of patients with Guillain-Barré syndrome—a  
+randomized control pilot study”
+Ragupathy Sendhilkumar1, Anupam Gupta1, Raghuram Nagarathna2 & Arun B. Taly3
+1Neurological Rehabilitation Division, Department of Psychiatric and Neurological Rehabilitation, National  
+Institute of Mental Health and Neuro-Sciences (NIMHANS), Bangalore, India, 2Division of yoga and physical sciences, Swamy  
+Vivekanandha Yoga Anusndhana Samsthana (SVYASA), (Yoga research foundation), Kempegowda Nagar, Bangalore India, 
+and 3Department of Neurology, National Institute of Mental Health and Neuro-Sciences (NIMHANS), Bangalore,  India
+Correspondence: Dr. Anupam Gupta, Associate professor, Neurological Rehabilitation Division, Department of Psychiatric and Neurological 
+Rehabilitation, National Institute of Mental Health and Neuro-Sciences (NIMHANS), Hosur Road, Bangalore-560029, India. Tel: +91 080 26995282 
+(H), +91 87626 89540 (M). Fax: +91 80 2656 4830. E-mail: [email protected]
+• GBS is an inflammatory demyelinating polyneuro 
+radiculopathy with multiple complications requiring 
+long term care.
+• Yoga and other rehabilitation measures contribute in 
+improving functional abilities, pain and sleep quality 
+in GBS patients.
+• This randomized control trial showed that short term 
+yoga practice can improve the quality of sleep as com-
+pare to other rehabilitation measures in GBS patients
+Implications for Rehabilitation
+(Accepted April 2012)
+Disabil Rehabil Downloaded from informahealthcare.com by Allied Publishers Subscription Agency on 05/24/12
+For personal use only.
+2  R. Sendhilkumar et al.
+	
+	
+Disability & Rehabilitation
+follow up with persistent sensory and motor impairments as 
+common sequelae [7,8].
+Multiple complications occur during the course of the 
+disease with several long term sequelae. Apart from physi-
+cal disability persistent pain, fatigue, paraesthesia, mood 
+changes, anxiety, depression [2,7,9] and sleep disturbances are 
+common during rehabilitation [10,11]. A multidisciplinary 
+approach is required for the rehabilitation of the GBS patients 
+which includes pharmacotherapy, nutrition management, 
+carefully modified exercises using gentle range of motion, 
+assisted range of motion, manual resistance, positioning 
+and orthotic management [12,13]. Therapeutic methods like 
+cognitive behavior therapy in the management of pain [14], 
+and psychological education programs designed specifically 
+for patients and the family members have been found to be 
+beneficial in managing pain and psychological sequelae of 
+GBS [15,16].
+Integrated yoga that includes postures, pranayama, relax-
+ation and meditation have been found to be effective in the 
+long term rehabilitation of diseases like rheumatoid arthritis 
+[17], bronchial asthma [18] and major depression [19]. Yoga 
+as an add-on to physiotherapy has shown benefits in patients 
+with chronic neck pain [20]. Addition of yogic prana ener-
+gization technique hastens the callus formation in fracture 
+of long bones [21]. Many other studies have shown demon-
+strable benefits of yoga after short duration of intensive inte-
+grated programs either as inpatient [22] or out patient [23] 
+with better quality of sleep in the elderly [24] and in cancer 
+patients [25] have been documented. There are no studies 
+in the literature that have tried to observe the effect of yogic 
+relaxation techniques during rehabilitation of GBS patients. 
+The aim of the present pilot study was to examine the effect of 
+yoga as an add-on therapy in patients with GBS undergoing 
+in-patient rehabilitation.
+Patients and methods
+In this randomized control trial, 44 GBS patients who were 
+admitted in the neurological rehabilitation unit in the uni-
+versity hospital after their initial treatment with either plas-
+mapheresis or intravenous immunoglobulin therapy in the 
+acute care neurological ward or in the ICU, from April 2010 
+to March 2011 were screened for our study. The inclusion 
+criteria were: (a) age group of 15–60 year of both gender, (b) 
+patients with stage 3 (able to walk 5 feet with assistance) and 
+4 (bed bound) of Hughes scale, (c) weaned off from venti-
+lator, (d) medically stable, (e) those with fair to good trunk 
+balance and (f) admitted in the unit for inpatient rehabilita-
+tion. The exclusion criteria were: (a) GBS with Hughes grade 
+1 (able to run) and 2 (able to walk independently), (b) those 
+with severe respiratory distress, (c) with poor trunk control, 
+(d) Miller–Fisher variant of GBS and (e) chronic inflamma-
+tory demyelinating polyneuropathy (CIDP) patients. Patients 
+with grade 5 and 6 according to Hughes scale would not be 
+able to perform yoga whereas patients with grade 1 and 2 on 
+Hughes scale would not agree for 3 weeks inpatient rehabilita-
+tion program as they would be independent for most of the 
+ADL including locomotion. This was the reason for including 
+patients’ only with Hughes grade 3 and 4 in the study. Twenty-
+five (10 AIDP, 12 AMAN, 3 AMSAN) patients met with the 
+eligibility criteria. The sample size calculation for the trial not 
+done as it was a pilot study only. Eleven patients were recruited 
+in each group. The study protocol was approved by the insti-
+tutes’ ethical committee. Informed consent was obtained 
+from all patients. Out of the total 25 patients, 22 patients who 
+consented to participate were recruited for the study (Figure 
+1). The patients from rehabilitation consultant were sent to 
+therapy section using serially numbered referral forms, then 
+they were randomly allocated to yoga or control group using a 
+computer generated random table. The random table was cre-
+ated using software from www.Randomizer.org. It was single 
+blind study with blinding of outcome assessor who would 
+assess all patients (both the groups) at the beginning and after 
+end of therapy sessions (after 3 weeks) without knowing the 
+group of the patient (Yoga vs. conservative therapy).
+Rehabilitation program
+All patients in both the groups (yoga and control) received 
+regular rehabilitation care which included pharmacotherapy, 
+physiotherapy, occupational therapy and orthotic manage-
+ment as per the need of individual patients. Physiotherapy 
+included active assisted range of motion, passive range of 
+motion, stretching of tight muscles, strengthening exercises 
+using weight cuffs, breathing exercises and gait training with 
+or without assistive devices. Functional ability training was 
+provided in the occupational therapy section which included 
+hand function training, trunk stability training and care 
+giver’s education about transfer techniques etc.
+Yoga intervention
+Patients in yoga group received 15 sessions of yoga (1 hour/
+day) in addition to the regular rehabilitation therapeutics by a 
+qualified post graduate yoga therapist. Five sessions per week 
+were conducted with no sessions on Saturdays and Sundays. 
+Patients completed sessions over a period of 3 weeks. The yoga 
+intervention was carried out in a place near the in-patient 
+neurological rehabilitation unit between 5 to 6 PM daily. 
+There was no scientific reason behind this particular time of 
+the day for conducting session. This time schedule was con-
+venient for the participant to attend after their routine regular 
+therapy sessions like physiotherapy and occupational therapy 
+etc. During this time, the patients in the control group were 
+allowed to relax with their friends or relatives in the adjacent 
+open lawn.
+The specific yoga module developed for GBS patients 
+included Quick relaxation technique (QRT), pranayama 
+and guided meditation (Mind Sound Resonance Technique-
+MSRT) that could be practiced in supine posture in bed 
+ 
+(Table I). Quick relaxation technique (QRT) could be prac-
+ticed in three phases in a comfortable supine position with 
+eyes closed that involves synchronization of breathing with 
+abdominal movement and energization of the whole body as 
+they chant ‘aaa’ slowly during exhalation.
+Pranayama, as defined by sage patanjali(swasa praswayoh 
+gatir vicchedah pranayamah [26]), is aimed at calming down 
+the mind by reducing the rate of breathing voluntarily while 
+Disabil Rehabil Downloaded from informahealthcare.com by Allied Publishers Subscription Agency on 05/24/12
+For personal use only.
+Role of yoga in rehabilitation of GBS patients  3
+© 2012 Informa UK, Ltd.
+maintaining the mindful awareness of the touch of the air 
+flowing in and out of the air passages.
+MSRT is an eight stepped guided meditation technique 
+where the participants are guided to experience the soothing 
+sound resonance in the whole body during repeated slow chant-
+ing of the Vedic syllables (a, u, m and om, etc) in a low pitch.
+Measurements
+Assessment for sleep, anxiety, depression and pain was done 
+before and after the period of intervention using Pittsburg 
+Sleep Quality Index (PSQI [27]), Hospital Anxiety and 
+Depression Scale (HADS [28]) and Numeric pain rating scale 
+(NPRS [29]), respectively. Functional status was recorded 
+using Barthel Index (BI [30]) at admission and at discharge.
+Pittsburg Sleep Quality Index [27] assesses the quality of 
+sleep in the previous 2 weeks through seven areas: subjective 
+sleep quality, sleep latency, sleep duration, habitual sleep 
+efficiency, sleep disturbances, use of sleeping medication, and 
+daytime dysfunction. The client self-rates each of these seven 
+areas of sleep. Scoring of answers is based on a 0–3 scale, 
+whereby 3 reflect the negative extreme on the Likert Scale. 
+The responses are added to give composite global PSQI [27], 
+score. A global sum of “5” or greater indicates a “poor” sleeper.
+Hospital Anxiety and Depression Scale [28], is used as a 
+screening scale to assess anxiety and depression level of the 
+patients. It contains a total of 14 questions related to anxiety 
+and depression, 7 questions each for anxiety and depression. 
+Each question is scored using 0–3 response, 0 being lowest 
+Figure 1   CONSORT flow diagram. *Reasons: age group not matching, medically unstable (e.g. uncontrolled diabetes), Hughes grades not matching.
+Table I  Daily yoga practice schedule.
+Name of the practice
+Duration 
+ (in minutes)
+A
+Pranayama
+1.
+Vibhagiya pranayama (sectional breathing)
+5
+2.
+Ujjayi pranayama (psychic breath)
+5
+3.
+Sheetali pranayama (cooling breath)
+5
+4.
+Seetkari pranayama (hissing breath)
+5
+5.
+Sadanta pranayama (clenched teeth breath)
+5
+6.
+Bhramari pranayama (humming bee breath)
+5
+B.
+QRT
+5
+C.
+MSRT
+25
+QRT, quick relaxation technique; MSRT, mind sound resonance technique.
+Disabil Rehabil Downloaded from informahealthcare.com by Allied Publishers Subscription Agency on 05/24/12
+For personal use only.
+4  R. Sendhilkumar et al.
+	
+	
+Disability & Rehabilitation
+level of response and 3 being the highest level response. Scores 
+are added to get total anxiety score and depression scores 
+separately. A score between 0 and 7 is normal, 8–10 is bor-
+derline abnormal and 11–21 is abnormal for both anxiety and 
+depression.
+Numeric pain rating scale [29] evaluates the level of pain 
+marked by the patients in a scale containing numbers from 
+0 to 10, 0 being ‘No’ pain and 10 being the worst maximum 
+pain.
+BI [30] consists of 10 items (bladder and bowel in the 
+preceding week, grooming, in preceding 24–48 h, toilet use, 
+feeding, transfers, mobility, dressing, stairs and bathing)with 
+scores ranging from 0 to 100.
+Data analysis
+Analysis was done using SPSS version 15.0 (SPSS Inc., 
+Chicago, IL). Descriptive statistics was made for the variables 
+showing the demographic details and Shapiro–Wilk’s test was 
+done for all the outcome measures for both groups to find out 
+normality of distribution. Assessment of effect of additional 
+yoga therapy was done by comparing the scores PSQI, HADS, 
+and Numeric pain rating scale at the time of starting therapy 
+and after the completion of 15 sessions between both the 
+groups using Mann–Whitney U test. Effect of therapy within 
+group was analyzed using Wilcoxon signed rank test.
+Results
+There were 11 subjects in each group with two drop outs, as 
+these two patients took discharge before the study completed 
+at their will due to their personal reasons. Age ranged from 
+20 to 55 years (32.30 ± 9.911) in yoga group. In the control 
+group age ranged from 15 to 58 years (31.30 ± 14.317). There 
+were eight (80%) male patients and two (20%) female patients 
+in the yoga group whereas five (50%) male and five (50%) 
+female patients in control group. Three patients (30%) had 
+typical AIDP, four patients (40%) had AMAN variant and 
+three patients (30%) had AMSAN variant in yoga group. In 
+the control group four (40%) had typical AIDP and six (60%) 
+patients had AMAN variant. The mean length of stay in the 
+rehabilitation unit in yoga group was 43 ± 3.8 days and in 
+control group was 40.70 ± 3.2 day. The baseline data did not 
+differ significantly between groups (p > 0.05, Shapiro–Wilk 
+test) although there were more males in the yoga group as 
+compare to control group (8 vs. 5).
+Yoga schedule of the patients has been shown in Table I. 
+Results after 15 sessions of intervention are shown in Table II.
+There was significant difference between groups (p = 0.048, 
+Mann–Whitney U test) in the quality of sleep. The global PSQI 
+[27] score in yoga group improved from 8.70 ± 4.24 to 4.00 ± 
+3.36 (p < 0.05, Wilcoxon’s test) with no significant change (p = 
+0.21) in control group from 9.30 ± 4.37 to 7.20 ± 3.49.
+The anxiety score of HADS [28] showed a reduction in 
+yoga group from 2.90 ± 2.18 to 1.60 ± 1.64 (p < 0.05) and in 
+control group from 6.60 ± 4.50 to 4.20 ± 4.51 (p < 0.05). No 
+significant difference observed between both group (p > 0.05). 
+The depression score of HADS [28] also showed a reduction 
+in yoga group from 4.70 ± 3.59 to 1.20 ± 1.22 (p < 0.05) and 
+in control group from 4.90 ± 2.84 to 3.20 ± 2.70 (p < 0.05). 
+No significant change between the groups existed (p > 0.05).
+There was a reduction in the level of pain in Numeric pain 
+rating scale [29] in yoga group with a shift from 3.5 ± 2.42 to 
+2.20 ± 1.47 (p < 0.05) and in control group from 5.90 ± 2.28 
+to 3.50 ± 2.46 (p < 0.05).There was no significant difference 
+observed between the groups (p > 0.05).
+Functional status improved in BI 30 from 33.50 ± 15.64 to 
+59 ± 24.58 (p < 0.05) in yoga group and from 32 ± 8.88 to 69 
+± 22.82 (p < 0.05) in control group. No significant difference 
+observed between the groups (p > 0.05). Sub group analysis 
+based on gender was not done because of the unequal number 
+of male and female patients in yoga group.
+Discussion
+To our knowledge, this is the first randomized control 
+study using yoga techniques (QRT, pranayama and MSRT 
+meditation) as adjuvant therapy for rehabilitation of GBS 
+patients. The results showed that the patients in the yoga 
+Table II  Results of intervention.
+Variables
+Within groups
+Between groups 
+(Mann–whitney 
+U test)
+p Value
+Yoga (Wilcoxon signed rank test)
+Control (Wilcoxon signed rank test)
+Median
+Inter quartile 
+range
+p Value
+Median
+Inter quartile 
+range
+p Value
+PSQI
+Pre
+9.00
+7
+0.005
+10.00
+6
+0.210
+0.048*
+Post
+3.00
+2
+8.00
+7
+NPRS
+Pre
+4.00
+3.50
+0.048
+6.50
+2.50
+0.026
+0.167
+Post
+2.50
+2.50
+3.50
+3.50
+HADS (anx)
+Pre
+2.50
+2
+0.033
+6.50
+7
+0.017
+0.133
+Post
+1.00
+2
+3.00
+6
+HADS (dep)
+Pre
+4.50
+7
+0.012
+4.00
+5
+0.036
+0.070
+Post
+1.00
+2
+3.50
+4
+BI
+Admission
+25.00
+17.50
+0.007
+27.50
+15
+0.008
+0.402
+Discharge
+57.50
+50
+75.00
+36.25
+PSQI, Pittsburg Sleep Quality Index; NPRS, Numeric pain rating scale; HADS (anx), Hospital Anxiety Depression Scale-anxiety domain; HADS (dep), Hospital Anxiety Depression 
+Scale-Depression domain; BI, Barthel Index.
+*Mann–Whitney U test; significance with p < 0.05.
+Disabil Rehabil Downloaded from informahealthcare.com by Allied Publishers Subscription Agency on 05/24/12
+For personal use only.
+Role of yoga in rehabilitation of GBS patients  5
+© 2012 Informa UK, Ltd.
+group had significantly better (p < 0.05, between groups on 
+Mann–Whitney) improvement in quality of sleep than the 
+control group, while there were significant improvements in 
+functional status, pain, anxiety and depression in both groups 
+with statistically insignificant differences between groups. 
+However, the results should be interpreted with caution 
+because its’ a pilot study only with relatively small sample size.
+In one of the studies continuous sleep monitoring among 
+the GBS patients admitted in ICU revealed some sleep abnor-
+malities in the form of reduced REM sleep latency, REM sleep 
+without atonia and NREM sleep with rapid eye movements. 
+These changes were observed even in patients staying out of 
+ICU [10]. Disordered breathing pattern leading to hypoxia 
+and hypercarbia and fragmented sleep pattern have also been 
+observed among GBS patients [11]. High (Global PSQI > 5) 
+baseline scores on PSQI [27], (Yoga = 8.70 ± 4.24, control = 
+9.30 ± 4.37) observed in our study reflects these observations. 
+The improvement in the median scores after yoga reached a 
+value of 4.00 ± 3.36 indicating that these patients slept nor-
+mally, while the patients in control group also showed some 
+improvement in their scores (7.20 ± 3.49) that did not reach 
+normalcy. Studies using meditation and chanting similar to 
+the techniques used in this study showed improved quality of 
+sleep in the form of appearance of theta rhythm during slow 
+wave sleep along with low EMG and enhanced REM duration 
+following Transcendental Meditation(TM) among healthy 
+volunteers [31,32] and enhanced slow wave sleep and REM 
+sleep state among different age groups of healthy Vipassana 
+meditation practitioners [33,34]. This improved quality of 
+sleep may be due to the improved REM sleep and slow wave 
+sleep by meditation practice and regularization of breathing 
+through pranayama practices.
+Pain control through pranayama and meditation (MSRT) 
+techniques in chronic pain conditions like low back pain 
+and neck pain was found to be significant in some studies 
+[20,22]. In this present study, the pain in GBS patients showed 
+improvement in both the groups and add on yoga techniques 
+did not have additional benefits. This may be due to the dif-
+ficult nature of GBS pain which includes both nociceptive 
+and neuropathic components. In one of the earlier studies in 
+neurological rehabilitation unit, it was reported that about 
+80% admitted GBS patients had neuropathic pain and 34.3% 
+of these patients required more than one medications and the 
+pain persisted for longer duration [13]. As the neuropathic 
+pain is more difficult to treat, 15 yoga sessions might not have 
+been sufficient and the results could have been different with 
+more yoga therapy sessions.
+The baseline median anxiety and depression scores in both 
+the group, showed that the anxiety and depression level were 
+in normal range. This can be attributed to natural history of 
+illness, nature of the disease progression and prognosis being 
+explained routinely to all patients including GBS patients in 
+rehabilitation unit and this might have contributed in improv-
+ing relaxation and allaying mood disorders in this popula-
+tion. Similar observation has been reported in a qualitative 
+analysis of the patients’ experiences during the acute stage 
+of GBS [35]. Though there was a significant improvement in 
+the post session scores in both anxiety and depression(less 
+score) there was no statistical significance existed between the 
+groups. When comparing the depression scores according to 
+HADS in our trial between yoga group and control group, we 
+observed a trend suggestive of better improvement in depres-
+sion in yoga group as compare to control group, although it 
+did not reach significant levels (p = 0.07). A future trail com-
+prising of healthier sample size using the same scale might 
+come up with some interesting findings.
+Some positive findings have been reported in the manage-
+ment of anxiety and depression levels with the use hyperven-
+tilating type of pranayama like kapalabathi and Bashthrika or 
+combination of Aasanas (physical postures)and pranayama [36]. 
+Hyperventilation techniques are difficult to practice by the GBS 
+patients because of the intercostals and abdominal muscles weak-
+ness. Similarly some physical postures also cannot be practiced 
+because of the motor paralysis of both trunk and limb muscles.
+Significant functional recovery found in both groups at 
+discharge time without statistical significance on comparison. 
+In one of the earlier study similar improvement in the func-
+tional status has been reported [13].
+Although study has a small sample size, it highlights the 
+importance of yoga in managing a number of co-morbidities 
+(complications) occurring as a result of GBS. Training para-
+medical staff to carry out these practices or hiring trained 
+yoga instructors to take care of such patient group could prove 
+be a cost-effective method of rehabilitation. Further, although 
+patients showed trend for improvement across all the domains 
+(functional ability, sleep quality, anxiety and depression) in 
+both the groups, a longer duration of yoga program should be 
+worth exploring in future studies.
+Conclusions
+Significant improvement in quality of sleep was observed 
+in GBS patients in yoga group as compare to control group 
+with yogic relaxation, pranayama, and meditation. There 
+was reduction of pain scores, anxiety and depression in both 
+the groups without statistical significance between groups. 
+Similarly overall functional status improved in both groups 
+without significant difference between the groups.
+Pranayama and meditation practices are simple and effec-
+tive techniques, which do not require any special equipment 
+or space, can be used in GBS patients to improve their quality 
+of sleep, anxiety, depression and level of pain during their stay 
+in the hospital for rehabilitation. Yoga practices can also be 
+incorporated as home-based programs with recorded materi-
+als with little direct contact training for the GBS patients. This 
+would also benefit many such patients, who are not able to 
+avail in-patient rehabilitation for various reasons.
+There were some limitations of this study like it was a 
+single blind study. The number of yoga therapy sessions was 
+confined to 15 only. More sessions would have provided better 
+insight on the role of yoga in improving other problem areas 
+and issues in GBS patients during in-patient rehabilitation. 
+Sleep recordings and pulmonary function test can be added in 
+future study with healthier sample size, increased frequency 
+and duration of yoga practice and adequate follow up to see 
+the lasting effects.
+Disabil Rehabil Downloaded from informahealthcare.com by Allied Publishers Subscription Agency on 05/24/12
+For personal use only.
+6  R. Sendhilkumar et al.
+	
+	
+Disability & Rehabilitation
+Declaration of interest: The authors declare no conflict of 
+interest. The authors alone are responsible for the content 
+and writing of the paper. No funding was received from any 
+source for this project.
+References
+	
+  1.	 Ropper AH. The Guillain-Barré syndrome. N Engl J Med 
+1992;326:1130–1136.
+  	
+2.	 Meythaler JM. Rehabilitation of Guillain-Barré syndrome. Arch Phys 
+Med Rehabil 1997;78:872–879.
+  	
+3.	 Barzegar M, Dastgiri S, Karegarmaher MH, Varshochiani A. 
+Epidemiology of childhood Guillan-Barre syndrome in the north west 
+of Iran. BMC Neurol 2007;7:22.
+  	
+4.	 Alter M. The epidemiology of Guillain-Barré syndrome. Ann Neurol 
+1990;27 Suppl:S7–12.
+  	
+5.	 McLean M, Duclos P, Jacob P, Humphreys P. Incidence of Guillain-Barré 
+syndrome in Ontario and Quebec, 1983-1989, using hospital service 
+databases. Epidemiology 1994;5:443–448.
+  	
+6.	 Hughes RA, Cornblath DR. Guillain-Barré syndrome. Lancet 
+2005;366:1653–1666.
+  	
+7.	 Forsberg A, Press R, Einarsson U, de Pedro-Cuesta J, Widén Holmqvist 
+L; Swedish Epidemiological Study Group. Impairment in Guillain-Barré 
+syndrome during the first 2 years after onset: a prospective study. J 
+Neurol Sci 2004;227:131–138.
+  	
+8.	 Koeppen S, Kraywinkel K, Wessendorf TE, Ehrenfeld CE, Schürks M, 
+Diener HC, Weimar C. Long-term outcome of Guillain-Barré syn-
+drome. Neurocrit Care 2006;5:235–242.
+  	
+9.	 Chan A, Gold R. Neuropsychological/-psychiatric deficits in immune-
+mediated neuropathies. J Neurol 2007;254 Suppl 2:93–95.
+	
+10.	 Cochen V, Arnulf I, Demeret S, Neulat ML, Gourlet V, Drouot X, 
+Moutereau S, et al. Vivid dreams, hallucinations, psychosis and REM 
+sleep in Guillain-Barré syndrome. Brain 2005;128:2535–2545.
+	
+11.	 Chokroverty S. Sleep dysfunction in neuromuscular disorders. Schwiez 
+Arch Neurol Psychiatr. 2003; 154: 400–406.
+	
+12.	 Hughes RA, Wijdicks EF, Benson E, Cornblath DR, Hahn AF, 
+Meythaler JM, Sladky JT, et al.; Multidisciplinary Consensus Group. 
+Supportive care for patients with Guillain-Barré syndrome. Arch Neurol 
+2005;62:1194–1198.
+	
+13.	 Gupta A, Taly AB, Srivastava A, Murali T. Guillain-Barre Syndrome-
+rehabilitation outcome, residual deficits and requirement of lower 
+limb orthosis for locomotion at 1 year follow-up. Disabil Rehabil 
+2010;32:1897–1902.
+	
+14.	 Sternbach RA. Psychophysiology of pain. Int J Psychiatry Med 
+1975;6:63–73.
+	
+15.	 Dattilio FM. Educating patients about symptoms of anxiety in the wake of 
+neurological illness. J Neuropsychiatry Clin Neurosci 2002;14:354–355.
+	
+16.	 Eisendrath SJ, Matthay MA, Dunkel JA, Zimmerman JK, Layzer 
+RB. Guillain-Barré syndrome: psychosocial aspects of management. 
+Psychosomatics 1983;24:465–475.
+	
+17.	 Haslock I, Monro R, Nagarathna R, Nagendra HR, Raghuram NV. 
+Measuring the effects of yoga in rheumatoid arthritis. Br J Rheumatol 
+1994;33:787–788.
+	
+18.	 Nagarathna R, Nagendra HR. Yoga for bronchial asthma: a controlled 
+study. Br Med J (Clin Res Ed) 1985;291:1077–1079.
+	
+19.	 Woolery A, Myers H, Sternlieb B, Zeltzer L. A yoga intervention for 
+young adults with elevated symptoms of depression. Altern Ther Health 
+Med 2004;10:60–63.
+	
+20.	 Yogitha B, Nagarathna R, John E, Nagendra H. Complimentary effect of 
+yogic sound resonance relaxation technique in patients with common 
+neck pain. Int J Yoga 2010;3:18–25.
+	
+21.	 Oswal P, Nagarathna R, Ebnezar J, Nagendra HR. The effect of add-
+on yogic prana energization technique (YPET) on healing of fresh 
+fractures: a randomized control study. J Altern Complement Med 
+2011;17:253–258.
+	
+22.	 Tekur P, Singphow C, Nagendra HR, Raghuram N. Effect of short-term 
+intensive yoga program on pain, functional disability and spinal flex-
+ibility in chronic low back pain: a randomized control study. J Altern 
+Complement Med 2008;14:637–644.
+	
+23.	 Vempati R, Bijlani RL, Deepak KK. The efficacy of a comprehensive 
+lifestyle modification programme based on yoga in the management 
+of bronchial asthma: a randomized controlled trial. BMC Pulm Med 
+2009;9:37.
+	
+24.	 Manjunath NK, Telles S. Influence of Yoga and Ayurveda on self-rated 
+sleep in a geriatric population. Indian J Med Res 2005;121:683–690.
+	
+25.	 Cohen L, Warneke C, Fouladi RT, Rodriguez MA, Chaoul-Reich A. 
+Psychological adjustment and sleep quality in a randomized trial of 
+the effects of a Tibetan yoga intervention in patients with lymphoma. 
+Cancer 2004;100:2253–2260.
+	
+26.	 Vivekananda S. Raja Yoga: Swami Bodhasarananda, Advaita Ashrama; 
+2008.p 214.
+	
+27.	 Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The 
+Pittsburgh Sleep Quality Index: a new instrument for psychiatric prac-
+tice and research. Psychiatry Res 1989;28:193–213.
+	
+28.	 Herrmann C. International experiences with the Hospital Anxiety 
+and Depression Scale–a review of validation data and clinical results. J 
+Psychosom Res 1997;42:17–41.
+	
+29.	 Straford PW, Spadoni G. The reliability, consistency and clinical applica-
+tion of pain rating scale. Physiother Canada. 2001; 51:88–91.
+	
+30.	 Mc Dowell I, Newell C. Measuring health: A guide to rating scales and 
+questionnaires. 2nd  edition. 1996. pp 56–63.
+	
+31.	 Travis F, Wallace RK. Autonomic and EEG patterns during eyes-closed 
+rest and transcendental meditation ™ practice: the basis for a neural 
+model of TM practice. Conscious Cogn 1999;8:302–318.
+	
+32.	 Mason LI, Alexander CN, Travis FT, Marsh G, Orme-Johnson DW, 
+Gackenbach J, Mason DC, et al. Electrophysiological correlates of higher 
+states of consciousness during sleep in long-term practitioners of the 
+Transcendental Meditation program. Sleep 1997;20:102–110.
+	
+33.	 Sulekha S, Thennarasu K, Vedamurthachar A, Raju TR, Kutty BM. 
+Evaluation of sleep architecture in practitioners of Suddharshan 
+kriya 
+yoga 
+and 
+Vipassana 
+Meditation. 
+Sleep 
+Biol 
+Rhythm.  
+2006; 4:207–214.
+	
+34.	 Ravindra P, Sulekha S, Sathyaprabha T, Pradhan N, Raju T, Bindu MK. 
+Practitioners of vipassana meditation exhibit enhanced slow wave sleep 
+and REM sleep states across different age groups. Sleep Biol Rhythm. 
+2010; 8:34–41.
+	
+35.	 Forsberg A, Ahlström G, Holmqvist LW. Falling ill with Guillain-Barré 
+syndrome: patients’ experiences during the initial phase. Scand J Caring 
+Sci 2008;22:220–226.
+	
+36.	 Saeed SA, Antonacci DJ, Bloch RM. Exercise, yoga, and medi-
+tation for depressive and anxiety disorders. Am Fam Physician  
+2010;81:981–986.
+Disabil Rehabil Downloaded from informahealthcare.com by Allied Publishers Subscription Agency on 05/24/12
+For personal use only.

subfolder_0/Effect of the Yoga on Anthropometric and Physical Assessments in Adolescent Obesity..txt

@@ -0,0 +1,944 @@
+E
+n
+d
+o
+c
+r
+i
+n
+o
+l
+o
+g
+y
+ 
+&
+ 
+M
+e
+t
+a
+b
+o
+l
+i
+c
+ 
+S
+y
+n
+d
+r
+o
+m
+e
+ISSN: 2161-1017
+Endocrinology & Metabolic Syndrome
+Rathi et al., Endocrinol Metab Syndr 2018, 7:5
+DOI: 10.4172/2161-1017.1000292
+Research Article
+Open Access
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+Volume 7 • Issue 5 • 1000292
+Effect of the Yoga on Anthropometric and Physical Assessments in Adolescent 
+Obesity
+Sunanda S Rathi1*, Ruchira R Joshi2, Padmini Tekur3, Nagaratna RN4  and Nagendra HR5
+1Swami Vivekananda Yoga Anusandhana Samsthana, Yoga and Life sciences 404 Pinnacle Pride Tilak Road, Pune, Maharashtra, India
+2Chiranjiv Foundation, Pune, Maharashtra, India
+3S-VYASA, Banglore, India
+4Yoga consulting Physician, S-VYASA, Bangalore, India 
+5S-VYASA, University Campus: Prashanti Kutiram, Vivekananda Road,  Kalluballu Post, Jigani, Anekal, Bengaluru, India
+Abstract
+Background: Adolescent Obesity is causing serious public health concern and in many countries threatening 
+the viability of basic health care delivery. Many co-morbid conditions are seen in association with adolescent obesity. 
+Interventions based on Yoga principles are found to have effective solutions for adolescent obesity.
+Aim: To evaluate the effect of the Yoga based intervention on anthropometric and physical assessments in 
+Adolescent Obesity.
+Methods: RCT (Randomized Controlled Trial) was conducted on 53 obese adolescents for 40 days. Special 
+yoga based training Program was conducted for yoga group. Parameters like weight, Body Mass Index (BMI) 
+parameters, pulse rate, blood pressure, MAC (Mid Upper Arm Circumferences), Ac (Abdominal Circumference), Waist 
+Circumference (WC), HC (Hip Circumference) along with physical tests like sit ups and Flamingo balance tests were 
+assessed before and after intervention for both yoga and control groups. Within and between groups analyses of the 
+variables were analysed.
+Result: The study showed significant reduction in weight, body mass index, Hip circumference, and total body 
+fat percentage, subcutaneous fat throughout the body in yoga group and percentage of improvement is more in yoga 
+group than that of control group.
+Conclusion: Yoga based intervention is effective to reduced obesity in adolescent children with respect to 
+anthropometric and physical assessments.
+*Corresponding author: Rathi SS, Swami Vivekananda Yoga Anusandhana 
+Samsthana Yoga and Life sciences 404 Pinnacle Pride Tilak Road, Sadhashiv 
+Peth, 411030, Pune, Maharashtra, India, Tel: 9860100251; 020-24330251; E-mail: 
+[email protected]  
+Received September 22, 2018; Accepted October 05, 2018; Published October 
+12, 2018
+Citation: Rathi SS, Joshi RR, Tekur P, Naratna RN, Nagendra HR (2018) Effect 
+of the Yoga on Anthropometric and Physical Assessments in Adolescent Obesity. 
+A Case Report. Endocrinol Metab Syndr 7: 292. doi:10.4172/2161-1017.1000292
+Copyright: © 2018 Rathi SS, et al. This is an open-access article distributed under 
+the terms of the Creative Commons Attribution License, which permits unrestricted 
+use, distribution, and reproduction in any medium, provided the original author and 
+source are credited.
+Keywords: Obesity; Adolescence; Yoga
+Introduction
+Adolescent obesity
+Overweight and obesity are metabolic conditions in which abnormal 
+or excessive fat accumulation is found to impair health. In 2016, more 
+than 1.9 billion adults aged 18 years and older were overweight. Of these 
+over 650 million adults were obese. The worldwide prevalence of obesity 
+nearly tripled between 1975 and 2016. The prevalence of overweight 
+and obesity among children and adolescents aged 5-19 years has risen 
+dramatically from just 4% in 1975 to just over 18% in 2016. The rise has 
+occurred similarly among both boys and girls: in 2016 18% of girls and 
+19% of boys were overweight [1]. Obesity leads to adverse impacts on 
+physical as well as psychological functions of the person. Energy-dense 
+overeating, nutrient-poor foods and a sedentary lifestyle have led to an 
+epidemic of obesity all over the world. Apart from physical problems 
+there are issues which affect psychological well-being of an individual 
+[2]. Children in low- and middle-income countries are more prone to 
+inadequate pre-natal, infant and young child nutrition. At the same 
+time, they are exposed to high-fat, high-sugar, high-salt, energy-dense, 
+micronutrient-poor foods. These dietary patterns in conjunction with 
+lower levels of physical activity, result in sharp increases in childhood 
+obesity while under nutrition issues remain unsolved [3].
+Assessment of obesity in adolescence 
+Obesity is a commonly used term with a wide range of meanings 
+with no widely accepted diagnostic definitions or cut-off points are 
+available for children. Mean body fat percentages and percentile curves 
+are available for children 5 to 18 years of age [4]. Several studies have 
+recommended BMI as the preferred measure for evaluating obesity 
+among adolescents 2 to 19 years of age. BMI can be correlated strongly 
+with body fat percentage as it is associated weakly with height, and it 
+identifies the fattest individuals correctly, with acceptable accuracy 
+at the upper end of the distribution like 85th or 95th percentile for age 
+and gender. In 1994, the Expert Committee on Clinical Guidelines 
+for Overweight in Adolescent Preventive Services recommended that 
+children whose BMI exceeds 30 kg/m2 or is more than 95th percentile 
+for age and gender should be considered obese [5].
+BMI is a fairly reliable indicator of body fatness for most people. 
+BMI does not measure boy fat directly, but research has shown that 
+BMI correlates to direct measures of body fat. BMI can be considered 
+an alternative for direct measures of body fat. Additionally, BMI is 
+an inexpensive and easy-to-perform method for screening for weight 
+categories that may lead to health problems. Measuring children’s BMI 
+regularly is the first step to maintaining a healthy weight. BMI being an 
+important variable, the full body sensor, composition monitor and scale 
+is used to calculate BMI and other BMI parameters. Full Body Sensing 
+provides a comprehensive understanding of the body composition. The 
+BMI machine calculates the estimated values for body fat percentage, 
+skeletal muscle percentage, resting metabolism and subcutaneous fat in 
+Research Article
+Citation: Rathi SS, Joshi RR, Tekur P, Naratna RN, Nagendra HR (2018) Effect of the Yoga on Anthropometric and Physical Assessments in Adolescent Obesity. A Case 
+Report. Endocrinol Metab Syndr 7: 292. doi:10.4172/2161-1017.1000292
+Page 2 of 6
+Volume 7 • Issue 5 • 1000292
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+different body parts like arms, trunk, and legs using the BI (Bioelectrical 
+Impedance) Method. The monitor also calculates the BMI (Body Mass 
+Index) and body age as well as weight. Resting metabolism is the energy 
+required to maintain vital functions. The total amount of energy used 
+by the body in a typical day contributes resting metabolism (60%-70%), 
+daily activity metabolism (20%-30%) and diet-induced thermogenesis 
+(10%). If less energy is consumed by resting metabolism that can be 
+consumed by daily activity metabolism. Percentage of subcutaneous 
+fat and skeletal muscles are inversely proposal to each other. Skeletal 
+muscle is the type of muscle that can see and feel. Building skeletal 
+muscle can help prevent rebound weight gain. The maintenance and 
+increase of skeletal muscle is closely linked to resting metabolism rate.
+Along with BMI, waist circumference in children provides a better 
+estimate of visceral adipose tissue [6,7]. Alternative measures that 
+account for fat distribution include abdominal circumference, hip 
+circumference and mid arm circumference. EUROFIT tests are also one 
+of the assessment tools in adolescent obesity to check physical fines. The 
+measurement of physical fitness for each child helps them to develop 
+positive attitudes towards their bodies and get information about their 
+physical status [8]. Handgrip strength, standing broad jump, flexed 
+arm hang, sit‐ups, sit‐and‐reach and Flamingo balance tests are few 
+EUROFIT tests out of which sit‐ups and Flamingo balance tests are 
+significant in adolescent obesity.
+Yoga for adolescent obesity
+A study consisted of 709 healthy children (with mean age=8.9 
+± 1.6 years) suggest that overweight and obesity are limiting factors 
+for fitness performance in  adolescence. Interventions promoting 
+children’s health should, ideally, begin early in life and involve 
+measures that simultaneously improve fitness and lower fatness [9]. 
+Yoga is widely recognized as an effective tool in maintaining a healthy 
+lifestyle resulting as a vaccine against lifestyle related disorders [10]. 
+According to a study of effect of aerobic & resistance exercise on 
+physical fitness conducted on 60 adolescent obese participants in 
+Karnataka (India), aerobic and resistance exercise in combination 
+reduces fat significantly [11]. But only physical activity has limited 
+scope of correcting the causes of obesity in preadolescence. Other than 
+physical causes like lack of physical exercise, genetic and sedentary 
+lifestyle there are few psychological causes of obesity like low self-
+esteem, depression, failures to cope up to demanding situations are also 
+not uncommon. The negative experiences in school and at home leads 
+to lower self-esteem found in childhood obesity [12]. Home, child care 
+centre, school, and community environments can influence children's 
+behaviours related to food intake and physical activity also which is a 
+contributing factor of causes of obesity [13]. Along with this, increasing 
+academic stress is also a contributing factor in causes of obesity [14]. 
+Any form of physical activity having limited scope to manage this 
+supportive cause of obesity can manage weight for short duration but 
+fails to provide long termed constant impacts in preadolescence obesity. 
+Whereas Yoga based programs have a wider impact on body, mind, 
+habits, perception and cognition also. 
+In one month randomized control trial of impact of Yoga on self-
+esteem in 44 adolescent participants in Hardwar (India), it is noted that 
+the level of self-esteem has significantly increased with experimental 
+group [15]. Yoga lays great significance on strengthening inherent 
+defensive mechanisms of human body and mind. It develops immunity 
+and resistance in human body and helps the body and mind in attaining 
+homeostatic balance. The strengthening of defence mechanism and 
+harmony between mind and body prevents causes of psychosomatic 
+disorders like obesity. The aim of yoga therefore is also the attainment 
+of physical, mental, social and spiritual health [16]. A study conducted 
+on Effect of yoga and physical exercise on physical, cognitive and 
+emotional measures in 98 school children, it is observed that Physical 
+exercise and yoga have different ways of influencing physical fitness, 
+cognitive performance and self-esteem. Both ways showed significant 
+improvements in tests for physical fitness [17]. But, this study has 
+two independent groups without control group and represents 
+geographically north part of India. The findings could be the possible 
+effects of the two interventions, with a degree of uncertainty due to the 
+absence of a control group. There was a need to check generalizability of 
+the findings in a sample drawn from diverse geo-graphical and cultural 
+backgrounds with control group. So, current study was designed to 
+evaluate the effect of validated and feasible yoga based intervention on 
+anthropometric and physical assessments in Adolescent Obesity. 
+Methods
+The complete study has been approved by ethical committee of 
+Swami Vivekananda Yoga Anusandhan Samsthana, Bangalore (Figure 
+1). 1400 students including both genders were screened from age of 9 
+year to 14 year (standard 5 to 9) in one of the reputed school in Pune 
+city of Maharashtra state in India. Height, weight and BMI of all the 
+students were recorded and obese participants (Figure 2) having BMI 
+>95th percentile were included who were ready to participate in the 
+study with written consent. Participants having any physical disability, 
+any psychosomatic disorder, consuming any medical drugs and 
+exposed to yoga within last 6 months were excluded from the study. 
+All the participants are randomly divided in two groups. Yoga group 
+(n=30) and control group (n=30). RCT (Randomized Controlled Trial) 
+was conducted on 60 obese adolescents for 40 days. Special yoga based 
+training Program was conducted for yoga group. Yoga intervention 
+was consisting of specially designed and validated yoga protocol of 60 
+minutes duration which included set of loosening exercises, asanas, 
+pranayamas, suryanamskara, breathing practises and meditation. 
+This intervention was conducted for 5 days a week for 40 days. 4 
+sessions of chanting, Karmayoga, Yoga counselling was also provided. 
+Participants of Yoga group were regular in throughout the intervention 
+and maintained 90 percent of attendance. Control group was under 
+observation with normal routine. The diet regulation was only provided 
+for both yoga and control group in order to acquire uniform base with 
+respect to diet. Parameters like weight, pulse rate, blood pressure, MAC 
+(Mid Upper Arm Circumferences), AC (Abdominal Circumference), 
+WC (Waist Circumference), HC (Hip Circumference) along with 
+physical tests like sit ups per minute and Flamingo balance test were 
+assessed before and after intervention for both yoga and control groups. 
+Body Mass Index (BMI) parameters like total body fat percentage, 
+resting metabolism, subcutaneous fat and muscle percentage of 
+whole body, arms, trunk and legs region also calculated using Body 
+composition monitor Model HBF-701 before and after intervention 
+for both yoga and control groups. In yoga group, there were 5 drop 
+outs and from control group 2 children were absent for post parameter 
+collection.
+Statistical Analysis
+The data was analysed using SPSS software 20 version. Normality 
+test was done using Shapiro Wilk test. The paired sample t test was 
+conducted for pre & post variables which were found normally 
+distributed for both the groups. For not normally distributed variables, 
+Wilcoxon signed ranks test was done. Between groups analysis was 
+done using independent sample t test for the post values of both the 
+groups.
+Citation: Rathi SS, Joshi RR, Tekur P, Naratna RN, Nagendra HR (2018) Effect of the Yoga on Anthropometric and Physical Assessments in Adolescent Obesity. A Case 
+Report. Endocrinol Metab Syndr 7: 292. doi:10.4172/2161-1017.1000292
+Page 3 of 6
+Volume 7 • Issue 5 • 1000292
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+Results 
+The baseline demographic data of age and height of the yoga 
+and control group is described in Table 1. Results of within group 
+analysis of Yoga group are given in Table 2. Parameters like abdominal 
+circumference, waist circumference, hip circumference, total body 
+fat percentage, trunk subcutaneous fat, trunk muscle percentage, 
+legs subcutaneous fat, legs muscle percentage and situps per minute 
+were normally distributed. Hip circumference (p=0.001), total 
+body fat percentage (p=0.001), trunk subcutaneous fat (p=0.005) 
+and legs subcutaneous fat (p=0.03) reduced significantly whereas 
+abdominal circumference (p=0.376) reduced but without significance. 
+Trunk muscle percentage (p=0.021) increased significantly. Waist 
+circumference (p=0.553) increased but without significance. Whole 
+body muscle percentage (p=0.076) and legs muscle percentage 
+(p=0.187) increased but without significance. Number of situps per 
+minute (p=0.566) is decreased but without significance.
+Parameters like weight, BMI, mid arm circumference, pulse rate, 
+systolic blood pressure, diastolic blood pressure, resting metabolism, 
+whole body subcutaneous fat, arm subcutaneous fat, arm muscle 
+percentage and flamingo balance test were not normally distributed. 
+Weight (p=0.018), BMI (p=0.001), whole body subcutaneous fat 
+(p=0.01), arm subcutaneous fat (p=0.021) reduced significantly whereas 
+systolic blood pressure (p=0.30), diastolic blood pressure (p=0.087) and 
+mid arm circumference (p=0.474) reduced but without significance. 
+Muscle percentage of arms (p=0.042) increased significantly whereas 
+pulse rate (p=0.597), Flamingo balance test (p=0.065) increased but 
+without significance.
+A result of within group analysis of Control group is given in 
+ 
+Table 3. Parameters like abdominal circumference, waist circumference, 
+Figure 1: Flow chart of group formation for intervention.
+Figure 2: Body Mass Index for age percentile.
+NO.
+GROUP
+YOGA
+CONTROL
+1
+Gender
+Male
+Female
+Male
+Female
+13
+17
+14
+16
+2
+Average Age (years)
+11 ± 1.4
+11 ± 1.3
+3
+Average Height (cm)
+152.91 ±  6.97
+152.71 ± 9.18
+4
+Average Weight (Kg)
+63.86 ± 15.52
+62.39 ± 14.21
+5
+Average BMI (Kg/m2)
+27.16 ± 5.04
+26.43 ± 3.53
+Table 1: The baseline demographic data of age and height of the yoga and control 
+group.
+Citation: Rathi SS, Joshi RR, Tekur P, Naratna RN, Nagendra HR (2018) Effect of the Yoga on Anthropometric and Physical Assessments in Adolescent Obesity. A Case 
+Report. Endocrinol Metab Syndr 7: 292. doi:10.4172/2161-1017.1000292
+Page 4 of 6
+Volume 7 • Issue 5 • 1000292
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+hip circumference, total body fat percentage, trunk subcutaneous fat, 
+trunk muscle percentage, legs subcutaneous fat, legs muscle percentage 
+and sit ups per minute were normally distributed. Number of sit ups 
+per minute (p=0.023) decreased significantly whereas abdominal 
+circumference (p=0.730), hip circumference (p=0.226), total body 
+fat percentage (p=0.876), trunk subcutaneous fat (p=0.186) and legs 
+subcutaneous fat (p=0.162) reduced but without significance. Waist 
+circumference (p=0.244), trunk muscle percentage (p=0.427) and legs 
+muscle percentage (p=0.270) increased but without significance. 
+Parameters like weight, BMI, mid arm circumference, pulse rate, 
+systolic blood pressure, diastolic blood pressure, resting metabolism, 
+whole body subcutaneous fat, arm subcutaneous fat, arm muscle 
+percentage and flamingo balance test were not normally distributed. 
+No.
+Variable
+Mean (Pre)
+Mean (Post) 
+t/z value 
+p value
+1
+Weight
+63.86 ± 15.52
+63.14 ± 15.28 
+2.359a
+0.018*
+2
+BMI
+27.16 ± 5.04
+26.47 ± 4.85
+3.344a
+0.001*
+3
+Pulse rate
+95.5 ± 11.7 
+97.37  ± 14.48
+0.529a
+0.597
+4
+Systolic blood pressure
+125.16 ± 11.06
+122.87 ± 13.42
+1.037a
+0.30
+5
+Diastolic blood pressure
+81 ± 6.83
+77.26 ± 17.63
+1.712a
+0.087
+6
+Mid arm circumference
+11.23 ± 1.03
+11.07 ± 0.93
+0.716a
+0.474
+7
+Abdominal circumference
+35.89  ± 3.69
+35.5 ± 3.77
+0.902b
+0.376
+8
+Waist circumference
+37.65 ± 4.48 
+37.77 ± 4.81
+0.602b
+0.553
+9
+Hip circumference
+39.49 ± 4.63 
+38.21 ± 4.71
+3.68b
+0.001*
+10
+Total body fat percentage
+29.83 ± 3.46
+27.76 ± 2.72
+4.40b
+0.001*
+11
+Resting metabolism
+1382.83 ± 205.34
+1404.33 ± 263.73
+1.33a
+0.183
+12
+Subcutaneous fat (Whole body)
+25.57 ± 5.58
+21.96 ± 4.32
+2.57a
+0.01∞
+13
+Muscle percentage (Whole body)
+27.13 ± 3.51 
+28.26 ± 2.89
+1.77b
+0.076
+14
+Subcutaneous fat (Arms)
+39.23 ± 8.58
+34.62 ± 6.47
+2.315a
+0.021∞
+15
+Muscle percentage (Arms)
+31.01± 6.78
+33.98 ± 5.07
+2.032a
+0.042∞
+16
+Subcutaneous fat (Trunk)
+22.21 ± 5.35
+19.23  ± 3.29
+3.085b 
+0.005∞
+17
+Muscle percentage (Trunk)
+20.58 ± 2.97
+21.55  ±  2.20
+2.480b
+0.021∞
+18
+Subcutaneous fat (Legs)
+38.35 ± 8.27 
+34.27 ± 6.29
+2.307b
+0.03∞
+19
+Muscle percentage (Legs)
+41.94 ± 5.21
+43.94 ± 4.65
+1.359b
+0.187
+20
+Sit ups
+32.95 ± 7.02
+ 31.5 ± 9.38
+0.582b
+0.566
+21
+Flamingo Balance test
+60.70 ± 37.07
+65.75 ± 38.48
+1.845 a
+0.065
+aWilcox test
+bPaired sample t test
+*significant at 0.01
+∞significant at 0.05
+Table 2: Result of within group analysis of Yoga group (n= 25).
+No.
+Variable
+Mean Pre value
+Mean Post value
+t value
+p value
+1
+Weight
+62.39 ± 14.21
+62.8 ± 14.73 
+1.646a
+0.100
+2
+BMI
+26.43 ± 3.53
+26.82 ± 3.58
+0.108a
+0.914
+3
+Pulse rate
+95.07 ± 12.7 7
+93.85  ± 11.31
+0.781a
+0.435
+4
+Systolic blood pressure
+125.96 ± 18.54
+119.25 ± 13.68
+2.596a
+0.009∞
+5
+Diastolic blood pressure
+83.71 ± 9.78
+77.5 ± 8.05
+2.90a
+0.004∞
+6
+Mid arm circumference
+11.21 ± 1.37
+11.35 ± 1.42
+1.160a
+0.246
+7
+Abdominal circumference
+35.51  ± 3.27
+35.42 ± 3.28
+0.348b
+0.730
+8
+Waist circumference
+36.50 ± 3.01 
+36.99 ± 3.67
+1.192b
+0.244
+9
+Hip circumference
+38.84 ± 3.71 
+38.57 ± 3.93
+1.240b
+0.226
+10
+Total body fat percentage
+29.02 ± 2.65
+28.96 ± 2.17
+0.157b
+0.876
+11
+Resting metabolism
+1369.25 ± 218.60
+1388.33 ± 238.43
+1.287a
+0.198
+12
+Subcutaneous fat (Whole body)
+24.80 ± 5.11
+22.75 ± 4.56
+1.150a
+0.250
+13
+Muscle percentage (Whole body)
+27.20 ± 3.06 
+28.12 ± 2.93
+1.059a
+0.290
+14
+Subcutaneous fat (Arms)
+38.90 ± 8.16
+36.02 ± 7.03
+0.997a
+0.319
+15
+Muscle percentage (Arms)
+30.62 ± 7.27
+33.47 ± 6.61
+1.261a
+0.207
+16
+Subcutaneous fat (Trunk)
+21.34 ± 4.32
+20.07 ± 3.52
+1.359b 
+0.186
+17
+Muscle percentage (Trunk)
+20.87 ± 2.40
+21.2  ±  2.08
+0.806b
+0.427
+18
+Subcutaneous fat (Legs)
+38.75 ± 8.81 
+35.92 ± 7.71
+1.439b
+0.162
+19
+Muscle percentage (Legs)
+42.06 ± 4.94
+43.78 ± 4.95
+1.128b
+0.270
+20
+Sit ups
+30.21 ± 8.74
+ 26.78 ± 7.36
+2.419b
+0.023∞  
+21
+Flamingo Balance test
+72.17 ± 56.41
+91.89 ± 58.65
+1.173a
+0.241
+aWilcox test
+bPaired sample t test
+∞significant at 0.05 
+Table 3: Result of within group analysis of Control group (n=28).
+Citation: Rathi SS, Joshi RR, Tekur P, Naratna RN, Nagendra HR (2018) Effect of the Yoga on Anthropometric and Physical Assessments in Adolescent Obesity. A Case 
+Report. Endocrinol Metab Syndr 7: 292. doi:10.4172/2161-1017.1000292
+Page 5 of 6
+Volume 7 • Issue 5 • 1000292
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+Systolic blood pressure (p=0.009), diastolic blood pressure (p=0.004) 
+reduced significantly whereas pulse rate (p=0.435), whole body 
+subcutaneous fat (p=0.250), arm subcutaneous fat (p=0.319) reduced 
+but without significance. Weight (p=0.100), BMI (p=0.914), mid arm 
+circumference (p=0.246), resting metabolism (p=0.198), whole body 
+muscle percentage (p=0.290) and Flamingo balance test (p=0.241) 
+increased but without significance.
+Analysis of in between Yoga and control group states that 
+abdominal circumference of Yoga group is decreased significantly than 
+that of Control group (p=0.05). Weight, BMI, mid-arm circumference, 
+hip circumference, total body fat percentage, subcutaneous fat of whole 
+body, arm, trunk and legs has been reduced more in Yoga group than that 
+of Control group but without significance. Number of situps, systolic 
+blood pressure and diastolic blood pressure is decreased in control 
+group more than that of Yoga group but without significance. Pulse rate 
+is found to be increased in Yoga group whereas that of control group 
+is reduced but without significance. Waist circumference is increased 
+more in control group than that of Yoga group but without significance. 
+Resting metabolism, muscle percentage of whole body, arm, trunk and 
+legs are increased more in Yoga group than that of Control group but 
+without significance. Flamingo balance test has been increased more in 
+control group than that of Yoga group but without significance.
+Discussion
+Obesity especially abdominal is related to academic achievement 
+and cognitive functions in children. Visceral adipose tissues  have 
+negative impact on cognitive functions leading to academic decrease 
+among children with obesity because of its dangerous metabolic nature 
+[18].
+Excessive adipose tissue also affects the physical inactivity leading 
+to psychological increased sensitivity. These childhoods obesity leaded 
+poorer cognitive function results in decreased measures of intra 
+individual response, even after accounting for intellectual abilities, 
+aerobic fitness [19]. So focus of this study was to evaluate the yoga 
+based validated intervention on anthropometric and physical variables 
+in adolescent Obesity [20]. Specific anthropometric and physical tests 
+are selected as variables were selected in order to conserve comfort and 
+convenience of the participants with average age of 11 ± 1.4 years. Hip 
+circumference, total body fat percentage, subcutaneous fat of trunk 
+and legs whereas these parameters are reduced in control group but 
+without significance. Subcutaneous fat reduction leads to significant 
+increase of muscle percentage of trunk and leg region. This provides 
+evidence of efficacy of validated yoga based intervention on reduction 
+of adipose tissues in hip, trunk and leg region resulting in reduction 
+of total body fat percentage and overall body weight. Abdominal 
+circumference is reduced significantly in Yoga group and without 
+significance in control group. Yoga group has improved significantly 
+better in this parameter than control group. Yoga intervention practices 
+like dynamic surya namaskara, asana, loosening practices are focused 
+to reduced abdominal adipose tissue. According to one RCT, yoga 
+intervention had moderately strong positive effects on anthropometric 
+variables in women with abdominal obesity. Yoga is safe in women and 
+can be recommended as a technique for combating abdominal obesity 
+in women [21]. Our study provides efficacy of Yoga in same concern in 
+adolescent population. Yoga improves emotional wellbeing in children. 
+The mechanisms underlying these benefits have not been clearly worked 
+out and may involve complex neuro-chemical changes and modified 
+functioning of brain areas within the limbic circuit. Physical activities 
+of control group was not monitored and compared with test group. This 
+is limitation of the study.
+Conclusion
+Yoga based intervention is effective to reduced obesity in adolescent 
+No.
+Variable
+Yoga Group
+(n= 25)
+Control Group
+ (n= 28)
+t value
+p value
+Pre
+Post
+Pre
+Post
+1
+Weight
+63.86 ± 15.52
+63.14 ± 15.28
+62.39 ± 14.21
+62.8 ± 14.73 
+0.517a
+0.60
+2
+BMI
+27.16 ± 5.04
+26.47 ± 4.85
+26.43 ± 3.53
+26.82 ± 3.58
+0.053a
+0.95
+3
+Pulse rate
+95.5 ± 11.7 
+97.37 ± 14.48
+95.07 ± 12.7 7
+93.85  ± 11.31
+1.052 a
+0.29
+4
+Systolic blood pressure
+125.16 ± 11.06
+122.87 ± 13.43
+125.96 ± 18.54
+119.25 ± 13.68
+0.883a
+0.37
+5
+Diastolic blood pressure
+81 ± 6.83
+76.95 ± 8.79
+83.71 ± 9.78
+77.5 ± 8.05
+0.330a
+0.74
+6
+Mid arm circumference
+11.23 ± 1.03
+11.07 ± 0.93
+11.21 ± 1.37
+11.35 ± 1.42
+0.027a
+0.97
+7
+Abdominal circumference
+35.89  ± 3.69
+35.5  ± 3.77
+35.51  ± 3.27
+35.42 ± 3.28
+0.530b
+0.05∞
+8
+Waist circumference
+37.65 ± 4.48 
+37.77 ± 4.81 
+36.50 ± 3.01 
+36.99 ± 3.67
+0.593b
+0.79
+9
+Hip circumference
+39.49 ± 4.63 
+38.21 ± 4.71 
+38.84 ± 3.71 
+38.57 ± 3.93
+2.479b
+0.54
+10
+Total body fat percentage
+29.83 ± 3.46
+27.76 ± 2.72
+29.02 ± 2.65
+28.96 ± 2.17
+3.236b
+0.92
+11
+Resting metabolism
+1382.83 ± 205.34
+1404.33 ± 263.33
+1369.25 ± 218.60
+1388.33 ± 238.43
+0.579 a
+0.56
+12
+Subcutaneous fat (Whole body)
+25.57 ± 5.58
+21.96 ± 4.32
+24.80 ± 5.11
+22.75 ± 4.56
+0.606 a
+0.54
+13
+Muscle percentage (Whole body)
+27.13 ± 3.51 
+28.26 ± 2.89 
+27.20 ± 3.06 
+28.12 ± 2.93
+0.036a
+0.97
+14
+Subcutaneous fat (Arms)
+39.23 ± 8.58
+34.62 ± 6.47
+38.90 ± 8.16
+36.02 ± 7.03
+0.383a
+0.70
+15
+Muscle percentage (Arms )
+31.01± 6.78
+33.98 ± 5.07
+30.62 ± 7.27
+33.47 ± 6.61
+0.330a
+0.74
+16
+Subcutaneous fat (Trunk)
+22.21 ± 5.35
+19.23 ± 3.29
+21.34 ± 4.32
+20.07 ± 3.52
+1.241b 
+0.88
+17
+Muscle percentage (Trunk)
+20.58 ± 2.97
+21.55 ± 2.20
+20.87 ± 2.40
+21.2  ±  2.08
+-1.637b
+0.36
+18
+Subcutaneous fat (Legs)
+38.35 ± 8.27 
+34.27 ± 6.29 
+38.75 ± 8.81 
+35.92 ± 7.71
+- 0.278b
+0.77
+19
+Muscle percentage (Legs)
+41.94 ± 5.21
+43.94 ± 4.65
+42.06 ± 4.94
+43.78 ± 4.95
+- 0.701b
+0. 14
+20
+Sit ups
+32.95 ± 7.02
+31.5 ± 9.38
+30.21 ± 8.74
+ 26.78 ± 7.36
+- 0.942b
+0.09
+21
+Flamingo Balance test
+60.70 ± 37.07
+65.75 ± 38.48
+72.17 ± 56.41
+91.89 ± 58.65
+1.568a
+0.11
+aMann-Whitney U test
+bIndependent samples t-test
+∞significant at 0.05
+Table 4: Result of In between group analysis.
+Citation: Rathi SS, Joshi RR, Tekur P, Naratna RN, Nagendra HR (2018) Effect of the Yoga on Anthropometric and Physical Assessments in Adolescent Obesity. A Case 
+Report. Endocrinol Metab Syndr 7: 292. doi:10.4172/2161-1017.1000292
+Page 6 of 6
+Volume 7 • Issue 5 • 1000292
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+Endocrinol Metab Syndr, an open access journal
+ISSN: 2161-1017
+children with respect to anthropometric and physical assessments. This 
+study provides evidence to prove efficacy of Yoga to manage increased 
+subcutaneous adiposity in trunk, hip and leg region resulting in weight 
+reduction in adolescent children.
+Acknowledgement
+We are thankful to Mr. Ramkumar Rathi and Rathi foundation for 
+his support. We also acknowledge the kind cooperation of Kaveri group 
+of education, Pune.
+References
+1.	 WHO (2017) Obesity and overweight.
+2.	 Batch JA, Baur L (2005) Management and prevention of obesity and its 
+complications in children and adolescents. Med J Aust 182: 130-135.
+3.	 WHO (2015) Obesity and overweight.
+4.	 Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, et al. (2007) 
+Assessment of Child and Adolescent Overweight and Obesity. Pediatrics 120: 
+S193-228.
+5.	 Koplan JP, Liverman CT, Kraak VI, (2005) Preventing Childhood Obesity: 
+Health in the Balance. Washington, DC: National Academies Press, Institute 
+of Medicine (US) Committee on Prevention of Obesity in Children and Youth.
+6.	 Brambilla P, Bedogni G, Moreno LA, Goran MI, Gutin B, et al. (2006) 
+Crossvalidation of anthropometry against magnetic resonance imaging for the 
+assessment of visceral and subcutaneous adipose tissue in children. Int J Obes 
+(Lond) 30: 23-30.
+7.	 Lofgren I, Herron K, Zern T, West K, Patalay M, et al. (2004) Waist circumference 
+is a better predictor than body mass index of coronary heart disease risk in 
+overweight premenopausal women. J Nutr 134: 1071-1076.
+8.	 Erikoglu O, Guzel NA, Pense M, Orer GE (2015) Comparison of Physical 
+Fitness Parameters with EUROFIT Test Battery of Male Adolescent Soccer 
+Players and Sedentary Counterparts. Int JSCS. 3: 43-52.
+9.	 Tokmakidis SP, Kasambalis A, Christodoulos AD (2006) Fitness levels of Greek 
+primary schoolchildren in relationship to overweight and obesity. Eur J Pediatr 
+165: 867-874.
+10.	Agarwal BB (2010) Yoga and Medical Sciences. JIMSA 23: 69-70.
+11.	Subhadra S, Jayable T (2017) Effect of aerobic & resistance exercise 
+on physical fitness components of Adolescent boys. Journal of Exercise 
+Rehabilitation 13: 95-100.
+12.	Pierce JW, Wardle J (1997) Cause and Effect Beliefs and Self-esteem of 
+Overweight Children. J Child Psychol Psychiatry 38: 645-650.
+13.	https://www.cdc.gov/chronicdisease/index.htm
+14.	Garcia DM (1986) The transactional model of stress and coping: Its implication 
+to young adolescents. University of Denver.
+15.	Bhardwaj KA, Agrawal G (2013) Yoga Practice Enhances the Level of Self- 
+Esteem in Pre-Adolescent School Children. International Journal of Physical 
+and Social Sciences 10: 189-199.
+16.	Kumar P (2016) Effects of Yoga on Mental Health. International Journal of 
+Science and Consciousness 2: 6-12.
+17.	Telles S, Singh N, Bhardwaj AK, Kumar A, Balkrishna A (2013) Effect of yoga or 
+physical exercise on physical, cognitive and emotional measures in children: a 
+randomized controlled trial. Child Adolesc Psychiatry Ment Health 7: 37.
+18.	Raine L, Drollette E, Kao SC, Westfall D, Chaddock-Heyman L (2018) The 
+Associations between Adiposity, Cognitive Function, and Achievement in 
+Children. Med Sci Sports Exerc 50: 1868-1874. 
+19.	Chojnacki MR, Raine LB, Drollette ES, Scudder MR, Kramer AF, et al. (2018) 
+The Negative Influence of Adiposity Extends to Intraindividual Variability in 
+Cognitive Control among Adoloscent Children. Obesity (Silver Spring) 26: 
+405-411.
+20.	Rathi SS, Raghuaram N, Tekur P, Joshi RR, Ramarao NH (2018) Development 
+and validation of integrated yoga module for obesity in adolescents. Int J Yoga 
+11: 231-238.
+21.	Cramer H, Thoms MS, Anheyer D, Lauche R, Dobos G (2016) Yoga in Women 
+With Abdominal Obesity a Randomized Controlled Trial. Dtsch Arztebl Int 113: 
+645-652.

subfolder_0/Effect of yoga on self-rated visual discomfort in computer users.txt

@@ -0,0 +1,571 @@
+BioMed 
+Central
+Page 1 of 6
+(page number not for citation purposes)
+Head & Face Medicine
+Open Access
+Research
+Effect of yoga on self-rated visual discomfort in computer users
+Shirley Telles*, KV Naveen†, Manoj Dash†, Rajendra Deginal† and 
+NK Manjunath†
+Address: Swami Vivekananda Yoga Research Foundation, No. 19, Eknath Bhavan, K.G. Nagar, Bangalore 560 019, India
+Email: Shirley Telles* - [email protected]; KV Naveen - [email protected]; Manoj Dash - [email protected]; 
+Rajendra Deginal - [email protected]; NK Manjunath - [email protected]
+* Corresponding author    †Equal contributors
+Abstract
+Background: 'Dry eye' appears to be the main contributor to the symptoms of computer vision
+syndrome. Regular breaks and the use of artificial tears or certain eye drops are some of the
+options to reduce visual discomfort. A combination of yoga practices have been shown to reduce
+visual strain in persons with progressive myopia. The present randomized controlled trial was
+planned to evaluate the effect of a combination of yoga practices on self-rated symptoms of visual
+discomfort in professional computer users in Bangalore.
+Methods: Two hundred and ninety one professional computer users were randomly assigned to
+two groups, yoga (YG, n = 146) and wait list control (WL, n = 145). Both groups were assessed at
+baseline and after sixty days for self-rated visual discomfort using a standard questionnaire. During
+these 60 days the YG group practiced an hour of yoga daily for five days in a week and the WL
+group did their usual recreational activities also for an hour daily for the same duration. At 60 days
+there were 62 in the YG group and 55 in the WL group.
+Results: While the scores for visual discomfort of both groups were comparable at baseline, after
+60 days there was a significantly decreased score in the YG group, whereas the WL group showed
+significantly increased scores.
+Conclusion: The results suggest that the yoga practice appeared to reduce visual discomfort,
+while the group who had no yoga intervention (WL) showed an increase in discomfort at the end
+of sixty days.
+Background
+Nowadays most people have some contact with comput-
+ers either at work or at home. This change has been asso-
+ciated with an increase in complaints of a number of
+health problems associated with working at visual display
+terminals (VDTs) [1]. Eye problems are the single most
+common complaints [2]. The main visual symptoms
+which VDT users report are eyestrain, irritation, tired eyes,
+a burning sensation, redness, blurred vision, and double
+vision [2-5]. The symptoms collectively constitute compu-
+ter vision syndrome [6]. The main contributor to the
+symptoms of computer vision syndrome appears to be
+'dry eye'.
+These symptoms are widely recognized as temporary,
+however the individual does experience considerable dis-
+Published: 03 December 2006
+Head & Face Medicine 2006, 2:46
+doi:10.1186/1746-160X-2-46
+Received: 15 June 2006
+Accepted: 03 December 2006
+This article is available from: http://www.head-face-med.com/content/2/1/46
+© 2006 Telles et al; licensee BioMed Central Ltd. 
+This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
+which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
+Head & Face Medicine 2006, 2:46
+http://www.head-face-med.com/content/2/1/46
+Page 2 of 6
+(page number not for citation purposes)
+comfort [7]. Reducing visual discomfort appears to
+improve productivity at work [8]. This was indirectly
+inferred, as adding regular breaks to the work schedule
+improved the efficiency between breaks and compensated
+for the extra time spent in breaks. Apart from breaks other
+options which have been tried to reduce discomfort are
+modifying the computer location, the lighting and reflec-
+tion, increasing humidity, the use of artificial tears [9] or
+certain eye drops [10].
+Yoga is an ancient Indian science which includes the prac-
+tice of specific postures, cleansing practices, regulated
+breathing and meditation [11]. A combination of yoga
+practices reduced symptoms of visual strain in persons
+with progressive myopia [12]. Among software develop-
+ment organizations worldwide, several are in Bangalore
+city [13]. Hence the present randomized controlled trial
+was planned to evaluate the effect of a combination of
+yoga practices on self-rated symptoms of visual discom-
+fort in professional computer users in Bangalore.
+Methods
+Participants
+The participants were 291 persons working in a software
+company in Bangalore, India. There was no attempt to cal-
+culate the sample size when planning the study. However
+based on the effect size obtained in the present study
+[0.66 with 0.9 power to detect a significant difference at
+alpha level 0.05], 50 subjects were required for each group
+while in fact at baseline there were 146 subjects in the
+yoga group and 145 in the control group.
+All of them used a computer for at least 6 hours each day,
+for 5 days in a week. Persons of both sexes participated in
+the trial and their ages ranged between 21 and 49 years.
+The participants were screened to exclude those who: (i)
+had consulted a specialist for their visual symptoms, (ii)
+had uncorrected errors of refraction, (iii) had clinical con-
+ditions such as Sjögren's syndrome or kerato-conjunctivi-
+tis sicca and (iv) used medication associated with drying
+of the eyes (e.g., anti-histaminics). None of the partici-
+pants had to be excluded based on these criteria. The
+details of the study were described to the participants and
+their consent to participate was obtained. The project was
+approved by the ethics committee of the yoga research
+foundation and had the approval of the human resource
+department of the software company.
+Design of the study
+291 participants were randomized prior to assessment as
+two groups using a standard random number table by the
+researchers responsible. The two groups were then desig-
+nated as (i) intervention (i.e., yoga, n = 146) and (ii) wait
+list control (n = 145) by an office assistant from the soft-
+ware company who had no other role in the study. The
+yoga (YG) and wait list control (WL) groups were compa-
+rable with respect to age (group average (± S.D.) 32.8 (±
+8.6) years and 31.9 (± 10.2) years, respectively) and gen-
+der-distribution (11 females in YG group and 13 in WL
+group).
+Both groups were assessed at baseline and after 60 days.
+During the 60 days the YG group practiced yoga for an
+hour per day, for five days in a week. While the YG group
+practiced yoga the WL group spent the time in the recrea-
+tion center of the software company where 60 percent of
+them talked to their friends, 12 percent spent time playing
+indoor games, 12 percent worked out in the gym and 16
+percent watched television. The WL group had already
+been spending this time each day doing the same activities
+and hence during the 60 day period they were following
+their usual routine. During the 60 days there were 84 drop
+outs from the trial in the YG group and 90 from the WL
+group. The large number of drop outs was mainly due to
+the fact that the participants had demanding work sched-
+ules which interfered with their participating in: (i) the
+intervention (YG group) or recreational activities (WL
+group) and/or (ii) the assessments (both groups). To be
+considered as regular in their participation the YG group
+had to have a minimum of 38 days of attendance during
+the 60 day period. The trial profile is given in Figure 1.
+Assessments
+Visual discomfort including dryness, irritation, burning,
+redness, photo-sensitivity and possible remedial measures
+(e.g., the use of lubricating eye drops) were determined
+using a questionnaire [14]. It had 12 items, each of which
+had 4 possible choices. These were: (i) absent, (ii) rarely
+present (meaning one or two days per week), (iii) often
+(meaning more than two days per week) and (iv) contin-
+uous. The symptoms were considered during the week
+before assessment and the four alternatives (i-iv) were
+graded as '0', '1', '2' and '3', respectively. The person who
+administered the questionnaire and scored the response
+sheets was not aware to which group the subjects
+belonged.
+Intervention (yoga)
+The 60 minute yoga program included yoga postures
+(asanas, 15 minutes), regulated breathing (pranayamas, 10
+minutes), exercises for the joints (sithilikarana vyayama, 10
+minutes), visual cleansing exercises (trataka, 10 minutes),
+and guided relaxation (15 minutes).
+The practice of trataka involves two sets of eye exercises. (i)
+Shifting the gaze (by moving the eyes alone) in eight
+directions. During this exercise, practitioners are asked to
+use their right thumb (and when gazing to the left, their
+left thumb) as a cue to direct their gaze. The directions are
+up, down, up to the left, down to the left, up to the right,
+Head & Face Medicine 2006, 2:46
+http://www.head-face-med.com/content/2/1/46
+Page 3 of 6
+(page number not for citation purposes)
+down to the right and rotation of the eyes clock-wise and
+anti clock-wise. (ii) During the second exercise, practition-
+ers gaze at a flame placed at eye level without blinking.
+While gazing at the flame, practitioners are instructed to
+focus their gaze on the flame and subsequently defocus
+while keeping their gaze on the flame. Throughout the
+practice practitioners should sit upright and should avoid
+moving their head to shift their gaze.
+These techniques were selected either because previous
+research showed that they reduced physiological arousal
+[15,16] or based on our unpublished clinical observa-
+tions.
+Data analysis
+The data were analyzed using SPSS Version 10.0. Repeated
+measures analyses of variance (ANOVA) were carried out
+with one Between-subjects factor, viz., Groups (with two
+levels, i.e., YG and WL groups) and one Within-subjects
+factor, viz., Assessments (with two levels, i.e., baseline and
+day 60). Post-hoc analyses for multiple comparisons
+between mean values were done with Bonferroni adjust-
+ment.
+Results
+291 participants attended their respective interventions
+[yoga and control] in three blocks across 18 months from
+October 2004 to April 2005.
+The repeated measures analyses of variance (ANOVA)
+showed a significant difference between YG and WL
+groups (F = 15.369, DF = 1,115, P < .001). There was no
+significant difference between assessments taken at base-
+line and on day 60. The interaction between groups and
+assessments was significant (F = 178.607, DF = 1,115, P <
+.001), suggesting that the two factors (groups, assess-
+ments) were not independent of each other.
+Post-hoc assessments with multiple comparisons of mean
+values showed a significant decrease in scores of self-rated
+visual discomfort for the YG group on day 60 compared
+to baseline (P < .001). In contrast, there was a significant
+increase in scores of self rated visual discomfort for the WL
+group on day 60 compared to baseline (P < .001).
+The groups mean values with 95% C.I. are given in Table
+1. The details of the ANOVA are given in Table 2.
+Discussion
+In the present single blind, randomized, prospective trial
+291 persons working in a software company were evalu-
+ated for self-rated symptoms of visual discomfort. They
+were randomized as yoga (YG) and wait list (WL) control
+groups. Both groups showed comparable discomfort at
+baseline. At the end of sixty days the YG group showed
+decreased scores, whereas the WL group showed an
+increase in visual discomfort.
+Trial profile of the randomized controlled study
+Figure 1
+Trial profile of the randomized controlled study.
+Total number selected & randomly assigned to two groups=291
+Yoga
+Group
+Pre
+(n=146)
+Pre
+(n=145)
+Post
+(n= 62)
+Post
+(n= 55)
+Drop outs, unable to 
+regularly attend: 
+1. Recreational
+activities (n=59)
+2. Assessments (n=31)
+Drop outs, unable to 
+regularly attend: 
+1. Intervention (n=57) 
+2. Assessments (n=27)
+Control
+Group
+Head & Face Medicine 2006, 2:46
+http://www.head-face-med.com/content/2/1/46
+Page 4 of 6
+(page number not for citation purposes)
+Visual discomfort in professional computer users is con-
+tributed to by various factors such as lighting, glare, dis-
+play quality, ergonomic positioning of the monitor and
+regularity of work breaks [6]. The symptom which largely
+contributes to subjectively rated visual discomfort is 'dry
+eye'. Dry eye is itself contributed to by various factors,
+including certain diseases (e.g., Sjögren's syndrome, use of
+certain medication (e.g., anti-histaminics), gender (being
+more common in females)), and individual factors [17].
+Individual factors include blink rate and completeness of
+blinking which significantly affect tear film dynamics and
+ocular surface health [18,19]. Blink rate especially has
+been shown to vary with the task performed [20]. The
+mean (± S.D.) rate of blinking was 22 (± 9) per minute
+under relaxed conditions, 10 (± 6) per minute while the
+subjects were reading a book at table level, and 7 (± 7) per
+minute while working at a video display terminal. Hence
+the frequency of blinking reduces while mentally alert and
+with gaze focused.
+Specific yoga practices have been found to bring about
+physiological changes suggestive of 'alertful rest' [21]. This
+description was based on a simultaneous decrease in heart
+rate and oxygen consumption along with a reduction in
+peripheral cutaneous blood flow. Also the visual cleans-
+ing practices used in the present trial have been shown to
+facilitate visual perceptual sensitivity in terms of a
+decrease in optical illusion [22]. A reduction in anxiety
+has been found to be associated with better visual percep-
+tual sensitivity [23]. A relaxed state (as described above) is
+associated with a higher frequency of blinking. Yoga prac-
+tice has been associated with better self rated relaxation
+[24] as well as with physiological relaxation [25]. Hence
+the reduction in visual discomfort in the yoga group in the
+present study may be attributed to an improvement in the
+ability to focus while remaining relaxed which may have
+increased the blink rate.
+In contrast to the yoga group the control group showed an
+increase in self rated visual discomfort. These differences
+between the groups could be due to psychological bene-
+fits that are reported with 'additional care' [26]. In the
+present study the frequent meetings which the yoga group
+had with the instructor could serve as additional care and
+may have contributed to the benefits seen in the yoga
+group. The absence of this psychological support and the
+yoga practice in the control group may have contributed
+to increased visual discomfort at follow-up.
+A main limitation of the study is that well recognized
+objective indicators of visual discomfort (especially dry-
+ness) were not measured. It would have been ideal to have
+carried out a semi-quantitative estimation of the superfi-
+cial lipid layer or have measured the tear breakup time
+[27]. However another variable which is an objective indi-
+cator of VDT related fatigue was measured in these sub-
+jects, and the results were reported elsewhere [28]. This is
+the critical flicker fusion frequency (CFF), which is the
+flicker frequency rate beyond which one can no longer
+perceive the flicker. Flicker related changes in the visual
+system from working at a cathode ray tube (CRT) compu-
+ter screen have also been measured [29]. A group of sub-
+jects worked for 3 hours at simulated CRT displays with
+different flicker rates. The CFF was found to decrease. A
+similar result was obtained when the effect of performing
+the same task on a CRT was compared with the perform-
+ance on a back slide projection system (BPS) [30]. The
+CFF of the group decreased after working on the CRT com-
+puter screen while it did not change when working on the
+BPS. These studies suggest that the visual system possibly
+gets fatigued as a result of viewing supra-threshold flicker.
+Table 2: Analysis of variance for scores in the 'Dry Eye Questionnaire'
+Source
+df
+MS
+F
+P' values
+Within subjects factor (Assessments)
+1
+0.133
+3.221
+0.075
+Between subjects factor (Groups)
+1
+8.326
+15.369
+0.001
+Interaction (Assessments and Groups)
+1
+7.381
+178.607
+0.001
+Error (Within subjects factor)
+115
+4.133
+Error (Between subjects factor)
+115
+0.542
+Greenhouse-Geisser epsilon = 1.000, hence Sphericity Assumed
+Table 1: Scores of the questionnaire for visual discomfort for yoga and control groups at baseline [BL] and day 60.
+Descriptive values
+YOGA [n = 62]
+CONTROL [n = 55]
+BL
+Day 60
+BL
+Day 60
+Mean (95 % C.I.)
+1.03 (.91–1.15)
+0.7*** (.58–.94)
+1.05 (.89–1.21)
+1.5*** (1.34–1.66)
+*** P < .001, post-hoc test for multiple comparisons
+Head & Face Medicine 2006, 2:46
+http://www.head-face-med.com/content/2/1/46
+Page 5 of 6
+(page number not for citation purposes)
+In the subjects of this study critical flicker fusion fre-
+quency was measured using a standard electronic appara-
+tus [28]. Each subject was assessed in 10 trials (5 each,
+ascending and descending, given alternately). The fre-
+quency of flicker for the ascending trials was gradually
+increased from a minimum of 8 Hz, with 1 Hz incre-
+ments, till the subjects reported that the light appeared
+"fused" or steady. This was the fusion threshold. For
+descending trials, the frequency was gradually reduced (1
+Hz per step) from 49 Hz, till the subject perceived the
+stimulus as "flickering". This was the flickering threshold.
+The average value of the ascending and descending trials
+was used for statistical analysis.
+After sixty days the yoga group showed an increase in CFF
+from a group average (± SD) of 31.8 (± 2.6) at baseline to
+an average of 33.6 (± 2.5) after sixty days. In contrast, the
+wait list control group showed a decrease in CFF, from a
+group average of 32.5 (± 2.5) at baseline to a group aver-
+age of 31.4 (± 2.5) at the end of sixty days. Hence the yoga
+group showed an average increase of 1.8 Hz in the CFF,
+compared with an average decrease of 1.1 Hz in the wait
+list control. This may suggest that the wait-list control
+group might have remained prone to visual fatigue,
+whereas the yoga group was not.
+These results suggest that sixty days of yoga practice may
+have reduced visual fatigue based on the self-rated symp-
+toms presented in this study and the CFF findings
+reported earlier [28]. However other factors may have
+influenced the subjective assessment of visual dryness. For
+example, certain personality traits were reported to be
+higher in contact lens wearers who had dryness of the eyes
+[31]. This study subjectively evaluated personality traits
+using the Yatabe Guilford Personality Test. No personality
+assessment was carried out in the participants studied
+here, which can be considered a limitation of the study.
+Also, it has been shown that for yoga practice to be effec-
+tive participants should be motivated to learn and practice
+yoga [32]. Hence it would also have been useful to assess
+levels of motivation in the yoga group and correlate them
+with the reduction in self-rated visual discomfort which
+was found.
+Conclusion
+The results of the present study suggest that a combination
+of yoga techniques practiced for 60 days improves self-
+rated visual discomfort in computer professionals. In con-
+trast, the wait list control group who continued with their
+usual routine showed an increase in self-rated visual dis-
+comfort. Hence the practice of yoga can be a potential
+non-pharmacological intervention for visual discomfort
+related to working at visual display terminals (VDTs).
+Competing interests
+The principal author and four co-authors declare that they
+have no competing interests.
+Authors' contributions
+ST conceived and designed the study and prepared the
+manuscript. NKV participated in the conception and
+design of the study and in compiling the manuscript. MD
+co-ordinated the project and supervised the intervention
+and data collection. RD participated in the recruitment of
+subjects, data collection and assisted in statistical analysis.
+MNK carried out data extraction and analysis. All authors
+read and approved the final manuscript.
+Acknowledgements
+The research was funded by the Central Council for Research in Yoga and 
+Naturopathy, Department of AYUSH, Ministry of Health and Family Wel-
+fare, Government of India, New Delhi, India.
+References
+1.
+Smith MJ, Cohen BG, Stammerjohn WL Jr: An investigation of
+health complaints and job stress in Video Display operations.
+Hum Factors 1981, 23:387-400.
+2.
+Collins MJ, Brown B, Bowman KJ: Visual Discomfort and VDTs.
+Report for National Occupational Health and Safety Commission (Australia)
+1998.
+3.
+Lie I, Watten RG: VDT work, Oculomotor strain and subjec-
+tive complaints – an experimental and clinical study.  Ergo-
+nomics 1994, 37:1419-1433.
+4.
+Bergqvist UO, Knave BG: Eye discomfort work with visual dis-
+play terminals.  Scand J Work Environ Health 1994, 20:27-33.
+5.
+Cole BL, Maddocks JD, Sharpe K: Effect of VDUs on the eyes –
+report of a six-year epidemiological study.  Optom Vis Sci 1996,
+73:512-528.
+6.
+Blehm C, Vishnu S, Khattak A, Mitra S, Yee RW: Computer Vision
+Syndrome: a review.  Surv Ophthalmol 2005, 50:253-262.
+7.
+Yeow PT, Taylor SP: Effect of short-term VDT usage on visual
+functions.  Optom Vis Sci 1989, 66:459-466.
+8.
+Grandjean E: Fitting the task to the man London: Taylor and Francis;
+1980. 
+9.
+Sheedy JE, Shaw-McMinn PG: Diagnosing and treating computer related
+vision problems Burlington, MA: Butterworth-Heinemann; 2003. 
+10.
+Apostol S, Filip M, Dragne C, Filip A: Dry eye syndrome. Etiolog-
+ical and therapeutic aspects.  Oftalmologia 2003, 59:28-31.
+11.
+Visweswaraiah NK, Telles S: Randomized trial of yoga as a com-
+plementary therapy for pulmonary tuberculosis.  Respirology
+2004, 9:96-101.
+12.
+Nagendra HR, Vaidehi S, Nagarathna R: Integrated approach of yoga
+therapy for ophthalmic disorders. Institutional report VKYOCTAS/84/015
+Bangalore: Vivekananda Kendra Yoga Therapy and Research Center;
+1984. 
+13.
+Killcrece G, Kossakowski K-P, Ruefle R: Organizational models for com-
+puter security incident response teams (CSIRTs). Pittsburgh: SEI: Hand book
+Carnegie-Mellon University (CMU)/Software Engineering Institute 2003-
+HB-001-15213-3890 2003.
+14.
+Bandeen-Roche K, Munoz B, Tielsch JM, West SK, Schein OD: Self-
+reported assessment of dry eye in a population-based set-
+ting.  Invest Ophthalmol Vis Sci 1997, 38:2469-2475.
+15.
+Tran MD, Holly RG, Lashbrook J, Amsterdam EA: Effects of hatha
+yoga practice on the health-related aspects of physical fit-
+ness.  Prev Cardiol 2001, 4:165-170.
+16.
+Vempati RP, Telles S: Yoga based guided relaxation reduces
+sympathetic activity in subjects based on baseline levels.  Psy-
+chol Rep 2002, 90:487-494.
+17.
+Duncan DD, Munoz B, Bandeen-Roche K, West SK: Assessment of
+Ocular exposure to ultraviolet-B for population studies.
+Salisbury Eye Evaluation Project Team.  Photochem Photobiol
+1997, 66:701-709.
+Publish with BioMed
+ Central  
+ and  
+every 
+scientist can read your work free of charge
+"BioMed Central will be the most significant development for 
+disseminating the results of biomedical research in our lifetime."
+Sir Paul Nurse, Cancer Research UK
+Your research papers will be:
+available free of charge to the entire biomedical community
+peer reviewed and published 
+immediately upon acceptance
+cited in PubMed and archived on PubMed Central 
+yours — you keep the copyright
+Submit your manuscript here:
+http://www.biomedcentral.com/info/publishing_adv.asp
+BioMedcentral
+Head & Face Medicine 2006, 2:46
+http://www.head-face-med.com/content/2/1/46
+Page 6 of 6
+(page number not for citation purposes)
+18.
+Lemp MA: Report on the National Eye Institute/Industry
+workshop on Clinical Trials in Dry Eyes.  CLAOJ 1995,
+21:221-232.
+19.
+Albietz JM: Prevalence of dry eye sub types in clinical optom-
+etry practice.  Optom Vis Sci 2000, 77:357-363.
+20.
+Tsubota K, Nakamori K: Dry eyes and Video Display Terminals.
+N Engl J Med 1993, 328:584.
+21.
+Telles S, Nagarathna R, Nagendra HR: Improvement in visual per-
+ception following yoga training.  J Indian Psychol 1995, 13:30-32.
+22.
+Vani PR, Nagarathna R, Nagendra HR, Telles S: Progressive
+increase in critical flicker fusion frequency following yoga
+training.  Indian J Physiol Pharmacol 1997, 41:71-74.
+23.
+Brown D, Forte M, Dysart M: Differences in visual sensitivity
+among mindfulness meditators and non-meditators.  Percept
+Mot Skills 1984, 58(3):727-733.
+24.
+Manjunath NK, Telles S: Influence of Yoga and Ayurveda on self
+rated sleep in a geriatric population.  Indian J Med Res 2005,
+121:683-690.
+25.
+Malathi A, Damodaran A: Stress due to exams in medical stu-
+dents – role of yoga.  Indian J Physiol Pharmacol 1999,
+43(2):218-224.
+26.
+Delbanco T: The healing roles of doctor and patient. Healing and the mind
+Edited by: InMoyers B. New York: David Grubin Productions;
+1993:7-23. 
+27.
+Brasche S, Bullinger M, Petrovich A, Mayer E, Gebhardt H, Herzog V,
+Bischof W: Self reported eye symptoms and related diagnos-
+tic findings-comparison of risk factor profiles.  Indoor Air
+2005:56-64.
+28.
+Telles S, Dash M, Manjunath NK, Deginal R, Naveen KV: Effect of
+yoga on visual perception and visual strain.  Opt Acta (Lond) [cur-
+rently called Journal of Modern Optics] 2006 in press.
+29.
+Laubli T, Hunting W, Grandjean E, Fellmann T, Brauninger U, Gierer
+R: Load factors at visual display terminals.  Klin Monatsbl Augen-
+heilkd 1982, 180(5):363-366.
+30.
+Harwood K, Foley P: Temporal resolution: an insight into the
+visual display terminal (VDT) "problem".  Hum Factors 1987,
+29:447-452.
+31.
+Chikama T, Ueda K, Nishida T: Clinical interpretation of the sub-
+jective complaint of dryness in contact lens wearers.  Nippon
+Ganka Gakkai Zasshi 2005, 109(6):355-361.
+32.
+Manjunath NK, Telles S: Factors influencing changes in tweezer
+dexterity scores following yoga training.  Indian J Physiol Pharma-
+col 1999, 43(2):225-229.

subfolder_0/Effect of yoga on somatic indicators of distress in professional computer users.txt

@@ -0,0 +1,238 @@
+PERS
+ON
+Effect of yoga on somatic indicators of distress in profes-
+sional computer users
+Comments to:
+Association between occupational asthenopia and psycho-phy-
+siological indicators of visual strain in workers using video dis-
+play terminals
+Ruta Ustinaviciene, Vidmantas Januskevicius
+Med Sci Monit, 2006; 12(7): CR296–301
+Dear Editor,
+Ophthalmologic and psycho-physiological indicators con-
+fi
+ rmed the subjective perception of visual strain due to vi-
+sual display terminal [VDT] work in two hundred and eight 
+professional computer users [1]. The report also mentio-
+ned that easily accessible and simple examinations could 
+be used to evaluate strain at the work place related to pre-
+ventive programs or interventional studies.
+Various interventions have been used to reduce visu-
+al discomfort, including breaks during work, modifying 
+the computer location, lighting and refl
+ ection, modify-
+ing the indoor environment, and the use of certain eye 
+drops [2].
+Yoga is an ancient Indian science which includes the practi-
+ce of specifi
+ c postures, cleansing practices, regulated bre-
+athing, and meditation [3]. A controlled trial was carried 
+out to evaluate the effect of a combination of yoga practi-
+ces on self-rated symptoms of visual discomfort in profes-
+sional computer users in India [4]. At the end of sixty days 
+of yoga practice there was a signifi
+ cant decrease in self-ra-
+ted visual discomfort, while the non-yoga control group 
+showed an increase.
+Apart from visual strain, VDT workers experienced a grea-
+ter subjective perception of stress than offi
+ ce workers [5]. 
+Stress is related to high work load, high work pressure, 
+diminished job control and stress related to the use of new 
+technology. The practice of yoga has been shown to redu-
+ce psycho-physiological indicators of mental stress in per-
+sons with high baseline stress levels associated with a phy-
+sical disability [6], their social circumstances [7] or their 
+occupation [8].
+Somatic indicators of distress were assessed in two hundred 
+and ninety one professional computer users with ages be-
+tween 21 and 49 years, who were randomly assigned to two 
+groups, yoga (YG, n=146) and wait-list control (WL, n=145). 
+The participants were from a software company in Bangalore 
+city (India) and they all used a computer for more than six 
+LE21
+Electronic PDF security powered by IndexCopernicus.com
+opy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for p
+PERSONAL USE
+ONLY
+hours each day, for fi
+ ve days a week. All of them had normal 
+health based on a clinical history and examination. Both 
+groups had comparable job assignments and responsibili-
+ties as rated by the human resource personnel from the sof-
+tware company. Both groups were assessed at baseline and 
+after sixty days. At the end of sixty days there were 62 per-
+sons in the YG group and 56 in the WL group.
+The YG group (average age of 32.8 years (±8.6 S.D.); 11 fe-
+males) practiced yoga for sixty minutes each day for fi
+ ve days 
+in a week. The practice consisted of joint loosening tech-
+niques (shithilikarana vyayama) for 10 minutes, physical po-
+stures (asanas, 15 minutes), regulated breathing practices 
+(pranayamas, 10 minutes), eye cleansing exercises (trataka, 
+10 minutes) and guided relaxation techniques (15 minu-
+tes). The WL group (average age of 31.9 years (±10.2 S.D.); 
+13 females) spent the same time talking to friends (60%), 
+watching television (16%), playing indoor games (12%) 
+or exercising in the gym (12%). This was how they usual-
+ly spent the time allotted as a work break. Hence they were 
+carrying on with their usual routine.
+A section of the symptom checklist 90 – Revised [SCL-90-R] 
+specifi
+ c to ‘somatization’ with 12 items was administered 
+to both groups at baseline and after two months of the in-
+terventions. The checklist was administered and scored by 
+the investigator who was blind to the allocation of subjects 
+to YG and WL groups. Each item was rated on a 0 to 4 sca-
+le for distress. The sum of the scores for the 12 items was 
+analyzed using a repeated measures analysis of variance 
+(ANOVA) followed by post hoc analyses with Bonferroni ad-
+justment (SPSS version 10).
+Both groups (YG and WL) had comparable baseline sco-
+res for the somatization dimension of the SCL-90-R as fol-
+lows: group average of 12.03 (±6.62 S.D.) and 9.93 (±7.38 
+S.D.), respectively (p>0.05). At the end of two months the 
+YG group showed a decrease in scores [average score of 
+6.34 (±6.13 S.D.)], (p<0.001) whereas the WL group sho-
+wed an increase in the score [average score of 12.82 (±8.24 
+S.D.)], (p=0.003).
+The somatization dimension of the SCL-90-R refl
+ ects distress 
+related to the way physical sensations are perceived [9]. The 
+cardiovascular, gastrointestinal, respiratory, and other sy-
+stems with autonomic mediation are included. It has alrea-
+dy been reported that physical and psychological symptoms 
+have signifi
+ cantly decreased following a 10 week behavio-
+ral medicine intervention, with a greater reduction in tho-
+se who were ‘high somatizers’ at baseline [10].
+Hence in the present study practicing yoga for sixty days 
+reduced somatic indicators of distress in professional com-
+puter users. Based on these results it may be interesting 
+to determine whether yoga practice prevents the develop-
+ment of actual somatic illness in asymptomatic professio-
+nal computer users.
+Sincerely,
+Shirley Telles and Naveen K.V., 
+Swami Vivekananda Yoga Research Foundation,
+No. 19, K.G. Nagar, Bangalore 560 019, India, 
+e-mail: [email protected]
+REFERENCES:
+ 1. Ustinaviciene R, Januskevicius V: Association between occupational asthe-
+nopia and psycho-physiological indicators of visual strain in workers using 
+video display terminals. Med Sci Monit, 2006; 12(7): CR296–301
+ 2. Sheedy JE, Shaw-McMinn PG: Diagnosing and treating computer rela-
+ted vision problems. Burlington, MA, Butterworth-Heinemann, 2003
+ 3. Visweswaraiah NK, Telles S: Randomized trial of yoga as a complemen-
+tary therapy for pulmonary tuberculosis. Respirology, 2004, 9: 96–101
+ 4. Telles S, Dash M, Manjunath NK et al: Effect of yoga on visual percep-
+tion and visual strain. J Mod Optics, 2006; in press
+ 5. Tomei G, Rosati MV, Martini A et al: Assessment of subjective stress in 
+video display terminal workers. Ind Health, 2006; 44(2): 291–95
+ 6. Telles S, Srinivas RB: Autonomic and respiratory measures in children 
+with impaired vision following yoga and physical activity programs. Int 
+J Rehab Health, 1999; 4(2): 117–22
+ 7. Telles S, Narendran S, Raghuraj P et al: Comparison of changes in au-
+tonomic and respiratory parameters of girls after yoga and games at a 
+community home. Percept Mot Skills, 1997; 84: 251–57
+ 8. Vempati RP, Telles S: Baseline occupational stress levels and physiologi-
+cal responses to a two day stress management program. J Indian Psychol, 
+2000; 18(1–2): 33–37
+ 9. Holi MM, Marttunen M, Aalberg V: Comparison of the GHQ – 36, the 
+GHQ – 12 and the SCL – 90 as psychiatric screening instruments in the 
+Finnish population. Nord J Psychiatry, 2003; 57(3): 233–38
+ 10. Nakao M, Myers P, Fricchione G et al: Somatization and symptom re-
+duction through a behavioral medicine intervention in mind/body me-
+dicine clinic. Behav Med, 2001; 26(4): 169–76
+Received: 2006.08.25
+LE22
+Electronic PDF security powered by IndexCopernicus.com
+opy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribu
+PERSONAL USE
+ONLY
+Index 
+Copernicus 
+integrates
+www.IndexCopernicus.com
+Index Copernicus
+Global Scientific Information Systems  
+for Scientists by Scientists
+Index 
+Copernicus 
+integrates
+IC Virtual Research Groups [VRG]
+Web-based complete research 
+environment which enables researchers 
+to work on one project from distant 
+locations. VRG provides: 
+ 
+customizable and individually  
+self-tailored electronic research 
+protocols and data capture tools, 
+ 
+statistical analysis and report 
+creation tools, 
+ 
+profiled information on literature, 
+publications, grants and patents 
+related to the research project, 
+ 
+administration tools.
+IC Scientists
+Effective search tool for 
+collaborators worldwide. 
+Provides easy global 
+networking for scientists.  
+C.V.'s and dossiers on selected 
+scientists available. Increase 
+your professional visibility.
+IC Patents
+Provides information on patent 
+registration process, patent offices 
+and other legal issues. Provides 
+links to companies that may want 
+to license or purchase a patent.
+IC Lab & Clinical Trial Register
+Provides list of on-going laboratory 
+or clinical trials, including  
+research summaries and calls for  
+co-investigators. 
+IC Grant Awareness
+Need grant assistance?  
+Step-by-step information on 
+how to apply for a grant. Provides 
+a list of grant institutions and 
+their requirements.
+IC Journal Master List
+Scientific literature database, 
+including abstracts, full text, 
+and journal ranking. 
+Instructions for authors 
+available from selected journals. 
+IC Conferences
+Effective search tool for 
+worldwide medical conferences 
+and local meetings.
+Index 
+Copernicus 
+integrates
+EVALUATION & BENCHMARKING
+PROFILED INFORMATION
+NETWORKING & COOPERATION
+VIRTUAL RESEARCH GROUPS
+GRANTS
+PATENTS
+CLINICAL TRIALS
+JOBS
+STRATEGIC & FINANCIAL DECISIONS
+EVALUATION & BENCHMARKING
+PROFILED INFORMATION
+NETWORKING & COOPERATION
+VIRTUAL RESEARCH GROUPS
+GRANTS
+PATENTS
+CLINICAL TRIALS
+JOBS
+STRATEGIC & FINANCIAL DECISIONS
+Electronic PDF security powered by IndexCopernicus.com
+opy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribu

subfolder_0/Effect of yoga therapy on quality of life and depression in premenopausal nursing students with mastalgia A randomized controlled trial.txt

@@ -0,0 +1,1046 @@
+Official Publication of 
+Academy of Advanced Dental Research
+Journal of
+Health Research & Reviews 
+Volume 3| Issue 2 | May-Aug 2016
+www.jhrr.org
+ISSN 2394-2010 
+© 2016 Journal of Health Research and Reviews | Published by Wolters Kluwer - Medknow
+48
+Effect of yoga therapy on quality of life and depression 
+in premenopausal nursing students with mastalgia: 
+A randomized controlled trial with 6‑month follow‑up
+Sukanya Raghunath, Nagarathna Raghuram, Sandhya Ravi1, Nidhi C Ram, Amritanshu Ram
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana University, 1Prameya Wellness Private Limited, 
+Bengaluru, Karnataka, India
+INTRODUCTION
+Mastalgia or breast pain is a common problem[1,2] with a 
+prevalence of 41–79%.[3‑5] Although the etiology of mastalgia is 
+not clearly understood, several factors including stress, anxiety, 
+and depression[6,7] have been a concern. A review of several 
+randomized controlled trials (RCTs) concluded that yoga was 
+better than many control interventions in reducing pain in 
+different parts of the body.[8,9]
+Literature says that there has been no research on yoga in 
+mastalgia. Hence, this study was planned to assess the role of 
+yoga therapy on the quality of life (QoL) and depression among 
+subjects with mastalgia through an randomized controlled 
+trial (RCT).
+Introduction: Mastalgia is a common problem and disturbs women’s reproductive lives. There is no known organic etiology 
+for mastalgia and also no definitive treatment. Considering the impact of mastalgia on the quality of life (QoL), it appears 
+that mind–body interventions such as yoga would play an important role. Yoga has shown a beneficial effect in reducing 
+pain, anxiety, and depression, thereby improving the QoL. Objective: To compare the benefits of yoga with the physical 
+activity in improving the QoL in nursing students with mastalgia. Materials and Methods: An institutional ethical committee 
+approved this randomized active control trial (RCT) with a follow‑up of 6 months on premenopausal women above 18 years 
+with breast pain (pain score >2) of more than 3 months duration. Women already practicing yoga, on hormonal treatment, 
+or diagnosed with malignancy were excluded. Eighty consenting nursing students were randomized into the yoga therapy 
+or control (brisk walk) arm (for 12 weeks). QoL and Beck Depression Inventory (BDI) questionnaires were administered prior 
+to the intervention and 3 months and 6 months after the intervention. Results: RM‑ANOVA group effect was significant in 
+BDI, F (1, 67) = 2632.72, P (<0.001) and in overall QoL, F (1, 67) =6881.41, (P < 0.001). Post hoc test (paired sample t‑test) 
+showed better improvement in the yoga group (0–3 months, 0–6 months) in both QoL (P < 0.001) (in all the four domains) 
+and depression scores (P < 0.001) compared to the control group. Conclusion: QoL and depression scores improved with 
+yoga in nursing students with mastalgia.
+Keywords: Depression, mastalgia, nursing students, quality of life, yoga
+ABSTRACT
+Access this article online
+Quick Response Code:
+Website:
+www.jhrr.org
+DOI:
+10.4103/2394-2010.184229 
+Address for correspondence:  Mrs. Sukanya Raghunath, 
+324, 5th Cross, 1st Block Jayanagar, Bangalore ‑ 560 011,  
+Karnataka, India. 
+E‑mail: [email protected]
+How to cite this article: Raghunath S, Raghuram N, Ravi S, Ram NC, Ram A. 
+Effect of yoga therapy on quality of life and depression in premenopausal 
+nursing students with mastalgia: A randomized controlled trial with 6-month 
+follow-up. J Health Res Rev 2016;3:48-54.
+This is an open access article distributed under the terms of the Creative 
+Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows 
+others to remix, tweak, and build upon the work non‑commercially, as long as the 
+author is credited and the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+Original Article
+Raghunath, et al.: Yoga in improving women’s quality of life with mastalgia/yoga in improving quality of life in women with mastalgia
+Journal of Health Research and Reviews | May ‑ August 2016 | Volume 3 | Issue 2
+49
+MATERIALS AND METHODS
+Female students between 18 years and 25 years of age, from two 
+residential nursing colleges, namely, IKON College of Nursing 
+in Bidadi and Sri Rajarajeswari College of Nursing in Bengaluru, 
+both in Karnataka in South India were the subjects of the study. 
+All the students lived in the hostel and had come from semi‑urban 
+and rural areas of six different states of India  (Karnataka, 
+Andhra Pradesh, Tamil Nadu, Maharashtra, and Kashmir) and 
+some parts of Nepal. They all had breast pain (cyclical or acyclical) 
+of more than 3 months.
+To ascertain the optimum sample size for the study, effect size 
+values obtained from our pilot study on 10 women with breast 
+pain in the same setting was used. Severity of pain, QoL, anxiety, 
+and depression were measured before and after 12  weeks of 
+yoga therapy practice. Results of seven women who completed 
+the study indicated reduction in pain [effect size (ES) =3.09], 
+anxiety (ES = 1.59) and depression (ES = 2.21), and increase in 
+QoL (ES = 0.80). Using these ES values of QoL powered at 0.95 
+for two‑tailed analysis a sample size of 23/arm was obtained; 
+anticipating an attrition rate of 70% due to the forthcoming 
+academic year, it was planned that 40 subjects would be recruited 
+in each arm.
+Inclusion criteria were: Premenopausal women 18  years and 
+above, breast pain more than 3 months requiring reassurance 
+and/or nondrug therapy, breast pain cyclical or acyclical, 
+unilateral or bilateral, with or without fibrocystic disease 
+of the breast, and those who satisfied 
+  Cleeland’s Breif pain 
+inventory with a pain score of >2. Women with malignancy, 
+postmenopausal women, those with hypothyroidism, those who 
+were on hormonal treatment or oral contraceptive pills, and those 
+already practicing yoga were excluded from the study.
+The trial started after the approval from the Institutional Ethical 
+Committee of Swami Vivekananda Yoga Anusandhana Samsthana 
+(SVYASA) University  (RES/IEC‑SVYASA/16/201). The written 
+approval was also obtained from the administrative heads of 
+both the colleges. This study was registered with the Clinical 
+Trial Registry of India (CTRI/2014/08/004911).
+After giving an introductory lecture, all the students were 
+asked to give signed informed consent, along with a filled 
+checklist of symptoms, which included questions regarding 
+their breast health, breast pain cyclical or acyclical, history of 
+fibroadenoma, fibrocystic disease, history of breast cancer, age 
+of menarche, menstrual cycle, information about past diagnosis, 
+management, scanning, surgery, other illness, their stress level, 
+happiness scores, diet, shifts in work, lifestyle pattern, along with 
+anthropometric and demographic data.
+The Research Medical Officer and a breast surgeon educated 
+the girls about the procedure and the importance of screening in 
+detail to make them comfortable. Along with four female medical 
+officers from the state government, the breast surgeon conducted 
+a detailed physical/clinical examination (breast screening) to look 
+for the features/signs and symptoms. Uniformity was maintained 
+by all the medical officers during the screening. Counseling and 
+educating them with regard to breast care were done during this 
+individual interaction. The screening was conducted in a hygienic 
+environment (biology laboratory of the college) providing them 
+privacy and comfort.
+This was a randomized, active control interventional trial wherein 
+80 participants were randomly divided into two arms. Concealed 
+envelope procedure was performed for randomization. One group 
+underwent yoga therapy and the control arm did brisk walk under 
+supervision for the same duration.
+This was an interventional study, and so double blinding was not 
+possible. Computer (www.randomizer.org)‑generated random 
+number table was used and the allocation of the subjects was 
+done by the prelabeled sealed envelope method. The research 
+medical officer and four gynecologists, ultrasonologists, and the 
+laboratory team were blind to the groups. The statistician had to 
+be blind as randomization and the final analysis was done by him. 
+The coded answer sheets of the questionnaires were decoded 
+only after completion of the scoring.
+The yoga group followed the precise list of practices 75 min 
+daily, 6 days a week for 3 months. During the 1st month, the 
+yoga sessions were taught by the certified yoga therapist for all 
+the 6 days. After this, the supervised 1‑h sessions were given 
+3  days a week by the therapist and subjects were asked to 
+do self‑practice for the other 3 days of the week for the next 
+2 months. After 3 months, they were asked to practice daily 
+on their own with weekly follow‑up classes when the therapist 
+reviewed their diary of daily practice and clarified the queries 
+of both groups. The detailed list of yoga therapy practices is 
+given in Table 1.
+The control group subjects did brisk walk for 1.5 h followed by 
+supine rest for 6 days 1 week under supervision. Lectures were 
+given on breast health, medical concept of a healthy lifestyle, 
+and benefits of diet and exercise. Attendance was taken for both 
+the groups.
+Sociodemographic details were obtained with the screening check 
+list. Cleeland’s Breif pain inventory and body mass index (BMI) 
+were documented after the clinical examination by the clinician. 
+Ultrasound scanning of the breast to look for fibroadenoma/cysts 
+and blood test to look for hypothyroidism were performed before 
+starting the intervention. Psychological assessments were done 
+by administering QoL and Beck Depression Inventory  (BDI) 
+questionnaires before and at 3 months and 6 months after the 
+intervention.
+BDI, developed by Dr. Beck in 1961,[10] aims to evaluate the 
+risk of depression and level of depressive symptoms objectively. 
+The inventory consists of 21 questions, each with four possible 
+answers scored between 0 and 3, with the total score ranging 
+0–63. The total score demonstrates the level of depression. 
+The score for each item ranges 0–3 and the range of total 
+score is 0–63. A score of 0 ≤ 9: No depression, 10–19: Mild 
+depression, 20–25: Moderate depression, and 26 and above: 
+Severe depression. BDI has been used widely and has Cronbach’s 
+alpha coefficient of 0.80 and r 0.74. This instrument has a 
+reliability of 0.48–0.86 and validity of 0.67 with the Diagnostic 
+Raghunath, et al.: Yoga in improving women’s quality of life with mastalgia/yoga in improving quality of life in women with mastalgia
+Journal of Health Research and Reviews | May ‑ August 2016 | Volume 3 | Issue 2
+50
+and Statistical Manual of Mental Disorders (DSM) diagnostic 
+criteria for depression.[11]
+BDI questionnaire attempts to measure the intensity, severity, 
+and depth of depression. It is commonly used in a clinical setting 
+as a novel way of diagnosing and categorizing depression in 
+psychiatric settings.
+QoL reflects the psychological imbalances that result from amplified 
+responses to incorrectly perceived environmental situations. The 
+World Health Organization quality of life‑BREF (WHOQOL‑BREF), 
+which is the short version of the WHOQOL‑100, is widely used. 
+WHOQOL‑BREF consists of 26 items assessing the QoL in four 
+domains (Physical health, Psychological health, Social relationships 
+and Environment) and a general evaluative facet (overall QoL and 
+general health). The psychometric properties of the WHOQOL‑BREF 
+is considered good for assessment of QoL in women with benign 
+breast disease.[12] Higher the scores in WHOQOL‑BREF, higher is 
+the QoL. Chronbach’s alpha being >0.70.
+Statistical analysis
+Data was analyzed using 
+ “R” software (ver. 3.1.0). Although the 
+data were not distributed normally, parametric tests were conducted 
+because of the large sample size. The paired and independent t‑tests 
+were used to compare within and between group differences. The 
+data for the 6 month follow‑up were compared using repeated 
+measures analysis of variance (ANOVA). All tests were two‑tailed, 
+with an alpha level of 0.05 and the power maintained at 0.8.
+RESULTS
+Detailed participant flow chart is given in Figure 1.
+The recruitment for the trial, data collection, and the baseline to 
+the 3rd month intervention, along with postdata collection were 
+from October 2013 to February 2014. Six months follow‑up was 
+done from March 2014 to August 2014.
+All the 80 residential subjects were unmarried [Mean (M) =19.84, 
+standard deviation (SD) =1.15] (range: 18–25 years), the onset of 
+menarche was M = 12.66, SD = 0.97 (range: 11–15 years), the 
+duration of breast pain was M = 13.13, SD = 10.06 (range: 4–60 
+months), and the BMI was M = 20.61, SD = 3.23. The breast pain 
+score in the pain analog scale was M = 3.67, SD = 1.11 (range: 
+3–6), a majority of the students, i.e., 58 (72.5%) had cyclical 
+mastalgia while 22  (27%) students had acyclical mastalgia. 
+Practice sessions varied from 56.89 ± 4.29 (out of 72 sessions) 
+in the yoga group and 54.83 ± 4.4 in the control group.
+Average scores in QoL were 87.28 ± 6.16 in the yoga group and 
+86.88 ± 7.07 in the control group. BDI scores were 15.28 ± 6.75 
+in the yoga group and 14.48 ± 4.67 in the control group. Detailed 
+sociodemographic data, along with psychological variables, are 
+shown in Table 2.
+Results after the intervention
+In QoL, comparison of means of the two groups by repeated 
+measures ANOVA 
+  showed highly significant between group 
+Table 1: List of yoga practices
+Sl. 
+No 
+List of practices
+Time (1 h 15 min)
+I
+Breathing exercises
+Hands in and out breathing
+Saśanka (moon) breathing
+Tiger breathing/stretch
+Bhujanga (cobra) breathing
+Salabha (plough) breathing
+II
+Loosening exercises
+Upper body twist
+4 min
+Lateral bend
+Forward-backward bend
+III
+Sun salutation (ṣūrya namaskāra)
+10 min
+IV
+Postures (āsanaās)
+Standing poses
+Half‑waist wheel pose (ardha kati cakrāsana)
+1 min
+Half‑wheel pose (ārdha cakrāsana)
+1 min
+Triangle pose (trikonāsana)
+1 min
+Tree pose (vrkśāsana)
+1 min
+Sitting poses
+Cow face pose (gomukhāsana)
+1 min
+Camel pose (uśtrāsana)
+1 min
+Moon pose (ṣaśankāsana)
+1 min
+Twisted pose (vakrāsana)
+1 min
+Prone poses
+Cobra pose (bhujangāsana)
+1 min
+Bow pose (dhanurāsana)
+1 min
+Plough pose (ṣalabhāsana)
+1 min
+Supine poses
+Shoulder stand (sarvāngāsana)
+1 min
+V
+Altered breathing (pranāyāma) and cleansing 
+technique (kriya)
+Kriya
+Active exhalation (kapāla bhāti)
+1 min
+Sectional breathing
+Abdominal, thoracic, clavicular, full yogic 
+breathing (vibhāgīya prānāyāma)
+2 min
+Alternate nostril breathing (anuloma‑viloma)
+3 min
+VI
+Deep relaxation (śavāsana)
+10 min
+VII
+Meditation
+Chanting of A, U, M, and Om (nādānusandhāna)
+4 min
+Observing silence (dhyāna)
+ 5 min
+VIII
+Lectures
+About culturing emotions, sātvik diet and 
+yogic counseling
+20 min
+Figure 1: Participant flowchart
+Raghunath, et al.: Yoga in improving women’s quality of life with mastalgia/yoga in improving quality of life in women with mastalgia
+Journal of Health Research and Reviews | May ‑ August 2016 | Volume 3 | Issue 2
+51
+effect, F (1, 67) =6881.41 (P < 0.001) in overall QoL. The 
+post hoc test (paired sample t‑test) showed highly significant 
+improvement at 3 months, t (37) =‑9.08, (P <.001) *** and 
+6 months, t (37) = ‑7.34, (P <.001) *** in the yoga group as 
+compared to the control group. The detailed results of all the four 
+domains are presented in Table 3.
+In BDI, comparison of means of the two groups by repeated 
+measures ANOVA showed highly significant reduction in 
+depression scores group effect: F (1, 67) =2632.72, P (<0.001). 
+The post hoc test (paired sample t‑test) showed significantly better 
+reduction at both 3 months: t (37) =12.96, (P <.001) *** and 
+6 months: t (37) =8.90, (P <.001) *** in the yoga group as 
+compared to the control group [Table 3]. Degrees of depression 
+before and after intervention in both the groups are presented 
+in Table 4.
+DISCUSSIONS
+The present RCT on 80 nursing students in the age range of 
+18–25 years with nonorganic breast pain looked at the effect 
+of yoga on QoL and depression in a 6‑month period. Results 
+of repeated measures ANOVA showed significant group time 
+interaction  (P  <  0.001). Post hoc tests revealed significant 
+improvement within the yoga group at the 3rd month and 6th month 
+follow‑up on all four domains of QoL and BDI [Figures 2 and 3].
+Although some studies point to a negative association of pain and 
+depression with QoL in women with nonorganic mastalgia,[13] 
+very few interventional studies have measured QoL. Those 
+that did look at QoL after pharmacotherapy did not show a 
+significant change in QoL as many of them were associated with 
+adverse effects.[14] Looking at nonpharmacological therapies, 
+Table 2: Baseline characteristics of both the groups
+Variables
+Yoga (n=40)
+Control (n=40)
+Total (n=80)
+Mean or N
+SD or %
+Mean or N
+SD or %
+Mean or N
+SD or %
+Age (years)
+20.10
+1.28
+19.58
+0.96
+19.84
+1.15
+Height (cm)
+155.08
+7.35
+155.95
+4.50
+155.51
+6.07
+Weight (kg)
+48.90
+6.86
+50.85
+9.72
+49.88
+8.42
+BMI
+20.33
+2.43
+20.90
+3.88
+20.61
+3.23
+Age at menarche
+12.48
+1.06
+12.85
+0.83
+12.66
+0.97
+Numberof students
+I BSc
+3
+7.5
+3
+7.5
+6
+7.5
+II BSc
+13
+16.25
+11
+27.5
+24
+30
+III BSc
+13
+16.25
+12
+30
+25
+31.25
+I GNM
+8
+20
+8
+20
+16
+20
+II GNM
+3
+7.5
+6
+15
+9
+11.25
+Regular menstrual cycle (n)
+28
+70
+33
+82.5
+61
+76.25
+Irregular menstrual cycle (n)
+12
+30
+7
+17.5
+19
+23.75
+Menstrual pain (n)
+2
+5
+30
+75
+32
+40
+Mastalgia (n)
+Cyclical
+30
+75
+28
+70
+58
+72.5
+Acyclical
+10
+25
+12
+30
+22
+27.5
+Breast pain: Duration in months (mean)
+13.78
+11.05
+12.38
+8.97
+13.13
+10.06
+Breast pain score (mean)
+3.85
+1.17
+3.63
+1.10
+3.67
+1.11
+Family history of breast cancer
+2
+5
+0
+0
+2
+5
+BMI: Body mass index, BSC: Bachelor of Science, GNM: General nursing midwifery, SD: Standard deviation. The two groups were matched on all variables 
+(P>0.05 in independent samples t‑test)
+Table 3: Results after intervention in both the groups
+Variable
+Group
+Baseline
+3 Months
+Sig within groups 
+(0-3 months)
+6 Months
+Sig within groups 
+(0‑6 months)
+RM ANOVA 
+between groups
+Mean
+SD
+Mean
+SD
+T (p)
+Mean
+SD
+T (p)
+QoL D1
+Yoga
+26.45
+2.82
+30.84
+3.96
+7.08 (<0.01)
+30.39
+3.07
+5.71 (<0.001)
+1045.01(<0.001)
+Control
+25.61
+3.21
+24.4
+2.45
+2.92 (=0.01)
+27.2
+3.61
+2.28 (0.02)
+QoL D2
+Yoga
+21.16
+2.15
+25.6
+2.55
+−7.88 (<0.001)
+25.6
+3.42
+6.3 (<0.001)
+471.58(<0.001)
+Control
+20.55
+1.8
+20.4
+2.06
+0.31 (=0.75)
+22.9
+3.25
+3.77 (0.001)
+QoL D3
+Yoga
+11.5
+1.43
+13.4
+1.64
+−5.68 (<0.001)
+12.7
+2.42
+2.79 (0.008)
+167.96(<0.001)
+Control
+12.16
+1.0
+11.6
+0.99
+2.53 (=0.01)
+11.8
+1.24
+1.07 (0.29)
+QoL D4
+Yoga
+28.37
+3.16
+34.7
+3.79
+−8.06 (<0.001)
+34.2
+4.71
+6.91 (<0.001)
+1087.42(<0.001)
+Control
+29.13
+3.03
+28.1
+2.65
+1.87 (=0.07)
+30
+3.94
+1.05 (0.30)
+QoL total
+Yoga
+87.47
+6.25
+105
+11.0
+−9.08 (<0.001)
+103
+11.6
+7.34 (<0.001)
+6881.41(<0.001)
+Control
+87.45
+7.22
+84.5
+6.19
+2.60 (=0.01)
+91.9
+10.7
+2.19 (0.03)
+BDI
+Yoga
+15.11
+6.88
+1.08
+1.22
+12.96 (<0.001)
+3.21
+5.79
+8.90 (<0.001)
+2632.72(<0.001)
+Control
+15.19
+4.94
+12.1
+5.61
+2.60 (=0.01)
+19.1
+4.74
+3.72 (=0.001)
+BDI: Beck depression inventory, ANOVA: Analysis of variance, D1 to D4: Domain 1 to domain 4, RM: Repeated measures, QoL: Quality of life
+Raghunath, et al.: Yoga in improving women’s quality of life with mastalgia/yoga in improving quality of life in women with mastalgia
+Journal of Health Research and Reviews | May ‑ August 2016 | Volume 3 | Issue 2
+52
+a pilot study of acupuncture on 37 women with noncyclic 
+breast pain gave four acupuncture sessions over two weeks, 
+with 3 months follow‑up showing no significant improvement 
+in any of the domains (mental, physical, emotional, social, or 
+spiritual well‑being) of QoL although there was a significant 
+reduction (P < 0.05) in the pain scores by about 67% and pain 
+interference by about 56%.
+A randomized pre‑post intervention study on 98 (66 experimental 
+and 32 control) Turkish patients with nonorganic mastalgia 
+looked at the effect of a session of psychoeducation on QoL and 
+pain [visual analog scale (VAS)]. While the baseline QOL in both 
+groups was poorer than the normative values for Turkish women, 
+the QoL of those who had psychoeducation was significantly 
+better (SF‑36) after 2 months as compared to the control group.[15]
+As there are no published studies on yoga in patients with 
+mastalgia, we have made an attempt to compare the effect 
+of integrated yoga (similar yoga module in a similar setting) 
+with that of other nonorganic pain conditions. In patients with 
+mechanical chronic lower back pain admitted for yoga therapy,[16] 
+the baseline mean QoL (12 to 13) was much lower in all domains 
+of WHOQOL‑BREF than our study (22 to 29) except the social 
+domain in which it was 11.5 in our study. The improvement 
+observed was highly significant in both studies (16–28% in back 
+pain study and 10– 20% in the present study) although the groups 
+were different in their demography (both genders and higher age 
+in the back pain study). A similar work by Deshpande et al. on 
+normal volunteers also looked at the QoL, which showed similar 
+improvements after 3 months intervention on all domains of 
+WHOQOL‑100.[17]
+Results of integrated yoga in patients with osteoarthritis of the 
+knee showed about 20–30% increase in (SF36) QoL.[18]
+In the survey on 105 Turkish women with mastalgia with a mean 
+score of 5 on VAS (1–10), 58% were depressive, 30% were 
+anxious, and 4% were depressive and anxious.[13] Yilmaz, Enver 
+Demirel et al. showed that anxiety, depression, harm avoidance, 
+self‑directedness, and self‑transcendence scores were significantly 
+higher in premenopausal women with mastalgia in comparison 
+with the age‑matched healthy control group of premenopausal 
+women.[19]
+A BDI score [Table 4] less than 9 indicates no depression and that 
+between 10 and 19 indicates mild depression. The mean baseline 
+scores in our sample (around 15) showed that both the groups 
+were in this range of mild depression and the yoga group moved 
+to normal values (<9) at 3 months. In the control group, there 
+were a good number (16) of subjects with reduced depression 
+scores at the 3rd month who reverted back to depression in the 
+6th month although they had the same instructions, monitoring, 
+and counseling by the therapists at regular intervals; the BDI 
+scores in the back pain study also showed similar trends with 
+significant reduction in mean scores moving from mild depression 
+zone (12.13) to no depression zone (6.43).[16]
+The various domains of the WHOQOL‑BREF assessed in this 
+study are described below.
+The physical health domain deals with features such as 
+mobility, fatigue, pain, sleep, and work capacity. The observed 
+improvement can be attributed to better physical stamina that 
+Table 4: BDI-Number of subjects in different degrees of depression before and after intervention (n yoga-38; control-31)
+BDI 
+scores
+Depression
+Baseline
+3 months
+6 months
+Y
+C
+Y
+C
+Y
+C
+n
+%
+n
+%
+n
+%
+n
+%
+N
+%
+n
+%
+0-9
+Nil
+7
+18.42
+0
+0
+38
+100
+16
+51.61
+32
+84.21
+0
+0
+10-19
+Mild
+22
+57.89
+27
+71.05
+0
+0
+9
+29.03
+5
+13.16
+14
+45.16
+20-25
+Moderate
+9
+23.68
+4
+10.53
+0
+0
+6
+19.35
+1
+2.63
+17
+54.84
+>26
+Severe
+0
+0
+0
+0
+0
+0
+0
+0
+0
+0
+0
+0
+BDI: Beck depression inventory
+0.00
+5.00
+10.00
+15.00
+20.00
+25.00
+30.00
+35.00
+Baseline (0)
+3 month
+6 month
+Quality Of Life  Yoga
+Quality Of Life  Control
+Figure 2: Bar graph for QoL mean shift from the baseline, intervention 
+at the end of 3 months, and follow-up after 6 months between the yoga 
+group (n = 38) and control group (n = 31)
+0
+5
+10
+15
+20
+25
+Baseline (0)
+3 month
+6 month
+BDI Yoga
+BDI Control
+Figure 3: Bar graph for Beck Depression Inventory (BDI) mean shift from 
+the baseline, intervention at the end of 3 months, and follow-up after 6 
+months between the yoga group (n = 38) and control group (n = 31)
+Raghunath, et al.: Yoga in improving women’s quality of life with mastalgia/yoga in improving quality of life in women with mastalgia
+Journal of Health Research and Reviews | May ‑ August 2016 | Volume 3 | Issue 2
+53
+occurs after maintained stretches followed by deep rest. Other 
+studies on integrated yoga in healthy children and adults have 
+shown better physical stamina.[20] Better quality and duration of 
+sleep after yoga have been reported in the elderly too.[21]
+In the psychological health domain, the improvement seen 
+deals with questions relating to feelings, self‑esteem, spirituality, 
+thinking, learning, memory, etc., may be attributed to a reduction 
+in depression. Yoga is defined as “mastery over the modifications 
+of the mind” (Patañjali),[22] which is the goal of our integrated 
+yoga program; several studies have shown the effect of yoga in 
+reducing anxiety,[23] depression,[24] and stress,[25] with enhanced 
+mental health as observed by improved perceptual sharpness[26] 
+and memory.[27]
+Social health domain has questions relating to problems with 
+interpersonal relationships, social support, etc., which could 
+be the main source of stress contributing to mastalgia. In this 
+domain, the baseline scores [Table 3] were lesser than the other 
+three domains in both the groups of students, which improved 
+significantly after the intervention. These were addressed during 
+lectures and at a personal level in yoga counseling sessions. They 
+were aimed at achieving an introspective cognitive change by 
+recognizing the psychological freedom “to react, not to react or 
+change the usual pattern of reaction to situations” highlighted 
+in yoga texts.[28]
+Environmental health domain has questions that deal with 
+problems relating to financial resources, physical safety, and 
+adaptability to physical environment such as pollution, noise, 
+and climate. One of the definitions of yoga (Bhagavad Gīta) says 
+that yoga results in equanimity and balance (samatvam) that can 
+help in better tolerance to environmental changes.[29]
+Studies have shown that yoga changes the physiological 
+responses to stressors by improving autonomic stability with 
+better parasympathetic tone in normal adults.[30]
+There is evidence to suggest that cyclical mastalgia is caused 
+by a latent stress‑induced hormonal imbalance as indicated 
+by hyper prolactinemia.[31] It is observed that patients with 
+cyclic mastalgia and noncyclic mastalgia have increased 
+catecholamine and decreased baseline dopamine level, which 
+suggests that catecholamine may be released due to stress, 
+resulting in altered abnormal sensitivity of the breast tissue.[32] 
+Yoga may improve the QoL by promoting voluntary reduction 
+in violence and aggressiveness.[33] Mastery over the emotional 
+reactions of anxiety[34] or depression[24] is achieved through restful 
+awareness during all the practices in general and meditation 
+in particular.[35] Kundalini yoga is found to be beneficial in 
+cases of depression. It stimulates the various autonomic nerve 
+plexus  (chakras) and activates pineal organ, which in turn 
+brings homeostasis between sympathetic and parasympathetic 
+activities.[36] This mastery over emotional surges leads to 
+controlled and need‑based physiological responses that may 
+reduce the overtones of hypothalamus‑pituitary‑adrenal (HPA) 
+axis[37] during chronic pain. Yoga has an influence on the HPA 
+axis as evidenced by a reduction in cortisol levels in normal[38] 
+and sick individuals.[39,40]
+Hence, it appears that the beneficial effects of yoga in mastalgia 
+could be mediated through HPA axis by stabilizing the HPA axis 
+and promoting autonomic balance. We may hypothesize that 
+yoga helps in restoring the normal biorhythm of reproductive 
+hormones in cases of cyclical or noncyclical mastalgia and thus, 
+improve the QoL .
+Strength of the study
+To the best of our knowledge, this is the first randomized 
+controlled study (RCT) on the role of yoga therapy in measuring 
+QoL and depression in nursing students with mastalgia. The 
+strengths of this RCT study are adequate sample size, supervised 
+practice sessions, randomization, and the 6 months follow‑up 
+with very few dropouts. The uniqueness of the results was the 
+highly significant reduction in depression scores and improved 
+QoL scores. This offers the first evidence to introduce yoga as 
+a noninvasive and cost‑effective therapy in treating mastalgia.
+Limitations of the study
+This study only addressed mastalgia as a solicited symptom. 
+Further study on patients presenting with mastalgia with or 
+without associated fibroadenosis and fibrocystic breast condition 
+will provide an insight into the use and acceptability of yoga as 
+an intervention in a clinical setting.
+CONCLUSION
+This randomized control study of 12 weeks of integrated yoga 
+therapy with 6 months follow‑up has shown that nursing students 
+with mastalgia showed a good improvement in QoL and the 
+decreased depression scores than physical therapy exercises for 
+mastalgia.
+Acknowledgements
+We are thankful to the Research Officer and the Vice Chancellor, 
+SVYASA, Bengaluru, Karnataka, India for funding and supporting 
+this project. We extend our gratitude to the Principal of the 
+college for permitting us to carry out the trial and the teachers 
+and the staff for assisting us in data collection and supervising 
+both the trial groups. We thank Dr. Judu Ilavarasu for his help 
+in the statistical analysis. We also thank the yoga therapists 
+for giving the sessions. We also extend our heartfelt thanks to 
+all the nursing students for their wholehearted participation in 
+the study.
+Financial support and sponsorship
+Institutional funding, SVYASA, Bangalore, Karnataka, India.
+Conflicts of interest
+We do not have any conflicts of interest.
+REFERENCES
+1.	
+Naz N, Sohail S, Memon MA. Utility of breast imaging in mastalgia. 
+J Liaquat Uni Med Health Sci 2010;9:12‑6.
+2.	
+Saeed Na. Is oil of evening primrose effective for mastalgia: A comparison 
+with danazol. ISRA Med J 2012;4:235-8.
+3.	
+Deschamps M, Band PR, Coldman AJ, Hislop TG, Longley DJ. Clinical 
+determinants of mammographic dysplasia patterns. Cancer Detect Prev 
+Raghunath, et al.: Yoga in improving women’s quality of life with mastalgia/yoga in improving quality of life in women with mastalgia
+Journal of Health Research and Reviews | May ‑ August 2016 | Volume 3 | Issue 2
+54
+1996;20:610‑9.
+4.	
+Leinster SJ, Whitehouse GH, Walsh PV. Cyclical mastalgia: Clinical 
+and mammographic observations in a screened population. Br J Surg 
+1987;74:220‑2.
+5.	
+Ader DN, South‑Paul J, Adera T, Deuster PA. Cyclical mastalgia: 
+Prevalence and associated health and behavioral factors. J Psychosom 
+Obstet Gynaecol 2001;22:71‑6.
+6.	
+Kanat BH, Atmaca M, Girgin M, Ilhan YS, Bozdağ A, Özkan Z, et al. 
+Effects of mastalgia in young women on quality of life, depression, and 
+anxiety levels. Indian J Surg 2015:1‑4.
+7.	
+Colegrave S, Holcombe C, Salmon P. Psychological characteristics of 
+women presenting with breast pain. J Psychosom Res 2001;50:303‑7.
+8.	
+Posadzki P, Ernst E, Terry R, Lee MS. Is yoga effective for pain? A 
+systematic review of randomized clinical trials. Complement Ther Med 
+2011;19:281‑7.
+9.	
+Peters F, Diemer P, Mecks O, Behnken L LJ. Severity of mastalgia in 
+relation to milk duct dilatation. Obstet Gynecol 2003;101:54‑60.
+10.	
+Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for 
+measuring depression. Arch Gen Psychiatry 1961;4:561‑71.
+11.	
+Hisli N. A study on the validity of beck depresion inventory. Turkish J 
+Psychol 1988;6:118‑23.
+12.	
+Van Esch L, Oudsten BD, De Vries J. The World Health Organization 
+quality of life instrument‑short form (WHOQOL‑BREF) in women with 
+breast problems. Int J Clin Health Psychol 2011;11:5‑22.
+13.	
+Eryılmaz MA, Eroglu C, Arslan K, Selvı Y, Civcik S. The interaction of 
+mastalgia with depression and quality of life in Turkish women. J Clin 
+Anal Med 2014;5:113‑8.
+14.	
+Murshid KR. A review of mastalgia in patients with fibrocystic breast 
+changes and the non‑surgical treatment options. J Taibah Univ Med Sci 
+2011;6:1‑18.
+15.	
+Ozenli  Y, Ozturk  AB, Ozturk  SB, Seydaoglu  G. The effects of 
+psycho‑education on the health‑related quality of life on mastalgia 
+patients. Appl Res Qual Life 2014;9:1097‑105.
+16.	
+Tekur P, Chametcha S, Hongasandra RN, Raghuram N. Effect of yoga on 
+quality of life of CLBP patients: A randomized control study. Int J Yoga 
+2010;3:10‑7.
+17.	
+Deshpande S. Influence of Yoga on Quality of Life a Randomized 
+Control Study. 2008. Available from: http://shodhganga.inflibnet.ac.in//
+handle/10603/9350. [Last accessed on 2015 Sep 4].
+18.	
+Ebnezar J, Nagarathna R, Bali Y, Nagendra HR. Effect of an integrated 
+approach of yoga therapy on quality of life in osteoarthritis of the knee 
+joint: A randomized control study. Int J Yoga 2011;4:55‑63.
+19.	
+Yilmaz ED, Deveci E, Kadıoğlu H, Gençer AG, Ünal O, Koçer E, et al. 
+Anxiety and depression levels and personality traits of mastalgia patients. 
+J Psychiatry 2014;17:118.
+20.	
+Raghuraj P, Telles S. Muscle power, dexterity skill and visual perception 
+in community home girls trained in yoga or sports and in regular school 
+girls. Indian J Physiol Pharmacol 1997;41:409‑15.
+21.	
+Bankar MA, Chaudhari SK, Chaudhari KD. Impact of long term Yoga 
+practice on sleep quality and quality of life in the elderly. J Ayurveda 
+Integr Med 2013;4:28‑32.
+22.	
+Swami Prabhavanada. Patanjali Yoga Sutras. Xi‑3M 7C‑0. Chennai‑4: 
+The President, Sri Ramakrsihna Math, Mylapore, Chennai‑4; 2002.
+23.	
+Michalsen A, Jeitler M, Brunnhuber S, Lüdtke R, Büssing A, Musial F, et al. 
+Iyengar yoga for distressed women: A 3‑armed randomized controlled 
+trial. Evid Based Complement Alternat Med 2012;2012:408727.
+24.	
+Sharma VK, Das S, Mondal S, Goswampi U, Gandhi A. Effect of Sahaj 
+Yoga on depressive disorders. Indian J Physiol Pharmacol 2015;49:462‑8.
+25.	
+Carmody J, Baer RA. Relationships between mindfulness practice 
+and levels of mindfulness, medical and psychological symptoms and 
+well‑being in a mindfulness‑based stress reduction program. J Behav 
+Med 2008;31:23‑33.
+26.	
+Telles S, Nagarathna R, Nagendra HR. Improvement in visual perception 
+following yoga training. J Indian Psychol 1995;13:30‑2.
+27.	
+Naveen KV, Nagarathna R, Nagendra HR, Telles S. Yoga breathing 
+through a particular nostril increases spatial memory scores without 
+lateralized effects. Psychol Rep 1997;81:555‑61.
+28.	
+Nagarathana. R, Nagendra HR. Yoga for Promotion of Positive Health. 
+Bangalore: Swami Vivekananda Yoga Prakashana; 2001. 
+29.	
+Tapasyānanda S. Srimad Bhagavad Gita. Mylapore: Sri Ramakrishna 
+Math; 2000.
+30.	
+Telles S, Nagarathna R, Nagendra HR. Breathing through a particular 
+nostril can alter metabolism and autonomic activities. Indian J Physiol 
+Pharmacol 1994;38:133‑7.
+31.	
+Carmichael AR. Can Vitex Agnus Castus be Used for the Treatment 
+of Mastalgia? What is the Current Evidence? Evid Based Complement 
+Alternat Med 2008;5:247‑50.
+32.	
+Bland KI, Copeland EM. The Breast E-Book: Comprehensive 
+Management of Benign and Malignant Diseases. 4th ed. St Louis: 
+Saunders; 2009.
+33.	
+Deshpande S, Nagendra HR, Raghuram N. A randomized control trial of 
+the effect of yoga on verbal aggressiveness in normal healthy volunteers. 
+Int J Yoga 2008;1:76‑82.
+34.	
+Miller JJ, Fletcher K, Kabat‑Zinn J. Three‑year follow‑up and clinical 
+implications of a mindfulness meditation‑based stress reduction 
+intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry 
+1995;17:192‑200.
+35.	
+Telles S, Nagarathna R, Nagendra HR. Autonomic changes during “OM” 
+meditation. Indian J Physiol Pharmacol 1995;39:418‑20.
+36.	
+Devi SK, Chansauria JP, Udupa KN. Mental depression and kundalini 
+yoga. Anc Sci Life 1986;6:112‑8.
+37.	
+Leonard BE. HPA and immune axes in stress: Involvement of the 
+serotonergic system. Neuroimmunomodulation 2006;13:268‑76.
+38.	
+Kamei T, Toriumi Y, Kimura H, Ohno S, Kumano H, Kimura K. Decrease 
+in serum cortisol during yoga exercise is correlated with alpha wave 
+activation. Percept Mot Skills 2000;90:1027‑32.
+39.	
+Vadiraja HS, Raghavendra RM, Nagarathna R, Nagendra HR, Rekha M, 
+Vanitha N, et al. Effects of a yoga program on cortisol rhythm and mood 
+states in early breast cancer patients undergoing adjuvant radiotherapy: 
+A randomized controlled trial. Integr Cancer Ther 2009;8:37‑46.
+40.	
+Curtis K, Osadchuk A, Katz J. An eight‑week yoga intervention is 
+associated with improvements in pain, psychological functioning and 
+mindfulness, and changes in cortisol levels in women with fibromyalgia. 
+J Pain Res 2011;4:189‑201.

subfolder_0/Effects of an integrated yoga program on chemotherapy induced nausea and emesis in breast cancer patients..txt

@@ -0,0 +1,1710 @@
+© 2007 The Authors
+Journal compilation © 2007 Blackwell Publishing Ltd
+European Journal of Cancer Care, 2007, 16, 462–474
+Original article
+Effects of an integrated yoga programme on chemotherapy-
+induced nausea and emesis in breast cancer patients
+R.M. RAGHAVENDRA, bnys, phd, Department of Life Sciences, Swami Vivekananda Yoga Anusandhana Samst-
+hana, R. NAGARATHNA, md, frcp (edin),  Department of Life Sciences, Swami Vivekananda Yoga Anusandhana
+Samsthana, H.R. NAGENDRA, phd, Department of Life Sciences, Swami Vivekananda Yoga Anusandhana Sam-
+sthana, K.S. GOPINATH, ms, Department of Surgical Oncology, Bangalore Institute of Oncology, B.S. SRINATH,
+ms, Department of Surgical Oncology, Bangalore Institute of Oncology, B.D. RAVI, md, Department of Medical
+Oncology, Bangalore Institute of Oncology, S. PATIL, md, Department of Medical Oncology, Bangalore Institute
+of  Oncology, B.S.  RAMESH,  md, Department  of  Radiation  Oncology,  Bangalore  Institute  of  Oncology,  &
+R. NALINI, md, Department of Radiation Oncology, Bangalore Institute of Oncology, Bangalore, India 
+RAGHAVENDRA  R.M.,  NAGARATHNA  R.,  NAGENDRA  H.R.,  GOPINATH  K.S.,  SRINATH  B.S.,
+RAVI B.D., PATIL S., RAMESH B.S. & NALINI R. (2007) European Journal of Cancer Care 16, 462–474
+Effects of an integrated yoga programme on chemotherapy-induced nausea and emesis in breast cancer patients
+This study examined the effect of an integrated yoga programme on chemotherapy-related nausea and emesis
+in early operable breast cancer outpatients. Sixty-two subjects were randomly allocated to receive yoga (n = 28)
+or supportive therapy intervention (n = 34) during the course of their chemotherapy. Both groups had similar
+socio-demographic and medical characteristics. Intervention consisted of both supervised and home practice
+of yoga sessions lasting for 60 min daily, while the control group received supportive therapy and coping
+preparation during their hospital visits over a complete course of chemotherapy. The primary outcome
+measure was the Morrow Assessment of Nausea and Emesis (MANE) assessed after the fourth cycle of
+chemotherapy. Secondary outcomes included measures for anxiety, depression, quality of life, distressful
+symptoms and treatment-related toxicity assessed before and during the course of chemotherapy. Following
+yoga, there was a significant decrease in post-chemotherapy-induced nausea frequency (P = 0.01) and nausea
+intensity (P = 0.01), and intensity of anticipatory nausea (P = 0.01) and anticipatory vomiting (P = 0.05) as
+compared with the control group. There was a significant positive correlation between MANE scores and
+anxiety, depression and distressful symptoms. In conclusion, the results suggest a possible use for stress
+reduction interventions such as yoga in complementing conventional antiemetics to manage chemotherapy-
+related nausea and emesis.
+Keywords: yoga, meditation, nausea, vomiting, complementary therapies, supportive care, stress.
+Correspondence address: Raghuram Nagarathna, Dean, Division of Life
+Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, No-19,
+Eknath Bhavan, Gavipuram Circle, K.G Nagar, Bangalore-560019, India
+(e-mail: [email protected]).
+Accepted 18 September 2006
+DOI: 10.1111/j.1365-2354.2006.00739.x
+INTRODUCTION
+Nausea and emesis are two of the most distressing side
+effects of chemotherapy and are experienced by as many as
+66–91% of patients receiving chemotherapy (Rhodes &
+McDaniel 2001). Complete control of emesis (i.e. no vom-
+iting with currently available antiemetic agents) is achiev-
+able in a majority of patients in the first 24 h and in only
+Yoga for CINV
+© 2007 The Authors
+463
+Journal compilation © 2007 Blackwell Publishing Ltd
+45% of patients during the first 5–7 days of chemotherapy
+(Gralla et al. 1999; Roila et al. 2005). However, chemo-
+therapy-induced nausea occurs at a greater frequency than
+vomiting and, despite the use of new-generation antiemet-
+ics, complete control rates for nausea remain low as com-
+pared with those for emesis (Perez et al. 1998). Another
+significant problem is that a substantial gap remains
+between antiemetic guidelines and practice and that most
+of these guidelines may not be widely implemented even
+in developed countries (De Angelis et al. 2003). This is
+even more so for developing countries such as India and
+other countries where nausea and emesis following che-
+motherapy are not adequately managed because of low
+affordability of new-generation antiemetic medications.
+However, various psychological techniques, such as cog-
+nitive behaviour therapy, biofeedback, relaxation, sup-
+portive therapy and coping preparation interventions,
+have been shown to complement antiemetics in managing
+chemotherapy-related nausea and emesis (Burish et al.
+1991; Burish & Tope 1992). We therefore evaluated the
+benefits of using traditional intervention strategies such
+as yoga and meditation in comparison with standard
+supportive care and coping preparation in managing
+chemotherapy-related nausea and emesis.
+There is a high prevalence of nausea and emesis follow-
+ing chemotherapy. This is attributed to high doses of eme-
+togenic antineoplastic agents and anticipatory nausea and
+emesis (King 1997). Distressing symptoms (such as nau-
+sea, vomiting, retching, anorexia, motion sickness, head-
+aches, etc.) commonly occur after chemotherapy and
+antiemetogenic administration. These distressing symp-
+toms can impede the ability of patients to perform normal
+household tasks, enjoy meals, and maintain daily function
+and recreation, thereby reducing their quality of life
+(Osoba et al. 1997). Some patients may even see the treat-
+ment and resulting distress worse than the disease itself
+(Rimer et al. 1983), while some may even discontinue the
+prescribed course of chemotherapy (Burish & Tope 1992),
+thereby reducing hope of recovery and life expectancy
+(Gilbar 1991).
+Studies have shown that some of these side effects that
+develop after chemotherapy may be partly psychological
+rather than purely pharmacological in nature (Burish &
+Tope 1992). Nearly 70% of patients who experience ant-
+icipatory nausea and emesis attribute these side effects to
+a psychological aetiology (Morrow 1982). This may be
+because the information from the vomiting centre in the
+brain to higher brain centres is involved in the perception
+of nausea and vice versa (Hawthorn 1995). Various studies
+have shown risk factors such as motion sickness, vomit-
+ing related to particular foods, and pre-treatment anxiety
+and expectations (Jacobsen et al. 1988; Morrow et al.
+1991) 
+to 
+have 
+a 
+strong 
+predisposition 
+for 
+post-
+chemotherapy and anticipatory nausea and vomiting, and
+these can further exacerbate the responses to conditioned
+stimuli in these subjects (Mattes et al. 1987). Therefore,
+these strong relationships between psychosocial variables,
+nausea and emesis justify the need for integrating mind/
+body therapies with pharmacological interventions in
+managing treatment-related nausea and emesis (Schwartz
+et al. 1996).
+Studies show that complementary and alternative med-
+icine (CAM) and mind/body approaches such as hypnosis,
+progressive muscle relaxation training with guided imag-
+ery, music therapy, acupuncture, acupressure, systematic
+desensitization, biofeedback and distraction are useful in
+reducing nausea and emesis either alone or in combina-
+tion with antiemetics and anxiolytic medications (Redd
+et al. 2001; Mundy et al. 2003). Of these, relaxation with
+guided imageries has been studied extensively, and has
+been shown to reduce the duration and frequency of both
+acute and delayed nausea and emesis following chemo-
+therapy in subjects with poor control of nausea and vom-
+iting (Burish & Tope 1992; Arakawa 1997; Molassiotis
+et al. 2002). Most of these techniques reduce anxiety,
+physiological arousal and psychological distress in cancer
+patients through stress reduction (Morrow & Rosenthal
+1996). A growing interest in the use of these therapies
+reflects a need for a more holistic approach to cancer treat-
+ment (Cassileth 1999).
+Yoga as a complementary modality is being practised
+increasingly in both Indian and western population. Yoga
+practices have been used for therapeutic benefits in
+numerous health-care concerns, such as asthma (Nagar-
+athna & Nagendra 1985), diabetes (Sahay & Sahay 2002),
+hypertension (Sainani 2003), heart disease (Jayasinghe
+2004), musculoskeletal disorders (Raub 2002), cancer
+(Cohen et al. 2004) and others in which mental stress
+(Gimbel 1998; Bijlani 2004) was believed to play a role.
+These practices include several techniques, such as
+asanas (postures done with awareness), pranayama (vol-
+untarily regulated nostril breathing), yoga nidra (guided
+relaxation with imagery) and meditation, which promote
+physical well-being and mental calmness. These practices
+are known to build inner awareness and attention of men-
+tal phenomena. This is thought to alter the perceptions
+and mental responses to both external and internal stim-
+uli, slow down reactivity and responses to such stimuli,
+and instill a greater control over stressful situations. This
+could be particularly useful in cancer patients who per-
+ceive cancer as a threat. Recent randomized waitlist con-
+trolled studies using meditation and mindfulness yoga
+RAGHAVENDRA et al.
+464
+© 2007 The Authors
+Journal compilation © 2007 Blackwell Publishing Ltd
+components (Mindfulness-Based Stress Reduction pro-
+gramme) have found beneficial effects in terms of
+improved affective states; decrease in mood disturbance,
+stress symptoms and disturbed sleep; improved quality of
+life; and benefits in terms of improved immune responses
+in early breast (Speca et al. 2000; Targ & Levine 2002) and
+prostate cancer patients (Carlson et al. 2003). However,
+most of these studies involve heterogeneous cancer pop-
+ulations at varying stages of their disease and treatment,
+and evaluate quality of life and psychosocial outcomes.
+However, studies reviewed using yoga/meditation com-
+ponents do not address issues pertaining to conventional
+treatment toxicity and chemotherapy-related nausea and
+vomiting.
+The purpose of this trial was to study whether a support
+intervention based on mind/body and psycho-spiritual
+interventions such as yoga might be a viable alternative to
+standard supportive therapy and coping preparation in
+reducing the frequency and intensity of nausea and emesis
+in chemotherapy-naïve stage II and III breast cancer
+patients receiving adjuvant chemotherapy.
+METHODS
+Subjects
+This study is a part and continuation of the original ran-
+domized control study that recruited 98 recently diag-
+nosed women with stage II and III operable breast cancer
+to assess the effect of a yoga programme on mood, quality
+of life, distressful symptoms, toxicity and immune
+responses in early breast cancer patients undergoing con-
+ventional treatment. These patients were recruited from
+Bangalore Institute of Oncology, a comprehensive cancer
+care centre in Bangalore, India, over a 2.5-year period from
+January 2000 to June 2002. Only subjects who were on
+adjuvant chemotherapy were included for analysis in this
+study. Patients were eligible to participate in this study if
+they met the following selection criteria at the start of the
+study: (1) recently diagnosed operable breast cancer; (2)
+aged between 30 and 70 years; (3) Zubrod’s performance
+status 0–2 (ambulatory >50% of time); (4) high-school edu-
+cation; (5) having a treatment plan with surgery followed
+by adjuvant chemotherapy or by both adjuvant radiother-
+apy and chemotherapy; and (6) consenting to participate in
+the study. Subjects were excluded if they had any concur-
+rent medical condition that was likely to interfere with
+the treatment, major psychiatric, neurological illness or
+autoimmune disorders, and any known metastases. Sub-
+jects were excluded from analyses in the current study if
+they had a history of intestinal obstruction and any
+known sensitivity to any class of antiemetics (such as
+5HT3 receptor antagonists or dopamine receptor antago-
+nists) and corticosteroids (such as dexamethasone). Of the
+98 subjects who were randomized to yoga and supportive
+therapy initially at the start of the study, 62 subjects (yoga
+n = 28; control n = 34) completed their prescribed chemo-
+therapy cycles. There were 29 dropouts immediately fol-
+lowing surgery, and seven subjects did not receive
+chemotherapy (see trial profile, Fig. 1). The reasons for
+dropouts were migration to other hospitals, use of other
+complementary therapies (e.g. homeopathy or ayurveda),
+lack of interest, time constraints and other concurrent
+illness.
+ 
+Randomization
+ 
+Subjects consenting to participate in this study to com-
+pare two interventions, ‘yoga versus supportive therapy
+and coping preparation’, were randomly allocated to
+receive either one of these interventions prior to their pri-
+mary treatment or surgery, using random numbers gener-
+ated by a random number table. These subjects were then
+followed up with interventions and assessments during
+their adjuvant treatment (radiotherapy and chemother-
+apy). Randomization was performed using opaque enve-
+lopes with group assignments. The envelopes were opened
+sequentially in the order of assignment during rec-
+ruitment, with  the  names  and  registration  numbers  of
+the participants written on the covers. The order of ran-
+domization was verified with the hospital date of admis-
+sion records for surgery at study intervals to make sure
+that field personnel had not altered the sequence of ran-
+domization to suit the allocation of consenting partici-
+pants into two study arms.
+Procedure
+This study evaluated the effects of yoga intervention ver-
+sus supportive therapy and coping preparation in chemo-
+therapy-naïve early stage II and III breast cancer patients
+undergoing adjuvant chemotherapy. The subjects in the
+study were prescribed four to eight cycles of FAC or CMF
+or both as adjuvant chemotherapy protocols following
+surgery, which was the standard care in the hospital
+during the study period. The FAC protocol consisted of
+5-fluorouracil (600 mg/m2), adriamycin (60 mg/m2) and
+cyclophosphamide (600 mg/m2), and the CMF protocol
+consisted of cyclophosphamide (600 mg/m2), methotrex-
+ate (50 mg/m2) and 5-fluorouracil (600 mg/m2). The stan-
+dard approach to chemotherapy-related nausea and emesis
+in the hospital when the study was conducted was 8-mg
+Yoga for CINV
+© 2007 The Authors
+465
+Journal compilation © 2007 Blackwell Publishing Ltd
+intravenous odansetron, with 8-mg dexamethasone given
+as a bolus injection 30 min before chemotherapy. This
+was followed by per-oral administration of either 8-mg
+odansetron (Emeses) bid for the next 3 days after chemo-
+therapy or 10-mg domperidone (Doomster) qid for 2 days
+to control delayed nausea and vomiting. Some subjects in
+the study were also prescribed anxiolytic medication,
+such as lorazepam (Aprazolam 0.5 mg o.d.), by the medical
+oncologists, who were blinded to the intervention.
+During the chemotherapy protocol, subjects in both
+groups were given intervention before starting their first
+adjuvant chemotherapy cycle. Subjects who were on che-
+motherapy were given a bolus injection of dexamethasone
+8 mg, with odansetron 8 mg intravenous 30 min before
+chemotherapy. Thereafter, subjects in the yoga group were
+taught bedside yoga relaxation by the instructor for the
+next 30 min, while the participants and their spouses in
+the control group were educated about chemotherapy-
+related nausea and vomiting, food aversions, nutrition,
+etc., and were counselled by the same yoga instructor,
+who was trained in counselling cancer patients. Thereaf-
+ter, subjects in the yoga group were provided with audio
+and video cassettes of the yoga modules for home practice
+and were asked to practise them every day for 1 h. Their
+practice was also supervised once in 10 days by their
+trainer through house visits. The supportive counselling
+and coping preparation sessions were of 60-min duration
+initially and lasted 30 min for the control group, given
+during their hospital visits for chemotherapy and investi-
+gations (once in 10 days). After each chemotherapy infu-
+sion, patients were prescribed antiemetic regimens as
+described above. They were asked to note down the epi-
+sodes of vomiting and nausea duration after every cycle of
+chemotherapy and, at the fourth cycle, they were asked to
+complete the Morrow Assessment of Nausea and Emesis
+(MANE) questionnaire, State Trait Anxiety Inventory
+Figure 1. Patient flow chart. CT, chemo-
+therapy; RT, radiotherapy.
+174 patients screened
+44 refused
+32 not eligible
+98 randomized
+Yoga
+12 discontinued
+Surgery
+Supportive therapy
+17 discontinued
+Post surgery 33 completed
+/analysed
+Post RT 32 completed/
+analysed/
+I did not receive RT
+Number of CT cycles received
+4 cycles. 6 cycles. 8 cycles
+(n = 3).
+(n = 22).
+(n = 3).
+Exclusions due to
+sensitivity ot CT
+or antienetics in
+both groups = Nil
+Mid CT (4th cycle) 28
+completed/analysed
+5 did not receive CT
+Mid CT (4th cycle)
+34 completed/analysed
+2 did not receive CT
+Number of CT cycles received
+4 cycles. 6 cycles. 8 cycles
+(n = 3).
+(n = 27).
+(n = 4).
+Post RT 35 completed/
+analysed
+I did not receive RT
+Post surgery 36 completed
+/analysed
+(RT)
+(CT)
+RAGHAVENDRA et al.
+466
+© 2007 The Authors
+Journal compilation © 2007 Blackwell Publishing Ltd
+(STAI), Beck’s Depression Inventory (BDI), Functional
+Living Index for Cancer (FLIC) and symptom checklist
+questionnaires.
+Sixty-two patients (yoga n = 28; control n = 34) contrib-
+uted data for the current analysis during chemotherapy.
+Signed 
+informed 
+consent 
+was 
+obtained 
+from 
+all
+participants.
+Measures
+During the initial visit, demographic information, includ-
+ing age, marital status, education, occupation, obstetric
+and  gynaecological  history,  medical  history  and  intake
+of medications, was obtained, and clinical data were
+abstracted on the history of breast cancer, investigative
+notes and chemotherapy treatment regimen. The follow-
+ing self-report questionnaires were distributed to the sub-
+jects during the study.
+The primary outcome measures were frequency and
+intensity of both post-chemotherapy and anticipatory
+nausea and vomiting assessed using the MANE scale. The
+test–retest reliability of this descriptive scale has been
+reported to range from 0.72 to 0.96 with different cancer
+patient samples and different chemotherapy protocols
+(Morrow 1992). Subjects were administered this question-
+naire after the fourth chemotherapy cycle as anticipatory
+nausea and emesis, which are learned responses to che-
+motherapy, develop by about the fourth cycle in 25% of
+the patients (Morrow & Rosenthal 1996).
+The secondary outcome measures were anxiety state
+and trait assessed using standard instruments such as
+Spielberger’s STAI (Spielberger et al. 1970), depression
+using BDI (Beck et al. 1961) and global quality of life
+assessed using FLIC (Schipper et al. 1984). Subjective
+symptom checklist was developed during the pilot phase
+to assess treatment-related side effects, problems with
+sexuality and image, and relevant psychological and
+somatic symptoms. The checklist consisted of 31 items,
+each evaluated on two dimensions: severity, graded from
+no to very severe (0–4), and distress, graded from not at all
+to very much (0–4). This scale measured the total number
+of symptoms experienced, total and mean severity and dis-
+tress, and was evaluated previously in a similar breast
+cancer population (Bhaskaran 1996). Finally, treatment-
+related toxicity and side effects were objectively analysed
+by the investigators using the World Health Organization
+(WHO, 1979) Toxicity Criteria during chemotherapy.
+These secondary outcome measures were used to study
+relationships between the psychological states, frequency
+and intensity of post-chemotherapy and anticipatory nau-
+sea and vomiting. Assessments were carried out before
+starting the first cycle of chemotherapy, during the mid-
+cycle and after chemotherapy, except for MANE and WHO
+Toxicity Criteria, which was assessed following the fourth
+cycle of chemotherapy.
+Interventions
+The intervention group received an ‘integrated yoga pro-
+gramme’ and the control group received ‘supportive coun-
+seling and coping preparation’. The yoga intervention
+consisted of a set of asanas (postures done with awareness)
+breathing exercises, pranayama (voluntarily regulated
+nostril breathing), meditation and yogic relaxation tech-
+niques with imagery. These practices were based on prin-
+ciples of attention diversion, mindful awareness and
+relaxation to cope with day-to-day stressful experiences.
+The yoga intervention was tailored to the patient’s needs
+during chemotherapy infusion and home practice. The
+yoga session was conducted 30 min before the start of che-
+motherapy infusion. This session consisted of yogic relax-
+ation, meditation using breath awareness and impulses of
+touch emanating from palms and fingers, or chanting a
+mantra from a Vedic text for 30 min. These sessions were
+administered by an instructor at the subject’s bedside
+before chemotherapy infusion. Subjects were also pro-
+vided with audiotapes of these exercises for home prac-
+tice, using the instructor’s voice, so that a familiar voice
+could be heard on the cassette. The subjects were asked to
+practise daily for 1 h for 6 days/week as homework during
+the intervals between chemotherapy cycles. They were
+required to practise a minimum of 3 h per week, but were
+told to practise for 6 h per week in their homes. These
+home sessions started with a few easy yoga postures,
+breathing exercises and pranayama (voluntarily regulated
+nostril breathing), and yogic relaxation. After this prepa-
+ratory practice for about 20 min, the subjects were guided
+through any one of the meditation practices for the next
+30 min, which included focusing awareness on sounds and
+chants from Vedic texts, or breath awareness and impulses
+of touch emanating from palms and fingers while practis-
+ing yogic mudras, or a dynamic form of meditation that
+involved practising with eyes closed of four yoga postures
+interspersed with relaxation while supine, thus achieving
+a combination of both ‘stimulating’ and ‘calming’ prac-
+tice. These sessions were followed by informal individual
+counselling sessions, which focused on problems related
+to impediments in home practice, clarification of the par-
+ticipant’s doubts, motivation, education and supportive
+interaction with spouses. The participants were also
+informed about practical day-to-day application of aware-
+ness and relaxation to attain a state of equanimity during
+Yoga for CINV
+© 2007 The Authors
+467
+Journal compilation © 2007 Blackwell Publishing Ltd
+stressful situations, and were given homework in learning
+to adapt to such situations in their daily life by applying
+these principles.
+The subjects were encouraged to practise one of these
+meditation techniques daily, were given booklets and
+instructions on these practices, and were encouraged to
+pursue relevant themes and gain greater depth through
+proficiency in practice. Their homework was monitored
+daily by their instructor, who conducted house visits
+(once in 10 days), and participants were encouraged to
+maintain a daily log, listing the yoga practices done, use of
+audiovisual aids for practice, duration of practice, experi-
+ence of distressful symptoms, intake of medication and
+diet history.
+The control intervention consisted of a psychodynamic
+supportive–expressive therapy with coping preparation.
+Supportive–expressive counselling sessions also included
+education as an important component. We chose to have
+this as a control intervention mainly to control for the
+non-specific effects of the yoga programme that may be
+associated with adjustment, such as attention, support
+and a sense of control. We also incorporated coping
+preparation sessions as a control intervention along with
+supportive–expressive therapy to enhance patients’
+knowledge of their disease and treatment options, thereby
+reducing any apprehensions and anxiety regarding their
+treatment. This coping preparation consisted of a single
+60-min session held at the treatment clinic before the
+start of the first chemotherapy cycle. Family members
+were invited to join the patient during the session, which
+included a tour of the oncology clinic and treatment area,
+describing the chemotherapy procedure, providing infor-
+mation about a variety of common questions, showing a
+patient coping successfully with the treatment, and
+finally, providing dietary advice and taking questions and
+answers. These didactic educational interventions are
+known to serve as an effective coping preparation in con-
+trolling chemotherapy-related side effects (Burish & Tope
+1992).
+This counselling was extended over the course of the
+patients’ chemotherapy cycles during their hospital visits
+(30-min sessions, once in 10 days). Subjects in the sup-
+portive therapy group also completed daily logs or diaries
+on episodes of nausea and vomiting. This therapy mainly
+involved preparing the patient to adequately cope with
+chemotherapy side effects, such as nausea and emesis.
+Similar supportive sessions have been used successfully as
+a control comparison group to evaluate psychotherapeutic
+interventions (Jacobs et al. 1983; Greer et al. 1992), and
+similar coping preparations have been effective in control-
+ling chemotherapy-related nausea and emesis (Burish
+et al. 1991). All subjects had received either yoga inter-
+vention or supportive counselling and coping preparation
+earlier during their surgery and radiotherapy period, and
+were followed up with their respective interventions dur-
+ing chemotherapy.
+Data analysis
+Data were analysed using Statistical Package for Social
+Sciences version 10.0. Descriptive statistics were used
+with all questionnaires of the study to summarize the
+data. Wherever differences between groups were sought,
+independent samples t-tests were used for analysis. Pear-
+son correlation coefficient was used to study the relation-
+ship and associations between various primary and
+secondary outcome measures.
+RESULTS
+Sixty-two subjects (yoga n = 28; control n = 34) received
+their prescribed chemotherapy cycles. The age, stages of
+disease, grade and node status were similar in the yoga and
+control groups, which received chemotherapy. The mean
+years of education were 10.4 ± 5 and 13.5 ± 3 years in the
+yoga and control groups respectively. Subjects were put on
+a chemotherapy treatment protocol of either FAC, CMF or
+CMF + FAC, conforming to the standard clinical protocol
+followed during that time at the hospital. All subjects
+were ambulatory and had a Zubrod’s performance status
+score of 0–2. All patients had prior mastectomy, 38 sub-
+jects had received radiotherapy before chemotherapy, and
+24 subjects received chemotherapy as the first adjuvant
+following mastectomy. A majority of the subjects (90.3%)
+received six or more cycles of chemotherapy, and six
+(9.7%) received only four cycles of chemotherapy. The two
+groups did not differ with respect to age, stage of disease,
+tumour grade, menopausal status, chemotherapy regimen,
+number of chemotherapy cycles and antiemetic regimen.
+Twenty-nine (47%) subjects were on antidopaminergics
+(domperidone), and 33 (53%) were on odansetron. Medical
+oncologists who were blinded to the intervention pre-
+scribed anxiolytic medication (lorazepam) (Alprazolam)
+0.5 mg bid to 22 subjects: 12 (35.3%) in controls and 10
+(28%) in the experimental group. A goodness-of-fit test
+between the socio-demographic and medical characteris-
+tics of the study sample revealed no significant differences
+between the two groups in any of the characteristics
+examined (P > 0.05) (Table 1).
+Overall, the administration of anxiolytic medication,
+chemotherapy  treatment  regimens  (CMF/FAC)  and
+antiemetic regimens (antidopaminergics/5-HT3 receptor
+RAGHAVENDRA et al.
+468
+© 2007 The Authors
+Journal compilation © 2007 Blackwell Publishing Ltd
+antagonists) had no significant influence on measures of
+nausea and emesis as assessed using the MANE question-
+naire. Overall, there was a significant influence only for
+age group on nausea frequency, with subjects aged less
+than 50 years having a greater frequency of nausea than
+those more than 50 years old (Table 2).
+Post-chemotherapy-related nausea and vomiting
+The severity of post-chemotherapy-related vomiting was
+mild to moderate in both the groups, and nausea severity
+was moderate to severe in controls and mild to moderate
+in the yoga group. Anticipatory vomiting was very mild in
+both groups, and nausea was mild to moderate in controls
+and very mild in the yoga group as seen with any moder-
+ately emetogenic treatment. Both the groups received
+antiemetics for an average of 2.6 ± 0.5 days.
+Independent samples t-tests on MANE scores showed that
+yoga intervention significantly reduced post-chemotherapy
+nausea frequency (t = 2.587, P = 0.01) and nausea severity
+(t = −2.670, P = 0.01), but not frequency of vomiting and
+severity, even though they tended to decrease more so in the
+yoga group as compared with controls (Table 3).
+Pearson correlation analysis was performed to see the
+relationship between MANE scores, anxiety states,
+depression, symptom number, severity and distress,
+chemotherapy-related toxicity and global quality-of-life
+scores during the mid-cycle of chemotherapy. Post-
+chemotherapy-related nausea frequency, nausea severity,
+vomiting frequency and severity correlated significantly
+and positively with anxiety state, depression, chemother-
+apy-related toxicity and distressful symptoms, and
+inversely with quality of life. The correlation was not sig-
+nificant for chemotherapy regimen and number of chemo-
+therapy cycles (Table 4).
+Anticipatory nausea and vomiting (Tables 2,4,5)
+Independent samples t-tests on anticipatory nausea and
+vomiting showed a significant reduction in anticipatory
+Table 1. Medical characteristics of the study population
+Yoga group
+(n = 28)
+n (%)
+Control group
+(n = 34) 
+n (%)
+All subjects
+(n = 62) 
+n (%)
+P-value
+Stage of breast cancer
+II
+16 (57.1)
+14 (41.1)
+30 (48.4)
+NS
+III
+12 (42.9)
+20 (58.8)
+32 (51.6)
+Grade of tumour
+I
+1 (3.5)
+0 (0)
+1 (1.6)
+NS
+II
+5 (17.8)
+2 (5.9)
+7 (11.2)
+III
+22 (78.6)
+32 (94.1)
+54 (87.1)
+Menopausal status
+Pre-menopausal
+18 (64.2)
+13 (38.2)
+31 (50.0)
+NS
+Post-menopausal
+8 (28.6)
+20 (58.8)
+28 (45.2)
+Perimenopausal
+1(3.5)
+0 (0)
+1 (1.6)
+Post-hysterectomy
+1 (3.5)
+1 (2.9)
+2 (3.2)
+CT regimen
+FAC
+17 (60.7)
+18 (52.9)
+35 (56.4)
+NS
+CMF
+10 (35.7)
+11 (32.4)
+21 (33.9)
+FAC + CMF
+1 (3.5)
+5 (14.7)
+6 (9.7)
+Number of CT cycles
+6
+22 (78.6)
+27 (79.4)
+49 (79.0)
+NS
+8
+3 (10.7)
+4 (11.8)
+7 (11.3)
+4
+3 (10.7)
+3 (8.8)
+6 (9.7)
+Treatment regimen
+S + RT + CT
+18 (64.2)
+20 (58.8)
+38 (61.3)
+NS
+S + CT + RT
+2 (7.1)
+2 (5.9)
+4 (6.5)
+S + CT3 + RT + CT3
+7 (25.0)
+10 (29.4)
+17 (27.4)
+S + CT
+1 (3.5)
+2 (5.9)
+3 (4.8)
+Antiemetic regimen
+5-HT3 receptor antagonists
+15 (54)
+18 (53)
+33 (53)
+NS
+Antidopaminergic
+13 (46)
+16 (47)
+29 (47)
+NS
+Anxiolytic administration
+Yes
+13 (46.4)
+17 (50)
+30 (48.4)
+NS
+No
+15 (53.6)
+17 (50)
+32 (51.6)
+NS, not significant for goodness-of-fit test.
+CT, chemotherapy; RT, radiotherapy; S, surgery.
+Yoga for CINV
+© 2007 The Authors
+469
+Journal compilation © 2007 Blackwell Publishing Ltd
+Table 2. Influence of age group (<50 years or >50 years), chemotherapy treatment regimen, class of antiemetic treatment regimen and
+days of oral antiemetic administration following chemotherapy on measures of Morrow Assessment of Nausea and Emesis (MANE)
+MANE outcome measure
+Nausea
+intensity
+Nausea
+frequency
+Vomiting
+frequency
+Vomiting
+intensity
+An Nau
+frequency
+An Nau
+intensity
+An Vom
+frequency
+An Vom 
+intensity
+Age group
+<50 years (n = 33), mean ± SD
+2.79 ± 1.2
+4.45 ± 1.2
+2.76 ± 1.4
+1.94 ± 1.3
+1.79 ± 1.2
+1.13 ± 1.5
+1.33 ± 0.96
+0.63 ± 1.2
+>50 years (n = 29), mean ± SD
+2.97 ± 1.3
+3.72 ± 1.4
+2.45 ± 1.4
+1.86 ± 1.3
+1.45 ± 1.1
+1.21 ± 1.3
+0.97 ± 0.5
+0.57 ± 0.9
+t-value
+d.f.
+−0.56
+60
+2.25
+60
+0.87
+60
+0.24
+60
+1.14
+60
+−0.24
+58
+1.86
+58
+0.22
+56
+P-value
+0.58
+0.028
+0.39
+0.81
+0.26
+0.81
+0.07
+0.83
+CT regimen
+FAC (n = 35), mean ± SD
+2.94 ± 1.2
+4.11 ± 1.3
+2.56 ± 1.2
+1.86 ± 1.13
+1.58 ± 1
+1.08 ± 1.3
+1.06 ± 0.5
+0.48 ± 0.83
+CMF (n = 21), mean ± SD
+2.7 ± 1.3
+3.95 ± 1.5
+2.55 ± 1.5
+1.75 ± 1.3
+1.80 ± 1.4
+1.47 ± 1.5
+1.4 ± 1.19
+0.89 ± 1.5
+t-value
+0.70
+0.42
+0.02
+0.33
+−0.66
+−0.97
+−1.76
+−1.28
+d.f.
+54
+54
+54
+54
+54
+53
+54
+50
+P-value
+0.49
+0.68
+0.99
+0.75
+0.51
+0.36
+0.084
+0.28
+Class of antiemetic treatment
+5HT3 receptor antagonists
+(n = 33), mean ± SD
+2.94 ± 1.3
+4.09 ± 1.3
+2.52 ± 1.4
+1.7 ± 1.9
+1.55 ± 1
+ 124 ± 1.4
+1.03 ± 0.5
+0.55 ± 0.89
+Antidopaminergics (n = 29), 
+mean ± SD
+2.8 ± 1.2
+4.14 ± 1.5
+2.72 ± 1.4
+2.14 ± 1.3
+1.72 ± 1.4
+1.07 ± 1.5
+1.31 ± 1.0
+0.67 ± 1.3
+t-value
+0.46
+−0.14
+−0.59
+−1.39
+−0.59
+0.46
+−1.39
+−0.49
+d.f.
+60
+60
+60
+60
+60
+60
+60
+56
+P-value
+0.64
+0.89
+0.56
+0.17
+0.56
+0.65
+0.17
+0.68
+No. of days of antiemetic administration
+2 days (n = 25), mean ± SD
+2.64 ± 1.3
+4.28 ± 1.3
+2.6 ± 1.4
+ 2 ± 1.4
+1.76 ± 1.5
+1.09 ± 1.6
+1.28 ± 1.06
+0.63 ± 1.4
+3 days (n = 37), mean ± SD
+3.03 ± 1.2
+4.0 ± 1.33
+2.62 ± 1.4
+1.84 ± 1.1
+1.54 ± 0.96
+1.22 ± 1.3
+1.08 ± 0.55
+0.59 ± 0.89
+t-value d.f
+−1.21
+60
+0.82
+60
+−0.059
+60
+0.49
+60
+0.72
+60
+−0.34
+58
+0.97
+60
+0.13
+60
+P-value
+0.23
+0.42
+0.95
+0.64
+0.51
+0.73
+0.39
+0.90
+An Nau, anticipatory nausea; An Vom, anticipatory vomiting; CT, chemotherapy; RT, radiotherapy; SD, standard deviation.
+Table 3. Independent samples t-test on measures of Morrow Assessment of Nausea and Emesis scores between yoga and control groups
+during CT
+Groups
+Yoga group
+(n = 28)
+Mean ± SD
+Control group
+(n = 34) 
+Mean ± SD
+t-value (d.f.)
+P-value
+Post-CT nausea frequency
+3.6 ± 1.6
+4.5 ± 0.9
+−2.67 (60)
+0.01
+Post-CT nausea intensity
+2.3 ± 1.2
+3.4 ± 1.1
+−3.71 (57)
+<0.001
+Post-CT vomiting frequency
+2.3 ± 1.4
+2.9 ± 1.4
+−1.9 (58)
+0.06
+Post-CT vomiting intensity
+1.6 ± 1.0
+2.2 ± 1.4
+−1.99 (60)
+0.05
+Anticipatory nausea frequency
+1.3 ± 0.98
+1.9 ± 1.3
+−1.9 (60)
+0.06
+Anticipatory nausea intensity
+0.6 ± 1.03
+1.7 ± 1.5
+−3.17 (55)
+0.003
+Anticipatory vomiting frequency
+1.1 ± 0.88
+1.2 ± 0.73
+−0.476 (53)
+0.63
+Anticipatory vomiting intensity
+0.3 ± 0.67
+0.87 ± 1.3
+−2.05 (56)
+0.04
+CT, chemotherapy; SD, standard deviation.
+Table 4. Pearson correlation between Morrow Assessment of Nausea and Emesis measures, mood states, quality of life and toxicity
+scores during chemotherapy
+All subjects (n = 62)
+Pearson correlation coefficient values, r
+Nausea
+frequency
+Nausea
+intensity
+Vomiting
+frequency
+Vomiting
+intensity
+An Nau
+frequency
+An Nau
+intensity
+An Vom
+frequency
+An Vom 
+intensity
+STAI score
+0.29*
+0.56**
+0.42**
+0.43**
+0.50**
+0.59**
+0.27*
+0.50*
+BDI score
+0.38**
+0.53**
+0.441**
+0.41**
+0.38**
+0.39**
+0.14
+0.33*
+Symptom distress score
+0.50**
+0.62**
+0.44**
+0.35**
+0.37**
+0.35**
+0.28*
+0.19
+FLIC score
+−0.46**
+−0.59**
+−0.50**
+−0.37**
+−0.47**
+−0.43**
+−0.32*
+−0.34*
+CT regimen
+0.17
+0.01
+0.12
+0.14
+0.01
+0.04
+0.08
+0.09
+No. of CT cycles
+0.08
+−0.06
+−0.12
+0.03
+−0.07
+0.03
+0.00
+0.05
+Mid CT toxicity score
+0.37**
+0.47**
+0.36**
+0.42**
+0.30*
+0.30*
+0.23
+0.27*
+*P < 0.05, **P < 0.01.
+An Nau, anticipatory nausea; An Vom, anticipatory vomiting; BDI, Beck’s Depression Inventory; CT, chemotherapy; FLIC, Functional 
+Living Index for Cancer; STAI, State Trait Anxiety Inventory.
+RAGHAVENDRA et al.
+470
+© 2007 The Authors
+Journal compilation © 2007 Blackwell Publishing Ltd
+nausea frequency (t = 1.979, P = 0.053), nausea severity
+(t = −3.08, P = 0.003) and vomiting severity (t = −2.056, P =
+0.044) in the yoga group as compared with controls
+(Table 3).
+Anticipatory nausea frequency and severity correlated
+significantly and positively with anxiety state, depression,
+chemotherapy-related toxicity and distressful symptoms,
+and inversely with quality of life. Anticipatory vomiting
+frequency correlated significantly and positively with
+anxiety state and distressful symptoms, and inversely
+with quality of life. Severity of anticipatory vomiting
+correlated significantly and positively with anxiety state,
+depression and chemotherapy-related toxicity, and in-
+versely with quality of life (Table 4).
+Approximately 35% of the subjects in the study
+received anxiolytic administration in both the groups.
+Administration of anxiolytic tended to be beneficial in
+reducing the severity of post-chemotherapy vomiting
+overall in both the groups (t = 4.04, P < 0.001), and indi-
+vidually in the intervention (t = 2.147, P = 0.04) and con-
+trol groups (t = 3.39, P = 0.002). Anxiolytics were also
+effective in reducing nausea severity (t = 2.01, P = 0.05)
+and anticipatory nausea frequency (t = 2.56, P = 0.016) in
+the control group alone (Table 5).
+When intervention effects were compared in the sample
+who did not use anxiolytics, the interventions were found
+to reduce significantly post-treatment related nausea
+frequency (t = 2.03, P = 0.05) and severity (t = 3.42, P =
+0.002), and vomiting frequency (t = 2.16, P = 0.039) and
+severity (t = 2.29, P = 0.03). Yoga intervention was also
+effective in significantly reducing anticipatory nausea
+severity (t = 2.49, P = 0.02) and anticipatory vomiting
+severity (t = 2.77, P = 0.01) (Table 6).
+Secondary outcome measures (Table 7)
+There was a significant decrease in reactive anxiety states,
+depression, number of treatment-related distressful symp-
+toms, severity of symptoms and distress experienced, and
+improvement in quality of life during chemotherapy in
+the yoga group as compared with controls.
+Common toxicity criteria (Table 3)
+Common toxicity criteria guidelines were used to evalu-
+ate the chemotherapy-induced systemic and organ toxic-
+ity. Both systemic and organ toxicity were graded from 0
+to 4 (no toxicity to very severe toxicity) using clinical
+notes and laboratory data , and the total score was extrap-
+olated. Independent samples t-test showed the yoga group
+with significantly reduced toxicity scores as compared
+with controls (t = −4.1, P < 0.001).
+Table 5. Effects of anxiolytic administration on measures of Morrow Assessment of Nausea and Emesis in each group and in the overall study sample.
+Nausea
+intensity
+Nausea
+frequency
+Vomiting
+frequency
+Vomiting
+intensity
+An Nau
+frequency
+An Nau
+intensity
+An Vom
+frequency
+An Vom 
+intensity
+Administration of anxiolytics
+Yoga group
+Yes (n = 10), mean ± SD
+2.22 ± 1.2
+3.3 ± 1.6
+2.06 ± 1.4
+1.28 ± 0.89
+1.22 ± 1
+0.61 ± 1.0
+1.1 ± 1.08
+0.22 ± 0.55
+No (n = 18), mean ± SD
+2.4 ± 1.1
+4.2 ± 1.5
+2.6 ± 1.2
+2.1 ± 1.1*
+1.5 ± 0.97
+0.6 ± 1.1
+1.1 ± 0.32
+0.44 ± 0.88
+Control group
+Yes (n = 14), mean ± SD
+3.05 ± 1.1
+4.35 ± 0.93
+2.55 ± 1.32
+1.60 ± 0.88
+1.45 ± 1.1
+1.28 ± 1.13
+1.15 ± 0.59
+0.56 ± 0.78
+No (n = 20), mean ± SD
+3.79 ± 1.1*
+4.71 ± 0.8
+3.43 ± 1.34
+3.0 ± 1.52**
+2.5 ± 1.3*
+2.14 ± 1.83
+1.29 ± 0.91
+1.31 ± 0.75
+Overall
+Yes (n = 24), mean ± SD
+2.7 ± 1.9
+3.87 ± 1.4
+2.32 ± 1.3
+1.45 ± 0.89
+1.3 ± 1.0
+0.94 ± 1.1
+1.13 ± 0.84
+0.39 ± 0.69
+No (n = 38), mean ± SD
+3.21 ± 1.3
+4.50 ± 1.1
+3.1 ± 1.3
+2.63 ± 1.4
+2.08 ± 1.3
+1.5 ± 1.7
+1.21 ± 0.72
+0.95 ± 1.5
+t-value
+1.74
+1.87
+2.17
+4.04
+2.52
+1.51
+0.36
+1.96
+d.f.
+60
+60
+60
+60
+60
+58
+60
+56
+P-value
+0.087
+0.067
+0.034
+<0.001
+0.014
+0.134
+0.714
+0.055
+An Nau, anticipatory nausea; An Vom, anticipatory vomiting.
+*p < 0.05.
+**p < 0.01.
+Yoga for CINV
+© 2007 The Authors
+471
+Journal compilation © 2007 Blackwell Publishing Ltd
+DISCUSSION
+The results of the study suggest that yoga intervention
+helped reduce post-chemotherapy-related nausea and
+anticipatory nausea and vomiting compared with support-
+ive therapy and coping preparation in stage II and III breast
+cancer subjects receiving adjuvant chemotherapy. There
+was a trend towards reduction in post-chemotherapy-
+related vomiting in the yoga group.
+Yoga intervention helped significantly to reduce the fre-
+quency and intensity of post-chemotherapy nausea by
+18% as compared with the supportive therapy group. Our
+intervention was also helpful in significantly reducing the
+frequency and intensity of anticipatory nausea by 12%
+and 18%, and vomiting intensity by 9% as compared with
+controls. Even though yoga intervention helped reduce
+the frequency and intensity of post-chemotherapy vomit-
+ing by 13% and 10% and anticipatory vomiting frequency
+by 2% compared with controls, the effects were not sig-
+nificant. However, when the effects of intervention were
+compared in the yoga and control groups, which did not
+receive anxiolytic medications, yoga intervention de-
+creased nausea intensity by 39%, nausea frequency by
+21.8%, vomiting frequency by 33.65%, vomiting intensity
+by 39.9%, anticipatory nausea intensity by 63.2%, and an-
+ticipatory vomiting intensity by 83%. These results indi-
+cate that addition of anxiolytics may have created a floor
+effect (Razavi et al. 1993), masking the actual effects of
+yoga intervention. Furthermore, these results also indi-
+cate that yoga may have had a significant anxiolytic effect
+in subjects who were not on any anxiolytic medication.
+Another reason why the intervention was not effective
+in reducing post-treatment vomiting could be that admin-
+istration of 5-HT3 receptor antagonist class of antiemetics
+may have significantly decreased the episodes of vomiting
+but increased the frequency and duration of nausea (Roscoe
+et al. 2000). Our results are similar to the studies reviewed
+by Burish and Tope (1992), in which supportive therapy and
+coping preparation interventions have been beneficial in
+reducing the conditioned side effects of chemotherapy.
+Our results are similar to other studies using behav-
+ioural interventions that have shown reductions in
+anticipatory and post-chemotherapy-related nausea and
+emesis, anxiety and levels of distress associated with che-
+motherapy (Redd et al. 2001; Mundy et al. 2003). Our
+results are also in congruence with other studies using
+relaxation that have shown decreases in the frequency and
+duration of chemotherapy-related nausea and emesis (Bur-
+ish & Tope 1992; Arakawa 1997; Molassiotis et al. 2002).
+However, the effect sizes seen with our intervention on
+nausea and vomiting variables was larger compared to
+above studies using relaxation. We could attribute these
+effects to two reasons. First, unlike earlier studies using
+relaxation intervention, where subjects were followed up
+over a single chemotherapy cycle, interventions in our
+study were given over the complete course of chemother-
+Table 6. Effects of intervention on measures of Morrow Assessment of Nausea and Emesis in subjects not on anxiolytic medication
+during chemotherapy
+Nausea
+intensity
+Nausea
+frequency
+Vomiting
+frequency
+Vomiting
+intensity
+An Nau
+frequency
+An Nau
+intensity
+An Vom
+frequency
+An Vom
+intensity
+Yoga group (n = 15),
+mean ± SD
+2.07 ± 1.0
+3.4 ± 1.6
+2.07 ± 1.4
+1.13 ± 0.8
+1.27 ± 1
+0.53 ± 0.92
+1.13 ± 1.1
+0.13 ± 0.35
+Control group (n = 17),
+mean ± SD
+3.41 ± 1.2
+4.35 ± 0.9
+3.12 ± 1.3
+1.88 ± 0.9
+2.5 ± 1.3
+2.14 ± 1.83
+1.29 ± 0.91
+1.31 ± 1.75
+t-value
+1.74
+1.87
+2.17
+4.04
+2.52
+1.51
+0.36
+1.96
+d.f.
+60
+60
+60
+60
+60
+58
+60
+56
+P-value
+0.087
+0.067
+0.034
+<0.001
+0.014
+0.134
+0.714
+0.055
+An Nau, anticipatory nausea; An Vom, anticipatory vomiting.
+Table 7. Comparison of scores of STAI, BDI, symptom number, severity, distress and FLIC during chemotherapy in yoga and control
+groups
+Secondary outcome measure
+Yoga (n = 28)
+Mean ± SD
+Control (n = 34)
+Mean ± SD
+t-value 
+d.f
+P-value
+STAI – anxiety state score
+29.2 ± 3.8
+37.5 ± 7.6
+−5.18 
+59
+<0.001
+Beck’s depression score
+6.6 ± 4.6
+14.2 ± 6.6
+−5.50 
+57
+Number of distressful symptoms
+11.4 ± 4.5
+14.7 ± 3.6
+−3.34 
+53
+0.002
+Severity of symptoms
+17.6 ± 9.3
+27.3 ± 9.2
+−3.89 
+58
+<0.001
+Symptom distress
+16.6 ± 10.1
+29.9 ± 11.2
+−4.70 
+59
+<0.001
+FLIC – overall quality of life
+142.1 ± 10.2
+111.7 ± 25.5
+6.48 
+59
+<0.001
+Total toxicity score
+7.3 ± 2.7
+11.1 ± 4.3
+−4.1
+56
+<0.001
+BDI, Beck’s Depression Inventory; FLIC, Functional Living Index for Cancer; STAI, State Trait Anxiety Inventory.
+RAGHAVENDRA et al.
+472
+© 2007 The Authors
+Journal compilation © 2007 Blackwell Publishing Ltd
+apy. Second, subjects in both the groups were given the
+intervention much before the commencement of chemo-
+therapy, during their surgery and radiotherapy. This long-
+term intervention may have contributed to increasing
+benefits resulting from our intervention against the earlier
+studies using relaxation.
+This long-term intervention may have also helped in
+improving quality of life and reducing anxiety, depression,
+distressful symptoms and treatment-related toxicity.
+Thus, maintenance of such interventions over a longer
+period could enhance the care provided to cancer patients
+and help them control the undesirable effects of
+chemotherapy.
+One of the major limitations of this study was that man-
+agement of delayed emesis was not according to current
+guidelines and consensus statements, as this study was
+carried out much before the publication of these guide-
+lines (Gralla et al. 1999). Thus, the results of this study
+may be applicable only to chemotherapy patients with a
+poor control of delayed nausea and emesis. Second, sub-
+jects in the control group were offered supportive coun-
+selling and coping preparation less frequently than their
+counterparts who received yoga intervention, and this dis-
+crepancy in the duration of interventions could account
+for the significant differences seen between the groups.
+However, it should be noted that most of these CAM
+interventions are time-intensive and involve more
+contact hours than these standard supportive therapy
+sessions. For practical purposes, this difference was
+acceptable, as we are using supportive therapy interven-
+tions only with an intention of negating the confounding
+variables, such as social support, attention, education and
+self-control, which are known to improve the psycholog-
+ical and social functioning of cancer patients (Roscoe et al.
+2000). Since both the groups received the same supportive
+therapy and coping preparation programme, in addition to
+yoga intervention in the yoga group, it is possible to
+attribute the effects of the yoga programme to stress
+reduction rather than supportive care. However, because
+of the desire to incorporate support and education in the
+yoga programme, it is not clear whether a yoga programme
+without support and education would have resulted in the
+same benefits. Third, subjects were given yoga interven-
+tion much before the start of chemotherapy during sur-
+gery and radiotherapy, and pre-exposure to interventions
+before chemotherapy may have reduced the responses of
+patients to conditioning stimuli during chemotherapy.
+This may also be the reason why our intervention was bet-
+ter than coping preparation and counselling which had the
+same beneficial effects as progressive muscle relaxation
+training in earlier studies (Burish et al. 1991). Finally,
+because of the overlap with physical symptoms of cancer,
+the use of BDI and STAI in cancer populations has its lim-
+itations and results should be interpreted with caution.
+Overall, the beneficial effects observed in this study can
+be attributed to yoga practices that helped in stress reduc-
+tion, rather than to mere social support and education.
+This is consistent with other behaviourally orientated
+programmes, which have shown better results with stress
+reduction than with purely supportive interventions
+(Telch & Telch 1986; Vasterling et al. 1993). It is in this
+context that our study has been able to elucidate the
+effects of a yoga-based stress reduction programme.
+Several studies mentioned above have demonstrated the
+effectiveness of attention-diversion strategies for the
+reduction of stress and pain. It is likely that relaxation and
+deep somatic restfulness induced by yoga practices may
+reduce anxiety, physiological arousal and stress associated
+with chemotherapy and prevent the exacerbation of
+responses induced by post-chemotherapy nausea and vom-
+iting, thereby reducing the general feelings of distress. The
+yoga postures may have also helped reduce muscular con-
+tractions in the gastrointestinal tract (Taneja et al. 2004)
+that accompany post-chemotherapy nausea and vomiting,
+or may have decreased the sensitivity of chemoreceptor
+trigger zone to vomiting response (stimuli) (Borison &
+McCarthy 1983).
+This indicates that yoga probably shares some common
+techniques with other behavioural interventions that
+influence pathways from stress to somatic symptoms.
+Yoga is one such intervention, which is gaining popularity
+among the Indian masses, and oncology clinics could
+adopt these interventions by training nurses involved in
+cancer care. Approximately 56% of the cancer patients in
+a developing country like India take recourse to comple-
+mentary and alternative therapies with an intention to
+gain benefit and not because of dissatisfaction with con-
+ventional treatment (Gupta et al. 2002). The popular
+beliefs associated with these treatments have helped can-
+cer patients to adopt healthy self-care behaviours. Use of
+these interventions in a hospital setting could help com-
+plement the effects of conventional antiemetic treatments
+in managing chemotherapy-related nausea and emesis.
+These interventions can be particularly useful in the
+Indian context and in developing countries where subjec-
+tive concerns regarding treatment-related side effects are
+not given due their concern. Moreover, infrastructure for
+offering supportive care and cancer support groups rarely
+exists, and access to care is not affordable for the majority
+of the cancer population.
+In summary, our yoga-based intervention was more
+effective in reducing post-chemotherapy and anticipatory
+Yoga for CINV
+© 2007 The Authors
+473
+Journal compilation © 2007 Blackwell Publishing Ltd
+nausea compared with supportive therapy and coping
+preparation. Yoga intervention served as a useful additive
+to antiemetic treatment in reducing post-chemotherapy
+and anticipatory vomiting. However, larger experimental
+studies under controlled conditions are required to vali-
+date our findings.
+ACKNOWLEDGEMENTS
+This research was supported by a grant from the Central
+Council for Research in Yoga and Naturopathy, Ministry
+of Health and Family Welfare, Government of India. We
+are thankful to Dr Jayashree and Mrs Anupama for impart-
+ing the yoga intervention.
+REFERENCES
+Arakawa S. (1997) Relaxation to reduce nausea, vomiting, and
+anxiety induced by chemotherapy in Japanese patients. Cancer
+Nursing 20, 342–349.
+Beck A.T., Ward C.H. & Mendelson M. (1961) An inventory for
+measuring depression. Archives of General Psychiatry 4, 561–
+571.
+Bhaskaran S.A. (1996) Behavioral Management of Patients with
+Cancer. Department of Clinical Psychology, National Institute
+of Mental Health and Neurosciences, Bangalore, India: 271.
+Bijlani R.L. (2004) Influence of yoga on brain and behaviour: facts
+and speculations. Indian Journal of Physiology and Pharma-
+cology 48, 1–5.
+Borison H.L. & McCarthy L.E., eds. (1983) Neuropharmacologic
+Mechanisms of Emesis. Antiemetics and Cancer Chemother-
+apy. Williams & Wilkins, Baltimore, MD, USA.
+Burish T.G. & Tope D.M. (1992) Psychological techniques for
+controlling the adverse side effects of cancer chemotherapy:
+findings from a decade of research. Journal of Pain and Symp-
+tom Management 7, 287–301.
+Burish T.G., Snyder S.L. & Jenkins R.A. (1991) Preparing patients
+for cancer chemotherapy: effect of coping preparation and
+relaxation interventions. Journal of Consulting and Clinical
+Psychology 59, 518–525.
+Carlson L.E., Speca M., Patel D.K. & Goodey E. (2003) Mindful-
+ness-based stress reduction in relation to quality of life, mood,
+symptoms of stress, and immune parameters in breast and
+prostate cancer outpatients. Psychosomatic Medicine 65, 571–
+581.
+Cassileth B.R. (1999) Evaluating complementary and alternative
+therapies for cancer patients. CA: A Cancer Journal for Clini-
+cians 49, 362–375.
+Cohen L., Warneke C., Fouladi R.T., Rodriguez M.A. & Chaoul-
+Reich A. (2004) Psychological adjustment and sleep quality in
+a randomized trial of the effects of a Tibetan yoga intervention
+in patients with lymphoma. Cancer 100, 2253–2260.
+De Angelis V., Roila F. & Sabbatini R. (2003) Cancer chemother-
+apy induced delayed emesis: antiemetic prescriptions in clini-
+cal practice. Proceedings of the ASCO. American Society of
+Clinical Oncology, Alexandria, VA, USA.
+Gilbar O. (1991) The quality of life of cancer patients who
+refuse chemotherapy. Society Science and Medicine 32,
+1337–1340.
+Gimbel M.A. (1998) Yoga, meditation, and imagery: clinical
+applications. Nurse Practitioner Forum 9, 243–255.
+Gralla R.J., Osoba D., Kris M.G., Kirkbride P., Hesketh P.J., Chin-
+nery L.W., Clark-Snow R., Gill D.P., Groshen S., Grunberg S.,
+Koeller J.M., Morrow G.R., Perez E.A., Silber J.H. & Pfister
+D.G. (1999) Recommendations for the use of antiemetics: evi-
+dence-based, clinical practice guidelines. American Society of
+Clinical Oncology. Journal of Clinical Oncology 17, 2971–
+2994.
+Greer S., Moorey S., Baruch J.D., Watson M., Robertson B.M.,
+Mason A., Rowden L., Law M.G. & Bliss J.M. (1992) Adjuvant
+psychological therapy for patients with cancer – a prospective
+randomized trial. British Medical Journal 304, 675–680.
+Gupta M., Shafiq N., Kumari S. & Pandhi P. (2002) Patterns and
+perceptions of complementary and alternative medicine (CAM)
+among leukaemia patients visiting haematology clinic of a
+north Indian tertiary care hospital. Pharmacoepidemiology
+and Drug Safety 11, 671–676.
+Hawthorn J. (1995) Understanding and Management of Nausea
+and Vomiting. Blackwell Science, Oxford, UK.
+Jacobs C., Ross R.D., Walker I.M. & Stockdale F.E. (1983) Behav-
+ior of cancer patients: a randomized study of the effects of
+education and peer support groups. American Journal of Clin-
+ical Oncology 6, 347–353.
+Jacobsen P.B., Andrykowski M.A., Redd W.H., Die-Trill M.,
+Hakes T.B., Kaufman R.J., Currie V.E. & Holland J.C. (1988)
+Nonpharmacologic factors in the development of post treat-
+ment nausea with adjuvant chemotherapy for breast cancer.
+Cancer 61, 379–385.
+Jayasinghe S.R. (2004) Yoga in cardiac health (a review). European
+Journal of Cardiovascular Prevention and Rehabilitation 11,
+369–375.
+King C.R. (1997) Nonpharmacologic management of chemother-
+apy-induced nausea and vomiting. Oncology Nursing Forum 24
+(7 Suppl.), 41–48.
+Mattes R.D., Arnold C. & Boraas M. (1987) Learned food aver-
+sions among cancer chemotherapy patients. Incidence, nature,
+and clinical implications. Cancer 60, 2576–2580.
+Molassiotis A., Yung H.P., Yam B.M., Chan F.Y. & Mok T.S.
+(2002) The effectiveness of progressive muscle relaxation train-
+ing in managing chemotherapy-induced nausea and vomiting
+in Chinese breast cancer patients: a randomised controlled
+trial. Support Care Cancer 10, 237–246.
+Morrow G.R. (1982) Prevalence and correlates of nausea and vom-
+iting in chemotherapy patients. Journal of the National Cancer
+Institute 68, 585–588.
+Morrow G.R. (1992) A patient report measure for the quantifi-
+cation of chemotherapy induced nausea and emesis: psycho-
+metric properties of the Morrow assessment of nausea and
+emesis (MANE). British Journal of Cancer Supplement 19,
+S72–S74.
+Morrow G.R. & Rosenthal S.N. (1996) Models, mechanisms and
+management of anticipatory nausea and emesis. Oncology 53
+(Suppl. 1), 4–7.
+Morrow G.R., Lindke J.L. & Black P.M. (1991) Predicting devel-
+opment of anticipatory nausea in cancer patients: prospective
+examination of eight clinical characteristics. Journal of Pain
+and Symptom Management 6, 215–223.
+Mundy E.A., DuHamel K.N. & Montgomery G.H. (2003) The
+efficacy of behavioral interventions for cancer treatment-
+related side effects. Seminars in Clinical Neuropsychiatry 8,
+253–275.
+Nagarathna R. & Nagendra H.R. (1985) Yoga for bronchial
+asthma: a controlled study. British Medical Journal Clinical
+Research ed. 291, 1077–1079.
+Osoba D., Zee B., Warr D., Latreille J., Kaizer L. & Pater J. (1997)
+Effect of postchemotherapy nausea and vomiting on health-
+related quality of life. The Quality of Life and Symptom Con-
+RAGHAVENDRA et al.
+474
+© 2007 The Authors
+Journal compilation © 2007 Blackwell Publishing Ltd
+trol Committees of the National Cancer Institute of Canada
+Clinical Trials Group. Support Care Cancer 5, 307–313.
+Perez E.A., Hesketh P., Sandbach J., Reeves J., Chawla S., Mark-
+man M., Hainsworth J., Bushnell W. & Friedman C. (1998)
+Comparison of single-dose oral granisetron versus intravenous
+ondansetron in the prevention of nausea and vomiting induced
+by moderately emetogenic chemotherapy: a multicenter, dou-
+ble-blind, randomized parallel study. Journal of Clinical Oncol-
+ogy 16, 754–760.
+Raub J.A. (2002) Psychophysiologic effects of hatha yoga on mus-
+culoskeletal and cardiopulmonary function: a literature review.
+Journal of Alternative and Complementary Medicine 8, 797–
+812.
+Razavi D., Delvaux N., Farvacques C., De Brier F., Van Heer C.,
+Kaufman L., Derde M.P., Beauduin M. & Piccart M. (1993)
+Prevention of adjustment disorders and anticipatory nausea
+secondary to adjuvant chemotherapy: a double-blind, placebo-
+controlled study assessing the usefulness of alprazolam. Jour-
+nal of Clinical Oncology 11, 1384–1390.
+Redd W.H., Montgomery G.H. & DuHamel K.N. (2001) Behav-
+ioral intervention for cancer treatment side effects. Journal of
+the National Cancer Institute 93, 810–823.
+Rhodes V.A. & McDaniel R.W. (2001) Nausea, vomiting, and
+retching: complex problems in palliative care. CA: A Cancer
+Journal for Clinicians 51, 232–248.
+Rimer B., Jones W. & Blumberg B. (1983) Challenges and pros-
+pects in cancer patient education. Patient Education Newslet-
+ter 6, 1–3.
+Roila F., Warr D., Clark-Snow R.A., Tonato M., Gralla R.J., Ein-
+horn L.H. & Herrstedt J. (2005) Delayed emesis: moderately
+emetogenic chemotherapy. Support Care Cancer 13, 104–108.
+Roscoe J.A., Morrow G.R., Hickok J.T. & Stern R.M. (2000) Nau-
+sea and vomiting remain a significant clinical problem: trends
+over time in controlling chemotherapy-induced nausea and
+vomiting in 1413 patients treated in community clinical prac-
+tices. Journal of Pain and Symptom Management 20, 113–121.
+Sahay B.K. & Sahay R.K. (2002) Lifestyle modification in man-
+agement of diabetes mellitus. Journal of the Indian Medical
+Association 100, 178–180.
+Sainani G.S. (2003) Non-drug therapy in prevention and control
+of hypertension. Journal of the Association of Physicians of
+India 51, 1001–1006.
+Schipper H., Clinch J., McMurray A. & Levitt M. (1984) Measur-
+ing quality of life of cancer patients: the functional living
+index-cancer: development and validation. Journal of Clinical
+Oncology 2, 472–483.
+Schwartz M.D., Jacobsen P.B. & Bovbjerg D.H. (1996) Role of
+nausea in the development of aversions to a beverage paired
+with chemotherapy treatment in cancer patients. Physiology
+and Behavior 59, 659–663.
+Speca M., Carlson L.E., Goodey E. & Angen M. (2000) A random-
+ized wait list controlled trial: the effect of a mindfulness med-
+itation-based stress reduction program on mood and symptoms
+of stress in cancer outpatients. Psychosomatic Medicine 62,
+613–622.
+Spielberger C.D., Gorsuch R.L. & Lushene R.E. (1970) Test Man-
+ual for the State Trait Anxiety Inventory. Consult Psycholo-
+gists Press, Paolo Alto, CA, USA.
+Taneja I., Deepak K.K., Poojary G., Acharya I.N., Pandey R.M. &
+Sharma M.P. (2004) Yogic versus conventional treatment in
+diarrhea-predominant irritable bowel syndrome: a randomized
+control study. Applied Psychophysiology and Biofeedback 29,
+19–33.
+Targ E.F. & Levine E.G. (2002) The efficacy of a mind–body–spirit
+group for women with breast cancer: a randomized controlled
+trial. General Hospital Psychiatry 24, 238–248.
+Telch C.F. & Telch M.J. (1986) Group coping skills instruction
+and supportive group therapy for cancer patients: a comparison
+of strategies. Journal of Consulting and Clinical Psychology
+54, 802–808.
+Vasterling J., Jenkins R.A., Tope D.M. & Burish T.G. (1993) Cog-
+nitive distraction and relaxation training for the control of side
+effects due to cancer chemotherapy. Journal of Behavioral
+Medicine 16, 65–80.
+World Health Organization. (1979) WHO Handbook for Report-
+ing Results of Cancer Treatment. WHO Offset Publication,
+Geneva, Switzerland. 48, 16–21.

subfolder_0/Effects of integrated yoga on quality of life and interpersonal relationship of pregnant women.txt

@@ -0,0 +1,1107 @@
+Effects of integrated yoga on quality of life and interpersonal
+relationship of pregnant women
+Abbas Rakhshani • Satyapriya Maharana •
+Nagarathna Raghuram • Hongasandra R. Nagendra •
+Padmalatha Venkatram
+Accepted: 29 June 2010 / Published online: 15 July 2010
+ Springer Science+Business Media B.V. 2010
+Abstract
+Purpose
+The objective of this study was to investigate the
+effects of integrated yoga on the quality of life and inter-
+personal relationships in normal pregnant women.
+Methods
+One hundred and two pregnant women between
+18 and 20 weeks of gestation who met the inclusion criteria
+were recruited from the obstetric units in Bangalore and
+were randomly assigned to two groups of yoga (n = 51)
+and control (n = 51). Women with medical conditions that
+could potentially lead to pregnancy complications and
+those with abnormal fetal parameters were excluded. The
+yoga group received integrated yoga while control group
+received standard antenatal exercises, both for 1-h three
+times a week from 20th to 36th week of gestation. Pre and
+post assessments were done using WHOQOL-100 and
+FIRO-B questionnaires.
+Results
+Of the six domains of WHOQOL-100, between
+groups analysis showed significant improvements in the
+yoga group compared to the control in the physical
+(P = 0.001),
+psychological
+(P \ 0.001),
+social
+(P =
+0.003), and environmental domains (P = 0.001). In FIRO-B,
+the yoga group showed significant improvements in
+‘Expressed Inclusion’ (P = 0.02) and ‘Wanted Control’
+(P = 0.009) domains compared to the control group.
+Conclusion
+The integrated yoga is an efficacious means of
+improving the quality of life of pregnant women and
+enhancing certain aspects of their interpersonal relationships.
+Keywords
+Yoga  Pregnancy  World Health
+Organization Quality of Life  WHOQOL-100 
+Fundamental Interpersonal Relationships Orientation 
+FIRO-B
+Abbreviations
+WHOQOL
+World Health Organization Quality of Life
+FIRO
+Fundamental Interpersonal Relationships
+Orientation
+Introduction
+World Health Organization defines health as ‘‘a state of
+physical, mental, social and spiritual [1] well-being, and
+not merely the absence of disease or infirmity’’ [2]. This
+broad definition of well-being is reflected in an increasing
+appreciation of quality of life issues and the interper-
+sonal relationships of the subject with his/her environment
+[3].
+Chronic psychosocial stress has become prevalent in
+modern society [4] and is associated with a substantial
+reduction in the quality of life [5]. Maternal psychological
+stress has been associated with reduced placental perfusion
+[6] and endothelial dysfunction [7], which are known as the
+main causes of many pregnancy complications, including
+intrauterine growth restriction (IUGR), pregnancy-induced
+hypertension (PIH), and preeclampsia [7]. In particular,
+maternal stress is strongly linked to many hypertension-
+related complications of pregnancy [8]. However, it is now
+documented that PIH and related complications can be
+reversed [9].
+Stress can affect maternal immunity adversely [10],
+contribute to reduced placental perfusion [11], and nega-
+tively impact the pregnancy outcome [12]. In addition,
+A. Rakhshani (&)  S. Maharana  N. Raghuram 
+H. R. Nagendra  P. Venkatram
+SVYASA University, Bangalore, India
+e-mail: [email protected]
+123
+Qual Life Res (2010) 19:1447–1455
+DOI 10.1007/s11136-010-9709-2
+pregnancy itself represents a time of significant physical,
+emotional, and psychological stress for the mother [13],
+which has been shown to take away from her overall
+quality of life and alter her ability to cope with her
+expected role [14]. In fact, social relationships have been
+shown to have a direct impact on our physical health and
+psychological well-being [15] and that these influences are
+not just spurious findings attributable to our personalities
+[16]. Therefore, it is important to take into consideration
+the social and interpersonal relationships of women when
+directing treatment during pregnancy.
+It is now well documented that yoga and meditation help
+in stress reduction [17–19]. Furthermore, yoga has been
+shown to improve not only the quality of life of healthy
+subjects [20] but also patients suffering from variety of
+ailments, including pulmonary disorders [21], cardiovas-
+cular dysfunctions [22], cancer [23], diabetes [24], rheu-
+matoid arthritis [25], menopause [26], and schizophrenia
+[27].
+The purpose of this study was to assess the effect of
+yoga in improving quality of life as well as the sources of
+tension, incompatibility, and dissatisfaction in women
+during their normal pregnancy that could potentially affect
+their interpersonal relationships.
+Materials and methods
+Subjects
+Two hundred and twenty normal pregnant women at
+18–20 weeks of gestation between 20 and 35 years of age
+were interviewed at antenatal clinics in south of Bangalore,
+India. One hundred and fifty of these women met the entry
+criteria for the study and only 111 agreed to sign the
+informed consent form. These 111 selected subjects were
+randomly assigned to yoga and control groups (n = 56 and
+n = 55, respectively) using a computerized random gen-
+erator number. During the course of the study five subjects
+dropped out of the yoga group and four dropped out
+of control (mostly due to relocation), leaving 51 subjects
+in each group for data analysis. Our power analysis
+(alpha = 0.05, power = 0.8, effect size = 0.54) had yiel-
+ded 44 subjects per group.
+The recruitment criteria aimed at normal pregnancies that
+were either primigravida or multigravida with at least one
+living child. High-risk pregnancy conditions that would
+heighten the stress adaptation responses during pregnancy
+were avoided. These exclusion criteria incorporated: (a)
+medical conditions that could potentially lead to pregnancy
+complications (such as diabetes or hypertension), (b) mul-
+tiple pregnancy, (c) IVF pregnancy, (d) previous history
+of
+IUGR,
+preeclampsia,
+or
+other
+severe
+pregnancy
+complications, (e) maternal structural abnormalities, (f)
+multigravida, (g) fetal abnormality on ultrasound scanning,
+and (h) previous exposure to yoga.
+Signed informed consent was obtained from all subjects
+before randomization and the project had received clear-
+ance from the ethical committee of SVYASA University
+prior to recruitment of the subjects.
+Design
+The study had adopted a prospective two-armed random-
+ized parallel controlled design with supervised practices for
+both groups from the time of recruitment until delivery.
+Assessments were obtained at baseline (18–20 weeks
+gestation) and at 36 weeks gestation. The yoga group
+practiced specific set of integrated yoga while the control
+group practiced standard antenatal exercises (both set of
+practices are listed in Table 1). Subjects in both groups
+received 1-h sessions from trained instructors 3 days per
+week (yoga classes were held on Monday, Wednesday, and
+Fridays while antenatal sessions were on Tuesday, Thurs-
+day, and Saturday) for the first month. All instructors were
+trained at SVYASA University in Bangalore, India.
+Thereafter, they continued their respective practices at
+home using a pre-recorded cassette until delivery. Addi-
+tionally, every time the subjects of each group came to the
+hospital for their regular antenatal check up, they received
+a refresher class of 1-h duration. The frequency and dura-
+tion of the daily practices of subjects at home were mon-
+itored closely by research staff through an ‘exercise diary’
+that was maintained by the subjects in each group. The
+follow-ups were through phone and in person when sub-
+jects visited the hospital. No incentives were given to the
+subjects for attending the classes.
+Due to the nature of the study, blinding was not a pos-
+sibility. However, all efforts were made to mask the staff
+whenever possible. The team who did the assessments was
+not involved in administering the intervention. The statis-
+tician who did the randomization and analysis was blind to
+the source of the data. Care was taken to avoid interaction
+and exchange of techniques between participants of the two
+groups by staggering the timings and venue of the classes
+for the two groups.
+Interventions
+Integrated approach of yoga
+Detailed information about yoga and its mechanism of
+action as a mind–body medicine from the yogic point of view
+can be found in many books including one by Nagendra and
+Nagarathna [28]. Briefly, integrated approach of yoga (IAY)
+is a holistic approach to well-being at physical, emotional,
+1448
+Qual Life Res (2010) 19:1447–1455
+123
+mental, and spiritual levels. It is designed to reduce chronic
+psychological stress that, from the yogic point of view, is the
+root causes of psychosomatic ailments [28].
+Practice modules
+The practices of IAY used in this study were selected
+carefully by the investigators for normal pregnancy. This
+means that certain yogic practices that are not advisable for
+pregnant women (such as postures that can put too much
+pressure on the uterus) were omitted. The practices for the
+control group involved simple stretches approved by the
+Executive Council of the society of Obstetrician and
+Gynecologists of Canada, and by the board of directors of
+the Canadian society for exercise physiology. The control
+exercises were followed by supine rest. Table 1 lists the
+Table 1 Interventions for the yoga and control groups
+Yoga group practices
+2nd
+trimester
+3rd
+trimester
+Control group practices
+2nd
+trimester
+3rd
+trimester
+Lecture topics
+15 min
+10 min
+Lecture topics
+15 min
+10 min
+Pregnancy is physiological, child birth, yogic
+concepts of healthy life style, and yogic
+management of stress including diet, daily
+activities, thinking, feeling and behavior
+Yes
+Yes
+Pregnancy is physiological, child birth, modern
+scientific concepts of healthy life style, and
+modern management of stress including diet,
+daily activities, thinking, feeling and behavior.
+Yes
+Yes
+Breathing exercises
+10 min
+5 min
+Loosening exercises
+10 min
+5 min
+Hasta a
+¯ya
+¯ma s
+´vasanam (Hands in and out
+breathing)
+Yes
+Yes
+Twisting
+Yes
+Yes
+Hasta vista
+¯ra s
+´vasanam (Hands stretch
+breathing)
+Yes
+Yes
+Forward and backward bend
+Yes
+No
+Gulpha vista
+¯ra s
+´vasanam (Ankle stretch
+breathing)
+Yes
+No
+Side bending
+Yes
+Yes
+Vya
+¯ghra s
+´vasanam (Tiger breathing)
+Yes
+Yes
+Calf-raise
+Yes
+Yes
+Setu bandha s
+´vasanam (Bridge posture
+breathing)
+Yes
+No
+Hamstring stretch
+Yes
+Yes
+Lat pulls-up and down
+Yes
+No
+Calf extension
+Yes
+No
+Hip abduction
+No
+Yes
+Asanas
+15 min
+10 min
+Stretch exercises
+15 min
+10 min
+Tadasana (tree pose)
+Yes
+Yes
+Thigh stretch
+Yes
+Yes
+Ardhakati-chakrasana (Lateral Arc Pose)
+Yes
+Yes
+Push-up and Down
+Yes
+Yes
+Trikonasana (triangle pose)
+Yes
+Yes
+Pulls downs
+Yes
+No
+Vajrasana (The Ankle Posture)
+Yes
+Yes
+Low-back lift
+Yes
+No
+Vakrasana (spine twist pose)
+Yes
+No
+Inner thigh stretch
+Yes
+Yes
+Siddhasana (sage pose)
+No
+Yes
+Calf stretch
+Yes
+Yes
+BaddhaKonasana (Bound Ankle Pose)
+No
+Yes
+Dips
+Yes
+No
+UpavistaKonasana (sit with legs apart)
+No
+Yes
+Squatting
+No
+Yes
+Squatting (Garland pose)
+No
+Yes
+Hip abduction
+Yes
+Yes
+Viparita karani (half shoulder stand)
+Yes
+No
+Shoulder-chest stretch
+Yes
+Yes
+ardha-pavanamuktasana (folded leg lumbar
+stretch)
+Yes
+Yes
+Neck and upper back stretch
+Yes
+Yes
+Seated rowing
+Yes
+Yes
+Oblique curis
+Yes
+Yes
+Kick backs
+Yes
+Yes
+Pelvic floor exercise
+Yes
+Yes
+Pelvic Tilt
+Yes
+Yes
+Pranayama and meditation
+10 min
+20 min
+Supine rest
+10 min
+20 min
+Sectional breathing, nadishiddhi, Sheetali,
+bharamari, Nadanusandhana, Om meditation
+Yes
+Yes
+Slow walking
+10 min
+20 min
+DRT (Deep relaxation technique)
+10 min
+15 min
+Supine rest
+10 min
+15 min
+Qual Life Res (2010) 19:1447–1455
+1449
+123
+practices for each group in greater detail. All subjects had
+sufficient understanding of English language and instruc-
+tions for both groups were given in English. There was no
+need to use any props, chairs, or wall support to practice
+the yoga poses. However, women sat in Siddhasana instead
+of Vajrasana in their third trimester.
+Instruments
+WHOQOL-100 instrument
+World Health Organization Quality of Life assessment
+instrument (WHOQOL-100) is a generic, client-completed
+measure of health-related quality of life that was simulta-
+neously developed in 15 sites worldwide [29]. It is focused
+around the definition of quality of life advocated by the
+World Health Organization which includes the culture
+and context which influence an individual’s perception
+of health [29]. It consists of six domains (physical
+health, psychological health, level of independence, social
+relationships,
+environment,
+spirituality/religion/personal
+beliefs) and 24 facets, each consisting of four items, dis-
+tributed across domains plus a general facet (overall quality
+of life and general health) [30]. Items are scaled on five-
+point Likert scale and scoring is available for domain,
+facet, and overall—with higher scores indicating higher
+quality of life [30]. The WHOQOL-100 instrument is
+widely used to compare the QOL of different populations.
+Its growing popularity is in part due to the substantial
+evidence that the questionnaire is sensitive and responsive
+to important changes in the physical and emotional
+domains of QOL [31].
+FIRO-B instrument
+Fundamental Interpersonal Relations Orientation (FIRO) is
+a theory of interpersonal relations, introduced by William
+Schutz in 1958 [32]. Schutz in this theory formulated three
+dimensions of interpersonal relations, which he believed
+were necessary and sufficient to explain most human inter-
+actions [32]. He named these dimensions as: Inclusion,
+Control and Affection [32]. Within these spaces, the level of
+interaction an individual wants can be measured in the areas
+of socializing, leadership and responsibilities, and more
+intimate personal relations [33]. FIRO-B scores are graded
+from 0 to 9 in scales of expressed and wanted behavior,
+which define how much a person expresses to others, and
+how much he wants from others [33]. Therefore, the stan-
+dard FIRO-B questionnaire consists of six different spheres:
+Expressed Inclusion (EI), Wanted Inclusion (WI), Expres-
+sed Control (EC), Wanted Control (WC), Expressed
+Affection (EA), and Wanted Affection (WA). Historically,
+FIRO-B is used in the corporate environment to determine
+leadership style and to identify team building and personal
+development requirements. However, to do so, the instru-
+ment tries to identify the sources of tension, incompatibility,
+and dissatisfaction. In the study, we wanted to know how
+yoga can contribute to the improvement of these factors in
+the stressful period of pregnancy.
+Data collection and analysis
+Statistical software SPSS version 16.0.1 was used for all
+data analysis. Test of normality (Kolmogorov–Smirnov)
+was performed on the data of each domain for both
+instruments. When the data was found not to be normal
+(P \ 0.05), the non-parametric Mann–Whitney test was
+used for comparison between groups and Wilcoxon’s
+signed rank’s test for within groups. We used paired t-test
+for within groups and Independent Sample t-test for
+between groups for analyzing the data that was normally
+distributed. Chi-squared test and Independent Samples
+t-tests were used for baseline comparisons of the two
+groups.
+Results
+Table 2 shows the demographic data of the subjects in both
+groups. All baseline maternal characteristics were matched
+between the two groups and there were no statistically
+significant differences between them except for profession.
+WHOQOL-100 test
+This study compared the mean test and retest scores for each
+domain of WHOQOL-100 instrument. Table 3 shows the
+results on all domains of WHOQOL-100 instrument.
+There were significant differences between groups with
+higher improvements in yoga than the control group in the
+Physical (P \ 0.01, Mann–Whitney test, effect size =
+0.48), Psychological (P \ 0.01, Independent Sample t-test,
+effect size = 0.65), Social Relationships (P \ 0.01, Inde-
+pendent Sample t-test, effect size = 0.65), and the General
+Health
+(P \ 0.01
+Independent
+Sample
+t-test,
+effect
+size = 0.65) domains.
+FIRO-B test
+We compared the mean pre-interventions and post-inter-
+ventions scores for each domain of FIRO-B questionnaire.
+The between groups statistical analysis showed signifi-
+cance in ‘‘Expressed Inclusion’’ (P = 0.02, Independent
+Sample t-test) and ‘‘Wanted Control’’ (P = 0.009, Mann–
+Whitney test) domains. However, within group analysis
+showed significant improvements in all domains for the
+1450
+Qual Life Res (2010) 19:1447–1455
+123
+yoga group (Expressed Inclusion: P = 0.038, Wanted
+Inclusion:
+P = 0.001,
+Expressed
+Control:
+P = 0.013,
+Wanted Control: P = 0.01, Expressed Affection: P =
+0.007, Wanted Affection: P = 0.001) while no significant
+improvement in any domain for the control group. Table 4
+outlines our results. Large effect sizes in each of the
+domains of the yoga group are notable.
+Discussion
+This prospective two-armed randomized controlled study
+of 102 normotensive pregnant women compared the qual-
+ity of life and interpersonal relationships of normal preg-
+nant women who received integrated yoga interventions
+from the twentieth week of gestation until 36 weeks ges-
+tation to those who received standard antenatal practices
+during the same period. Our study has shown that inte-
+grated yoga interventions can significantly improve the
+quality of life of pregnant women in the physical, psy-
+chological, social, and general health domains using
+WHOQOL-100 instrument. In the Independence domain,
+our results were just above the borderline (P = 0.065).
+Overall, the effect sizes for the IAY interventions used
+in the yoga group were significantly higher than those used
+in the control group, except for the spiritual domain that the
+control group scored higher (P: 0.27 control vs. 0.12 yoga).
+Aside from the general health quality, the largest effect size
+among the six domains of WHOQOL-100 in the yoga
+group was of the psychological domain (0.65) followed by
+social relationships (0.59), physical (0.48), and environ-
+mental (0.48) domains. Our results are consistent with
+previous studies that have used WHOQOL instrument in
+evaluating the quality of life of patients with various ail-
+ments using yoga interventions [34–36].
+In the FIRO-B instrument, our within groups’ analysis
+showed significant improvements in each domain (EI:
+P = 0.038; WI: P \ 0.001; EC: P = 0.013; WC: P =
+0.01; EA: P = 0.007; WA: P = 0.001) for the yoga group
+and no statistically significant improvements for the control
+group. The between groups’ analysis showed statistically
+significant improvements in the Expressed Inclusion and
+Wanted Control. A quick glance of the pre-interventions
+means for the subjects in both groups (listed in Table 4)
+shows that the scores are all low to moderate across the
+board. To understand the significance of this, we must
+review Schutz’s own classifications of the scores. He
+identified individuals based on their scores in each of the
+FIRO-B domains into the following nine categories [32]:
+I.
+Inclusion types
+a.
+The under-social (low EI, low WI)
+b.
+The over-social (high EI, high WI)
+c.
+The social (moderate EI, moderate WI)
+II.
+Control types
+a.
+The under-controller or abdicrat (low EC, high
+WC)
+b.
+The over-controller or autocrat (high EC, low
+WC)
+c.
+The democrat (moderate EC, moderate WC)
+III.
+Affection types
+a.
+The under-personal (low EA, low WA)
+b.
+The over-personal (high EA, high WA)
+c.
+The personal (moderate EA moderate WA)
+Using Schutz’s above classification, our subjects in this
+study could be described as generally under-social, under-
+control, and under-personal. The nature of our subjects
+could have a direct impact on our results. In fact, Schutz
+himself warned that many factors, including cultural
+influences, could affect these scores. To our knowledge,
+there has not been a large cohort study that can provide the
+normative values for FIRO-B instrument among normal
+pregnant Indian women. But if our data is any indication,
+Table 2 Demographic data on the subjects
+Variables
+Yoga (n = 51)
+Control (n = 51)
+P-values
+Age
+26.23 ± 2.98
+25.47 ± 2.87
+0.50*
+Height (cms)
+63.58 ± 1.96
+62.98 ± 2.04
+0.13*
+Weight (kg)
+Pre
+63.45 ± 10.06
+62.90 ± 8.82
+0.77*
+Post
+72.30 ± 10.37
+71.65 ± 9.05
+0.74*
+BMI
+Pre
+25.07 ± 3.45
+25.45 ± 3.85
+0.60*
+Post
+28.55 ± 3.53
+28.89 ± 3.76
+0.64*
+BP (Sys)
+Pre
+114.53 ± 14.62
+115.88 ± 7.87
+0.57*
+Post
+116.60 ± 10.18
+110.16 ± 0.04
+0.40*
+BP (Dia)
+Pre
+73.57 ± 5.54
+73.22 ± 6.36
+0.77*
+Post
+74.68 ± 5.31
+75.94 ± 6.37
+0.28*
+Gravida
+G1
+45 (88.24%)
+43 (84.31%)
+0.77^
+G2
+6 (11.76%)
+8 (15.69%)
+Profession
+W
+33 (64.71%)
+21 (38.18%)
+0.03^
+HW
+18 (35.29%)
+30 (58.82%)
+BP blood pressure (sys-systolic and dia-diastolic), BMI body mass
+index, G1 prime, G2 Gravida 2, HW house wife, W working
+P-values were calculated using: ^Chi-Square; *Independent Samples
+t-tests
+There were no significant differences between groups on any of
+maternal characteristics except in the profession
+Qual Life Res (2010) 19:1447–1455
+1451
+123
+the values would be expected to be lower than those of
+similar population in the western countries.
+As mentioned above, we found statistical significance in
+the Expressed Inclusion and Wanted Control domains and
+near significance in the Wanted Affection domain in the
+yoga group when compared to the control. In other words,
+compared to non-yoga group, the integrated yoga interven-
+tions helped the subjects in developing a sense of belonging,
+wanting more influence on their environment, and desiring
+more warmth and closeness. One might wonder if these
+could be considered improvements to the subjects’ inter-
+personal relationships. For example, if a subject wants more
+influence on her environment but cannot get it, would not
+that add to her frustrations? Of course, it could if she totally
+fails in gaining any control. However, the chances are that
+she will gain a certain degree of control on her environment
+and that would be an improvement.
+We also used paired sample test to compare the means
+within groups. The yoga interventions showed statistically
+significant improvements in all domains: EI (P = 0.038),
+WI (P \ 0.001), EC (P = 0.01), WC (P = 0.013), EA
+(P = 0.007),
+and
+WA
+(P = 0.001). In
+contrast,
+the
+improvements of the control interventions were not statis-
+tically significant in any of the FIRO-B spheres.
+Finally, we obtained bivariate Pearson correlations
+between the domains of WHOQOL-100 and FIRO-B
+instruments. The correlations were low and statistically
+insignificant. However, this does not mean that there is no
+relationship between the two instruments. A more plausible
+explanation would be that our study was not large enough to
+find such correlations. After all, it would be logical to think
+that individuals feeling less control over their environment or
+those who perceive less affection from their environment
+could be more prone to have a lower quality of life than
+Table 3 Results of the
+WHOQOL-100 test after
+intervention in both groups
+Statistically significant P-values
+are shown in bold
+a Independent Sample t-test
+b Mann–Whitney test
+c Paired samples test
+Domain
+Groups
+Between groups
+P-values
+Mean ± standard deviation [95% confidence interval]
+Yoga
+Control
+Physical (n = 51)
+Pre
+14.55 ± 2.4 [13.88–15.22]
+14.27 ± 2.32 [13.62–14.92]
+0.001b
+Post
+15.79 ± 2.77 [15–16.57]
+14.12 ± 2.14 [13.51–14.72]
+Effect size
+0.48
+0.07
+Psychological (n = 51)
+Pre
+14.6 ± 2.42 [13.92–15.28]
+14.5 ± 1.83 [13.98–15.01]
+0.001a
+Post
+16.08 ± 2.12 [15–16.57]
+14.7 ± 1.63 [14.24–15.17]
+Effect size
+0.65
+0.12
+Independence (n = 51)
+Pre
+15.44 ± 2.31 [14.79–16.08]
+14.94 ± 2.14 [14.34–15.54]
+0.065a
+Post
+15.91 ± 2.2 [15.29–16.53]
+15.01 ± 2.1 [15.01 ± 2.1]
+Effect size
+0.21
+0.03
+Social relationships (n = 51)
+Pre
+15.58 ± 2.46 [14.89–16.27]
+15.11 ± 2.76 [14.34–15.89]
+0.003a
+Post
+16.88 ± 1.91 [16.34–17.42]
+15.67 ± 2.09 [15.08–16.26]
+Effect size
+0.59
+0.23
+Environment (n = 51)
+Pre
+15.32 ± 1.86 [14.8–15.85]
+14.93 ± 2.49 [14.23–15.63]
+0.001b
+Post
+16.25 ± 2 [15.69–16.82]
+15 ± 1.69 [14.52–15.47]
+Effect size
+0.48
+0.03
+Spiritual (n = 51)
+Pre
+15.73 ± 2.48 [15.03–16.42]
+14.71 ± 2.44 [14.02–15.39]
+0.23b
+Post
+16.02 ± 2.42 [15.34–16.70]
+15.41 ± 2.67 [14.66–16.16]
+Effect size
+0.12
+0.27
+General health quality (n = 51)
+Pre
+15.76 ± 2.84 [14.97–16.56]
+14.98 ± 1.94 [14.43–15.53]
+0.001b
+Post
+17.08 ± 2.31 [16.43–17.73]
+15.35 ± 2.51 [14.65–16.06]
+Effect size
+0.51
+0.17
+1452
+Qual Life Res (2010) 19:1447–1455
+123
+otherwise. But this has to be proven by a larger multi-center
+study.
+Our data demonstrates that QOL of pregnant women can
+be substantially improved after 16 weeks of integrated
+yoga practices. These results reaffirm that on most
+dimensions, changes in the scores of WHOQOL-100 are
+responsive to behavioral, emotional, and physical change
+over time. Our results are in-line with other studies that
+have used yoga to improve quality of life of patients with
+other ailments using WHOQOL instrument [35, 36]. Even
+in healthy non-pregnant subjects, yoga has shown to
+improve the quality of life [27]. Oken et al. used the SF-36
+instrument to assess health-related quality-of-life of heal-
+thy seniors using yoga interventions [27]. Their results
+demonstrated a significant yoga assignment group effect on
+vitality/energy
+and
+fatigue
+(P = 0.006),
+role-physical
+(P = 0.001), bodily pain (P = 0.006), social functioning
+(P = 0.015), and the physical composite scale (P = 0.005)
+[27]. While it is not possible to compare the different
+components of SF-36 and WHOQOL-100 instruments
+directly, it is meaningful to observe the closeness of the
+results in the pregnant and non-pregnant population.
+Strength of this study
+This study has several prominent features: (1) both study
+and control groups received supervised training, (2) the
+groups were matched at baseline for maternal characteris-
+tics, (3) the sample size was sufficiently large to reduce the
+possibility of type 1 and type 2 errors. We used the data
+from 51 subjects in each group for our data analysis.
+Qualified instructors for both yoga and control interven-
+tions were used throughout the 16 weeks study. Further-
+more, this is the first study that we are aware of that has
+focused on improving and assessing the quality of life of
+women during pregnancy using yoga. The WHOQOL-100
+and FIRO-B instruments are widely used and their reli-
+ability has been well-documented globally and within dif-
+ferent socioeconomic populations. We were not able to find
+the exact reliability and validity of these two instruments
+for the Indian population; however, the internal reliability
+of WHOQOL (as measured by Cronbach alpha) has been
+shown to range from 0.65 to 0.93 globally.
+We believe the results obtained in this study can be used
+effectively with future projects as the foundation for
+Table 4 Results from the FIRO-B test
+Domain
+Measurements in
+time and effect sizes
+Groups
+Pre-post
+P-values
+Mean ± standard deviation [95% confidence interval]
+Yoga
+Control
+Expressed Inclusion (EI)
+Pre
+5.24 ± 2.17 [4.64–5.87]
+5.18 ± 2.06 [4.6–5.75]
+0.02a
+Post
+5.84 ± 2.09 [5.24–6.43]
+4.88 ± 2.07 [4.3–5.46]
+Effect size
+0.29
+0.15
+Wanted Inclusion (WI)
+Pre
+2.47 ± 2.46 [1.78–3.16]
+2.25 ± 2.82 [1.46–3.05]
+0.07b
+Post
+1.29 ± 1.91 [0.76–1.83]
+2.16 ± 2.56 [1.44–2.88]
+Effect size
+0.54
+0.03
+Expressed Control (EC)
+Pre
+2.61 ± 1.98 [2.05–3.16]
+3.16 ± 2.77 [2.38–3.94]
+0.3b
+Post
+3.43 ± 2.06 [2.85–4.01]
+3.12 ± 2.71 [2.36–3.88]
+Effect size
+0.41
+0.02
+Wanted Control (WC)
+Pre
+3.37 ± 2.17 [2.76–3.98]
+3.94 ± 2.56 [3.22–4.66]
+0.009b
+Post
+2.41 ± 2.39 [1.74–3.08]
+3.69 ± 2.6 [2.95–4.42]
+Effect size
+0.42
+0.1
+Expressed Affection (EA)
+Pre
+2.67 ± 2.31 [2.02–3.32]
+3.06 ± 2.03 [2.49–3.63]
+0.29b
+Post
+3.61 ± 2.26 [2.97–4.24]
+3.10 ± 1.81 [2.59–3.61]
+Effect size
+0.41
+0.02
+Wanted Affection (WA)
+Pre
+3.1 ± 2.3 [2.45–3.74]
+2.84 ± 2.1 [2.25–3.43]
+0.057b
+Post
+2.12 ± 1.98 [1.56–2.67]
+2.76 ± 1.98 [2.21–3.32]
+Effect size
+0.46
+0.04
+Statistically significant P-values are shown in bold
+a Independent Sample t-test
+b Mann–Whitney test
+c Paired samples test
+Qual Life Res (2010) 19:1447–1455
+1453
+123
+improving the quality of life of women at such a special
+and crucial period of their lives.
+Limitations
+This study excluded high-risk pregnancies. Among these
+risk factors were women with hypertension and diabetes,
+which are quite prevalent in India. That could raise the
+question that whether the results of this study would apply
+to the general population. A larger sample size could have
+produced a different result, particularly in the FIRO-B data.
+Suggestions for future direction
+Future
+larger
+multi-center
+studies
+with
+interventions
+beginning at earlier gestational age (or even prior to
+pregnancy) are needed to establish the exact role that
+integrated yoga practices can play in improving the inter-
+personal relationships of pregnant women. Large cross-
+cultural cohort studies using FIRO-B and WHOQOL-100
+instruments would offer normative data for these instru-
+ments. Finally, it would be interesting to see if similar
+results could be obtained from a study targeting high-risk
+pregnancy population.
+Applications of this study
+The stressful lifestyle of modern women superimposed on
+the challenges that pregnancy imposes on the mothers can
+be too much to cope with. Many women turn to medica-
+tions for help, which can compromise the health of their
+pregnancy. Yoga is non-invasive, economical, and easy to
+learn solution to improve the quality of life of pregnant
+women, improve their abilities to perform their social roles,
+and potentially prevent adverse obstetrics outcome. Preg-
+nancy is a very special time in a woman’s life. Yoga can
+give her the opportunity and the tools to enjoy this
+miraculous period to the fullest.
+Conclusion
+This prospective randomized controlled trial was able to
+show that integrated yoga practices can be used effectively
+to improve the quality of life of pregnant women who are
+distressed by the overwhelming physiological, psycholog-
+ical, and emotional changes of pregnancy. We were also
+able to show that yoga interventions as well as other simple
+exercises could have a certain level of impact on the
+interpersonal relationships of the pregnant women.
+Acknowledgments
+We acknowledge with deep gratitude the efforts
+made by the staff members of Maiya Hospital and SVYASA Uni-
+versity who facilitated this study. We particularly appreciate Dr. Ravi
+Kulkarni’s guidance during the data analysis and Mrs. Sushama
+Kirtikar’s assistance in proof reading the article. This project was
+institutionally funded by the SVYASA University of yogic sciences
+based in Bangalore, India.
+References
+1. Larson, J. S. (2006). The World Health Organization’s definition
+of health: Social versus spiritual health. Social Indicators
+Research, 38, 181–192.
+2. World Health Organization. (1948). Preamble to the constitution
+of the World Health Organization. Geneva: WHO.
+3. Symon, A. (2003). A review of mothers’ prenatal and postnatal
+quality of life. Health Qual Life Outcomes, 1, 38.
+4. Tamashiro, K. L., et al. (2007). Dynamic body weight and body
+composition changes in response to subordination stress. Physi-
+ology & Behavior, 91, 440–448.
+5. Zahran, H. S., Kobau, R., Moriarty, D. G., Zack, M. M., Holt, J.,
+& Donehoo, R. (2005). Health-related quality of life surveil-
+lance—United States, 1993–2002. MMWR Surveill Summ, 54,
+1–35.
+6. Gheorghe, C. P., Goyal, R., Mittal, A., & Longo, L. D. (2010).
+Gene expression in the placenta: Maternal stress and epigenetic
+responses. International Journal of Developmental Biology, 54,
+507–523.
+7. Cindrova-Davies, T. (2009). Gabor than award lecture 2008: Pre-
+eclampsia—from placental oxidative stress to maternal endothe-
+lial dysfunction. Placenta, 30(Suppl A), S55–S65.
+8. Higgins, J. R., Walshe, J. J., Conroy, R. M., & Darling, M. R.
+(2002). The relation between maternal work, ambulatory blood
+pressure and pregnancy hypertension. Journal of Epidemiology
+and Community Health, 56, 389–393.
+9. Marcoux, S., Brisson, J., & Fabia, J. (1989). The effect of leisure
+time physical activity on the risk of pre-eclampsia and gestational
+hypertension. Journal of Epidemiology and Community Health,
+43, 147–152.
+10. Coussons-Read, M. E., Okun, M. L., & Simms, B. S. (2003). The
+psychoneuroimmunology of pregnancy. Journal of Reproductive
+and Infant Psychology, 21, 103–112.
+11. Weissgerber, T. L., Wolfe, L. A., & Davies, G. A. (2004). The
+role of regular physical activity in preeclampsia prevention.
+Medicine and Science in Sports and Exercise, 36, 2024–2031.
+12. Armour, B., Pitts, M.M. & Walker, M.B. (2007) Maternal job
+stress and birth outcomes. Social Science Research Network
+Working Paper Series, 09–29.
+13. Da Costa, D., Larouche, J., Dritsa, M., & Brender, W. (1999).
+Variations in stress levels over the course of pregnancy: Factors
+associated with elevated hassles state anxiety and pregnancy—
+specific stress. Journal of Psychosomatic Research, 47, 609–621.
+14. Gjerdingen, D. K., Froberg, D. G., & Fontaine, P. (1991). The
+effects of social support on women’s health during pregnancy,
+labor and delivery and the postpartum period. Family Medicine,
+23, 370–375.
+15. House, J. S., Landis, K. R., & Umberson, D. (1988). Social
+relationships and health. Science, 241, 540–545.
+16. Cohen, S. (2004). Social relationships and health. American
+Psychologist, 59, 676–684.
+17. Parshad, O. (2004). Role of yoga in stress management. West
+Indian Medical Journal, 53, 191–194.
+18. Michalsen, A., Grossman, P., Acil, A., Langhorst, J., Ludtke, R.,
+Esch, T., et al. (2005). Rapid stress reduction and anxiolysis among
+distressed women as a consequence of a three-month intensive
+yoga program. Medical Science Monitor, 11, 555–561.
+1454
+Qual Life Res (2010) 19:1447–1455
+123
+19. Berger, B. G., & Owen, D. R. (1988). Stress reduction and mood
+enhancement in four exercise modes: Swimming, body condi-
+tioning, hatha yoga and fencing. Research Quarterly for Exercise
+and Sport, 59(2), 148–159.
+20. Oken, B. S., et al. (2006). Randomized, controlled six-month trial
+of yoga in healthy seniors: Effects on cognition and quality of
+life. Altern Ther Health Med, 12, 40–47.
+21. Donesky-Cuenco, D., Nguyen, H. Q., Paul, S., & Carrieri-Kohl-
+man, V. (2009). Yoga therapy decreases dyspnea-related distress
+and improves functional performance in people with chronic
+obstructive pulmonary disease: A pilot study. J Altern Comple-
+ment Med, 15, 225–234.
+22. Pullen, P. R., et al. (2008). Effects of yoga on inflammation and
+exercise capacity in patients with chronic heart failure. J Card
+Fail, 14, 407–413.
+23. Moadel, A. B., et al. (2007). Randomized controlled trial of yoga
+among a multiethnic sample of breast cancer patients: Effects on
+quality of life. Journal of Clinical Oncology, 25, 4387–4395.
+24. Skoro-Kondza, L., Tai, S. S., Gadelrab, R., Drincevic, D., &
+Greenhalgh, T. (2009). Community based yoga classes for type 2
+diabetes: An exploratory randomised controlled trial. BMC
+Health Serv Res, 9, 33.
+25. Badsha, H., Chhabra, V., Leibman, C., Mofti, A., & Kong, K. O.
+(2009). The benefits of yoga for rheumatoid arthritis: Results of a
+preliminary, structured 8-week program. Rheumatology Interna-
+tional, 29(12), 1417–1421.
+26. Mastrangelo, M. A., Galantino, M. L., & House, L. (2007).
+Effects of yoga on quality of life and flexibility in menopausal
+women: A case series. Explore (NY), 3, 42–45.
+27. Duraiswamy, G., Thirthalli, J., Nagendra, H. R., & Gangadhar, B.
+N. (2007). Yoga therapy as an add-on treatment in the management
+of patients with schizophrenia—A randomized controlled trial.
+Acta Psychiatrica Scandinavica, 116, 226–232.
+28. Nagendra, H. R., & Nagarathna, R. (1993). Therapeutic appli-
+cations of an integrated approach of yoga therapy. Health
+Administrator, 4, 52–55.
+29. WHOQOL Group. (1995). Field trial WHOQOL-100. February
+1995: Facet definitions and questions. WHO: Geneva (MNH/
+PSF/95.1.B).
+30. De Vire, J., & Van Heck, G. L. (1997). The World Health
+Organization Quality of Life assessment instrument (WHOQOL-
+100): Validation study with the Dutch version. European Journal
+of Psychological Assessment;, 13(3), 164–178.
+31. Bonomi, A. E., Patrick, D. L., Bushnell, D. M., & Martin, M.
+(2000). Validation of the United States’ version of the World
+Health Organization Quality of Life (WHOQOL) instrument.
+Journal of Clinical Epidemiology, 53, 1–12.
+32. Schutz, W. C. (1958). FIRO: A three dimensional theory of
+interpersonal behavior. New York, NY: Holt, Rinehart & Winston.
+33. Ryan, L. R. (1977). Clinical interpretation of the FIRO-B. Palo
+Alto, CA: Consulting Psychologists.
+34. Lundgren, T., Dahl, J., Yardi, N., & Melin, L. (2008). Acceptance
+and commitment therapy and yoga for drug-refractory epilepsy: A
+randomized controlled trial. Epilepsy & Behavior, 13, 102–108.
+35. Lundgren, T., Dahl, J., Yardi, N., & Melin, L. (2008). Acceptance
+and commitment therapy and yoga for drug-refractory epilepsy:
+A randomized
+controlled
+trial. Epilepsy & Behavior, 13,
+102–108.
+36. Duraiswamy, G., Thirthalli, J., Nagendra, H. R., & Gangadhar, B.
+N. (2007). Yoga therapy as an add-on treatment in the manage-
+ment of patients with schizophrenia—A randomized controlled
+trial. Acta Psychiatrica Scandinavica, 116, 226–232.
+Qual Life Res (2010) 19:1447–1455
+1455
+123

subfolder_0/Effects of yoga program on quality of life and affect the early breast cancer.txt

@@ -0,0 +1,898 @@
+This article appeared in a journal published by Elsevier. The attached
+copy is furnished to the author for internal non-commercial research
+and education use, including for instruction at the authors institution
+and sharing with colleagues.
+Other uses, including reproduction and distribution, or selling or
+licensing copies, or posting to personal, institutional or third party
+websites are prohibited.
+In most cases authors are permitted to post their version of the
+article (e.g. in Word or Tex form) to their personal website or
+institutional repository. Authors requiring further information
+regarding Elsevier’s archiving and manuscript policies are
+encouraged to visit:
+http://www.elsevier.com/copyright
+Author's personal copy
+Complementary Therapies in Medicine (2009) 17, 274—280
+available at www.sciencedirect.com
+journal homepage: www.elsevierhealth.com/journals/ctim
+Effects of yoga program on quality of life and affect
+in early breast cancer patients undergoing adjuvant
+radiotherapy: A randomized controlled trial
+H.S. Vadiraja a, M. Raghavendra Rao b, Raghuram Nagarathna a,∗,
+H.R. Nagendra a, M. Rekha a, N. Vanitha a, K.S. Gopinath b,
+B.S. Srinath b, M.S. Vishweshwara c, Y.S. Madhavi c, B.S. Ajaikumar c,
+S. Ramesh Bilimagga b, Nalini Rao b
+a Department of Yoga Research, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, India
+b Departments of Complementary and Alternative Medicine, Surgical Oncology and Radiation Oncology, Bangalore Institute of
+Oncology, Bangalore, India
+c Department of Radiation Oncology, Bharath Hospital Institute of Oncology, Mysore, India
+Available online 28 October 2009
+KEYWORDS
+Yoga;
+Breast cancer;
+Meditation;
+Quality of life;
+Affect
+Summary
+Objectives: This study compares the effects of an integrated yoga program with brief supportive
+therapy in breast cancer outpatients undergoing adjuvant radiotherapy at a cancer centre.
+Methods: Eighty-eight stage II and III breast cancer outpatients were randomly assigned to
+receive yoga (n = 44) or brief supportive therapy (n = 44) prior to their radiotherapy treatment.
+Intervention consisted of yoga sessions lasting 60 min daily while the control group was imparted
+supportive therapy once in 10 days. Assessments included European Organization for Research
+in the Treatment of Cancer-Quality of Life (EORTCQoL C30) functional scales and Positive and
+Negative Affect Schedule (PANAS). Assessments were done at baseline and after 6 weeks of
+radiotherapy treatment.
+Results: An intention to treat GLM repeated measures ANOVA showed significant difference
+across groups over time for positive affect, negative affect and emotional function and social
+function. There was significant improvement in positive affect (ES = 0.59, p = 0.007, 95%CI 1.25
+to 7.8), emotional function (ES = 0.71, p = 0.001, 95%CI 6.45 to 25.33) and cognitive function
+(ES = 0.48, p = 0.03, 95%CI 1.2 to 18.5), and decrease in negative affect (ES = 0.84, p < 0.001,
+95%CI −13.4 to −4.4) in the yoga group as compared to controls. There was a significant positive
+correlation between positive affect with role function, social function and global quality of life.
+There was a significant negative correlation between negative affect with physical function,
+role function, emotional function and social function.
+ Sources of support: Central Council for Research in Yoga and Naturopathy, Ministry of Health and Family Welfare, Govt. of India.
+∗Corresponding author at: Division of Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, No-19, Eknath Bhavan,
+Gavipuram Circle, K.G. Nagar, Bangalore 560019, Karnataka, India.
+Tel.: +91 080 26507585; fax: +91 080 26608645.
+E-mail address: [email protected] (R. Nagarathna).
+0965-2299/$ — see front matter © 2009 Elsevier Ltd. All rights reserved.
+doi:10.1016/j.ctim.2009.06.004
+Author's personal copy
+Effects of yoga program
+275
+Conclusion: The results suggest a possible role for yoga to improve quality of life and affect in
+breast cancer outpatients.
+© 2009 Elsevier Ltd. All rights reserved.
+Introduction
+Quality of life is an important concern and outcome of
+cancer treatment. Several studies have documented that
+both diagnosis and treatment of breast cancer have an
+impact on quality of life.1,2 Further, there is evidence to
+suggest that decrements in quality of life are related to
+treatment related distress and psychological well being.2,3
+Various dimensions of quality of life such as physical,
+emotional, social, functional and spiritual well being are
+affected in both newly diagnosed and long-term survivors
+of breast cancer.2,4—6 However, growing evidence suggests
+that psychosocial and psycho-educational interventions are
+beneficial adjunctive treatments for cancer patients.7—11
+Patients who have used active behavioral coping meth-
+ods have reported positive affective states, decrease in
+anxiety and depression, higher levels of self-esteem and
+fewer physical symptoms while those with avoidance cop-
+ing showed greater depression, anxiety and lower quality
+of life.12 Similarly mind—body approaches such as prayer,
+meditation, affirmation, imagery and movement therapies
+have shown improvements in overall quality of life in cancer
+patients.13—15
+Yoga as a mind—body intervention is being practiced
+increasingly in both Indian and western populations. It is
+an ancient Indian science that has been used for thera-
+peutic benefits in numerous health care concerns where
+stress is believed to play a role.16 Beneficial effects have
+been seen on a variety of outcomes, including sleep quality,
+mood, stress, cancer-related distress, cancer-related symp-
+toms, and overall quality of life, as well as functional and
+physiological measures. These effects were similar across a
+number of different therapeutic approaches that employed
+postures, meditation breathing practices or a combination
+of all these.17 The results from these studies are bolstered by
+several randomized studies using yoga interventions in both
+healthy and chronically ill populations.18—20 Results from
+recent randomized controlled studies are mixed with one
+study showing improvement in various quality of life domains
+in breast cancer population at different stages of cancer
+treatment21 and the other showing no improvement in qual-
+ity of life domains.22 In both these studies adherence to
+intervention and contact time for yoga intervention was low
+compared to our earlier study that has shown decrements in
+anxiety states23; reduction in chemotherapy induced nau-
+sea and emesis24 and improved immune outcomes.25 In the
+former adherence seemed to be affected by radiotherapy
+treatment and distress and in the latter the intervention
+was based on a different form of yoga intervention known
+as Tibetan yoga.
+Overall effects following yoga or similar interventions
+have been attributed to an improvement in positive affect
+and decrease in negative affect.26—28 Patients on radiother-
+apy experience distressing side effects such as fatigue, skin
+changes, pulmonary symptoms during radiotherapy and anx-
+iety and depression before, during, and after radiotherapy.29
+Reducing treatment related distress and improving quality
+of life is known to improve adjustment later30 and manage
+related morbidity that accumulates over time.31 Moreover
+earlier study has shown radiotherapy to predict poorer
+adherence to yoga intervention.21
+We hypothesize that yoga intervention would help
+improve quality of life, improve positive affect and decrease
+negative affect in stage II and III breast cancer patients
+undergoing adjuvant radiotherapy.
+In this study, we compared the effects of a 6-week
+‘‘Integrated yoga program’’ with ‘‘Brief supportive ther-
+apy’’ as a control intervention in early operable breast
+cancer patients undergoing adjuvant radiotherapy.
+Methods
+Subjects
+This randomized control trial recruited 85 recently diag-
+nosed women with stage II and III breast cancer from two
+different urban cancer centres. All subjects had undergone
+primary treatment as surgery and were receiving adjuvant
+radiotherapy. Subjects in this study were recruited over a 2-
+year period from January 2004 to June 2006. Patients were
+eligible to participate in this study if they met the following
+selection criteria at the study start: (i) women with recently
+diagnosed operable breast cancer, (ii) age between 30 and
+70 years, (iii) Zubrod’s performance status 0—2 (ambulatory
+>50% of time), (iv) high school education and, (v) consent-
+ing to participate in the study. Subjects were excluded, (i) if
+they had any concurrent medical condition that was likely to
+interfere with the treatment, (ii) major psychiatric, neuro-
+logical illness or autoimmune disorders, and, (iii) any known
+metastases. Each study participant was prescribed adjuvant
+radiotherapy with a cumulative dose of 50.4 Gy with frac-
+tionations spread over 6 weeks. The details of the study were
+explained to the participants and their informed consent was
+obtained in writing.
+Randomization
+Of the 103 eligible participants 88 (85.4%) consented to
+participate and were randomized to receive yoga (n = 44)
+or supportive therapy (n = 44) initially before intervention
+(prior to radiotherapy) using computer generated ran-
+dom numbers. Randomization was performed using opaque
+envelopes with group assignments. Personnel who had no
+part in the trial performed randomization. The envelopes
+were opened sequentially in the order of assignment dur-
+ing recruitment, with the names and registration numbers
+of the participants written on the covers. The order of
+Author's personal copy
+276
+H.S. Vadiraja et al.
+randomization was verified with the hospital date of admis-
+sion records for radiation therapy at study intervals to make
+sure that field personnel had not altered the sequence of
+randomization to suit the allocation of consenting partici-
+pants into two study arms.
+Sample size
+Earlier study with Mindfulness Based Stress Reduction Pro-
+gram (MBSR) had shown a modest effect size (ES = 0.38) on
+EORTC QLC30 global quality of life measure.32 We used G
+power to calculate the sample size with ˛ = 0.05 and ˇ = 0.2
+and above effect size of 0.38 for repeated measures ANOVA
+between factor effects. The sample size thus required was
+n = 44 in each group.
+Among the 88 participants 75 (yoga n = 42; control n = 33)
+completed their prescribed radiation therapy of 6 weeks
+and follow-up assessment. There were 13 dropouts in the
+study (see trial profile, Fig. 1). The reasons for dropouts
+were migration to other hospitals (n = 4), use of other com-
+plementary therapies (e.g. homeopathy or ayurveda) (n = 2),
+refusal to continue the study (n = 2), time constraints (n = 4)
+and other concurrent illnesses such as infections delaying
+radiotherapy and intervention (n = 1).
+Measures
+During the initial visit, demographic information, including
+age, marital status, education, occupation, obstetric and
+gynecological history, medical history and intake of med-
+ications, was obtained, and clinical data were abstracted
+on the history of breast cancer. The following self-report
+questionnaires were distributed to the subjects during the
+study.
+Figure 1
+Trial profile.
+Positive and Negative Affect Schedule (PANAS)
+Positive affect and negative affect was assessed using the
+PANAS scale.33 PANAS contains two subscales, each consist-
+ing of 10 items: positive affect (PA) and negative affect (NA).
+PA reflects the extent to which a person feels enthusiastic,
+active, and alert. A high PA score reflects a state of high
+energy, full concentration, and pleasurable engagement. In
+contrast, NA is a general dimension of subjective distress
+with a variety of aversive mood states, and a high NA score
+indicates more distress. Patients were instructed to indicate
+how they had been feeling during the last 2 weeks. The reli-
+ability of this descriptive scale has been reported to range
+from 0.86 to 0.90 for PA and from 0.84 to 0.87 for NA.33
+European Organization for Research and Treatment
+of Cancer-Quality of life C30
+Health related quality of life was assessed using the Euro-
+pean Organization for the Research and Treatment of
+Cancer-Quality of Life (EORTCQoL C30 questionnaire ver-
+sion 1).34 This 30-item questionnaire provides a measure
+on the dimensions of global health status, physical, role,
+emotional, cognitive and social functioning (with high scores
+representing good quality of life) and cancer-related symp-
+tomatology. The reliability of this descriptive scale during
+the study has been reported to range from 0.52 to 0.89
+for functional and global quality of life scales. Assessments
+were carried out before and after radiotherapy treatment.
+However, we report results for only functional quality of life
+subscales in this study.
+Interventions
+The intervention group received integrated yoga program
+and the control group received brief supportive therapy both
+imparted individually. This integrated yoga program has a
+combination of a set of asanas (postures done with aware-
+ness) breathing exercises, pranayama (voluntarily regulated
+nostril breathing), meditation and yogic relaxation that are
+based on principles of stimulation and relaxation taken from
+ancient Indian texts called Upanishads. Contrary to the west
+where yoga is considered to be a form of exercise and various
+components such as asanas, meditation and breathing exer-
+cises are being used separately, in the east these practices
+are interspersed with a view to developing greater relax-
+ation and internal awareness.35 Subjects develop insight in
+recognizing inherent tensions and stress responses and learn
+ways to relax them. This would be particularly useful in
+cancer patients who perceive cancer as a threat. These
+practices were based on principles of attention diversion,
+mindful awareness and relaxation to cope with day-to-day
+stressful experiences. Participants were asked to attend a
+minimum of at least three in-person sessions/week for 6
+weeks during their adjuvant radiotherapy treatment in the
+hospital with self-practice as homework on the remaining
+days. Each of these sessions lasted 1 h and was administered
+by a trained yoga therapist either before or after radiother-
+apy. These sessions started with a few easy yoga postures,
+breathing exercises and pranayama (voluntarily regulated
+nostril breathing), and yogic relaxation. After this prepara-
+Author's personal copy
+Effects of yoga program
+277
+tory practice for about 20 min, the subjects were guided
+through any one of the meditation practices for the next
+30 min, which included focusing awareness on sounds and
+chants from Vedic texts,36 or breath awareness and impulses
+of touch emanating from palms and fingers while practic-
+ing yogic mudras, or a dynamic form of meditation that
+involved practicing with eyes closed of four yoga postures
+interspersed with relaxation while supine, thus achieving a
+combination of both ‘stimulating’ and ‘calming’ practice.37
+The instructions were recorded on an audio tape so that
+the patients could practice the same at home. The control
+intervention consisted of brief supportive therapy with edu-
+cation as a component that is routinely offered to patients
+as a part of their care in this centre. We chose to have
+this as a control intervention mainly to control for the non-
+specific effects of the yoga program that may be associated
+with factors such as attention, support and a sense of con-
+trol as described in our earlier study.23 Subjects and their
+caretakers underwent counseling by a trained social worker
+(once in 10 days, 15 min sessions) during their hospital vis-
+its for adjuvant radiotherapy. The control group received
+3—4 such counseling sessions during a 6-week period, where
+as the intervention group received anywhere between 18
+and 24 yoga sessions. Supportive counseling was a part of
+routine care offered in hospitals. While the goals of yoga
+intervention were stress reduction and appraisal changes,
+the goals of supportive therapy were education, reinforcing
+social support and coping preparation.
+Data analysis
+Data were analyzed using Statistical Package for Social
+Sciences version 10.0. Descriptive statistics were used
+to
+summarize
+the
+data.
+A
+GLM
+repeated
+measures
+ANOVA was done with the within-subjects factor being
+time/assessments at two levels and between-subjects fac-
+tor being groups at two levels (yoga vs. supportive therapy).
+Both group by time interaction effects, between-subjects
+and within-subjects effect were assessed. Post hoc tests
+were done using Holms—Bonferroni correction for changes
+at different time points between groups. Intention to treat
+analysis was also done on the initially randomized sample
+(n = 88) with baseline measure (T1) and post-measure (post-
+RT
+, T2) for all participants. Missing value analysis was done
+using SPSS 16 by regression using the corresponding baseline
+Table 1
+Demographic and medical characteristics of the initially randomized sample.
+All subjects
+Yoga group
+Control group
+n = 88
+%
+n = 44
+%
+n = 44
+%
+Religion
+Hindu
+73
+83
+36
+81.8
+37
+84.1
+Muslim
+9
+10.2
+6
+13.7
+3
+6.9
+Christian
+6
+6.8
+2
+4.5
+4
+9
+Stage of breast cancer
+I
+5
+5.7
+2
+4.5
+3
+6.8
+II
+18
+20.4
+11
+25.0
+7
+15.9
+III
+65
+73.9
+31
+70.5
+34
+77.3
+Grade of breast cancer
+I
+1
+1.1
+1
+2.3
+0
+0
+II
+33
+37.5
+21
+47.7
+10
+22.7
+III
+54
+61.4
+22
+50
+34
+77.3
+Menopausal status
+Pre
+48
+54.5
+26
+59.1
+23
+52.3
+Post
+40
+45.5
+18
+40.9
+21
+47.7
+Histopathology type
+IDC
+72
+81.8
+37
+84.1
+35
+39.7
+ILC
+7
+7.9
+2
+4.5
+5
+11.4
+IPC
+3
+3.4
+2
+4.5
+1
+2.2
+DCI
+2
+2.2
+2
+4.5
+0
+0
+CC
+2
+2.2
+1
+2.3
+1
+2.2
+PC
+2
+2.2
+0
+0
+2
+4.5
+Regimen
+After ChemoTherapy
+68
+77.3
+32
+72.7
+37
+84
+After surgery
+20
+22.7
+12
+27.3
+7
+15.9
+Marital status
+Single
+2
+2.2
+1
+2.3
+1
+2.2
+Married
+86
+97.8
+43
+97.7
+43
+97.8
+IDC- Infiltrating Ductal Carcinoma, IPC- Infiltrating Papillary Carcinoma, ILC- Infiltrating Lobular Carcinoma, CC- Comedo Carcinoma, PC-
+Papillary Carcinoma.
+Author's personal copy
+278
+H.S. Vadiraja et al.
+Table 2
+Comparison of scores for affect and functional scales of EORTCQoL C30 scores using GLM repeated measures ANOVA
+between yoga and control groups.
+Outcome variables
+Yoga (n = 47)
+Control (n = 44)
+Effect size, Cohen’s f
+Pre-mean (SD)
+Post-mean (SD)
+Pre-mean (SD)
+Post-mean (SD)
+PANAS-positive
+24.05 (7.28)
+27.85(7.11)**
+21.81 (7.37)
+23.33(8.3)
+0.59
+PANAS-negative
+22.15 (10.6)
+12.91 (10.39)**
+25.22 (8.82)
+21.85 (10.86)
+0.84
+Physical function
+73.2 (23.2)
+73.26 (25.33)
+62.72 (30.98)
+68.96 (30.12)
+0.16
+Role function
+72.72 (34.86)
+79.88 (34.41)
+71.59 (36.40)
+72.85 (39.94)
+0.19
+Emotional function
+56.45 (19.77)
+75.12 (21.16)**
+51.58 (17.44)
+59.23 (23.32)
+0.71
+Cognitive function
+85.29 (18.0)
+90.57 (15.88)*
+82.67 (21.12)
+80.77 (24.10)
+0.48
+Social function
+52.82 (26.55)
+54.96 (23.98)
+52.41 (24.43)
+49.93 (24.23)
+0.21
+* p-Values < 0.05, for post hoc tests comparing groups at pre and post-radiotherapy using Holms—Bonferroni correction.
+** p-Values < 0.01, for post hoc tests comparing groups at pre and post-radiotherapy using Holms—Bonferroni correction.
+value as predictors. Pearson correlation analyses were used
+to study the bivariate relationships between quality of life
+domains and affect.
+Results
+75 Participants (yoga n = 42; control n = 33) completed the
+prescribed radiotherapy regimen. All participants were
+ambulatory and had a Zubrod’s performance status score
+of 0—2. All patients had mastectomy as primary treatment,
+16 subjects received radiotherapy following mastectomy
+and 59 subjects received radiotherapy following mastec-
+tomy and three cycles of chemotherapy. The mean age of
+the study population in yoga group was (46.7 ± 9.3 years)
+and control group was (48.5 ± 10.2 years). Majority of sub-
+jects belonged to middle class (94.2%) and remaining 5.8%
+belonged to upper middle class. 9% of the population had
+some previous exposure to yoga practices though none of
+them seemed to practice it in the last few years. Par-
+ticipants in both groups were comparable with respect to
+socio-demographic and medical characteristics (Table 1). All
+subjects in the intervention group tolerated the intervention
+with out any adverse events.
+Outcome measures
+A repeated measures analysis of variance was done using
+post hoc Holms—Bonferroni correction on positive affect
+scores. Intention to treat analysis on the initially randomized
+sample showed significant improvement in PA (Mean dif-
+ference ± SE, p-value, 95%CI) (4.52 ± 1.7, p = 0.007, 1.25 to
+7.8), decrease in NA (−8.95 ± 2.3, p < 0.001, −13.4 to −4.4),
+improvement in emotional function (15.88 ± 4.75, p = 0.001,
+6.45 to 25.33) and cognitive function (9.8 ± 4.35, p = 0.03,
+1.2 to 18.5) in yoga group as compared to controls following
+intervention. There was a significant improvement in posi-
+tive affect (−3.81 ± 1.1, p < 0.001, 1.75 to 5.89), decrease
+in negative affect (9.25 ± 1.45, p < 0.001, 6.4 to 12.1),
+improvement in emotional (−18.63 ± 2.8, p < 0.001, −24.3
+to −12.9) and cognitive function (5.27 ± 2.69, p = 0.05,
+−10.63 to −0.007) in yoga group following intervention
+(T1—T2). There was also a significant decrease in negative
+affect (3.37 ± 1.5, p = 0.02, 0.49 to 6.24), improvement in
+physical function (−6.23 ± 2.9, p = 0.03, −11.9 to −0.49)
+and emotional function (−7.66 ± 2.88, p = 0.009, −13.4 to
+−1.9), in control group following intervention.
+There was no significant change in social function and role
+function following intervention in both the groups (Table 2).
+Bivariate relationships
+Bivariate relationships were determined between the out-
+come measures. There was a significant positive correlation
+between PA with physical function (p = 0.002), emotional
+function (p < 0.001), cognitive function (p = 0.01), social
+function (p = 0.007) and global quality of life (p < 0.001).
+There was a significant negative correlation between
+NA with emotional function (p < 0.01), physical function
+(p = 0.004), cognitive function (p = 0.001), global quality of
+life (p = 0.001) and social function (p = 0.008) (Table 3).
+Adherence to intervention
+Adherence to intervention was good with 29.7% attending
+10—20 supervised sessions, 56.7% attending 20—25 super-
+vised sessions and 13.7% attending >25 supervised sessions
+over a 6-week period. Level of adherence did not seem to
+affect quality of life or affect scores (results not shown).
+Table 3
+Pearson correlation (r-values) between affect
+(PANAS) and functional subscales on EORTCQoL C30.
+Functional subscales
+on EORTCQoL C30
+PANAS-P
+, r
+PANAS-N, r
+Physical function
+0.32**
+−0.31**
+Role function
+0.26*
+−0.16
+Cognitive function
+0.27***
+−0.35**
+Emotional function
+0.4***
+−0.64***
+Social function
+0.29**
+−0.28**
+GQOL
+0.50***
+−0.36**
+p-Values for Pearson correlation coefficients.
+* p < 0.05.
+** p < 0.01.
+*** p < 0.001.
+Author's personal copy
+Effects of yoga program
+279
+Discussion
+We compared the effects of a 6-week integrated yoga pro-
+gram with supportive therapy in stage II and III breast cancer
+patients undergoing adjuvant radiotherapy. There was a
+significant difference across groups over time for positive
+affect, negative affect, and emotional function. There was
+significant improvement in positive affect, emotional func-
+tion and cognitive function, and decrease in negative affect
+in the yoga group as compared to controls.
+Though intervention showed small to large effect size for
+these outcome measures, the effect size was highest for
+decrease in negative affect and lowest for physical function
+scores on quality of life subscale. This is in contrast to earlier
+study (Moadel et al.) that has shown improvements in qual-
+ity of life, emotional, social and spiritual well being even
+with poor adherence to yoga intervention. This could be
+due to the fact that their study21 lacked a control interven-
+tion and differed from ours with respect to scales used for
+measuring QoL (Functional Assessment of Cancer Treatment-
+Breast), ethnicity of study population and heterogeneity in
+conventional cancer treatments. In their study radiother-
+apy predicted poor adherence to treatment and outcome
+measures. However, adherence to intervention was better in
+our study with 56.7% attending 20—25 supervised yoga ses-
+sions and 13.7% attending >25 supervised yoga sessions over
+a 6-week period. This was primarily due to the fact that all
+patients were undergoing adjuvant radiotherapy and were
+visiting the hospital 5 days a week for six consecutive weeks
+and this could have contributed to improved adherence. Our
+results are also in contrast to earlier study using MBSR inter-
+vention that has shown some improvement in functional
+scales that were not significant following intervention. In
+this study too adherence to intervention, duration and het-
+erogeneity in cancer population could have confounded the
+actual effects of intervention.32 However, adherence did not
+seem to influence the outcome measures possibly due to
+the fact that an improved adherence created an ‘‘overall
+floor effect’’ thereby not influencing the outcome mea-
+sures.
+Several studies have shown that both psychological and
+treatment related distress affect quality of life concerns
+in cancer patients.38—41 Cancer patients have to constantly
+make lifestyle changes to adjust and cope with these treat-
+ment related distress and seek supportive care.42 Yoga
+and exercise as a lifestyle and stress reduction interven-
+tion has shown to decrease negative affect and improve
+positive affect.26—28 This change in affect could have con-
+tributed to improvement in quality of life concerns in these
+patients. This is further corroborated by our results with
+decrease in negative affect being related to improvement
+in physical function, emotional function and social func-
+tion and improvement in positive affect being related to
+improvement in role function. Possible threat perceptions
+and intrusive thoughts could motivate cancer patients to
+pursue health care behaviors that offer spiritual solace.43
+It is here that yoga as a psycho-spiritual intervention could
+offer much needed support. However, in our study we were
+not able to assess this spiritual component in quality of life,
+nevertheless it could be one of the possible mechanisms
+by which yoga could have influenced other quality of life
+domains.
+Using patients with high school education could have
+affected the generalizability of the study findings. Though
+the intervention was imparted as individual sessions, group
+sessions could have been more feasible and far more acces-
+sible. Sessions in a group setting could have instilled a sense
+of community where patients could model successful coping
+and gain self-esteem and motivation in their ability to help
+others in a group contributing to improvement in outcome
+measures.44,7 This could have confounded the effects of our
+intervention and hence we chose to have individual sessions
+in this study. However, considering the adherence neither
+access nor feasibility was a problem. None of the subjects
+who underwent intervention had any adverse effects of
+intervention suggesting that these interventions were safe
+and feasible.
+The contrast in results from earlier studies could be due
+to lack of concordance between EORTCQoL C30 and FACT
+scales on several domains of quality of life.45 Though this
+could be a limitation, our results still offer support for
+improving quality of life concerns in a homogenous group of
+breast cancer patients similar to our earlier observations on
+reductions in anxiety23 and distressful symptoms.24 However,
+larger randomized controlled studies using more structured
+behavioral approaches and multiple assessment tools are
+needed to further validate our findings.
+Acknowledgements
+We are thankful to Ms. Jayalakshmi for imparting the yoga
+intervention. We are thankful to Dr Ravi Kulkarni for his
+advice and help with statistical analyses.
+References
+1. Ganz P
+, Coscarelli A, Fred C, Kahn B, Polinsky ML, Petersen L.
+Breast cancer survivors: psychosocial concerns and quality of
+life. Breast Cancer Research and Treatment 1996;38:183—99.
+2. Shapiro SL, Lopez AM, Schwartz GE, Bootzin R, Figueredo
+AJ, Braden CJ. Quality of life and breast cancer: relation-
+ship to psychosocial variables. Journal of Clinical Psychology
+2001;57:501—19.
+3. Levenson JL, Bemis C, Presberg BA. The role of psychological
+factors in cancer onset and progression, a critical appraisal.
+In: Lewis CE, O’Sullivan C, Barraclough J, editors. The psy-
+choimmunology of cancer. Oxford: Oxford Univ Press; 1994. p.
+246—65.
+4. Weitzer MA, Meyers CA, Stuebing KK, Saleeba AK. Relation-
+ship between quality of life and mood in long-term survivors of
+breast cancer treated with mastectomy. Support Care Cancer
+1997;5:241—8.
+5. Smith EM, Gomm SA, Dickens CM. Assessing the independent
+contribution to quality of life from anxiety and depression in
+patients with advanced cancer. Palliat Med 2003;17:509—13.
+6. Vacek PM, Winstead-Fry P
+, Secker-Walker RH, Hooper GJ,
+Plante DA. Factors influencing quality of life in breast cancer
+survivors. Qual Life Res 2003;12:527—37.
+7. Anderson BL. Psychological interventions for cancer patients to
+enhance quality of life. J Consult Clin Psychol 1992;60:552—68.
+8. Carey M, Burish TG. Etiology and treatment of the psychological
+side effects associated with cancer chemotherapy: a critical
+review and discussion. Psychol Bull 1988;104:307—25.
+9. Fawzy FI, Fawzy NW, Hyun CS, Elashoff R, Guthrie D, Fahey
+JL. Malignant melanoma: effects of an early structured
+Author's personal copy
+280
+H.S. Vadiraja et al.
+psychiatric intervention, coping, and affective state on recur-
+rence and survival 6 years later. Archives of General Psychiatry
+1993;50:681—9.
+10. Meyer TJ, Mark MM. Effects of psychosocial interventions with
+adult cancer patients: a meta-analysis of randomized experi-
+ments. Health Psychology 1995;14:101—8.
+11. Tjisburg R, van Knippenberg FC, Rijpma SE. Effects of psy-
+chological treatment on cancer patients: a critical review.
+Psychosom Med 1992;54:489—517.
+12. Classen C, Hermanson KS, Spiegel D. Psychotherapy, stress and
+survival in breast cancer. In: Lewis CE, O’Sullivan C, Barra-
+clough J, editors. The psychoimmunology of cancer. Mind and
+body in the fight for survival?. Newyork: Oxford University
+Press; 1994. p. 132—62.
+13. Cassileth BR, Lusk EJ, Strause TB, Bodenheimer BJ. Contempo-
+rary unorthodox treatments in cancer medicine. Annals Behav
+Med 1994;101:105—12.
+14. Gruber BL, Hall NR, Hersh SP
+, Dubois P
+. Immune system and
+psychological changes in metastatic cancer patients using
+relaxation and guided imagery: a pilot study. Scand J Behav
+Ther 1988;17:25—45.
+15. Kabat-Zinn J, Massion AO, Herbert JR, Rosenbaum E. Medita-
+tion. New York: Oxford University Press; 1998.
+16. Khalsa SB. Yoga as a therapeutic intervention: a bibliometric
+analysis of published research studies. Indian J Physiol Phar-
+macol 2004;48:269—85.
+17. Bower
+JE,
+Alison
+Woolery
+MA,
+Sternleib
+B,
+Garet
+D.
+Yoga for cancer patients and survivors. Cancer Control
+2005;12:165—71.
+18. Raub JA. Psychophysiologic effects of Hatha Yoga on muscu-
+loskeletal and cardiopulmonary function: a literature review.
+J Altern Complement Med 2002;8:797—812.
+19. Kirkwood G, Rampes H, Tuffrey V, Richardson J, Pilkington K.
+Yoga for anxiety: a systematic review of the research evidence.
+Br J Sports Med 2005;39:884—91.
+20. Pilkington K, Kirkwood G, Rampes H, Richardson J. Yoga
+for depression: the research evidence. J Affect Disord
+2005;89:13—24.
+21. Moadel AB, Shah C, Wylie-Rosett J, Harris MS, Patel SR, Hall CB,
+et al. Randomized controlled trial of yoga among a multiethnic
+sample of breast cancer patients: effects on quality of life. J
+Clin Oncol 2007;25:4387—95.
+22. Cohen L, Chandwani KD, Perkins G, Thornton B, Arun B, Raghu-
+ram NV, et al. Randomized trial of yoga in women with breast
+cancer undergoing radiation treatment: long-term effects.
+Journal of Clinical Oncology 2008;26(May (Suppl.)).
+23. Rao MR, Raghuram N, Nagendra HR, Gopinath KS, Srinath BS,
+Diwakar RB, et al. Anxiolytic effects of a yoga program in
+early breast cancer patients undergoing conventional treat-
+ment: a randomized controlled trial. Complement Ther Med
+2009;17:1—8.
+24. Raghavendra RM, Nagarathna R, Nagendra HR, Gopinath
+KS, Srinath BS, Ravi BD, et al. Effects of an integrated
+yoga programme on chemotherapy-induced nausea and eme-
+sis in breast cancer patients. Eur J Cancer Care 2007;16:
+462—74.
+25. Rao RM, Telles S, Nagendra HR, Nagarathna R, Gopinath K,
+Srinath S, et al. Effects of yoga on natural killer cell counts
+in early breast cancer patients undergoing conventional treat-
+ment. Med Sci Monit 2008;14:LE10.
+26. Mutrie N, Campbell AM, Whyte F
+, McConnachie A, Emslie C, Lee
+L, et al. Benefits of supervised group exercise programme for
+women being treated for early stage breast cancer: pragmatic
+randomized controlled trial. BMJ 2007;337:517.
+27. Danhauer SC, Mihalko SL, Russell GB, Campbell CR, Felder L,
+Daley K, et al. Restorative yoga for women with breast can-
+cer: findings from a randomized pilot study. Psychooncology
+2009;18:360—8.
+28. West J, Otte C, Geher K, Johnson J, Mohr DC. Effects of Hatha
+yoga and African dance on perceived stress, affect, and salivary
+cortisol. Ann Behav Med 2004;28:114—8.
+29. Chaturvedi SK, Chandra P
+, Channabasavanna SM, Anantha
+N, Reddy BKM, Sharma S. Levels of anxiety and depression
+in patients receiving radiotherapy in India. Psychooncology
+1996;5:343—6.
+30. Cordova MJ, Andrykowski MA, Kenady DE, McGrath PC, Sloan
+DA, Redd WH. Frequency and correlates of posttraumatic-
+stress-disorder-like symptoms after treatment for breast
+cancer. J Consult Clin Psychol 1995;63:981—6.
+31. Overgaard M, Hansen PS, Overgaard J. Postoperative radiother-
+apy in high-risk premenopausal women with breast cancer. N
+Engl J Med 1997;337(14):949—55.
+32. Carlson LE, Speca M, Patel DK, Goodey E. Mindfulness-based
+stress reduction in relation to quality of life, mood, symp-
+toms of stress, and immune parameters in breast and prostate
+cancer out patients. Psychosom Med 2003;65:571—81.
+33. Watson D, Clark LA, Tellegen A. Development and validation
+of brief measures of positive and negative effect: the PANAS
+scales. J Pers Soc Psychol 1988;54:1063—70.
+34. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez
+NJ, et al. The European Organization for Research and Treat-
+ment of Cancer QLQ-C30: a quality-of-life instrument for use
+in international clinical trials in oncology. J Natl Cancer Inst
+1993;85:365—76.
+35. Nagendra HR, Nagarathna R. An integrated approach of yoga
+therapy for bronchial asthma: a 3—54-month prospective study.
+J Asthma 1986;23(3):123—37.
+36. Telles S, Nagarathna R, Nagendra HR. Autonomic changes while
+mentally repeating two syllables—
+–one meaningful and another
+neutral. Indian J Physiol Pharmacol 1998;42:57—63.
+37. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and
+respiration following two yoga relaxation techniques. Appl Psy-
+chophysiol Biofeedback 2000;25:221—7.
+38. Stark D, Kiely M, Smith A, Velikova G, House A, Selby P
+. Anxiety
+disorders in cancer patients: their nature, associations, and
+relation to quality of life. J Clin Oncol 2002;20:3137—48.
+39. Visser MRM, Smets EMA. Fatigue, depression and quality of life
+in cancer patients: how are they related? Support Care Cancer
+1998;6:101—8.
+40. Courneya KS, Friedenreich CM. Physical exercise and quality of
+life following cancer diagnosis: a literature review. Annals of
+Behavioural Medicine 1999;21:171—9.
+41. Perry S, Kowalski TL, Chang C-H. Quality of life assessment in
+women with breast cancer: benefits, acceptability and utiliza-
+tion. Health and Quality of Life Outcomes 2007;5:24.
+42. Umesh SB. Psychosocial aspects of cancers in women. Banga-
+lore: Dept of Psychiatry, NIMHANS; 1998.
+43. Chaturvedi S. What’s important for quality of life to Indians—
+–in relation to cancer? Indian Journal of Palliative Care
+2003;9:62—70.
+44. Toseland R, Hacker L. Self help groups and professional involve-
+ment. Social Work 1982:341—7.
+45. Kemmler G, Holzner B, Kopp M, Dünser M, Margreiter R, Greil R,
+et al. Comparison of two quality-of-life instruments for cancer
+patients: the functional assessment of cancer therapy-general
+and the European Organization for Research and Treatment
+of Cancer Quality of Life Questionnaire-C30. J Clin Oncol
+1999;17:2932—40.

subfolder_0/Efficacy of yoga based life style modification program on medication score and lipid profile in type 2 diabetes.txt

@@ -0,0 +1,1100 @@
+ORIGINAL ARTICLE
+Efficacy of yoga based life style modification program
+on medication score and lipid profile in type 2
+diabetes—a randomized control study
+R. Nagarathna & M. R. Usharani & A. Raghavendra Rao & R. Chaku &
+R. Kulkarni & H. R. Nagendra
+Received: 13 April 2011 /Accepted: 15 May 2012 /Published online: 1 August 2012
+# Research Society for Study of Diabetes in India 2012
+Abstract Several studies have documented the beneficial
+short term effects of yoga in type 2 diabetics. In this pro-
+spective two-armed interventional randomized control study,
+277 type 2 diabetics of both genders aged above 28 years
+who satisfied the study criteria were recruited from 5 zones
+in and around Bengaluru, India. They were allocated to a
+yoga-based life style modification program or exercise-based
+life style modification program. Integrated yoga special tech-
+nique for diabetes included yogasanas, pranayama, medita-
+tion and lectures on yogic life style. Control intervention
+included physical exercises and life style education. Medi-
+cation score, blood glucose, HbA1c and lipid profile were
+assessed at baseline and after 9 months. Intention to treat
+analysis showed better reduction (P<0.05, Mann-Whitney
+test) in the dose of oral hypoglycemic medication required
+(Yoga - 12.8 %) (Yoga-12.3 %) and increase in HDL (Yoga-
+7 %) in Yoga as compared to the control group; FBG
+reduced (7.2 %, P00.016) only in the Yoga group. There
+was significant reduction within groups (P<0.01) in PPBG
+(Yoga-14.6 %, Control-9 %), HbA1c (Yoga-14.1 %,
+Control-0.5 %), Triglycerides (Yoga-15.4 %, Control-
+16.3 %), VLDL (Yoga-21.5 %, Control-5.2 %) and total
+cholesterol (Yoga-11.3 %, Control-8.6 %). Thus, Yoga based
+life style modification program is similar to exercise-based
+life style modification in reducing blood glucose, HbA1c,
+triglycerides, total cholesterol and VLDL. Yoga is better than
+exercise in decreasing oral hypoglycemic medication re-
+quirement and LDL; and increasing HDL in type 2 diabetics.
+Keywords Yoga . Exercise . Hypoglycemic agent . HDL .
+Blood glucose
+Introduction
+Diabetes mellitus is a major global health problem affecting
+150 million people worldwide. In India, the prevalence of
+type 2 diabetes (T2DM) and premature coronary artery
+disease is rapidly escalating in all socioeconomic groups
+parallel with the obesity epidemic [1].
+R. Nagarathna (*)
+Division of Yoga and Life Sciences, Swami Vivekananda
+Yoga Anusandhana Samsthana, (SVYASA) University,
+Eknath Bhavan, 19, Gavipuram circle, Kempegowda Nagar,
+Bengaluru 560019, India
+e-mail: [email protected]
+R. Nagarathna
+e-mail: [email protected]
+M. R. Usharani: A. R. Rao: R. Chaku: R. Kulkarni:
+H. R. Nagendra
+SVYASA University,
+Eknath Bhavan, 19, Gavipuram circle, Kempegowda Nagar,
+Bengaluru 560019, India
+M. R. Usharani
+e-mail: [email protected]
+A. R. Rao
+e-mail: [email protected]
+R. Chaku
+e-mail: [email protected]
+R. Kulkarni
+e-mail: [email protected]
+H. R. Nagendra
+e-mail: [email protected]
+R. Chaku
+WHO project, Morarji Desai National Institute of Yoga,
+New Delhi, India
+Present Address:
+A. R. Rao
+HOD, Department of Complementary and Alternative Medicine,
+Bangalore Insititute of Oncology,
+Bengaluru 560027, India
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130
+DOI 10.1007/s13410-012-0078-y
+The primary reasons for this rapid global epidemiological
+transition include aging of the population [2], genetic factors
+[3], changing life style with altered dietary patterns with
+decreased physical activity [4], and psychosocial stresses
+[5]. The associated lipoprotein abnormalities such as elevated
+concentrations of triglycerides and LDL, with decreased
+HDL, and the oxidative stress play an important role in the
+occurrence of early atherosclerosis in diabetics. Hence, the
+primary role of life style modification programs that include
+exercise, diet and stress reduction has been widely accepted
+to reduce the incidence of type 2 diabetes [6, 7, 8]. There are
+reports that the physician’s advice in a diabetic clinic is
+usually ineffective [8]. Studies have also shown that people
+have considerable interest in lifestyle interventions than a
+pharmaceutical trial [9]. Incidence of type 2 diabetes has
+reduced by 40 to 60 % over 3 to 4 years in high risk
+population in USA after modest weight loss through diet
+and physical activity [7].
+Alternative methods of exercise, stress reduction [10],
+and relaxation techniques [11] including cognitive behav-
+iour therapy [12] have been shown to improve the mood
+with better glycemic control and prevention of complica-
+tions of the metabolic syndrome. Psychological stresses
+resulting in depression contributes to poor compliance and
+outcome of therapeutic measures [6] and its treatment has
+shown better glycemic control and improved quality of life
+[13]. Yoga has been explored scientifically since the 1970’s
+as a widely available resource for life style-related problems
+such as hypertension [14], bronchial asthma [15], diabetes
+[16] and coronary artery disease [17]. A critical review of all
+published literature from 1970 to 2006 on the effects of
+yoga based programs on the risk profiles in adults with
+T2DM showed that yoga reduces the risk profiles and may
+help in prevention and management of its cardiovascular
+complications [18]. These beneficial effects of yoga seem to
+be due to the relaxation response [16] that has the potential
+to reduce the heightened stress responses through techni-
+ques that promote mastery over the modifications of mind
+[19].
+Studies in India have also shown the beneficial effects of
+yoga in diabetics. Damodaran et al observed decrease in
+blood pressure, drug scores, sympathetic activity (VMA
+catecholamine and MDA), oxidant stress (vitamin C cholin-
+esterase) and improvements in risk factors such as blood
+glucose, cholesterol and triglycerides with better subjective
+well being and quality of life in a non randomized study
+on outpatients for 3 months [20]. Singh et al showed
+significant decrease in fasting and post prandial blood
+glucose levels and glycosylated hemoglobin with stable
+autonomic functions after forty days of yogic exercises in
+Type 2 Diabetics [21].
+More recently, Hegde et al (2011) in south India in a
+stratified control trial studied diabetics with and without
+complications (peripheral neuropathy or microvascular or
+macrovascular) and observed significant reduction in BMI,
+improved glycemic control, and oxidative stress within
+3 months when yoga was added to standard care [22]. Yoga
+improved the ‘heart friendly’ status of lipid profile in peri
+and post-menopausal patients receiving standard medical
+treatment for type 2 DM with decrease in low density
+lipoprotein as well as fasting and postprandial blood glucose
+levels within six weeks [23]. A review by the American
+diabetes association on yoga and other mind body interven-
+tion concluded that clinical trials on patients with diabetes
+have shown improvement in measures of quality of life and
+stress but consistent long-term improvements in glycemic
+control or HbA1C have not been documented [24].
+There are not many long-term follow up studies which
+have directly compared the effects of exercise with yoga on
+medication requirement and lipid profile. Hence, the present
+study was planned with an objective to compare the efficacy
+of a Yoga based Life Style modification Program (YLSP)
+with conventional Exercise based Life Style modification
+Program (ELSP) in type 2 diabetics, with the hypothesis that
+YLSP will be better than ELSP, in achieving better control
+of diabetes with favourable changes in medication require-
+ment and lipid profile.
+Subjects and methods
+Design
+The study Registered Trial number - CTRI/2008/091/
+000293 was a prospective randomized two arm parallel
+control study with active intervention for the control group.
+The research protocol was approved by the Ethics Committee
+of SVYASA University. Signed informed consent was
+obtained from all participants before recruitment.
+Subjects
+The participants were selected from five different zones
+(east, west, north, south and central) in and around Bengaluru
+city, India, between 2003–2007. Inclusion criteria were, (a)
+type 2 diabetics of both sexes above 25 years, (b) fasting
+venous blood glucose level >120 mg% at the time of diag-
+nosis (checked from their records), (c) T2DM of more than
+one year, (d) those stabilized on a stable dosage of oral
+hypoglycemic agents or insulin for at least three weeks
+and (e) no prior exposure to yoga practice. Those with major
+complications of T2DM such as chronic infections (tubercu-
+losis, HIV), coronary artery disease, severe hypertension,
+nephropathy, proliferative retinopathy and/or cerebrovascular
+disease were excluded. Those with peripheral neuropathy,
+mild urinary or cutaneous fungal infections, mild to moderate
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130
+123
+hypertension and obesity were not excluded. The sample size
+was calculated by Cohen’s formula [25] with alpha of 0.05,
+powered at 0.80 for an effect size of 0.34 based on our earlier
+interventional study [16]. All participants who satisfied the
+selection criteria and signed the informed consent were
+assigned a numbered envelope containing a computer gener-
+ated random number (using www.randomizer.org). To conceal
+bias during randomization, the statistician at the university
+centre, who was not involved in administering the interven-
+tion, allocated them to yoga or control groups. Different
+random number tables were used for five different venues.
+Masking
+As this was an interventional study blinding was not possible.
+The laboratory staff and the statistician were blind to the
+source of the data. Care was taken to prevent crossover of
+participants or interaction between the two groups.
+Methods
+Within one week after recruitment all baseline data were
+documented. Those who needed any change in the dosage of
+oral hypoglycemic medication or insulin were made to wait
+for 3 weeks for a second assessment before starting the
+intervention. Both groups were trained by certified thera-
+pists through daily (one hour/day - 5 days /week) classes, for
+12 weeks followed by weekly follow up classes for 2 h for
+9 months. During the follow up period they were asked to
+continue the practices for 1 h daily at home using a pre-
+recorded instruction audio tape. All participants were pro-
+vided with a diary to tick the type and duration of their daily
+recommended practice, monthly fasting and post-prandial
+blood glucose levels, body weight, visits to family physician
+for any health problem, episodes of hypoglycemia, and any
+change in their diet, medication or daily practice of yoga or
+exercise. The medical officer and the dietitian were avail-
+able at the venue once a month to check their progress and
+advise suitable changes. All outcome measures for the study
+were checked at the end of 9 months.
+Intervention
+The modules of intervention for the two groups were care-
+fully developed by a team consisting of two senior yoga
+experts of the university, a psychiatrist and a diabetologist.
+Table 1 shows the details of the intervention for the two
+groups. The interventions for both modules were aimed at
+achieving, (a) conventional diabetes education, (b) stress man-
+agement, and (c) empowerment for adherence to long term life
+style change. The specific yoga module for YLSP was the
+same as that used in our earlier study on yoga in diabetes [16].
+This ‘Integrated Approach of Yoga for Diabetes (IAYD)’ is
+based on the knowledge culled out from yoga scriptures
+(Patanjali yoga sutras, Bhagvadgita and Mandukya karika).
+The practices included (i) physical practices such as cleans-
+ing techniques (kriyas), loosening practices (shithilikarana
+vyayama), sun salutation (suryanamaskara) and yoga pos-
+tures (asanas) to provide mild intensity physical exercise
+effect. (ii) Pranayama and meditation (dharana and dhyana)
+for calmness of mind, (iii) devotional sessions (Bhakti
+yoga) for better emotional stability and (iv) lectures and
+yogic counseling for notional correction through self
+analysis (Jnana yoga) [16, 26]. The kriyas (Neti, Dhouti
+and Shankaprakshalana) were done once a week. The ELSP
+module consisted of (i) standard physical training (PT) exer-
+cises and walking designed to achieve a comparable intensity
+of physical exertion, (ii) non-yogic breathing exercises used in
+physiotherapy and (iii) supine rest. Both groups had access to
+reading material on conventional diabetes education.
+Measurements
+Baseline measurements before recruitment included demo-
+graphic data and investigations to satisfy the selection crite-
+ria. They were (i) fasting blood glucose, (ii) resting blood
+pressure using a sphygmomanometer, (iii) electrocardio-
+gram using a portable ECG recorder (one channel recorder,
+version 6108 T, BPL, India), (iv) fundoscopy by a certified
+ophthalmologist and (v) serum urea and creatinine [27] to
+look for nephropathy.
+Outcome measures
+A semi-structured interview for medical history, and demo-
+graphic data were recorded by the medical officer after
+recruitment.
+1.
+Medication score: The oral medication scores (standard
+quantity of the drug per tablet as indicated in CIMS
+India [28] expressed as number of tablets per day) were
+calculated separately for each category i.e. Oral Hypo-
+glycemic Agents (OHA), Lipid Lowering Drugs (LLD)
+and Antihypertensive drugs (AHT). Total medication
+score indicates the total number of tablets of all drugs
+consumed in a day. The insulin score was calculated by
+using a scoring system ranging from 0–3 (00nil, 1e15
+units, 2016–30 units, 3>30 units), for the total number
+of units of insulin injected in 24 h.
+2.
+Biochemical measures included blood glucose, HbA1c
+and lipid profile. Blood samples were drawn from an ante-
+cubital vein in the fasting state (Fasting Blood Glucose—
+FBG) between 8 am and 9 am, and 2 h after breakfast
+(Post-Prandial Blood Glucose—PPBG) between 10 am
+and 11 am. The participants were instructed to abstain
+from morning yoga or PT exercises on the day of blood
+124
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130
+Table 1 Practices used for the
+intervention in both groups
+YLSP Yoga based Life Style
+change Program, ELSP Exercise
+based Life Style change Program
+Practices for Yoga (YLSP) group
+Practices for control (ELSP) group
+Breathing Exercises
+Exercises in standing position
+Shasha Shwasa (Rabbit Breathing)
+Forward backward bending
+Vyaghra Shwasa(Tiger Breathing )
+Side bending
+Navasana Shwasa (Boat Breathing)
+Jogging
+Shithilikarana Vyayama (yogic loosening)
+Sit-up
+Padahatasana Ardha Cakrasana Chalana
+(Forward Backward Bending)
+Twisting
+Cross leg lifting
+Trikonasana Chalana (Side Bending)
+Alternative toe touching
+Kati Parivartana Chalana (Twisting)
+Hip rotation
+Dhanurasana Chalana (Swinging in Bow)
+Knee rotation
+Pavanamuktasana Kriya (wind releasing)
+forward drill
+Surya Namaskara (Sun Salutation)
+Backward drill
+Shavaansa (Quick Relaxation Technique—QRT)
+Sideward drill
+Asanas (Yoga postures)
+Neck movements
+Parivritta Trikonasana (Twisted triangle)
+Shoulder rotation
+Vakrasana or Ardha Matsyendrasana
+(Spinal Twist or Sage Matsyendra posture)
+Full arm rotation
+Ustrasana (Camel)
+Free walking
+Hamsasana or Mayurasana (Swan or Peacock)
+Exercises in sitting position
+Bhujangasana (Cobra)
+Knee cap tightening
+Dhanurasana (Bow)
+Swimming
+Sarvangasana (Whole Body Inverted posture)
+Supine relaxation
+Matsyasana (Fish)
+Half butterfly exercise
+Deep Relaxation Technique (DRT)
+Chakki chalana (waist twisting))
+Bandhas (locks) and Kriyas (cleansing)
+Ankle bend exercise
+Jala Neti (nasal wash with water)
+Toe Bend exercise
+Sutra Neti (nasal wash with catheter)
+Crow walking
+Vaman Dhouti (yogic vomiting)
+Knee rotation
+Shankha Prakshalana(yogic bowel cleansing)
+Exercises in prone position
+Uddiyana Bandha (diaphragm lock)
+Prone bow swing
+Agnisara Kriya( abdominal flap)
+Prone Alternate
+Kapalabhati (Blasting breath)
+head and leg swing
+Pranayama (yogic breathing)
+Boating
+Vibhagiya Pranayama (Sectional Breathing)
+Rolling
+ujjayi (glottis breathing)
+Alternate Arm swing
+Nadi Suddhi (alternate nostril)
+Hip stretch
+Sitali or Sitkari (cooling breath)
+Exercises in Supine position.
+Bhramari (Bee Breathing)
+Cycling
+Meditation (Dharana and Dhaya)
+Straight leg rising
+Nadanusandhana (sound resonance Merger)
+Side leg rising
+Om Meditation (meditation on Om syllable)
+Knee exercise
+Lectures—topics covered
+Dorsal Stretch
+Diabetes: burden, causes, management
+Rolling and rocking
+Yogic concepts of healthy life style
+Supine rest
+including thinking, feeling and behaviour,
+Lectures—topics covered
+Yogic management of stress,
+Diabetes: burden, cause, management causes, management.
+Diabetes and yoga Diet,
+Modern scientific concepts of healthy life style including
+thinking, feeling and behaviour
+How to stop smoking, the yogic way
+Modern concepts of management of stress and how to stop
+smoking
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130
+125
+collection. The sera were separated within an hour of
+collection. A certified technician carried out all the tests
+at the SVYASA university laboratory. Heparinised blood
+was used to analyze HbA1c by using affinity assay meth-
+od on a Nycocord reader [29]. The concentration of
+glucose was determined by using glucose-oxidase method
+[30] and serum total cholesterol, triglyceride and HDL by
+enzymatic methods [31]. High density lipoprotein was
+measured after precipitating VLDL and LDL cholesterol
+in the presence of magnesium ions. The VLDL and LDL
+fractions were calculated by the Friedwald’s formula [32].
+Statistical analysis
+Data were analyzed using SPSS version 16. The baseline data
+were not normally distributed (Shapiro Wilk’s test P<0.05).
+Mann Whitney test was used for pre values for checking the
+baseline matching. As there was an attrition rate of about 38 %
+by the 9th month, we carried out ‘intention to treat analysis’
+considering both pre and post data as predictors [33–35] based
+on the concept of ‘Expectation Maximisation’. Wilcoxon’s
+signed ranks test was used to compare the pre-post changes
+and Mann-Whitney ‘U’ test to compare groups.
+Results
+Figure 1 shows the trial profile. Out of 520 screened, 277
+(87 females) participants (141 in YLSP and 136 in ELSP),
+were randomized into two groups; 264 completed the initial
+12 weeks of training and 173 (88 in yoga and 85 in control
+group) completed the study. The reasons for drop outs are
+given in Fig. 1. Table 2 shows the demographic features.
+There was no baseline matching between groups in mean
+duration of diabetes before recruitment (6.19±5.49 years
+in YLSP and 4.75±4.18 years in ELSP). The baseline
+measurements used to rule out nephropathy before recruit-
+ment was matched for creatinine concentration and blood
+urea nitrogen in both groups.
+Medication score (Table 3)
+Oral hypoglycemic drug requirement reduced in 30 partic-
+ipants in YLSP and 14 in ELSP with significant reduction of
+mean scores in YLSP (12.8 %, P<0.001) and non-signifi-
+cant reduction (3.7 %) in ELSP. There was significant dif-
+ference between groups at P00.05 (Mann Whitney). The
+total medication that included all categories of drugs re-
+duced by 10.9 % in YLSP (P00.004) with no significant
+difference in ELSP or between groups. It reduced in 35
+patients in YLSP and 19 patients in ELSP. Amongst those
+who were taking insulin (16 in YLSP and 10 in ELSP) at the
+time of recruitment, five in YLSP group and one in ELSP
+had discontinued (no significant statistical change).
+Lipid profile (Table 4)
+HDL increased by 7 % in YLSP (P00.002) with significant
+difference between groups (P00.007). LDL reduced signif-
+icantly in YLSP by 12.3 % (P<0.001), with difference
+between groups at P00.003. Triglycerides, total cholesterol
+and VLDL reduced significantly in both groups with non
+significant differences between groups and better effect
+sizes in yoga group.
+Changes in blood glucose (Table 4)
+There was a significant reduction in FBG by 7.2 % in
+YLSP (P00.016) at 9th month. PPBG reduced significant-
+ly in both the groups, 14.6 % in YLSP (P<0.001) and
+8.9 % in ELSP (P00.019) groups, with non-significant
+difference between groups. The concentration of HbA1c
+reduced in both groups, 14.1 % in YLSP (P<0.001) and
+0.5 % in ELSP (P00.002) with no significant difference
+between groups.
+Subgroup analysis based on duration of illness:
+A subgroup analysis was done between groups with a
+median cut off of 5 years for duration of illness. The
+trends observed between groups when duration of
+illness was <5 years or >5 years was similar to trends
+seen when groups were compared without cut offs for
+duration of illnesses as reported above. Hence, this has
+not been reported separately in tables.
+Discussion
+This was a prospective randomized control study that com-
+pared YLSP with ELSP on 277 participants with type 2
+diabetes selected from 5 zones in and around Bengaluru.
+After 9 months of intervention there was significant differ-
+ence between groups (P<0.01) in HDL, LDL and medica-
+tion requirement with higher effect sizes in YLSP group.
+There was reduction in PPBG and HbA1c, triglycerides,
+total cholesterol and VLDL in both groups with better effect
+sizes in yoga group (non-significant differences between
+groups) whereas FBG reduced significantly only in the yoga
+group. A review by Innes KE et al [18] of 25 yoga studies
+on type 2 diabetics (of which 4 were RCTs), concluded that
+yoga practice was associated with reduction of 6.1–34.4 %
+126
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130
+in blood glucose and 10.5–27.3 % in HbA1c. A recent three
+armed RCT showed a 30 % reduction in FBG with no
+changes in HbA1c or medication scores after 6 months of
+yoga [36]. Our study adds evidence to the efficacy of yoga
+in a south Indian diabetic population. This is the first study
+that has documented significantly better reduction in oral
+hypoglycemic agents (12.8 %) in YLSP than ELSP.
+Significant reduction in serum total cholesterol, triglycer-
+ides and LDL concentrations in type 2 diabetics after yoga
+exercises [37] and Sudarshan Kriya Yoga (SKY) [38] have
+Table 2 Demographic data
+YLSP Yoga based Life Style
+change Program, ELSP Exercise
+based Life Style change
+Programs
+Variables
+YLSP group (141)
+ELSP group (136)
+1
+Gender
+Males
+91
+99
+Females
+50
+37
+2
+Age
+Range
+30–78 years
+30–74 years
+Mean±SD
+53.46±8.86
+51.38±8.39
+3
+Education
+School
+78
+73
+Undergraduates
+36
+38
+Graduates
+27
+22
+Post Graduates
+–
+3
+4
+Socio-Economic Status
+Upper class
+1
+0
+Middle class
+140
+136
+5
+Duration of DM
+Mean±SD
+6.19±5.49
+4.75±4.18
+1–5
+92
+96
+5.1–10
+25
+29
+10–20
+20
+9
+20–30
+2
+1
+30–40
+2
+1
+6
+Family History of DM2
+63
+45
+7
+Tobacco chewing
+19
+9
+8
+Alcohol Consumption
+13
+12
+Control group -136
+Yoga group - 141
+SCREENED - 520
+Recruited & Randomized - 277
+Not interested - 63
+Did not fulfill the selection criteria - 78
+Interested but could not commit for the 
+study - 102
+9 months - 88
+(62.4%)
+Drop outs - 53
+Time constraints - 13
+Minor Illnesses - 6
+Personal reasons - 15
+Secondary complications - 3
+Shifted to other systems - 6
+Change of address - 10
+4 weeks -135
+(96%)
+Drop outs - 51
+Time constraints - 12
+Minor Illnesses - 4
+Personal reasons-10
+Secondary complications - 8
+Shifted to yoga - 5
+Shifted to other systems - 5
+Change of address - 7
+Death - 1
+4 weeks -129
+(95%)
+3 months -112
+3 months -105
+6 months - 97
+6 months - 91
+9 months - 85
+(62.5%)
+Fig. 1 Trial profile
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130
+127
+Table 3 Results- Changes in
+medication scores after 9 months
+of intervention in both groups
+OHA Oral Hypoglycemic
+Agents, LLD Lipid Lowering
+Drugs, Anti HT Antihyperten-
+sive drugs, ES Effect Size, NS
+Not Significant
+Variable
+Group
+Pre-intervention
+Post-intervention
+% Change
+Within groups
+Between groups
+Mean±SD
+Mean±SD
+P
+ES
+P
+ES
+Total
+YLSP (N0141)
+3.38±2.19
+3.01±1.88
+10.94
+0.004
+0.29
+NS
+–
+ELSP (N0136)
+3.24±1.95
+3.15±1.74
+2.77
+0.37
+0.09
+OHA
+YLSP
+2.27±1.29
+1.98±1.27
+12.77
+<0.001
+0.37
+0.05
+0.25
+ELSP
+2.41±1.52
+2.32±1.42
+3.65
+0.22
+0.11
+NS
+–
+LLD
+YLSP
+0.76±0.44
+0.88±0.48
+15.79
+NS
+–
+NS
+–
+ELSP
+0.77±0.43
+0.92±0.28
+19.48
+NS
+Anti HT
+YLSP
+1.10±0.52
+1.08±0.47
+1.81
+NS
+–
+NS
+–
+ELSP
+0.98±0.68
+1.02±0.51
+4.08
+NS
+Table 4 Changes in glycemic control and lipids in both groups after 9 months of intervention
+Variables
+YLSP (N0141)
+ELSP (N0136)
+Between Groups
+Mean±SD
+95% CI
+pre-post
+Mean±SD
+95% CI
+pre-post
+ES
+P Post YLSP vs
+Post ELSP
+LB
+%
+P
+LB
+%
+P
+UB
+ES
+UB
+ES
+FBG
+Pre
+133.72±44.52
+126.65
+7.2%
+0.016
+130.31±39.58
+123.21
+3.9 %
+NS
+0.03
+0.53
+140.78
+137.40
+Post
+124.08±32.46
+118.93
+0.22
+125.20±32.65
+119.34
+0.12
+129.23
+131.05
+PPBG
+Pre
+184.02±72.53
+172.51
+14.6%
+<0.001
+171.90±65.25
+160.21
+8.9%
+0.019
+0.01
+0.72
+195.53
+183.60
+Post
+157.19±55.22
+148.43
+0.36
+156.48±55.01
+146.62
+0.21
+165.95
+166.34
+HbA1c
+Pre
+8.54±1.68
+8.27
+14.1%
+<0.001
+8.07±1.42
+7.81
+0.5%
+0.002
+0.19
+0.11
+8.80
+8.32
+Post
+7.33±3.00
+6.86
+0.38
+8.03±4.26
+7.27
+0.01
+7.81
+8.80
+HDL
+Pre
+44.75±13.82
+42.56
+7%
+0.002
+45.11±13.43
+42.70
+2.1%
+NS
+0.32
+0.007
+46.95
+47.52
+Post
+47.88±11.80
+46.01
+0.20
+44.16±11.51
+42.10
+0.06
+49.75
+46.22
+LDL
+Pre
+91.16±33.10
+85.90
+12.3%
+0.001
+92.59±35.26
+86.27
+0.9%
+NS
+0.38
+0.003
+96.41
+98.91
+Post
+79.89±30.20
+75.10
+0.28
+91.72±31.93
+86.00
+0.02
+84.68
+97.45
+Trigly
+Pre
+174.10±81.22
+161.22
+15.4%
+<0.001
+180.86±102.59
+162.47
+16.3%
+0.018
+0.08
+0.64
+186.99
+199.25
+Post
+147.28±49.14
+139.49
+0.31
+151.38±51.66
+142.12
+0.28
+155.08
+160.64
+T.Cho
+Pre
+182.86±39.55
+176.58
+11.3%
+<0.001
+182.09±41.31
+174.69
+8.6%
+<0.001
+0.11
+0.38
+189.13
+189.50
+Post
+162.20±36.74
+156.37
+0.47
+166.34±37.94
+159.54
+0.32
+168.03
+173.14
+VLDL
+Pre
+44.30±23.26
+40.61
+21.5%
+<0.001
+42.33±17.71
+39.16
+5.2%
+0.009
+0.23
+0.18
+47.99
+45.50
+Post
+34.76±12.12
+32.84
+0.38
+40.13±31.14
+34.55
+0.06
+36.69
+45.71
+YLSP Yoga based Life Style change Program, ELSP Exercise based Life Style change Program, ES Effect Size, FBG Fasting Blood Glucose, PPBG
+Post Prandial Blood Glucose, HbA1c Glycosylated Hemoglobin, HDL High Density Lipoprotein, LDL Low Density Lipoprotein, Trigly
+Triglycerides, T.chol Total Cholesterol, VLDL Very Low Density Lipoprotein
+128
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130
+been observed. The yoga exercise study [37] showed an
+increase in HDL whereas this was not achieved after SKY.
+Significant improvement in HDL and LDL profiles in YLSP
+group in the present study with an increase in HDL (7 %) in
+the yoga group is noteworthy.
+Several studies have proven the efficacy of different
+types of exercises in increasing HDL and decreasing LDL
+[6, 10–12, 39]. It appears that moderate intensity exercises
+(and not vigorous intensity exercises) are effective in reduc-
+ing VLDL complex of triglycerides, whereas sustained in-
+crease in HDL may occur only after vigorous exercises such
+as jogging [39]. This may explain the non-significant
+changes in HDL and LDL in our ELSP group. This also
+seems to indicate that the increase in HDL found in the
+YLSP group may involve pathways other than its exercise
+component. Activation of hypothalamic pituitary axis
+(HPA) axis and sympatho-adrenal system is known to in-
+hibit glucose uptake by peripheral tissues by inhibiting
+insulin release, inducing insulin resistance and increasing
+hepatic glucose production [40]. Better sympathovagal bal-
+ance [16, 41] better insulin receptor sensitivity [42, 43] and
+reduced oxidative stress [44] may have contributed to the
+beneficial effects of the integrated yoga practices.
+Major strengths of this study includes, the longitudinal
+prospective randomized multi-venue control design with
+good sample size selected from five zones of a metropolitan
+city in south India, active intervention for the control group,
+follow up duration of nine months and the results showing
+significant reduction in oral hypoglycemic medication better
+than control group. Limitations of this study were: (a) the
+data of body weight, BMI and calorie intake before and after
+the intervention could not be reported because different
+instruments were used in different venues. These parameters
+were documented in the diaries and used for advice during
+the monthly medical monitoring; (b) the compliance for the
+initial classes of 12 weeks was good with 95 % attendance
+with an attrition rate of 38 % by 9th month. This attrition rate
+is similar to that reported in clinical trials involving diabetics
+for self monitoring and management of diabetes (2.3 % –
+50 %) [33]. This attrition rate could be attributed to longer
+duration of intervention. The yoga based lifestyle program
+was safe and did not cause any injuries to participants. All
+facets of the yoga program were equally adhered to by the
+participants.
+In conclusion, YLSP is better than ELSP in reducing the
+requirement of oral hypoglycemic agents, increasing HDL
+and decreasing LDL and YLSP is similar to ELSP in reduc-
+ing blood glucose, HbA1c, triglycerides, VLDL and total
+cholesterol levels. Our study suggests that yoga, a non-
+expensive technique that has become popular around the
+globe with good acceptability and generalizability, may be
+incorporated in all primary and secondary prevention pro-
+grams for type 2 diabetics in clinical practice.
+Future research should be three armed randomised con-
+trol designs to control for other confounding variables such
+as diet, weight and monitoring of VO2 max to match the
+intensity of exercises between groups and inclusion of other
+measures to understand the underlying mechanisms.
+Acknowledgments
+The study was funded by the Department of
+Ayurveda, Yoga, Unani, Siddha and Homoeopathy (AYUSH), Ministry
+of Health and family welfare, New Delhi, India under the ‘Extra Mural
+Research’ scheme. The AYUSH technical expert committee had
+reviewed the study design. We thank Dr Srikanta SS, Dr Vadiraja
+HS, Dr Shruddha K, Dr Bogavi L, Dr Mallikarjuna, Dr Srividya, Dr
+Pradhan B, Omkar G, the management, doctors and the paramedical
+staff of TVS company, and BEML company the management of Satya
+Sai trust, Diwakar hospital.
+References
+1. Mohan V, Jaydip R, Deepa R. Type 2 diabetes in Asian Indian
+youth. Pediatr Diabetes. 2007;8 Suppl 9:28–34.
+2. Winer N, Sowers JR. Diabetes and arterial stiffening. Adv Cardiol.
+2007;44:245–51.
+3. Ramachandran A, Snehalatha C, Sivasankari S, Hitman GA, Vijay V.
+Parental influence on the spectrum of type 2 diabetes in the offspring
+among Indians. J Assoc Physicians India. 2007;55:560–2.
+4. Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiol-
+ogy of type 2 diabetes: Indian scenario. Indian J Med Res.
+2007;125:217–30.
+5. Chandola T, Brunner E, Marmot M. Chronic stress at work and the
+metabolic syndrome: prospective study. BMJ. 2006;332:521–5.
+6. Gross R, Olfson M, Gameroff MJ, Carasquillo O, Shea S, Feder A,
+et al. Depression and glycemic control in Hispanic primary care
+patients with diabetes. J Gen Intern Med. 2005;20:460–6.
+7. Williamson DF, Vinicor F, Bowman BA. Primary prevention of
+type 2 diabetes mellitus by lifestyle intervention: implications for
+health policy. Ann Intern Med. 2004;140:951–7.
+8. Egede LE. Lifestyle modification to improve blood pressure con-
+trol in individuals with diabetes: is physician advice effective?
+Diabetes Care. 2003;26:602–7.
+9. Sigal RJ, Kenny GP, Boule NG, Wells GA. Prud’homme D, Fortier
+M, et al. Effects of aerobic training, resistance training, or both on
+glycemic control in type 2 diabetes: a randomized trial. Ann Intern
+Med. 2007;147:357–69.
+10. Surwit RS, van Tilburg MA, Zucker N, McCaskill CC, Parekh P,
+Feinglos MN, et al. Stress management improves long-term
+glycemic control in type 2 diabetes. Diabetes Care. 2002;25:30–4.
+11. Surwit RS, Feinglos MN. The effects of relaxations on glucose
+tolerance in non-insulindependent diabetes. Diabetes Care.
+1983;6:176–9.
+12. Lustman PJ, Griffith LS, Freedland KE, Kissel SS, Clouse RE.
+Cognitive behavior therapy for depression in type 2 diabetes
+mellitus. A randomized, controlled trial. Ann Intern Med.
+1998;129:613–21.
+13. Delamater AM, Jacobson AM, Anderson B, Cox D, Fisher L,
+Lustman P. et al. Psychosocial therapies in diabetes: report
+of the Psychosocial Therapies Working Group. Diabetes Care.
+2001;24:1286–92.
+14. Sundar S, Agrawal SK, Singh VP, Bhattacharya SK, Udupa KN,
+Vaish SK. Role of yoga in management of essential hypertension.
+Acta Cardiol. 1984;39:203–8.
+15. Nagarathna R, Nagendra HR. Yoga for bronchial asthma: a
+controlled study. Br Med J (Clin Res Ed). 1985;291:1077–9.
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130
+129
+16. Monro R, Powar J, Anil C, Nagarathna R, Dandona P. Yoga
+therapy for NIDDM- a control trial. J Complemen Med Res.
+1992;6:66–8.
+17. Manchanda SC, Narang R. Yoga and coronary artery disease.
+Indian Heart J. 1998;50:227–8.
+18. Innes KE, Vincent HK. The influence of yoga-based programs on
+risk profiles in adults with type 2 diabetes mellitus: a systematic
+review. Evid Based Complement Alternat Med. 2007;4:469–86.
+19. Nagarathna R, Nagendra HR, Monro R. Yoga for common ailments.
+3rd ed. London: GAIA; 1991.
+20. Damodaran A, Malathi A, Patil N, Shah N, Suryavansihi, Marathe S.
+Therapeutic potential of yoga practices in modifying cardiovascular
+risk profile in middle aged men and women. J Assoc Physicians
+India. 2002;50:633–40.
+21. Singh S, Malhotra V, Singh KP, Madhu SV, Tandon OP. Role of
+yoga in modifying certain cardiovascular functions in type 2
+diabetic patients. J Assoc Physicians India. 2004;52:203–6.
+22. Hegde SV, Adhikari P, Kotian S, Pinto VJ, D’Souza S, D’Souza V.
+Effect of 3-month yoga on oxidative stress in type 2 diabetes with
+or without complications: a controlled clinical trial. Diabetes Care.
+2011;34:2208–10.
+23. Madanmohan, Bhavanani AB, Dayanidy G, Sanjay Z, Basavaraddi
+IV. Effect of yoga therapy on reaction time, biochemical parame-
+ters and wellness score of peri and post-menopausal diabetic
+patients. Int J Yoga. 2012;5:10–5.
+24. Birdee GS, Yeh G. Complementary and Alternative Medicine
+Therapies for Diabetes: A Clinical Review. Clinical Diabetes.
+2010;28:147–55.
+25. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible
+statistical power analysis program for the social, behavioral, and
+biomedical sciences. Behav Res Methods. 2007;39:175–91.
+26. Rai L, Ram K, Kant U, Madan SK, Sharma SK. Energy expendi-
+ture and ventilatory responses during Siddhasana–a yogic seated
+posture. Indian J Physiol Pharmacol. 1994;38:29–33.
+27. Schreiber WE, Busser JR, Huebsch S. Which laboratory tests do
+students in an internal medicine clerkship need to learn about? Am
+J Clin Pathol. 2008;130:696–701.
+28. Current Index of Medical Specialties (CIMS). India:CMP Medica,
+2007 http://www.mims.com/drug/dose. Accessed 17 July 2011.
+29. St John A, Davis TM, Goodall I, Townsend MA, Price CP. Nurse-
+based evaluation of point-of care assays for glycated haemoglobin.
+Clin Chim Acta. 2006;365:257–63.
+30. Fossati P, Prencipe L. Serum triglycerides determined colorimetri-
+cally with an enzyme that produces hydrogen peroxide. Clin
+Chem. 1982;28:2077–80.
+31. Lindgren FT, Silvers A, Jutaglr R, Layshot L, Bradley DD. A
+comparison of simplified methods for lipoprotein quantification
+using the analytic ultracentrifuge as a standard. Lipids. 1977;12:278–
+82.
+32. Yagi K. Lipid peroxides and human diseases. Chem Phys Lipids.
+1987;45:337–51.
+33. Heneghan C, Perera R, Ward AA, Fitzmaurice D, Meats E,
+Glasziou P. Assessing differential attrition in clinical trials: self-
+monitoring of oral anticoagulation and type II diabetes. BMC Med
+Res Methodol. 2007;7:18.
+34. Schafer JL, Graham JW. Missing data: our view of the state of the
+art. Psychol Methods. 2002;7:147–77.
+35. Dempster AP, Laird NM, Rubin DB. Maximum likelihood from
+incomplete data via the EM algorithm. J Royal Stat Soc, Ser B.
+1977;39:1–38.
+36. Gordon LA, Morrison EY, McGrowder DA, Young R, Fraser YT,
+Zamora EM, et al. Effect of exercise therapy on lipid profile and
+oxidative stress indicators in patients with type 2 diabetes. BMC
+Complement Altern Med. 2008;8:21.
+37. Agrawal R, Aradhana R, Hussain S, Sabir M, Kochar D, Kothari
+R. Influence of yogic treatment on quality of life outcomes,
+glycaemic control and risk factors in diabetes mellitus. Int J Diabet
+Dev Ctries. 2003;23:130–4.
+38. Agte VV, Tarwadi K. Sudarshan kriya yoga for treating type 2 diabetes:
+a preliminary study. Altern Complet Therap. 2004;10:220–2.
+39. Iborra RT, Ribeiro IC, Neves MQ, Charf AM, Lottenberg SA,
+Negrao CE, et al. Aerobic exercise training improves the role of
+high-density lipoprotein antioxidant and reduces plasma lipid
+peroxidation in type 2 diabetes mellitus. Scand J Med Sci Sports.
+2008;18:742–50.
+40. Fehm HL, Kern W, Peters A. The selfish brain: competition for
+energy resources. Prog Brain Res. 2006;153:129–40.
+41. Vempati RP, Telles S. Yoga-based guided relaxation reduces
+sympathetic activity judged from baseline levels. Psychol Rep.
+2002;90:487–94.
+42. Chaya MS, Ramakrishnan G, Shastry S, Kishore RP, Nagendra H,
+Nagarathna R, et al. Insulin sensitivity and cardiac autonomic
+function in young male practitioners of yoga. Natl Med J India.
+2008;21:217–21.
+43. Timmermans RJ, Saris WH, van Loon LJ. Insulin resistance: the
+role of intramuscular triglyceride and the importance of physical
+activity. Ned Tijdschr Geneeskd. 2006;150:122–7.
+44. Singh S, Malhotra V, Singh K, Sharma S. A preliminary report on
+the role of yoga asanas on oxidative stress in non-insulin
+dependant diabetes. Indian J Clin Biochem. 2001;16:216–20.
+130
+Int J Diabetes Dev Ctries (July–September 2012) 32(3):122–130