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+Health Care for Women International, 36:256–275, 2015
+Copyright © Taylor & Francis Group, LLC
+ISSN: 0739-9332 print / 1096-4665 online
+DOI: 10.1080/07399332.2014.942900
+A Holistic Antenatal Model Based on Yoga,
+Ayurveda, and Vedic Guidelines
+ABBAS RAKHSHANI and RAGHURAM NAGARATHNA
+Department of Life Sciences, Svyasa University, Bengaluru, India
+AHALYA SHARMA
+Shalya Tantra (Ayurveda Surgery), Government Ayurvedic Medical College, Mysore, India
+AMIT SINGH and HONGASANDRA RAMARAO NAGENDRA
+Department of Life Sciences, Svyasa University, Bengaluru, India
+The prevalence of pregnancy complications are on the rise globally
+with severe consequences. According to the World Health Organi-
+zation (WHO, 2009), every minute, at least one woman dies and
+20 are affected by the complications related to pregnancy or child-
+birth. While the root cause of pregnancy complications is unclear, it
+likely has physical, psychological, social, and spiritual aspects. The
+Vedas are a rich source of antenatal health care guidelines in all
+these aspects. The primary objective of the authors was to compile
+the scriptural and scientific evidence for a holistic antenatal model
+of yoga with emphasis on sociocultural Indian practices.
+Millions of women globally suffer from some form of pregnancy complica-
+tion each year (World Health Organization [WHO], 2009). While scientific
+advances in antenatal health care have saved many lives with reduced ma-
+ternal and infant mortality (Seibel, Kiessling, Bernstein, Bernstein, & Seibel,
+1993), they have not been able to explain the root cause of pregnancy
+complications and, as a result, the prevalence of these disorders is on the
+rise (Narendran, Nagarathna, & Nagendra, 2008). Maternal stress has been
+implicated as a contributing factor to the etiology of many complications
+of pregnancy (Zamorski & Green, 1996). Yoga has been shown to reduce
+maternal stress and improve pregnancy outcomes (Rakhshani et al., 2012).
+Received 20 September 2012; accepted 2 July 2014.
+Address correspondence to Abbas Rakhshani, Department of Life Sciences, Svyasa Uni-
+versity, #19, Eknath Bhavan, Gavipuram Circle, Kempe Gowda Nagar, Bengaluru 560018,
+India. E-mail: [email protected]
+256
+Holistic Antenatal Model
+257
+Based on previous studies, the authors believe that a holistic model based
+on the yogic and Ayurvedic guidelines can be effective in the management
+of low-risk and high-risk pregnancies.
+A pregnancy complication is defined as a problem that arises during
+pregnancy and can potentially put the health of the mother, fetus, or both
+at risk (Beers, Fletcher, Jones, & Porter, 2003). According to the WHO, more
+than 20 million pregnant women worldwide annually suffer from at least
+one obstetric complication of pregnancy (WHO, 2009), excluding Caesarean
+section; with miscarriage, preterm deliveries, low birth weight, and fetal de-
+formities being the most prevalent (Porter, 2009). While the root causes of
+these disorders are not clear, maternal stress has been shown to play a
+major role in their development (Roy-Matton, Moutquin, Brown, Carrier, &
+Bell, 2011). Maternal stress has been shown to adversely affect pregnancy
+outcomes (Zamorski & Green, 1996). In fact, several studies have reported
+that events in the maternal environment will filter through the placental
+barrier and can affect the development of the placenta (Grammatopoulos,
+2008; Hecht et al., 2008). Furthermore, there is now mounting evidence that
+maternal stress can not only increase the risk of morbidity and premature
+mortality (Pinar & Carpenter, 2010) but it can also predispose the affected
+individuals to diseases over the course of their lives (Li & Wi, 1999). In
+addition to maternal psychological stress, poor diet and sedentary lifestyle
+of the mother has been linked to increased risk of complications during
+pregnancy (Krishna & Harigopal, 1979; Saraswati, 2008). Additionally, ma-
+ternal diet has been shown to influence fetal growth (Drake et al., 2012).
+Therefore, maintaining a good regime of diet, exercise, and a lifestyle that
+promotes minimum psychological stress for the mother can be a prelude to
+a successful pregnancy.
+Yoga, a 5,000-year-old Indian practice, is a holistic approach that pro-
+motes physical, mental, and spiritual well-being in practitioners (Bijlani,
+2008). A recent review has enlisted the potential positive effects of yoga
+during pregnancy (Babbar, Parks-Savage, & Chauhan, 2012). Yoga has been
+shown to reduce perceived pain (Reis, 2012), improve sleep efficiency (Bed-
+doe, Lee, Weiss, Kennedy, & Yang, 2010), promote shorter duration of
+labor (Chuntharapat, Petpichetchian, & Hatthakit, 2008), and improve ma-
+ternal quality of life (Rakhshani, Maharana, Raghuram, Nagendra, & Venka-
+tram, 2010). The Integrative Approach of Yoga Therapy (IAYT) is a set of
+yoga modules to address many lifestyle-related health conditions. In low-
+risk pregnancy, IAYT has been shown to improve pregnancy outcomes
+(birthweight and APGAR scores) and reduce the frequency of occurrence of
+pregnancy complications, including pregnancy-induced hypertension (PIH),
+intra-uterine growth restriction (IUGR), and small for gestational age (SGA;
+Narendran, Nagarathna, Narendran, Gunasheela, & Nagendra, 2005b). In
+high-risk pregnancy, yoga has been shown to dramatically reduce incidence
+of hypertension-related complications, improve pregnancy outcomes, and
+258
+A. Rakhshani et al.
+promote the health of the fetus (Rakhshani et al., 2012). An important
+observation in the latter study was that participants were inclined to go
+to their hometowns at the first sign of any complication, and more so at the
+time of delivery. Further inquiry revealed that these tendencies were woven
+into the fabric of the Indian culture and perhaps into many other cultures
+around the globe. The importance of local traditions to modern clinical trials
+is another reason for the development of this model.
+Sociocultural factors play an important role in increasing maternal stress
+during pregnancy. Through millenniums, Indian traditions have evolved to
+reduce such stress and promote well-being in the mother and her fetus
+(Pandey, 2002). The focus continues after the child is born and throughout
+his or her life (Pandey, 2002). In fact, Indian beliefs are based on the ide-
+ology that life is a precious gift from God and it should be celebrated, at
+every stage, from conception to death (Tull, 2008). From this social point of
+view, a baby is the product of that sacred union, and, therefore, it is con-
+sidered a divine gift. It is not then surprising that there are numerous rituals
+centered around marriage and pregnancy in the Indian traditions. These rit-
+uals, often referred to as Samsk¯
+aras (a word which literally means “making
+complete”) in the Vedic literature, are meant to infuse divinity at every step
+of the reproductive process (Tull, 2008). Such rituals are not exclusive to the
+Indian traditions though. Nearly every culture around the globe has strong
+established rituals for marriage, pregnancy, and birth (Hamon & Ingoldsby,
+2003).
+The primary objective of the authors was to formulate a potential com-
+prehensive and holistic antenatal health care model that can provide guide-
+lines: (a) for design of future studies in this important area, and (b) for
+providing sustainable and effective health care to pregnant women. The
+model takes into account previous studies involving yoga and nutrition dur-
+ing pregnancy, as well as the related Vedic scriptures and the Indian ritu-
+als, Samsk¯
+aras, that may be of value for timing the interventions. Although
+the social and spiritual aspects of the model are geared toward the Indian
+traditions and philosophies, practices from other traditions could easily be
+incorporated into the model without affecting the other elements of it.
+Health From the Modern Medicine Point of View
+The WHO defines health as “a state of physical, mental, social and spiritual
+well-being, and not merely the absence of disease or infirmity” (Larson, 2006,
+p. 181). We chose this definition as the framework to develop this holistic
+antenatal model.
+Health From the Vedic Point of View
+From the Vedic point of view, the physical body is the grossest part of
+the human existence. There are also other metaphorical bodies, sometimes
+Holistic Antenatal Model
+259
+FIGURE 1 Effects of lifestyle stress versus yoga on health.
+Note: The yogic practices and lifestyle stress have opposing effects on the different ko´
+sas. The
+negative impact of the lifestyle stress has been illustrated in this figure by uneven arrows.
+called ko´
+sa (
+) or sheaths, that are more subtle than the physical body
+but play equally important roles in our emotional, mental, and spiritual well-
+being (Rakhshani, 2013). Including the physical body, there are a total of
+five ko´
+sas that are collectively referred to as pancha ko´
+sas (
+). Yoga
+seeks the root causes of illnesses within the four subtle bodies, believing
+that the diseases of the physical body are manifestations of disturbances in
+those metaphorical layers (Rakhshani, 2013). Table 1 outlines the different
+bodies and their primary functions.
+Manomaya ko´
+sa is of particular importance in maintaining optimum
+health. Disturbances in this ko´
+sa, due to lifestyle stress or past traumas,
+interfere with the flow of prana in pranamaya ko´
+sa, which ultimately result in
+failure of a particular weak organ in the annamaya ko´
+sa. Such disturbances
+can also affect the vijnanamaya ko´
+sa and distort viveka (discrimination),
+which in turn blocks proper contacts with the anandamaya ko´
+sa (blissful
+state). Figure 1 shows this interaction graphically.
+Embryology From the Vedic and Modern Standpoints
+The classic Ayurvedic literature describes the fertilization process, under the
+heading of “S¯
+ar¯
+ira Sth¯
+ana.” These texts also give details on the composition of
+the matter based on the following five elements that constitute the universe
+outside and inside of the body: (a) earth (prthvi = solid), (b) fire (agni =
+heat), (c) water (ap = fluid), (d) air (vayu = movement), and (e) space
+(aakasa). The Vedic literature gives a particular emphasis on the role of vayu
+in the conception and development of an embryo since vayu controls the
+mind. For that reason, anxiety, stress, and other emotions could potentially
+interfere with conception (Bhishagratna, 1991). Of all the factors stated for
+260
+A. Rakhshani et al.
+TABLE 1 Ko´
+sas and Their Primary Characteristics
+Ko´
+sa1,2
+Description
+Annamaya ko´
+sa
+“Anna” means food. This physical body needs food as its
+nourishment “annadhyeva khalvimani bhut¯
+ani jayante”
+(everything is born out of physical matter); “annena jat¯
+ani
+jivanti” (they live because of anna); “annam prayanti
+abhisa ˙
+mvisanti” (they merge into anna); and “j¯
+atanyannena
+vardhante” (they grow because of anna).3 If this ko´
+sa is
+neglected, improvement in other ko´
+sa become difficult if not
+impossible.
+Pranamaya ko´
+sa
+“Pr¯
+ana” means vital energy. It refers to the energy that is
+responsible for the physiological activities of all living cells. Five
+sections of the main pr¨
+a¨
+ea manage the functions in five zones:
+pr¯
+ana (respiration and special senses), ap¯
+ana (defecation,
+micturition, menstruation, etc), sam¯
+an¯
+a (digestion), vy¯
+an¯
+a (touch
+sense, circulation of fluids all over etc), and ud¯
+ana (thinking,
+belching, vomiting, etc).4 pr¯
+ana circulates through an intricate
+and invisible system of pathways called nadis. The main three
+nadis are ida, pi`
+ıgal¯
+a, and c
+¸uc
+¸uman¨
+a in the spine. They branch
+out to about 72,000 nadis throughout the body. The ida and
+pi ˙
+ngal¨
+a channels correlate with the left and right nostrils, making
+it possible to manipulate pr¯
+ana through controlled breathing.
+Manomaya ko´
+sa
+“Manah” means mind. This ko´
+sa is the seat of perception and
+emotions. Using the five senses, information is acquired to create
+a perception of the world outside and then used to prepare
+appropriate emotional responses to those perceptions.
+Vijnanamaya ko´
+sa
+“Vji˜
+n¯
+ana” means knowledge. This is the seat of wisdom that
+facilitates the thinking process of the mind. Utilizing this faculty,
+we are able to discriminate right from wrong and make
+appropriate judgments (viveka) for a healthy lifestyle. More
+significantly, this is the place of intuition that is used when
+analytical process fails to guide us.
+Anandamaya ko´
+sa
+“¯
+ananda” means bliss. This forms the unchanging template of
+(existence, consciousness, and bliss) of our being on which the
+other ko´
+sas carry on their activities. This is also the basic stuff of
+this entire creation. ¨
+anandamaya ko´
+sa is experienced as a
+blissful ecstatic state of pure awareness when all mental activity
+ceases. The main approach of yoga therapy as a mind-body
+medicine is to maintain the practitioner in this state that is
+regarded as a state of perfect health.
+1The bodies are listed from the grossest, the physical body, to the subtlest, the bliss body.
+2‘Maya’ means illusion. Therefore, all these five bodies must be conquered by the spiritual practitioner of
+yoga in order for he or she to realize the nature of his soul, which sits beyond these illusions.
+3Taittiriya upanis
+.ada 3.2.
+4Reference to the pancha pranas appears in several scriptures; including Mahabharata and Shikshavalli
+Upanishad.
+conception, therefore, Saumanasya (happiness/tranquility of mind) of the
+mother is considered to be the most important factor (Sharma & Bhagwan,
+1992). The unborn child is also said to emulate the nature of the maternal
+mindset during fertilization (Sharma & Bhagwan, 1992).
+Holistic Antenatal Model
+261
+The Garbha or embryo is described in the Vedic literature as the union of
+the sperm, the ovum, and the soul in the womb. First, the conscious element
+(i.e., the soul) endowed with mental faculty, unites with the mahabhutas
+(maha means great and bhutas means elements; the term refers to the five
+great elements: ether, air, fire, water, and earth) in a fraction of a second.
+This would be a Vedic explanation for the reason why in-vitro fertilization
+fails so often. The embryo also requires the maternal and paternal factors:
+saatmya (wholesomeness), rasa (digestive product of mother’s food), and
+mind (Bhishagratna, 1991). The mind is said to propel the jeeva (soul) into
+the uterus impelled by the deeds of previous lives.
+The Bh¯
+agavata Pur¯
+ana states the concept of conception in canto 3, chap-
+ter 31, verse 1, as, “The living entity, the soul, is made to enter into the womb
+of a woman through the particle of male semen to assume a particular type
+of body (
+)”
+(Gupta & Valpey, 2013). This concept parallels science’s view that the sper-
+matozoon joins the oocyte in the uterine tube to form a zygote. In the
+following verse, the next development of the embryo is explained:
+The sperm and the ovum mix on the first night and by the fifth night,
+the union looks more like a bubble, which gradually turns into a lump
+like a plum by the tenth night and later into an egg. (
+)
+Once again, an unprecedented description of mitosis is put forward. The
+zygote becomes a morula (of 12 to 16 cells) after 5 nights and then develops
+into a blastocyst with a fluid-filled center (just like a bubble) in 10 days (The
+Endowment for Human Development, 2010). The accuracy of this develop-
+ment is uncanny and clearly shows the ability of the seers to visualize the
+process through meditation since there were no other means to do so at that
+time. The next verse further explains the organ development of the embryo
+in the first trimester:
+By the end of the first month, the head is formed and by the end of
+the first three months, the hands and the feet are formed along with
+the nails, fingers, toes, body hair, and the bones. By this time, the
+skin appears, as do the organ of generation and the other apertures
+in the body, namely the eyes, nostrils, ears, mouth and anus. (
+)
+Once again, this passage mirrors discoveries of modern science with amazing
+accuracy. Indeed, the formation of the brain starts at the very early stages
+of embryo development. Between the fourth and fifth weeks of pregnancy,
+the head has developed to a much larger size compared with the rest of
+262
+A. Rakhshani et al.
+the body, giving the embryo the look of a tadpole (The Endowment for
+Human Development, 2010). In the same line, the next few verses describe
+the growth of the organs formed in the first trimester.
+The Sixteen Samsk¯
+aras
+It is important to point out that the role of women in Hindu society is
+complex due to its dual nature. On one hand, they are viewed as fertile and
+compassionate caregivers, but, on the other hand, they can be viewed as
+hostile and overprotective (Wadley, 1977). A woman’s overemphasized role
+as a caregiver may be the primary cause of her aggressiveness toward people
+whom she suspects may want to hurt her family physically, financially, or
+socially. A point of particular concern to her is an “evil eye” (or evil spirit)
+that envies her life and wants to damage it through negative energy. Part
+of the childbearing rituals are concerned with repelling such external forces
+(Jacobson & Wadley, 1992) through mantras and divine offerings, which are
+believed to ensure normal progression of the different stages of pregnancy
+and provide the mother with the necessary social acceptance. Table 2 lists
+the 16 most frequently practiced Samsk¯
+aras in India. Here, we shall very
+briefly describe only the first four, which are relevant from the point of
+conception through delivery of the newborn.
+First
+Samsk¯
+ara:
+Garbh¯
+adh¯
+ana
+(
+)—The
+conception
+ritual.
+“Garbha” means womb, and “adaana” means donation (Dasji, 2010). There-
+fore, the term “Garbhadana” literally means donation to the womb (Alter,
+1997). In India, the procreation of offspring is regarded as necessary for
+paying off debt to the forefathers (Dasji, 2010).
+Second Samsk¯
+ara: Pu ˙
+msavana (
+)—The ritual for seeking a male
+offspring.
+Pumsavana literally means engendering a male offspring. Tradi-
+tionally, male offsprings have been preferred since they maintain the conti-
+nuity of the family lineage (Pandey, 2003). Also, sons are required to perform
+the necessary cremation rituals that guarantee a safe passage for the father
+and the mother after they leave this world (Pandey, 2003). Some authors,
+however, have distanced themselves from the gender connotation of this
+Samsk¯
+ara and have interpreted it as a ritual to secure a child full of vi-
+tality (Tambe, 2011). After Garbhadhan Samsk¯
+ara, and when symptoms of
+pregnancy have manifested, the Pumsavana Samsk¯
+ara is performed, usu-
+ally during the second month of pregnancy when the moon is in a male
+constellation. Pumsavana and Simantonyana (the third Samsk¯
+ara) are only
+performed during a woman’s first pregnancy (Dasji, 2010). During the cer-
+emony, the pregnant woman consumes one bead of barley and two beads
+of black grain, along with a little curd (Dasji, 2010). This is accompanied by
+a Homa (a fire ritual, where offerings are given to the deities through fire)
+and chanting of the following by the acharya (the priest; Dasji, 2010): “The
+Holistic Antenatal Model
+263
+TABLE 2 The 16 Samsk¯
+aras
+Samsk¯
+ar¯
+a (
+)
+Pregnancy stage
+Description
+1
+˙
+garbh¯
+adh¯
+ana
+Prior to conception
+The ritual of conception
+2
+pu ˙
+ms¯
+avana
+During pregnancy
+The ritual of seeking a male child
+3
+s¯
+imantonnayana
+During pregnancy
+The ritual for safe delivery
+4
+jat¯
+akarma
+At birth
+The ritual to purify the newborn
+5
+n¯
+amakara¨
+eam
+After birth
+The naming ceremony
+6
+niskrama¨
+eam
+After birth
+The first outing ceremony
+7
+annaparasana
+After birth
+The first solid food feeding ceremony
+8
+c¯
+ud
+. ¯
+akaran
+. am
+After birth
+The tonsure ceremony
+9
+karnabhedhah
+.
+After birth
+The ear piercing ceremony
+10
+vidy¯
+arambhah
+.
+Childhood
+The education ceremony
+11
+upanayanam
+Childhood
+The sacred thread wearing ceremony
+12
+ved¯
+arambhah
+.
+Youth
+The initiation into the Vedic studies
+13
+ke´
+s¯
+antah
+Youth
+The first shaving ceremony
+14
+sam¯
+avartanam
+Adult
+The school graduation ceremony
+15
+viv¯
+ahah
+Adult
+The marriage ceremony
+16
+anty¯
+esti
+Adult
+The funeral rites
+Pumsavana Samsk¯
+ara is performed with a view that a healthy and bright
+child may born” (Dasji, 2010, p. 15).
+Third Samsk¯
+ara: S¯
+imant¯
+onnayana (
+) —A ritual for safe deliv-
+ery.
+The objective of this Samsk¯
+ara is to ensure a complication-free preg-
+nancy and a safe delivery of the child. It is usually performed in the fourth
+month of pregnancy (Pandey, 2003). First, a prayer is offered to the deities
+and, then, while combing the hair of his wife from front to back, the husband
+chants the following to protect the fetus: “I perform this Simantonnayanam
+Samsk¯
+ara to please God and for the development of the fetus of my wife
+and to remove any obstacles caused by evil spirits and to bring all things of
+prosperity [to the fetus]” (Dasji, 2010, p. 17). Finally, “other old and young
+ladies of the noble families bless the pregnant woman” (Dasji, 2010, p. 17).
+264
+A. Rakhshani et al.
+Fourth Samsk¯
+ara: J¯
+atakarma (
+) —The ritual to purify the newborn.
+Jatakarman literally means natal rites and it is similar in concept to that
+of baptizing the newborn in Christianity. This Samsk¯
+ara is performed right
+before severing the umbilical cord. Its purpose is to ensure proper intellectual
+development, adequate strength, and a long life for the newborn (Dasji,
+2010). The father places a mixture of honey and ghee on the tongue of the
+child and blesses him with the following prayer: “You [the fetus] may become
+strong like a stone. Brave against the enemies like the great sage Parshuram
+and you may remain pious forever like the gold” (Dasji, 2010, p. 18). Then
+the father cuts the umbilical cord and the child is bathed with milk to bless
+him with physical, mental, and spiritual progress. Finally, the acharya chants
+the following prayer to seal the ritual: “I perform this jatakarma Samsk¯
+ara for
+pleasing the God and to remove all kinds of obstacles produced by this child
+staying in the womb and getting nourishments from the mother through the
+placenta” (Dasji, 2010, p. 18).
+The Integrative Approach of Yoga Therapy (IAYT)
+Yoga is a holistic approach to well-being that originated in India (Bijlani,
+2008). It involves a combination of stretching, breathing, posture, and med-
+itation that promotes health and spiritual growth in the practitioners (Chan-
+dler, 2001). These techniques are lowimpact, noninvasive, and have few
+side-effects (Benson & McCallie, 1979). A growing body of research data now
+supports the use of yoga for prevention and management of chronic lifestyle-
+related ailments (Bijlani, 2008; Hanser, 2009; McCall, 2007; Taylor, 2003). The
+IAYT is a holistic approach of health management that uses kriyas, asanas,
+pranayamas, meditation, devotional chanting, and self-analysis (Narendran
+et al., 2008).
+METHODS
+An antenatal model was planned based on WHO’s definition of health and
+the Vedic perspective of well-being with a focus on Indian sociocultural
+practices (Samsk¯
+aras). The model can easily be adapted to other cultures
+and incorporate their traditions. We have adopted a systematic approach for
+the development of the model, which consists of three phases that are ex-
+plained below. Through this process, we research, collect, and put together
+guidelines from the Vedic literature, the yogic sciences, and Ayurvedic
+medicine to formulate a holistic model that addresses the well-being of
+the women physically, psychologically, emotionally, socially, and spiritually.
+Figure 2 illustrates the three developmental phases for this model.
+Procedure
+Phase 1: Compilation of the data from the literature.
+A Vedic literature
+search for the ancient pregnancy practices, which are relevant to modern
+Holistic Antenatal Model
+265
+FIGURE 2 Phases of the antenatal model development.
+medicine, was conducted and was summarized in the first section of this
+article. In this phase, the results were compiled into a table based on their
+potential applications to modern antenatal care.
+Phase 2: Compilation of the data from the field.
+The present model was
+developed by incorporating the recommendations of health practices for the
+well-being of pregnant women gathered in Phase I.
+Phase 3: Development of the antenatal model.
+The main aim of this
+phase was to collect all available evidences for the effects of these health
+practices. While there are some published data indicating the potential ben-
+efits of yoga in pregnancy, we found that the literature lacks evidence on
+the effects of another school of Indian medicine, particularly Ayurveda, that
+is widely practiced in India. Hence, Ayurvedic physicians who have adopted
+these Samsk¯
+aras in their routine practices were interviewed and the relevant
+collected data was compiled and has been presented below.
+RESULTS
+Phase 1
+Table 2 summarizes the data collected from the Vedic literature regarding
+the applicable Samsk¯
+aras.
+Phase 2
+The results of the second phase of this work are presented in Tables 3 and 4.
+The model has four domains, with the recommended practices highlighted
+under each heading. Detailed accounts of the physical, psychological, social,
+and spiritual domains are provided here.
+Physical domain.
+At the physical level, a healthy lifestyle (dinacharya)
+is recommended, which includes proper diet, cleansing techniques, and yoga
+266
+A. Rakhshani et al.
+TABLE 3 Diet During Pregnancy Based on the Yogic and Ayurvedic Principles
+Gestational age
+Diet recommendations
+First trimester
+0–4 weeks
+Non-medicated milk repeatedly, generally sweet, cold and
+liquid diet
+5–8 weeks
+Milk medicated with herbs belonging to the group of
+Madhura-aushadhi, such as kakoli (Roscaea procera), draksha
+(grapes), and yashti madhu (Glycyrrhiza glabra)
+9–12 weeks
+Milk with honey and ghee
+Second trimester
+13–16 weeks
+Butter mixed with milk (Ch.Sh.8/32), cooked Shasti rice (rice
+grown for 60 days) with curd
+17–20 weeks
+Ghee and milk
+21–24 weeks
+Milk prepared with madhura guna dravyas with ghee plus ghee
+and rice gruel medicated with Gokshura (Small caltrops)
+Third trimester
+25–28 weeks
+Ghee medicated with the drugs of pr˚
+athak parny¨
+adi (Uraria
+picta etc) group
+29–32 weeks
+Medicated oil enemas: (a) Asthapana Basti using a decoction of
+badara (jujube fruit), bal¨
+a (Country mallow), atibal¨
+a (Indian
+mallow), ´
+satapusp¯
+a (fennel), palala (pestled sesame seeds),
+milk, curd, mastu (whey/supernatant liquid of butter milk),
+oil, salt, madanaphala (emetic nut), honey and ghee, and (b)
+followed by Anuvasana Basti with ghee medicated with
+Madhura guna Dravyas mentioned above
+33 weeks to delivery
+Thick rice gruel, mixed with ghee (Yav¨
+agu)
+postures. Vedic literature emphasizes the effects of diet on the internal milieu
+of subtle energy systems (vata, pitta, kapha as described by Ayurveda or
+prana according to yoga) and the mind (Frawley, 1999).
+Rice, milk, and clarified butter (ghee) medicated with various herbs play
+a major role in the diet of a pregnant woman according to the yogic and
+Ayurvedic teachings as outlined in Table 3 (Sharma & Bhagwan, 1992). These
+medicinal herbs include those belonging to the group of Madhura-aushadhi,
+such as roscaea procera (a genus of 22 species belonging to the ginger
+family, such as kakoli, known in English as Fritillary), wild grapes (also
+known as draksha, a plant that pacifies vata and pitta; it is often used to treat
+ulcers, inflammations, fracture, dysentery, diarrhea, fever, poisonous bites,
+and respiratory infections), and licorice (also known in English as Tribulus
+terrestris Linn, is the root of glycyrrhiza glabra and belongs to the legume
+family) during the second month (Sharma & Bhagwan, 1992). No medicinal
+herbs are recommended during the third, fourth, and fifth months of preg-
+nancy (Bhishagratna, 1991). During the sixth month, ghee prepared with
+“small caltrops” (also known as Gokshura or Tribulus Terrestris, is believed
+to contain steroidal saponins, alkaloids, and flavanoids, and has been shown
+to improve fetal development in sheep [Walker, Bird, Flora, & O’Sullivan,
+1992] and reduce oxidative stress in rats [Kamboj, Aggarwal, Puri, & Singla,
+2011]) must be given and in the seventh month ghee made with the prithak
+Holistic Antenatal Model
+267
+TABLE 4 Antenatal Holistic Model
+Domain
+Description
+Psychological domain
+Pranayama and breathing
+practices
+Sectional breathing, nadishuddhi, Sheetali,
+bhramari, Nadanusandhana
+Kriyas
+Jala neti throughout pregnancy.
+Meditation
+Visualization, guided imagery, trataka, sectional
+breathing, nadishuddhi, Sheetali, bhramari,
+Nadanu-sandhana, Om meditation
+Social domain
+Interventions beginning prior to
+conception
+Garbhaadhaana Samsk¯
+ara for the Indian population
+and local conception traditions for the global
+population.
+Interventions during pregnancy
+Pumsavana and Simanatonnayana Samsk¯
+aras for
+the Indian population and local pregnancy
+traditions for the global population.
+Interventions after delivery
+Jatakarma Samsk¯
+ara for the Indian population and
+local birth traditions (such as baptizing) for the
+global population.
+Spiritual domain
+Jnana yoga, bhakti yoga, karma yoga, raja yoga:
+dharana, bhavana, pathana, satsanga, japa, seva,
+viveka, vairagya, and bhakti.
+parny¯
+adi group of herbs (which is said to help the fetal development accord-
+ing to the Su´
+sruta Sa ˙
+mhit¯
+a, the ancient text of Hindu system of medicine) are
+recommended (Bhishagratna, 1991). During the eighth month, the expectant
+mother is recommended to take a medicated enema (¯
+asth¯
+apana basti) of the
+decoction of jujube fruit (known in India as badara and scientifically as Zizi-
+phus zizyphus, is commonly known as red date, Chinese date, Korean date,
+or Indian date, belonging to the buckthorn family Rhamnaceae) mixed with
+country mallow (bal¯
+a), Indian mallow (atibal¯
+a), fennel (´
+satapusp¯
+a), pestled
+sesame seeds (palala), milk, curd, whey/buttermilk (mastu), oil, salt, emetic
+nut (madanaphala), honey, and ghee (Bhishagratna, 1991). This should be
+followed by a medicated oil enema (anuv¯
+asana basti), with oil prepared with
+milk and madhura gana dravyas described above (Bhishagratna, 1991). The
+pregnant woman is advised to consume rice cooked with milk and added
+ghee for the additional protein needed for the proper development of the
+fetus (Sharma & Bhagwan, 1992). Such a diet will provide proper nourish-
+ment for the annamaya kosha, enriches the pranamaya kosha, and provides
+calmness of the mind in the manomaya kosha (see Figure 1).
+Several cleansing techniques, kriyas, that are safe and useful for healthy
+progression of pregnancy and prevention of complications are incorporated
+in the model. Vamana dhouti is recommended for prevention and treatment
+of pregnancy-induced nausea and vomiting (Rao et al., 2009). Mild Kapal-
+abhati (done at a rate of 27 breaths/minute) helps in normalizing breathing
+patterns and promoting calmness of the mind during the first trimester of
+268
+A. Rakhshani et al.
+low-risk pregnancies. Jalaneti is useful to cleanse the nasal passage and may
+be safely practiced throughout high- and low-risk pregnancies.
+Yogic postures aim to achieve mastery over the fluctuations of
+the mind (
+: y¯
+oga´
+scittavrtti nir¯
+odhah; Woods, 2003). This
+is achieved by maintaining the final posture with ease and effortless-
+ness (
+prayatna ´
+saithily¯
+ananan tasam¯
+a pattibhy¯
+am;
+Woods, 2003). Yogic postures help in providing deep rest to the organs.
+The following exercises and asanas were used in high-risk pregnancies
+without any reported difficulties or safety issues (Rakhshani et al., 2012):
+p¯
+adasa˜
+nc¯
+alanam (cycling in supine pose), gulphag¯
+uranam (ankle rotation),
+j¯
+anuphalak¯
+akarsanam (kneecap contraction), ardh¯
+atitali¯
+asana (half-butterfly
+exercise), poorn¯
+atitali¯
+asana (full-butterfly exercise), jyotitr¯
+ataka (eye exer-
+cises), and matsyakr¯
+id¯
+asana (lateral shavasana). Other asanas have been
+shown to be safe in low-risk pregnancies (Rakhshani et al., 2010): tadasana
+(mountain pose), ardhakati-chakrasana (lateral arc pose), trikonasana (tri-
+angle pose), vajrasana (the ankle posture), vakrasana (spine twist pose),
+siddhasana (sage pose), Baddhakonasana (bound ankle pose), upavista
+konasana (sit with legs apart), malasana (garland pose), viparita karani (half
+shoulder stand), and ardha-pavanamuktasana (folded leg lumbar stretch).
+Breathing practices aim at reducing the breathing rate, which in
+turn calm the mind (
+´
+sv¯
+asa pra´
+sv¯
+asay¯
+orgati
+vicch¯
+edah pr¯
+an¯
+ay¯
+amah; Woods, 2003). The following breathing exercises
+were used in both high- and low-risk pregnancies (Rakhshani et al., 2010,
+2012): hasta ¯
+ayama ´
+svasanam (hands in and out breathing), hastavist¯
+ara
+´
+svasanam (hands stretch breathing), gulphavist¯
+ara ´
+svasanam (ankles stretch
+breathing with wall support), katiparivartana ´
+svsanam (side twist breathing),
+utt¯
+anap¯
+ad¯
+asana ´
+svasanam (leg raise breathing), setubandh¯
+asana ´
+svasanam
+(hip raise breathing), supta udar¯
+akarsanasana ´
+svasanam (supine abdominal
+stretch breathing), and vy¯
+aghr¯
+asana ´
+svasanam (tiger stretch breathing).
+The asanas and the breathing exercises are intended to strengthen
+the musculoskeletal system, stretch ligaments, massage organs, and bring
+oxygen-rich circulation to the various parts of the body in the annamaya
+kosha. In the pranamaya kosha, they move the prana, remove blockages in
+the nadis, and open the chakras. Finally, and most importantly, they gradu-
+ally make the mind one-pointed in the manomaya kosha (Rakhshani, 2013).
+Daily care also plays an important role in the wellness of the expect-
+ing mother. For example, after the thirty-sixthweek of gestation, Ayurvedic
+physicians recommend the following: (a) daily bathing with water boiled
+with leaves, such as those of castor bean (Eranda-Ricinus communis) and
+five-leaved chaste tree (Nirgundi-Vitex negundo), which reduce the v¨
+ata
+dosha; (b) daily massage with medicated oils (Tripathi, 2009); (c) applica-
+tion of enema (sth¯
+apan¯
+a basti) from twenty-eighth to thirty-second weeks
+followed by unctuous enema (anuvasana basti) of medicated oil with milk
+and decoction of drugs of sweet group, like madhuka (Shastri, 2009); and
+Holistic Antenatal Model
+269
+(d) insertion of vaginal tampons soaked with oil can be performed from
+thirty-sixth week onward to lubricate the cervix, the vaginal canal, and the
+perineum (Tripathi, 2009).
+Psychological domain.
+This forms the core of all practices recom-
+mended at all levels because, from the Vedic point of view, stress be-
+gins in the mind as suppressed emotions. The scriptures provide the log-
+ical steps of arriving at an understanding of the nature of any emotion
+(suppressed or expressed) and define it as “uncontrolled fast rewinding
+of thoughts in the mind” (
+k¯
+amakr¯
+odh¯
+odbhavam v¯
+egam;
+Ranganathananda, 2000). All recommended practices are meant to reduce
+stress by slowing down the mind (
+: Manah pra´
+saman¯
+op¯
+ayah).
+These include meditation of various types. Many of the recommended prac-
+tices have been used successfully as interventions in past studies (Rakhshani
+et al., 2010; Satyapriya, Nagendra, Nagarathna, & Padmalatha, 2009). The
+following pranayamas that have been used in several published studies have
+been incorporated in the model: sectional breathing, nadishiddhi, Sheetali,
+bharamari, Nadanusandhana (Satyapriya et al., 2009).
+Social domain.
+Trials targeting the Indian population should take into
+account the Samsk¯
+aras to reduce dropouts and attrition. Interventions be-
+ginning prior to conception should include marital status as part of their
+selection criteria and, in the event that unmarried couples are included,
+the Garbhadana ceremony. Astrology is the cornerstone of the Indian cul-
+ture. It would behoove the investigators, therefore, to consult with a reliable
+astrologer to find the auspicious days during the duration of the study execu-
+tion and incorporate them into the design. For example, if the interventions
+are administered during the second month of pregnancy, knowing when the
+moon is in its male constellation would allow women to anticipate the Pum-
+savana Samsk¯
+ara. Auspicious days during the fourth month of pregnancy
+would also be the time that Simanatonayan Samsk¯
+ara could be performed.
+Studies targeting other populations of the world would need to incorporate
+their own regional customs and rituals into the model.
+Spiritual domain.
+Responsibility (prabhutvam), tolerance (titiksha),
+contentment (santosha), and self-confidence (aatma vishwasah) are some of
+the essential qualities necessary for moving toward a healthy motherhood.
+Yoga is defined as “freedom” or “personal autonomy”; to be able to shift
+from established patterns of psychological responses to a desired response
+at will. To do, not to do, or to do differently is the freedom we all pos-
+sess (
+kartumakartumanyath¯
+a v¯
+a kartum ´
+sakyam;
+Badarayana, 1960). This freedom evolves by dwelling in the inner silent
+state marked by blissful awareness during yoga practices. There are numer-
+ous such practices that could be incorporated in the design of trials based
+on the teachings of the four paths of yoga, which are jnana yoga (yoga of
+knowledge), bhakti yoga (yoga of devotion), karma yoga (yoga of service),
+and raja yoga (yoga of controlling the mind): (a) dharana (concentration),
+270
+A. Rakhshani et al.
+(b) bhavana (contemplation on a deity), (c) pathana (study of the scriptures),
+(d) satsanga (being in the company of wise people), (e) japaya (chanting of
+the holy names), (f) seva (selfless service), (g) viveka (developing discrimi-
+nation between right and wrong), (h) viragia (developing dispassion toward
+the objects of the senses), and (i) bhakta (transforming hard emotions into
+soft, divine emotions, as it is said in the Narada Bhakti sutra: the purest form
+of love is devotion
+parama pr¯
+ema r¯
+upa bhaktih). Practices of
+bhakti yoga are deeply embedded in the Indian traditions starting with reg-
+ular daily worship of the personal God (ishtadevata) to special celebrations
+(Samsk¯
+aras) with intense practices (vrat¯
+as) for different phases of pregnancy.
+The abode of the mother should be well fumigated, worshiped, and have
+sound of the Vedic hymns (or other spiritual songs from other faiths) being
+recited by br¯
+ahman¯
+as (holy priests). The pregnant woman after getting up in
+the morning and performing her regular chores should be busy in worship
+of god and should do selfless service (seva; Bhishagratna, 1991). By using
+different religious icons from other faiths, these spiritual practices could be
+utilized by other studies that use yoga and Ayurveda as interventions but are
+targeting other world populations.
+DISCUSSION
+The authors’ aim was to compile the scriptural and scientific evidence for a
+holistic antenatal model of yoga with emphasis on sociocultural Indian prac-
+tices (Samsk¯
+aras). We believe that the model provides practices that promote
+positive well-being at physical, psychological, social, and spiritual levels as
+recommended by the WHO in its definition of heath and by the yogic scrip-
+tures. Except for the social elements, most of the other components of the
+model are replicable in different cultures. While many other studies have
+used various components of this model in trials conducted at different parts
+of the globe, the mechanism of action of yoga in pregnancy is not clear.
+Some speculations have been offered in the next section.
+MECHANISMS
+According to the studies we have reviewed, yoga-based therapies seem to be
+promising interventions during pregnancy. None of these studies, however,
+explain the underlying mechanisms of the physiologic and psychological
+effects of yoga during pregnancy. The collective results suggest that the
+reported improvements likely occur through a number of pathways.
+Yoga by directly activating the vagus nerve may improve parasympa-
+thetic output, leading to enhanced cardiac-vagal function, mood, energy
+state, and related neuroendocrine, metabolic, and inflammatory responses
+(Taylor, Goehler, Galper, Innes, & Bourguignon, 2010). Yoga may pro-
+mote a feeling of well-being by reducing the activation and reactivity of the
+Holistic Antenatal Model
+271
+sympathoadrenal system through increased vagal activity (Bowman et al.,
+1997) and better autonomic reactivity after yoga as pregnancy advances
+(Satyapriya et al., 2009). Improved stability of the hypothalamic pituitary
+adrenal (HPA) axis may also contribute as evidenced by decreased corti-
+sol levels in normal adults (Kamei et al., 2000; West, Otte, Geher, Johnson,
+& Mohr, 2004) and increased early morning cortisol in pregnancy (Beddoe
+et al., 2010; Kabat-Zinn, 1990) after yoga. Field attributes this to the “stimula-
+tion of dermal and/or sub-dermal pressure receptors that are innervated by
+vagal afferent fibers, which ultimately project to the limbic system including
+hypothalamic structures involved in cortisol secretion” (Field, 2011, p. 6).
+Another explanation could be that stress reduction, through mind manage-
+ment, could have an impact on reduction of oxidative stress, which in turn
+reduces pregnancy complications (Hsieh et al., 2012).
+It is also possible that a yogic lifestyle has a positive impact on proper
+placentation (particularly if practiced early in pregnancy), although research
+data are needed to substantiate this. Improved blood volume and hemodilu-
+tion with better blood supply to the placenta may be a major contribution of
+the restful relaxation techniques used in yoga (Jayashree, Malini, Rakhshani,
+Nagendra, & Nagarathna, 2013).
+These speculations would not be complete without a reference to the
+yogic vantage on the mechanism of action of yoga on the body given in the
+yogic text by Patanjali (Woods, 2003) and others (Nagarathna & Nagendra,
+2001). These scriptures tell us that all of these practices produce calmness of
+the mind in the manomaya kosha, which results in proper prana flow in the
+pranamaya kosha and better functioning of the organs in the annamaya
+kosha (Venkatesananda, 1984; Rakhshani, 2013):
+(changing the lifestyle by good abiding to good coun-
+seling, the samanya adhija vyadhi is destroyed (Gupta, 2013).
+LIMITATIONS OF THE STUDY
+The study is a retrospective presentation of the steps that were followed
+over the years and not a prospective planned study to assess the valid-
+ity and reliability of the model. Statistically acceptable checklists and scor-
+ing were not used during the literature search. Not all authors of the arti-
+cle met in groups before finalizing the model. No statistical calculations of
+split half reliability or validity were planned because this was a preliminary
+study.
+STRENGTHS OF THE STUDY
+The aim was to highlight the conceptual basis for the holistic practices
+that were prevalent in ancient India that have been carried on (modified
+272
+A. Rakhshani et al.
+suitably) even today. This model formed the basis of the interventions used in
+several control trials (Narendran, Nagarathna, & Nagendra, 2005a; Rakhshani
+et al., 2010, 2012).
+SUGGESTIONS FOR FUTURE WORK
+Yoga is now widely recognized and practiced throughout the world. Ante-
+natal yogic practices recommended in this model can be adapted and imple-
+mented in different cultures. Future studies may cull out some of the mean-
+ingful evidence-based cultural and spiritual practices from different cultures
+that may be incorporated or reinstated for healthy progression of pregnancy
+and promotion of well-being of the mother and the offspring.
+CONCLUSION
+Complications of pregnancy are serious life-threatening disorders with se-
+vere economical and social consequences globally. Clearly there is a need
+to identify a noninvasive and cost-effective solutions for the management of
+these disorders. Several studies have shown yoga to be useful in management
+of low-risk and high-risk pregnancies. The yoga and Ayurvedic guidelines
+incorporated in this model are holistic treatments (both physical and psycho-
+logical), which intend to define normal health as harmony and balance and
+not just a fight for survival. They can be practiced in any country or culture
+and offer a solution to restore normalcy and balance using soft techniques
+that correct the stress pathology. We believe that this model opens up a new
+holistic approach to antenatal care for women internationally.
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+Copyright of Health Care for Women International is the property of Routledge and its
+content may not be copied or emailed to multiple sites or posted to a listserv without the
+copyright holder's express written permission. However, users may print, download, or email
+articles for individual use.

subfolder_0/A Perspective on Yoga as a Preventive Strategy for Coronavirus Disease 2019.txt

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+Int J Yoga. 2020 May-Aug; 13(2): 89–98.
+Published online 2020 May 1. doi: 10.4103/ijoy.IJOY_22_20
+PMCID: PMC7336943
+PMID: 32669762
+A Perspective on Yoga as a Preventive Strategy for Coronavirus
+Disease 2019
+R Nagarathna,  HR Nagendra,  and Vijaya Majumdar
+Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru,
+Karnataka, India
+Address for correspondence: Dr. Vijaya Majumdar, Division of Life Sciences, Svyasa University, Bengaluru -
+560 105, Karnataka, India. E-mail: [email protected]
+Received 2020 Mar 24; Revised 2020 Mar 29; Accepted 2020 Apr 1.
+Copyright : © 2020 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
+The pandemic outbreak of coronavirus disease 2019 (COVID-19) infection caused by severe acute
+respiratory syndrome-coronavirus 2 has led to profound public health crisis. In particular, individuals
+with preexisting conditions of heart disease, diabetes, cerebrovascular diseases and the elderly are most
+vulnerable to succumb to this infection. The current COVID-19 emergency calls for rapid development
+of potential prevention and management strategies against this virus-mediated disease. There is a
+plethora of evidence that supports the add-on benefits of yoga in stress management, as well as
+prevention and management of chronic noncommunicable diseases. There are some studies on the
+effect of yoga in communicable diseases as well but very few for acute conditions and almost none for
+the rapidly spreading infections resulting in pandemics. Based on the available scientific evidences on
+yoga in improving respiratory and immune functions, we have formulated very simple doable
+integrated yoga modules in the form of videos to be practiced for prevention of the disease by children,
+adults, and the elderly.
+Keywords: Coronavirus disease 2019, immune function, yoga
+Introduction
+The current outbreak of coronavirus disease 2019 (COVID-19) is an infection caused by severe acute
+respiratory syndrome-coronavirus 2 (SARS-CoV-2)[1,2,3,4,5,6,7,8,9,10] with the recently analyzed
+mortality of 5·7% (95% CI 5·5–5·9)[5] The initial reports of disease outbreak were reported in Wuhan,
+Hubei Province of China, COVID-19 followed by its worldwide expansion[3,6,7] owing to the highly
+contagious nature of the virus. In a meeting on January 30, 2020, as per the International Health
+Regulations (2005), the WHO declared the outbreak as a Public Health Emergency of International
+Concern as it has spread across 18 countries across the globe with four countries reporting human-to-
+human transmission.[8]
+1
+2
+2
+1
+2
+Phylogenetic analysis has indicated a zoonotic origin of SARS-CoV-2,[6] with person-to-person
+transmissibility.[10] SARS-CoV-2 is a β-CoV with highly identical genome to bat CoV, pointing to bat
+as the natural host.[9,11] CoVs belong to a large family of single-stranded RNA viruses (+) with a
+broad distribution across humans, other mammals, and birds and cause respiratory, enteric, hepatic, and
+neurologic infections.[7] These RNA viruses derive their name due to the crown-like or coronal
+appearance (coronam is the Latin term for crown) given by the club-shaped glycoprotein spikes in the
+envelope. Importantly, the past two decades have witnessed the emergence of three highly pathogenic,
+novel zoonotic CoVs – SARS-CoV (SARS-CoV now named SARS-CoV-1) discovered in November
+2002, Middle East respiratory syndrome (MERS)-CoV (MERS-CoV) in June 2012, and SARS-CoV-2,
+identified in December 2019 – and have been of global public health concerns.[2,7] These periodic
+emergencies occur due to frequent cross-species infections and increasing interfaces between humans
+and other animal interface.[7,12] These frequent emergences also derive from the high prevalence and
+wide distribution of CoVs, their large genetic diversity, and frequent recombination of their genomes.
+[12]
+SARS-CoV-2 causes a respiratory viral infection that represents the most prevalent and pathogenic
+forms of communicable infectious diseases.[6,13] In severe cases, wherein there is a delay or absence
+of early and effective antiviral treatment, the infection could manifest in a compromised systemic and
+local respiratory defense mechanisms leading to bacterial coinfection culminating into severe acute
+respiratory illness and occasionally into acute respiratory distress syndrome (ARDS).[7,8,9] The
+current estimates indicate a basic reproduction number (R ) of 2.2, implying that on an average, each
+infected person spreads the infection to an additional two persons.[14]
+The latest updates suggest that the pandemic of COVID-19 has entered a new stage with rapid spread
+in countries outside China indicating the need of practicing the measures for self-protection toward the
+prevention of transmission of the infection to others.[4] As of March 16, 2020, a drastic escalation in
+the number of cases of COVID-19 was observed outside China with a number of 143 affected
+countries, states, or territories reporting infections to the WHO.[15] The COVID-19 outbreak is an
+indication of the prevailing challenge of the recurrent surfacing of the unprecedented pathogenic
+infections that demand regular monitoring and preparedness.[14] There is an urgent need of basic and
+clinical research efforts to aid in the understanding of the disease biology and development of robust
+combat measures.[14]
+Clinical Course of Coronavirus Disease 2019
+SARS-CoV-2 primarily spreads by droplets, and is postulated to have higher transmissibility as
+compared to seasonal influenza. A major concern arises due to its likely spread via even asymptomatic
+or minimally symptomatic individuals who may not seek any clinical evaluation.[16] As reported by
+Huang et al., patients with COVID-19 primarily present with fever, fatigue, and dry cough.[17] Most of
+the patients exhibit favorable prognosis, however, older patients and those with chronic underlying
+conditions may present with worse outcomes.[17,18] In the early stages of infection, patients could be
+afebrile represented with only chills and respiratory symptoms.[19] The clinical spectrum varies from
+asymptomatic or mild symptomatic forms to severe forms characterized by respiratory failure that
+necessitates mechanical ventilation and support in an intensive care unit (ICU) or multi-organ and
+systemic manifestations in terms of sepsis, septic shock, and multiple organ dysfunction syndromes.[8]
+Challenges toward the Combat of Coronavirus Disease 2019
+Effective prevention or treatment of COVID-19 remains a top priority toward the curtailing of this
+pandemic. Implementation of several infection control measures (e.g., social isolation, distancing, or
+quarantine of entire communities) have been posited for control and prevention of the COVID-19
+outbreak.[4,20] The most important and effective challenge seems to establish preventive intervening
+strategies before the human–pathogen interface. Vaccination is the one of the most radical
+countermeasures to combat an infectious disease epidemic. Although substantial progress has been
+made toward characterization of the causative virus for COVID-19, a time period of probably a least 1
+year to 18 months has been speculated for substantial vaccine production.[21] In the early stage of the
+pandemic, antiviral treatment is the most effective method. Very recently hydroxychloroquine has been
+0
+reported to be apparently effective against the treatment of COVID-19-associated pneumonia in clinical
+studies.[22,23] However, implementation of antiviral treatment and prophylaxis has several
+requirements, in particular an adequate stockpile of drugs along with the safety of the treatment and
+cost-effectiveness.[24] Most importantly, the preventive/controlling measures should be implemented
+in a judicious and cost-effective manner.[24]
+Integrated Yoga for the Management of Noncommunicable Clinical Conditions
+Yoga, an ancient mind–body technique, is defined as samatvam (balance/equipoise/homeostasis) at
+both mind and body levels to be achieved through mastery over the modifications of the mind
+(chittavrittinirodhah). The available evidence indicates that yoga/meditation facilitates the coordination
+among the set of homeostatic responses involving the interaction among the nervous, endocrine, and
+immune systems.[25] Hence, the recent definition of yoga states it as a comprehensive skill set of
+synergistic process tools that aids in bidirectional feedback and modulation of autonomic nervous
+system outputs through integration between central nervous system (CNS) and afferent and re-afferent
+inputs from interoceptive processes such as the somatosensory, viscerosensory, and chemosensory.[25]
+Postures (Sanskrit: asana), breath regulation (Sanskrit: pranayama), and meditation along with the
+conceptual corrections comprise the integrative system of yoga techniques that could promote physical
+as well as mental well-being. The postures or asanas are purported to have different effects. Some are
+stimulatory to the nervous and circulatory systems, some develop coordination and concentration,
+while others have a calming effect on the body. Some postures such as the corpse pose are used for
+elongated periods of relaxation.
+Clinically, these therapeutic techniques of yoga have been reported to be beneficial against the
+management of acute stress as in posttraumatic stress disorder after tsunami[26] or in chronically
+stressed people with depression or anxiety[26,27,28] and in many noncommunicable diseases such as
+asthma,[29,30] hypertension,[31,32] heart disease,[33] and diabetes.[34,35,36,37,38] In particular,
+yoga has been repeatedly reported to facilitate the attainment of glycemic control and mitigate the
+influence of other risk factors associated with the complications in patients with diabetes as compared
+to control conditions. It has been proposed that the abdominal pressure created during exhalation in
+Kapalabhati improves the efficiency of β-cells of the pancreas.[35] It can be further viewed as
+modulated interoception or sensory modulation evoked by the vigorous practice of Kapalabhati aids in
+the increased interoception of the abnormal glycemic control that is signaled through the sensory inputs
+of the CNS that in turn modulates the autonomic outputs to the pancreas and other organs related to
+disease pathophysiology.
+Insights from Clinical Evidence on Efficacy of Yoga/Meditation against
+Communicable Disease Settings
+There is evidence for the beneficial effects of yoga as an add-on strategy for the management of
+communicable diseases including influenza,[39,40] tuberculosis (TB),[41] and human
+immunodeficiency virus (HIV) infection,[42,43,44] wherein status of immune system is an important
+factor that determines the progression of the disease. The results from the Meditation or Exercise for
+Preventing Acute Respiratory Illness Trial (MEPARI) trial indicated that training in meditation evoked
+a larger reduction in global acute respiratory infection (ARI) severity as compared to exercise or the
+wait-list control participants.[39,40] The findings of the study were found to be in concordance with
+prior literature on beneficial effects of moderate-intensity exercise against immune system and
+reduction in the incidence of ARI illness.[39]
+Similarly, a prospective, randomized trial compared the efficacy of two programs (yoga and breath
+awareness) as an add-on to anti-TB treatment in sputum-positive cases in a sanatorium in Bangalore.
+[41] A total of 1009 pulmonary TB patients were screened and 73 were alternately allocated to yoga (n
+= 36) or breath awareness (n = 37) groups. At the end of 2 months, the yoga group showed a
+significantly better reduction in symptom score and an increase in weight and lung capacity with an
+improved level of infection control and radiographic image as compared to the nonyoga group.
+Effect of 1 month of integrated yoga (IY) intervention has reported to significant improvement in the
+psychological states as well as in the viral loads in patients suffering from HIV-1 infection.[42] Further,
+yoga has also been reported to be an effective intervention for stress management and improvement in
+psychological health among HIV/AIDS patients.[42,43,44] These findings indicate toward a potential
+complementary role for yoga in the management of communicable diseases.
+Yoga for the alleviation of stress induced immune deregulation and strengthening
+of innate immune response-Paradigm for Viral Infections
+Immunity of the host is an essential requisite to facilitate the eradication of infections. Impaired
+immunity characterized by lymphopenia and elevated CRP levels is an essential clinical feature of
+COVID-19.[19] Frequent representation of elderly individuals in the COVID-19-infected cases
+indicates the plausible role of immunosenescence underlying their vulnerability to the infection. The
+severity and outcome of the viral infection could be either an outcome of an effective cellular/innate
+immune response that combats SARS-CoV-2 as observed in the patients with mild clinical signs of
+infection or a state of immunosuppression that debilitates and sometimes overwhelms the host's
+defense.[2] Available evidence indicates that stress modulates immune competence through
+immunosuppression[45] (latency of herpesvirus as represented by the antibody titers), upper respiratory
+tract infection, and wound healing time, indicating that stress causes a significant immune response
+dysfunction. Both acute and chronic stressors can mediate their effects on sympathetic nervous system
+and the hypothalamic–pituitary–adrenal (HPA) axis, thereby impairing antiviral immune responses and
+innate immunity and deregulation of different immune parameters, primarily the inflammatory
+pathways.[46,47] Fear, uncertainty, and stigmatization are psychological stress factors during public
+health emergencies such as COVID-19.[48] These factors hinder appropriate medical and mental health
+interventions and could serve as psychological risk factors and alter the immune function of subjects in
+quarantine or health-care workers. In the context of pandemics with individuals experiencing high
+levels of psychological stress, the modulation of HPA axis through practice of yoga could alleviate
+stress and could aid in the strengthening of the antiviral immune responses.
+Innate immunity is needed for precise regulation to eliminate the virus, otherwise will result in
+immunopathology. A randomized controlled study in nonstressed young healthy students showed a
+significant increase in interferon-gamma (IFN-γ) levels (a central regulator of cell-mediated immunity,
+having antiviral, immune-regulatory functions) in the yoga group as compared to students who did not
+do yoga.[49] On the contrary, a study by Gopal et al.[50] on students with examination stress showed a
+significant reduction in the levels of IFN-γ levels after yoga as compared to the nonyoga control group.
+(Academic stress, the stressful condition of students taking examination, has been proposed to be
+considered as a more appropriate model of naturalistic stress in human beings as compared with
+laboratory-induced stress situations). These physiological aspects of yoga-based mechanisms indicate
+toward the buffering effect of the yoga that aids in restoring the imbalance characterized by either
+suboptimum or excessive expression of immune responses. Based on its ability to induce and precisely
+regulate the IFN-γ levels, yoga could boost innate immune responses during the incubation and
+nonsevere stages to eliminate the virus.[51] Interestingly, these preliminary observations point to the
+phenomenon of samatvam or shift toward homeostasis by the holistic approach of IY on the human
+immune system and all other physiological functions. Further, practice of yoga has been associated
+with increased immune surveillance in terms of the modulation of the frequency of blood lymphocytes.
+[46] Infante et al. reported that in transcendental meditation (TM) practitioners, count of
+CD3+CD4−CD8+ lymphocytes (P < 0.05), B-lymphocytes (P < 0.01), and natural killer (NK) cells (P
+< 0.01) was higher as compared to the control group.[52] Kamei et al. reported a significant correlation
+between the frontal alpha wave activation and the increase in NK activity during yoga exercises.[53]
+NK cells are innate lymphocytes that serve as the first line of defense against invading viruses limiting
+their spread and subsequent tissue damage. Further, Tooley et al. reported significantly higher plasma
+melatonin levels in mediators practicing TM-Sidhi.[54] Melatonin is known to regulate cellular as well
+as humoral immunity and stimulates the production of NK cells. A study on 96 women with breast
+cancer, who participated in a MBSR program for 8 weeks, showed restoration of their NK cell activity
+and IFN-γ levels as compared to continued deregulation in the non-MBSR group.[55] In addition,
+postyoga increases in IgA (an antibody isotype central to mediating mucosal immunity) in pregnant
+women support the protective potential of yoga against invading pathogens.[56] As mentioned above,
+the immunity scores (CD4 counts) of HIV patients have been reported to improve with yoga practice.
+[42] Overall, these studies indicate that practice of yoga might strengthen cell-mediated or mucosal
+immunity and could be used as a preventive measure against virus or other pathogen-mediated
+infections.
+Yoga for alleviation of erratic immune responses
+The available evidence supports the potential of yoga as a complementary intervention for populations
+at risk or already suffering from diseases with an inflammatory component.[46] Several evidences
+indicate that yoga might influence chronic inflammatory state and might optimize impaired immune
+function in stress-induced conditions.[46] The available evidence also uniformly supports that yoga
+practice could downregulate pro-inflammatory markers. Among its influence on pro-inflammatory
+markers, significant decreases in interleukin-1 (IL-1) beta, as well as indications for reductions in IL-6
+and tumor necrosis factor (TNF)-alpha, have been indicated.[46] Cytokine storm represented by
+increased cytokine levels (IL-6, IL-10, and TNF-α), lymphopenia (in CD4  and CD8  T-cells), and
+decreased IFN-γ expression in CD4  T-cells is associated with severe COVID-19.[57] These findings
+support the utility of yoga as a complementary intervention for populations at risk or already suffering
+from COVID-19. Duration of the yoga intervention could significantly influence the effects of yoga
+practice on inflammatory markers. Based on the findings of Pullen et al.,[33] in populations with a high
+risk of increased inflammation such as heart failure, shorter course of interventions of only 8 weeks has
+been suggested to be sufficient to reduce inflammatory processes. The authors have indicated that a
+reciprocal influence of duration of intervention required depends on the severity or deviation from
+normal physiology.[33]
+Integrated Yoga for the Management of Coronavirus Disease 2019 with
+Comorbidities
+Respiratory tract infections are highly prevalent in patients with diabetes as compared to those without
+diabetes.[58] Extending on the same note, prevalence of diabetes has also been reported to be one of
+the most distinctive comorbidities in patients with COVID-19; in the study by Xiaobo Yang et al. 22%
+of the non-survivor critically ill COVID-19 patients were reported to have diabetes.[59] This highly
+prevalent association between diabetes and COVID-19 could be attributed to the compromised immune
+function, reduced T-cell response, reduced neutrophil function, and disorders of humoral immunity.[58]
+Further, the hyperglycemic environment in these patients could also increase the virulence of
+pathogens, lower the production of interleukins in response to infection, with reduced chemotaxis and
+phagocytic activity, and immobilization of polymorphonuclear leukocytes.[58] As mentioned above,
+fear, uncertainty, and stigmatization are psychological stress factors during public health emergencies
+such as COVID-19.[48] The stress-induced activation of the HPA axis could also significantly
+contribute to poor glycemic control (hyperglycemia),[35] thereby exacerbating the clinical symptoms.
+The stress-reducing aspects of yoga through modulation of HPA axis in patients with aberrant glycemic
+control (diabetes and prediabetes) could aid in the attainment of glycemic control as has been
+frequently reported.[34,35,36,37,38] The practice of yoga might aid in reducing the exacerbations and
+clearance of virus infection in COVID-19 patients with diabetes through reducing the influence of
+systemic hyperglycemic and inflammatory milieu.
+Similarly, hypertension is also a distinct comorbidity of COVID-19 infection.[60] A study by Guan et
+al. on 1099 patients with confirmed COVID-19 reported the high prevalence of comorbidities of
+hypertension (23·7%) and diabetes mellitus (16·2%) in 173 severe cases.[60] Hypertension is typically
+treated with drug inhibitors that target the renin–angiotensin system (RAS).[18,61] These drugs are
+mainly the angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs).
+These RAS inhibitors have been well established against the effective management of blood pressure
+(BP) as well as protection from disease-associated inflammation. However, RAS inhibitors have been
+postulated to affect the expression of ACE2 mRNA and the activity of ACE2 in tissues.[18,61] ACE2
+is a key counterregulatory enzyme of ACE that degrades angiotensin II to angiotensin-(1–7), thereby
+attenuating the effects on vasoconstriction, sodium retention, and fibrosis,[62] although there have been
+no definitive conclusions regarding the association of COVID-19 with RAS inhibitors. ACE2 has been
++
++
++
+proposed to be a likely cellular receptor of COVID-19,[62] and in vitro findings have been reported
+that the receptor mediates the entry of COVID-19 virus into HeLa cells.[63] Further long-term use of
+ACEIs might suppress the adaptive immune response, which is a key defense against viral infection.
+[61]
+Yoga and meditation, in particular slow deep breathing, have been reported to decrease sympathetic
+nervous system activity, and increase the baroreflex sensitivity in hypertensive patients, thereby
+reducing their blood pressure values.[64] Modulation of HPA axis and autonomic outputs including BP
+has also been reported to underlie its physiological effects of yoga.[64] However, there has been a lack
+of evidence on specific targeting of RAS or its effector components through yoga. Inflammatory
+systematic milieu in hypertensive patients with already altered autonomic regulations could exacerbate
+disease outcomes. Based on the anti-inflammatory potential of yoga in hyperinflammatory settings
+such as hypertension, we further extend that yoga could reduce the clinical nonfavorable outcomes in
+hypertensive patients. Further, a Class II-A level of Evidence B recommendation for BP-lowering
+efficacy has been conferred on slow breathing.[65] Hence, yoga/slow breathing techniques could
+provide a safe adjunct/complementary approach for the management of hypertension in COVID-19
+patients with hypertension.
+Yoga for Better Respiratory Capacity
+There is a plethora of evidence that breathing exercises have beneficial effects on the respiratory
+system.[66] Pranayama, a yoga-based respiratory exercise, is a simple and cost-effective intervention
+that could be easily integrated in daily routine and has been proven beneficial in subjects across
+different age groups including the elderly.[67] Yoga training has been reported to improve strength of
+expiratory as well as inspiratory muscles.[68] Joshi et al. reported beneficial effects of a 6-week course
+of pranayama on ventilatory lung functions.[69] The authors reported improved ventilatory functions
+with respect to lowered respiratory rate (RR) and increased forced vital capacity (FVC), forced
+expiratory volume at the end of 1  s (FEV1%), maximum voluntary ventilation (MVV), peak
+expiratory flow rate (PEFR), and prolongation of breath-holding time.[69] Repeated practice of
+pranayama has been shown to strengthen cardiorespiratory coupling and increases in the
+parasympathetic activity in healthy individuals.[64] The breathing practice called Kapalabhati is
+comprised of powerful strokes of exhalations accompanied with the contraction of abdominal and
+diaphragmatic muscles followed by passive inhalations.[70] Kapalabhati aids in appropriate training
+and toning of diaphragm and abdominal muscles. It also helps in removal of secretions from bronchial
+tree, cleansing up respiratory passages and the alveoli.[70] A combination of yogic breathing
+techniques improved the pulmonary functions in competitive swimmers.[71]
+Yoga Practice and Chronic and Acute Respiratory Distress
+There have been several reports of clinical trials that suggest an overall effect of yoga training toward
+improved pulmonary function in patients with chronic obstructive pulmonary disease (COPD),
+[72,73,74,75,76,77] an important cause of morbidity and mortality, and poses a major public health
+problem. When meta-analyzed, a significant clinical effect of yoga in COPD patients with respect to
+FEV1 was observed.[72] In addition, the studies reported training effects of yoga on improved exercise
+capacity, lung function decline, quality of life, and dyspnea in patients with COPD.[72] Several
+mechanistic factors have proposed to underlie the beneficial effects seen in the patients undergoing
+yoga such as increasing respiratory stamina, relaxing chest muscles, expanding the lungs, raising
+energy levels, and calming the body.[72] However, due to the lack of adequate data and insufficient
+clinical evidence provided by these studies, the clinical relevance of these findings needs further
+thorough robust experimental evaluations.[72]
+Findings of Meditation or Exercise for Preventing Acute Respiratory Illness Trial –
+Paradigm for viral-mediated respiratory infections
+There has been a dearth of clinical evidence on influence of yoga against acute respiratory distress.
+However, there have been two major relevant successive reports of MEPARI trials that tested the effect
+of training in mindfulness-based stress reduction (MBSR) or sustained moderate-intensity exercise on
+st
+incidence, duration, severity, and impact of all-cause mortality of ARI.[39,40] MEPARI-1 reported
+statistically and clinically significant reductions in ARI illness for participants randomly assigned to 8
+weeks of MBSR training, compared to the observational controls. The MEPARI-2 trial was designed to
+replicate and extend findings from the first MEPARI trial.[40] The authors reported a consistent pattern
+of benefits across the two trials suggestive of preventive effects ranging from 14% to 33% proportional
+reductions in ARI illness.[40] Very importantly, the authors presented a comparative perspective of the
+findings of MEPARI trials against vaccinations against influenza.[40] Flu shots or vaccines are known
+to reduce influenza, with published estimates of proportional reductions in symptomatic illness,
+medical visits, and absenteeism ranging from 13% to 70%.[78,79,80,81,82] The authors Vaccinations
+are disease specific; in other words, these are specific to virus strains, so the protection provided is also
+specific and restrictive. However, mindfulness and exercise trainings have more generic mechanisms,
+regardless of etiological agent. A recent study has reported beneficial effect of meditation on adaptation
+to the hypoxic high altitude conditions that requires synergistic functioning of respiratory, cardiac, and
+hematological system.[83] The authors reported increase in the partial pressure of oxygen, (PO2) a
+marker of bio-availability of oxygen at the cellular levels.[83]
+Pilot study on yoga module in coronavirus disease 2019
+Breathing exercises using the concepts of yoga could also be adopted to help during states of acute
+respiratory distress. We have previously taught an eight-stepped yoga breathing procedure consisting of
+very simple neck muscle relaxation movements and asanas with breathing exercises using the support
+of a chair during 110 episodes of acute airway obstruction in 86 bronchial asthma patients. There was a
+significant improvement in their PEFR by >20% within 30 min of the practice with successful relief
+from the episode. The patients reported reduction in panic and anxiety element, cutting the vicious
+cycle of aggravating bronchial obstruction. Based on the above discussed several beneficial aspects of
+yoga on the immune and respiratory systems against varied clinical settings including that of infectious
+diseases, we postulate a therapeutic potential of yoga towards COVID-19 prevention and management
+[Figure 1]. We have evolved age-specific sets of yoga modules [Tables 1 and 2] based on our extensive
+experience of over past 35 years on clinical research on yoga. The modules have been made available
+for public use on our website https://svyasa.edu.in. To this end, a pilot study was conducted on request
+providing a 4-min video of very simple practices as a voluntary clinical aid to the hospitalized COVID-
+19 patients in Milano, Italy, visited by 1000 people between March 17 and 20, 2020. The report by a
+cardiac surgeon who was also admitted in the intensive care unit of the Italy based hospital due to
+severe COVID-19 infection stated “We have reached scientific evidence that this simplified protocol
+sent by you is effective and we intend to disseminate to the overall Scientific Community”.
+Figure 1
+Potential beneficial effects of Yoga against COVID-19 infection
+Table 1
+Yoga modules for management of coronavirus disease 2019 9 patients with mild symptoms
+Open in a separate window
+Serial
+number
+Category
+Name of the yoga practice
+Children 6-18
+years
+Adults, 18-60 years
+Elderly > 60
+years
+Prayer
+Vinayaka
+Remover of
+all obstacles
+Maha Mrityunjaya
+Remover of fear of
+death
+Dhanvantari
+Lord of health
+1
+Loosening
+Exercises
+(Shithilikarana
+Vyayama)
+Forward and
+backward
+bending(1
+min)
+Spinal twisting (1
+minute)
+Forward and
+backward bending
+(1 min)
+Spinal twisting
+on chair (1 min)
+Spinal twisting
+(1 min)
+Forward and
+backward bending
+(1 min)
+Spinal twisting (1
+min)
+Mukha Dhouti
+(1/2 min)
+Mukha Dhouti
+(1/2 min)
+Surya
+Namaskar (2
+rounds - 2
+min)
+2
+Breathing
+exercises and
+asana
+Hands stretch
+breathing (1
+min)
+Hands in and out
+breathing (1 min)
+Hands in and out
+breathing (1 min)
+Hands in and out
+breathing (1
+min)
+Tiger
+breathing (1
+min)
+Hands stretch
+breathing (1 min
+each variation)
+Hands stretch
+breathing (1 min
+each variation)
+Hands stretch
+breathing (1
+min)
+Matsyasana/Sulabha
+ 
+Matsyasana (1 min)
+Chair Vakrasana
+(1 min)
+Sulabha
+Matsyasana (1
+min)
+3
+Kriya (cleansing
+techniques) and
+pranayama
+Kapalabhati
+Kriya (30
+strokes - 1
+min)
+Kapalabhati Kriya
+(30 strokes - 1 min)
+Kapalabhati Kriya
+(30 strokes - 1
+min)
+Kapalabhati
+Kriya (15
+strokes - 1 min)
+Nadishuddhi
+Pranayama (2
+min)
+Abdominal
+breathing (1 min)
+Abdominal
+breathing (1 min)
+Nadishuddhi
+Pranayama (2
+min)
+Table 2
+Script of the prayers and figures of the yoga practices
+Open in a separate window
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Vinayaka mantra
+Mahamrityunjaya mantra
+Dhanvantari mantra
+OM HAM SAM bhagavate
+Nityayoga yuktaya
+ 
+Sacchidananda murtaye
+ 
+Vihayakaaya namah
+ 
+(I offer my salutation to lord
+ 
+Vinayaka who is established in
+yoga state and is the manifestation
+of the universal existence,
+consciousness, and bliss through
+these syllables OM, HAM, and
+SAM)
+Trayambakam yajamahe
+ 
+Sugandhim
+pushtivardhanam
+ 
+Urvarukamiva Bandhnaat
+ 
+Mrityormuksheeyamamritaat
+ 
+Om shaantih Shaantih
+shantih
+ 
+(I offer my salutation to the
+three-eyed lord who is full of
+fragrance and gives energy
+and strength
+ 
+Drop off the fear of death
+just like a ripe cucumber
+drops from its stalk)
+Om namami dhanvantarim aadi devam
+ 
+Suraasurairvandita paadapadmam
+ 
+Loke jara rugbhaya mrityunaasham
+ 
+Dataarameesham vividhoushadheenaam
+ 
+Om shaantih Shaantih shantih (I offer
+my salutation to the lotus feet of that
+original lord Dhanvantari who has given
+many medicines to remove fear of
+diseases and overcome aging and death
+to the world and saluted by all other
+gods)
+Loosening practices
+Forward and backward bending
+Spinal twist
+Spinal twist on chair
+Surya Namaskar
+Breathing practices
+Hands in and out breathing
+Hands stretch breathing
+Tiger breathing
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+Basu‑Ray et al. 
+BMC Complementary Medicine and Therapies          (2022) 22:191  
+https://doi.org/10.1186/s12906-022-03666-2
+REVIEW
+A narrative review on yoga: 
+a potential intervention for augmenting 
+immunomodulation and mental health 
+in COVID‑19
+Indranill Basu‑Ray1,2,3*   
+, Kashinath Metri4, Dibbendhu Khanra5, Rishab Revankar6, Kavitha M. Chinnaiyan7, 
+Nagaratna Raghuram8, Mahesh Chandra Mishra9, Bhushan Patwardhan10, Manjunath Sharma11, 
+Ishwar V. Basavaraddi12, Akshay Anand13, Shrinath Reddy14, K. K. Deepak15, Marian Levy2, Sue Theus1, 
+Glenn N. Levine16, Holger Cramer17, Gregory L. Fricchione18 and Nagendra R. Hongasandra7 
+Abstract 
+Background:  The ongoing novel coronavirus disease 2019 (COVID-19) pandemic has a significant mortality rate 
+of 3–5%. The principal causes of multiorgan failure and death are cytokine release syndrome and immune dysfunc‑
+tion. Stress, anxiety, and depression has been aggravated by the pandemic and its resultant restrictions in day-to-day 
+life which may contribute to immune dysregulation. Thus, immunity strengthening and the prevention of cytokine 
+release syndrome are important for preventing and minimizing mortality in COVID-19 patients. However, despite a 
+few specific remedies that now exist for the SARS-CoV-2virus, the principal modes of prevention include vaccina‑
+tion, masking, and holistic healing methods, such as yoga. Currently, extensive research is being conducted to better 
+understand the neuroendocrinoimmunological mechanisms by which yoga alleviates stress and inflammation. This 
+review article explores the anti-inflammatory and immune-modulating potentials of yoga, along with its role in reduc‑
+ing risk for immune dysfunction and impaired mental health.
+Methods:  We conducted this narrative review from published literature in MEDLINE, EMBASE, COCHRANE databases. 
+Screening was performed for titles and abstracts by two independent review authors; potentially eligible citations 
+were retrieved for full-text review. References of included articles and articles of major non-indexed peer reviewed 
+journals were searched for relevance by two independent review authors. A third review author checked the excluded 
+records. All disagreements were resolved through discussion amongst review authors or through adjudication by a 
+fourth review author. Abstracts, editorials, conference proceedings and clinical trial registrations were excluded.
+Observations:  Yoga is a nonpharmacological, cost-effective, and safe intervention associated with several health 
+benefits. Originating in ancient India, this vast discipline consists of postures (asanas), breathing techniques (pranay‑
+ama), meditation (dhyana/dharana), and relaxation. Studies have demonstrated yoga’s ability to bolster innate immu‑
+nity and to inhibit cytokine release syndrome. As an intervention, yoga has been shown to improve mental health, as 
+© The Author(s) 2022. 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 
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+Open Access
+BMC Complementary
+Medicine and Therapies
+*Correspondence:  [email protected]
+1 Cardiologist & Cardiac Electrophysiologist, Memphis VA Medical Center, 
+1030 Johnson Ave, Memphis, TN 38104, USA
+Full list of author information is available at the end of the article
+Page 2 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+Introduction
+Coronavirus disease (COVID-19) is a highly contagious 
+viral disease that has affected 238,349,712 people world-
+wide as of October 9, 2021. Its outbreak was initially 
+reported in 2019 in Wuhan, Hubei Province, China. 
+Nearly 5 million deaths had been reported worldwide 
+as of the first week of October 2021. Many countries are 
+still “locked down” to prevent extensive spread of infec-
+tion, whereas others have relaxed these measures; even 
+so, social isolation measures are still generally recom-
+mended, at least to some extent. Many argue that easing 
+social restrictions has contributed to spikes in the num-
+ber of cases nationwide [1–5].
+Given the limited treatment options and the emer-
+gence of multiple strains with variable susceptibility to 
+vaccines, clinicians are searching for other interventions 
+to aid in the prevention and treatment of COVID-19. 
+In the context of integrative medicine, yoga is a mind-
+body discipline that promotes healthy living through 
+various components, such as the practice of postures 
+(asana), breathing techniques (pranayama), concentra-
+tion (dharana), and meditation (dhyana) [2, 6]. A grow-
+ing body of evidence suggests that yoga practice leads to 
+better integrative management of a number of non-com-
+municable diseases that share the same pathophysiology, 
+including cardiovascular diseases, stroke, and diabetes 
+mellitus type II. The underlying reasoning is that these 
+diseases, like COVID-19, express rogue immunologi-
+cal aberration, resulting in many of their manifestations, 
+which are often triggered or exacerbated by stress [2, 
+7]. A meta-analysis of ten randomized controlled trials 
+including 431 individuals suggested that yoga programs 
+improved exercise capacity (mean change 2.69, 95% con-
+fidence interval 1.39- 3.99) and health related quality of 
+life (mean change 1.24, 95% confidence interval − 0.37- 
+2.85) among patients with chronic ailments namely heart 
+disease, chronic obstructive pulmonary disease and 
+stroke when compared with normal care [8]. Consistent 
+practice of yoga strengthens innate and adaptive immu-
+nity and helps to enhance physiological functions, such 
+as respiration, digestion, circulation, and hormone pro-
+duction [2, 9–11].
+In this review article, we discuss inflammatory, infec-
+tious, and psychosocial aspects of COVID-19 and 
+explore the anti-inflammatory and immune-modulating 
+potentials of yoga, along with its role in reducing risk fac-
+tors for immune dysfunction and impaired mental health. 
+We propose yoga as an intervention for expediting recov-
+ery in patients with COVID-19 and for enhancing innate 
+immunity and mental health to bolster resistance to the 
+virus [2].
+Methods
+We conducted this narrative review from published lit-
+erature in MEDLINE, EMBASE, and COCHRANE data-
+bases. Articles were retrieved from database searches 
+using keywords related to complementary therapy, 
+COVID-19, immunomodulation, psychological stress, 
+and yoga. Observational and experimental studies and 
+discussing the role of yoga in anxiety, immunomodula-
+tion, and COVID-19 were considered relevant for this 
+narrative review. Screening was performed for titles and 
+abstracts by two independent review authors; poten-
+tially eligible citations were retrieved for full-text review. 
+References of included articles and articles of major 
+non-indexed peer reviewed journals were searched for 
+relevance by two independent review authors. A third 
+review author checked the excluded records. All disa-
+greements were resolved through discussion amongst 
+review authors or through adjudication by a fourth 
+review author. Abstracts, editorials, conference proceed-
+ings and clinical trial registrations were excluded. Only 
+articles in English language were included.
+SARS‑COV‑2 infection
+SARS-CoV-2, the coronavirus that causes COVID-19, is 
+an acute infectious agent that enters the body through 
+the respiratory system. Droplet transmission is under-
+stood to be the primary mode of transmission. Mounting 
+evidence also suggests airborne transmission, although 
+the World Health Organization has yet to confirm this. 
+A person can become infected when his or her mucus 
+membrane (within the nose, eyes, or mouth) comes into 
+contact with the respiratory secretions of an actively 
+infected person discharging virus particles. Having 
+entered the body, the SARS-CoV-2 virus uses its S-spike 
+to bind angiotensin-converting enzyme (ACE)-2 recep-
+tors as an entry point into the cell. The ACE2 receptor is 
+it alleviates anxiety, depression, and stress and enhances mindfulness, self-control, and self-regulation. Yoga has been 
+correlated with numerous cardioprotective effects, which also may play a role in COVID-19 by preventing lung and 
+cardiac injury.
+Conclusion and relevance:  This review paves the path for further research on yoga as a potential intervention for 
+enhancing innate immunity and mental health and thus its role in prevention and adjunctive treatment in COVID-19.
+Keywords:  Catastrophization, Complementary therapies, Covid-19, Immunomodulation, Psychological stress, Yoga
+Page 3 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+	
+expressed primarily in both type I and type II pneumo-
+cytes but also in other types of cells, including endothe-
+lial cells. Thus, it plays a vital role in vascular integrity 
+and hemodynamic regulation [12–14].
+Evidence indicates that cardiac involvement is ubiqui-
+tous in patients with COVID-19, particularly in hospi-
+talized patients [14]. Patients with cardiac risk factors or 
+established cardiovascular disease have heightened vul-
+nerability, along with worse mortality and morbidity pro-
+files. In various studies, nearly 30% of afflicted patients 
+had hypertension and 15% had preexisting cardiovascular 
+disease [15, 16].
+Role of immunity in COVID‑19
+The human immune system comprises multiple organs, 
+such as the spleen, thymus, lymph nodes, tonsils, and 
+bones. Immune cells and their products destroy the 
+intruding infective organisms and neutralize them. The 
+immune system includes both innate immunity and 
+adaptive immunity. Innate immunity is the rapid-act-
+ing first line of defense that effectively inhibits infec-
+tive agents from entering the body. However, if this line 
+of defense fails, the immune system activates adaptive 
+immunity, which is important to control most viral infec-
+tions. The emerging picture reveals that CD4+ T cells, 
+CD8+ T cells and neutralizing antibodies has important 
+role in COVID-19 and thus its prevention and manage-
+ment [17].
+Innate immunity is garnered to restrict infections by 
+novel pathogens, such as SARS-CoV-2. This elaborate 
+immunological cascade appropriately arrests the disease 
+and helps to initiate the repair mechanism, thus ensur-
+ing satisfactory resolution of the infection and generating 
+targeted resistance to defend the body against reinfection 
+by the same organism [18]. The adaptive immune system 
+involves T lymphocytes, B lymphocytes, and pathogen-
+specific antibodies in addition to the proinflammatory 
+cytokines and chemokines that help to eliminate the 
+pathogen [19]. Although these processes are very potent 
+and effective, they can render bystander damage to the 
+body’s own cells and organs.
+Infection with COVID-19 presents with three dif-
+ferent clinical scenarios: (1) asymptomatic carriers 
+who have adequately functioning innate immunity; 
+(2) symptomatic carriers with mild symptoms who 
+achieve spontaneous recovery as their innate immu-
+nity detects infection and restricts it, while generating 
+adaptive immunity that optimally gets rid of the virus; 
+and (3) patients who develop moderate to severe illness 
+and either recover or die from the infection [20]. In this 
+third category of patients, the body’s immune system, 
+in both its innate and adaptive expressions, is activated. 
+In those who die, the immune system is overwhelmed, 
+leading to cytokine release syndrome (CRS), a massive, 
+cascading release of cytokines that initiates widespread 
+destruction and multiorgan failure, ultimately leading to 
+death [13]. In essence, the virus does not directly kill but 
+instead initiates an immunological reaction that is mor-
+bid and occasionally fatal (Fig. 1). It is therefore unfortu-
+nate that the resources harnessed by the body to kill the 
+virus largely outweigh the appropriate levels needed and 
+instead produce tissue destruction, organ failure, and 
+eventually death. Interleukin (IL)-6 is the primary can-
+didate cytokine suspected of perpetrating this fatal reac-
+tion [14, 15]. This knowledge has spawned initiatives to 
+block IL-6 using receptor inhibitors, including biologics 
+like tocilizumab, which are undergoing trials in moder-
+ately to severely ill patients with COVID-19 [19].
+An optimal innate immune response may thus play 
+a vital role in the prevention and early disposal of most 
+COVID-19 infections. A response of this nature is 
+believed to occur in 80% or more of those infected, who 
+either are asymptomatic or develop mild symptoms that 
+defervesce and culminate in an uneventful recovery. The 
+precise cause of immune dysfunction and CRS led by the 
+overproduction of IL-6 is unknown. Nonetheless, con-
+siderable evidence points to the fact that the severity of 
+the disease is based on the immune response to the virus, 
+among other factors [22].
+Pandemics, immunity, and mental health
+Remdesivir, the antiviral agent effective against COVID-
+19, only shortens the illness timetable by around 33% 
+[23]. The antiviral treatments recently approved by the 
+FDA would lead to resistance if randomly used. Moreo-
+ver, their efficacy is not absolute and is only effective if 
+started early in the course of the infection. These limita-
+tions render preventive measures—including vaccina-
+tion, hygiene, social distancing, and personal protective 
+equipment—to be the primary means of managing the 
+COVID-19 pandemic. Social distancing through par-
+tial or complete lockdowns often leads to psychological 
+issues such as anxiety, depression, and panic attacks—all 
+of which are known to downregulate the immune system 
+[2, 24]. Associated economic downturns, featuring job 
+losses and financial hardships, have accentuated mental 
+health issues during the pandemic [25]; suicides, opioid 
+overdoses, and domestic violence also have increased. 
+When vulnerable persons such as children, pregnant 
+women, or elderly relatives are part of the household, 
+stress and anxiety levels appear to worsen, given the 
+higher disease severity and mortality rates in these 
+groups. The conglomeration of stress states is associated 
+with downregulation of immunity and, consequently, 
+with worsened disease manifestations.
+Page 4 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+Stress
+Both chronic and sub-acute stress have a significant 
+negative impact on the immune system [26]: on the 
+one hand, the ability to cope with stress helps preserve 
+immune function; on the other hand, individuals with 
+higher stress levels and poor coping mechanisms have 
+subpar immunity. Lower resilience to stress is associated 
+with poor antibody response and decreased natural-killer 
+cell activity [27, 28].
+Stress affects immune function by increasing glucocor-
+ticoid and catecholamine secretion. Stress also induces 
+chronic sympathetic overdrive as it simultaneously 
+attenuates the parasympathetic system [29]. Escalated 
+sympathetic drive with its attendant hormonal milieu 
+(including cortisol excess and a robust catecholaminergic 
+drive) attenuates the efficacy of the immune system [30]. 
+The aberrant pathophysiology at play under such condi-
+tions is increased inflammation and decreased protection 
+against invading microorganisms [30]. Increased gluco-
+corticoid levels significantly affect the immune function 
+by dysregulating cytokine production, affecting natural-
+killer cell activity and reducing immunoglobulin A (IgA) 
+production [30]. Elevated cortisol potentiates glucose 
+intolerance and diabetes and thus further increases the 
+risk for infection [31]. Moreover, evidence suggests that 
+people who have stressful life events have greater risk for 
+Fig. 1  Pathological changes in lungs in early and severe stages of COVID-19 [From “SARS-CoV-2 and viral sepsis: observations and hypotheses” by Li 
+H, Liu L, Zhang D, et al.; accessed 10 April 2021] [Permission for re-use granted by Elsevier COVID-19 resource center guidelines] [21]
+Page 5 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+	
+respiratory infections [32]. The higher stress levels asso-
+ciated with extended lockdowns and the concomitant 
+fear, anxiety, and depression lead to weakened immunity, 
+opening the floodgates of infection [33].
+The paradoxical response of augmented inflammation 
+that is elicited during stress despite increased corticos-
+teroid levels in the blood is not clearly delineated. After 
+all, chronic stressors should ameliorate the symptoms 
+of inflammation-related diseases, but this conclusion is 
+at odds with the excess morbidity and mortality docu-
+mented in chronically stressed individuals. Miller and 
+colleagues [34] have put forth an alternative hypothesis 
+that posits the development of macrophage resistance to 
+cortisol negative feedback under conditions of chronic 
+stress, due to compensatory downregulation at the 
+immune cell (glucocorticoid) receptor. Early life stress 
+can give rise to blunted cortisol negative feedback of the 
+innate inflammatory response [35]. This may set the stage 
+for the stress-related chronic inflammation thought to 
+lower the threshold for stress-related noncommunicable 
+disease [36]. However, the research establishing cell sur-
+face receptor compensatory changes under conditions of 
+stress has thus far been unimpressive. Further research 
+is needed to discern the probable mechanism for this 
+phenomenon.
+Depression
+During lockdowns, social isolation and lack of physical 
+activity are two prominent risk factors for depression. 
+Depression increases the risk ofCOVID-19 infection sig-
+nificantly. There was increased mortality and hospitali-
+zation rates among COVID-19 infected patients having 
+recently diagnosed depression [37].
+Compared with nondepressed cohorts, individu-
+als with recently diagnosed depression were found to 
+have a significantly higher risk for COVID-19 infec-
+tion (Adjusted Odds Ratio 7.64, 95% confidence interval 
+7.45- 7.83) [35, 36]. Depression is correlated with altera-
+tion in immune markers, including decreases in mitogen 
+proliferation, natural-killer cell activity, and the types 
+and respective quantities of antibodies produced [38]. 
+Depression also dysregulates the neuroendocrine system 
+[39] and consequently increases inflammation, altering 
+the immune system’s effectiveness while simultaneously 
+increasing bystander damage [40]. Patients with depres-
+sion have disrupted T-cell function and elevated levels of 
+cytokines, such as tumor necrosis factor (TNF)-α, IL-1, 
+and IL-6 [40].
+Anxiety
+Pandemics are associated with heightened anxiety, on 
+both the collective and individual levels. The highly con-
+tagious nature of COVID-19 and the lack of treatment 
+options add to the increased threat to survival and may 
+trigger or aggravate existing anxiety and panic disorders.
+Anxiety contributes to significant dysfunction in 
+immune function by dysregulating the hypothalamic-
+pituitary-adrenal (HPA) axis [41, 42]. In a study of 42 
+patients with panic disorder and 42 healthy individuals, 
+Koh and Lee observed significantly lower IL-2 produc-
+tion and lymphocyte proliferation levels in patients with 
+anxiety disorder than in those without [43]. Complex 
+changes in the inflammation milieu related to aberrant 
+cytokines, particularly IL-1β, IL-6, TNF-α, and interferon 
+(IFN)-γ, have been documented in anxiety-based disor-
+ders [44]. Furthermore, patients with anxiety disorder 
+exhibit lower CD4+ cell counts, compared with healthy 
+controls. Studies have also documented the elevation of 
+suppressor CD8+ cells in these conditions, along with 
+a potentiated cytokine response [45]. This abnormal 
+response of the body’s immunological system in anxiety 
+and depression may contribute to heightened infection 
+and mishandling of severe infection, leading to a magni-
+fied, self-damaging cytokine response [46].
+Yoga and immunity
+Yoga is noted to have a positive impact on the immune 
+system [47–49] and inflammation pathways (Table  1). 
+It reduces inflammation and increases the number and 
+activity of natural-killer cells [50–52], thus enhancing 
+cell-mediated cytotoxicity of invading infective agents. 
+Evidence shows that yoga practice is associated with 
+improvement in CD3+ and CD4+ cell counts, salivary 
+cortisol levels, and IgA [53], a dominant player in innate 
+immunity that is present on body linings, such as those of 
+the lungs and the gastrointestinal tract [54]. With yogic 
+intervention, IgA levels increase at the exposed lung bor-
+der, where type II pneumocytes are prevalent. Addition-
+ally, cortisol, which dampens the body’s ability to fight 
+infection, is decreased by practicing yoga.
+Yoga has been found to be effective in immunocompro-
+mised conditions such as HIV. It helps to improve CD4+ 
+count and anxiety, depression, and stress among patients 
+with HIV [47, 56]. It has found to be equally effective in 
+improving CD56+ cell count, anxiety, and depression in 
+chronic disorders such as cancer [51].
+The cytokine storm unleashed by the body’s unregu-
+lated response to SARS-CoV-2 induces multiorgan 
+damage, resulting in high morbidity and mortality. 
+Myocarditis with severe refractory acute heart failure 
+has been noted [57]. As myocarditis is a clear signal for 
+cytokine-mediated damage, direct damage by the SARS-
+CoV-2 virus cannot be discounted, as both the heart and 
+vascular endothelium express the ACE2 receptors that 
+are entry gates for COVID-19 [13]. Cytokine profiles 
+in patients diagnosed with COVID-19 showed marked 
+Page 6 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+Table 1  Studies on Yoga and Immunity
+IgA denotes immunoglobulin A, IL interleukin, TNF tumor necrosis factor
+Author/Year
+Sample size
+Participant 
+characteristics
+Location/ Setting of 
+study
+Study design
+Intervention
+Results
+Conclusion
+Agnihotri et al., 2014 
+[40]
+276
+patients of mild to 
+moderate asthma (FEV 
+1 > 60%) aged between 
+12 to 60 years
+Department of 
+Pulmonary Medicine, 
+King George’s Medical 
+University, U.P., Lucknow, 
+India
+Randomized controlled 
+trial
+6-week yoga interven‑
+tion (30 minutes/day, 
+5 days/week of asana 
+and pranayama)
+Decreased eosinophil 
+and neutrophil counts 
+among patients with 
+asthma in yoga group
+Asana and pranay‑
+ama help to improve 
+hemoglobin counts and 
+to decrease bronchial 
+inflammation
+Chen et al., 2017 [50]
+94
+94 healthy pregnant 
+women at 16 weeks’ 
+gestation
+a prenatal clinic in Taipei
+longitudinal, prospec‑
+tive, randomized 
+controlled trial
+20-week yoga interven‑
+tion (60 minutes/day, 
+twice a week of asana 
+and pranayama)
+Significantly lower 
+cortisol levels; high IgA; 
+improvement in CD3+ 
+and CD4+ cell counts in 
+yoga group
+Asana and pranayama 
+bolster immune response 
+by reducing cortisol levels 
+and increasing IgA and 
+CD3/4+ counts
+Naoroibam et al., 2016 
+[45]
+44
+HIV-1 infected individu‑
+als
+Two HIV rehabilitation 
+centers of Manipur State 
+of India
+A randomized con‑
+trolled pilot study
+1-month yoga interven‑
+tion (60 minutes/day, 
+6 days/week of asana 
+and pranayama)
+Significantly higher 
+CD4+ cell counts in 
+yoga group
+Asana and pranayama 
+improve immunity in 
+HIV-1–infected adults
+Kuloor et al., 2019 [53]
+60
+HIV-positive (aged 
+30-50 years)
+Rehabilitation centres 
+across Bangalore
+A randomized con‑
+trolled study
+8-week yoga interven‑
+tion (60 minutes/day, 
+5 days/week of asana 
+and pranayama)
+Significantly lower rates 
+of anxiety, stress, and 
+depression in yoga 
+group
+Asana and pranayama 
+help lower stress, anxiety, 
+and depression levels of 
+HIV-positive patients
+Yadav et al., 2012 [55]
+86
+Patients with chronic 
+inflammatory diseases 
+and overweight/obese 
+subjects
+Integral Health Clinic, 
+Department of Physiol‑
+ogy, All India Institute of 
+Medical Sciences, New 
+Delhi, India.
+Preliminary results from 
+a nonrandomized pro‑
+spective ongoing study 
+with pre-post design.
+10-day yoga inter‑
+vention (asana and 
+pranayama)
+Decreased levels of 
+cortisol, IL-6, and TNF-α; 
+increased β-endorphin 
+levels
+Asana and pranayama 
+reduce inflammation and 
+stress levels over a short 
+span of intervention
+Rao et al., 2008 [39]
+98
+Recently diagnosed 
+stage II and III breast 
+cancer patients
+Comprehensive cancer 
+care center in Bangalore, 
+India
+Randomized controlled 
+trial
+1-month yoga interven‑
+tion (pranayama)
+Increased CD56+ cell 
+counts in yoga group
+Pranayama bolsters innate 
+immunity after surgery
+Page 7 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+	
+Table 2  Studies on Yoga and Inflammation
+IL denotes interleukin, TNF tumor necrosis factor
+Author/Year
+Sample size
+Participant 
+characteristics
+Location/ Setting of 
+study
+Study design
+Intervention
+Results
+Conclusion
+Kiecolt-Glaser et al., 
+2014 [63]  
+200
+Breast cancer survivors
+The Ohio State Univer‑
+sity, Columbus, OH.
+A randomized con‑
+trolled trial
+12-week yoga interven‑
+tion (twice weekly) 
+among breast cancer 
+survivors
+Significant decrease in 
+IL-6, TNF-α, and IL-1β
+Yoga practice helps 
+reduce inflammation
+Chen et al., 2016 [61]
+30
+Healthy, female Chinese 
+subjects
+School of Public Health, 
+Soochow University, 
+Jiangsu Province, China
+A Randomized Clinical 
+Trial
+8-week Hatha yoga 
+intervention (twice 
+weekly) among healthy 
+females
+Significant decrease 
+in IL-6, IL-8, IL-1β, and 
+TNF-α
+Yoga intervention 
+improves risk for 
+metabolic disorder and 
+inflammatory cytokine 
+dysregulation
+Rajbhoj et al., 2016 [64]
+48
+Male industrial workers
+Scientific Research 
+Department, Kaivaly‑
+adhama, Lonavla, Pune, 
+Maharashtra, India.
+A Randomized Clinical 
+Trial
+12-week yoga interven‑
+tion among healthy 
+male participants
+Significant decrease in 
+IL-10 and IL-1β
+Yoga practices could 
+reduce pro- and anti-
+inflammatory cytokines
+Page 8 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+elevation of T-helper lymphocyte type 1, IFN-γ, and 
+inflammatory cytokines IL-1β, IL-6, and IL-12 for at least 
+2 weeks after disease onset [58]. Among these, IL-6 is a 
+predictor of mortality in COVID-19 patients, which may 
+explain why primary evidence suggests that IL-6 inhibi-
+tors have shown promise as treatments [2, 59].
+Nagarathna et al. have documented the downregulation 
+of pro-inflammatory markers by yoga in their review arti-
+cle, hence supporting the utility of yoga as a complemen-
+tary intervention for subjects at risk or already infected 
+by SARS-CoV-2 virus [60]. Evidence indicates that yoga 
+practice helps to reduce inflammation by downregulating 
+a vast array of initiators and modulators that perpetuate 
+chronic inflammation, including IL-6, TNF-α, and IL-1β 
+[59, 60].
+Multiple randomized controlled trials have docu-
+mented a significant reduction in IL-6 levels in yoga 
+groups as compared with controls [61]. In one study, 
+researchers observed a significant reduction in IL-6 at 
+the 3-month follow-up in breast cancer patients who 
+practiced yoga, compared with a non-yoga control group 
+[62]. Moreover, increasing the amount of yoga practice 
+led to a more pronounced decrease in IL-6, pointing 
+towards a potential dose-response effect. Another rand-
+omized trial showed significantly reduced IL-6 secretion 
+after yoga practice in healthy individuals and significantly 
+reduced secretion of IL-6 when cultured blood was chal-
+lenged with a toll-like receptor agonist [62]. Multiple 
+studies have substantiated the beneficial effect of yoga on 
+inflammation and how it leads to CRS reduction, if not 
+inhibition (Table 2).
+Yoga during stressful events
+Various clinical trials have suggested a significant role for 
+yoga in reducing depression and its associated variables 
+(Table  3). In one study, 16 distressed women received 
+3 months of Iyengar yoga intervention, and a group of 
+8 women served as a control. After 3 months, women 
+in the yoga group showed a significant decrease in per-
+ceived stress, depression, and anxiety and in salivary cor-
+tisol; well-being improved significantly in the yoga group, 
+compared with controls [65].
+Yoga practice helps adherents to develop a positive 
+attitude during stress and to enhance self-awareness and 
+coping ability (Fig. 2). Yoga (asana, pranayama, and medi-
+tation) improves calmness and mindfulness and increases 
+an individual’s awareness and self-control [52]. Hatha 
+yoga (a variation in which only yoga postures are prac-
+ticed, with little or no meditation) improves HPA axis 
+dysregulation, corrects autonomic balance, and enhances 
+homeostasis by hastening recovery from stress [66]. 
+In a study among 131 participants with mild to moder-
+ate stress levels, 10 weeks of a Hatha yoga intervention 
+resulted in significant decreases in stress and anxiety, 
+along with enhanced relaxation [70]. In another study, 
+90-minute Hatha yoga sessions led to a significant reduc-
+tion in titers, negative affect, and cortisol levels [2, 72].
+Yoga helps to reduce the allostatic load of the stress 
+response [73]. It reduces sympathetic overactivity and 
+improves parasympathetic tone during a stressful situ-
+ation, as indicated by oxygen consumption level, heart 
+rate, and the high-frequency component of heart rate 
+variability [69].
+In a meta-analysis by Cramer et  al., yoga was found 
+to be an effective intervention for improving depression 
+[68]. Multiple studies have confirmed that yoga prac-
+tice reduced depression and improved mood and cog-
+nitive function among patients with mild to moderate 
+depression. This is achieved by enhancing the HPA axis 
+function, increasing brain-derived neurotrophic factor 
+(BDNF) levels and serotonin levels, and decreasing cor-
+tisol and inflammatory markers [68, 74, 75]. Autonomic 
+dysfunction is a hallmark of both anxiety and depres-
+sion [76]; regular yoga practice of pranayama can help 
+improve autonomic balance by decreasing sympathetic 
+overactivity and improving parasympathetic activity 
+[69]. Yoga also enhances the γ-aminobutyric acid system, 
+which is implicated in anxiety and depression [69].
+Yoga also improves various cognitive facets, such as 
+attention, concentration, memory, and executive func-
+tioning [71]. By improving body awareness, feelings, and 
+thoughts, yoga facilitates the experience of body sensa-
+tions in a nonjudgmental way [77]. It also enables the 
+practitioner to focus on present experience instead of 
+ruminating over future or past worries [78]. Self-aware-
+ness aids in avoiding addictive or overindulgent behav-
+iors, including overeating and excess sleeping. Yoga helps 
+people remain active and fosters a positive attitude dur-
+ing a lockdown.
+Cardio‑respiratory protective effects of yoga
+Given the severe cardiorespiratory illness manifested 
+in COVID-19 [1], consistent training in yoga may play 
+a protective role. Yoga has numerous positive effects 
+on the cardiovascular and respiratory systems. It has 
+been proven to improve various forms of cardiac 
+arrhythmia, congestive cardiac failure, ischemic heart 
+disease, and hypertension [79–83]. Regular yoga prac-
+tice attenuates systolic and diastolic blood pressure 
+and mean arterial pressure; it has also been credited 
+with maintaining appropriate blood pressure with less 
+medication [84]. Simply lying down in the Savasana 
+yogic posture for 20 minutes daily was found to be 
+effective in reducing systolic and diastolic blood pres-
+sure and the need for antihypertensive medication 
+[85]. Yoga has been shown to improve cardiac function 
+Page 9 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+	
+Table 3  Studies on Yoga and Stress, Anxiety and Depression
+BDNF denotes brain-derived neurotrophic factor, GABA γ-aminobutyric-acid
+Author/Year
+Sample size
+Participant 
+characteristics
+Location/ Setting of 
+study
+Study design
+Intervention
+Results
+Conclusion
+West et al., 2004 [66]
+69
+Healthy college stu‑
+dents
+Reed College, USA
+Longitudinal cohort 
+study
+90-minute Hatha yoga 
+session
+Significant reduction in 
+titers, negative affect, 
+and cortisol
+Hatha yoga reduces both 
+cortisol and perceived 
+stress level
+Michalsen et al., 2005 
+[67]
+24
+24 self-referred female 
+subjects who perceived 
+themselves as emotion‑
+ally distressed
+Germany
+Controlled prospective 
+non-randomized study
+3-month Iyengar yoga 
+intervention among 
+mental distressed 
+women
+Compared to the con‑
+trol groups significant 
+reduction in perceived 
+stress was observed
+Yoga helps to improve 
+perceived stress among 
+distressed women
+Janakiramaiah et al., 
+2000 [68]
+45
+Untreated melancholic 
+depressive patients
+Department of Psychia‑
+try, National Institute 
+of Mental Health and 
+Neurosciences, Banga‑
+lore, India.
+Randomized compara‑
+tive trial
+Sudarshan Kriya for 
+4 weeks among patients 
+with melancholic 
+depression
+Significant reduction in 
+depression score
+Sudarshan Kriya demon‑
+strated its antidepressant 
+effects in depression
+Smith et al., 2007 [65]
+131
+Subjects with mild to 
+moderate levels of stress
+Community in South 
+Australia
+A randomised compara‑
+tive trial
+10-week Hatha yoga 
+intervention
+Significant improve‑
+ment in SF-36 scores 
+was observed in yoga 
+group
+Hatha yoga intervention 
+helps to improve stress, 
+anxiety and health status 
+compared to relaxation
+Naveen et al., 2016 [69]
+54
+Adult outpatients with 
+Major Depression
+Out-patient services of 
+NIMHANS, Bangalore, 
+India
+Prospective cohort 
+study
+3-month yoga interven‑
+tion among patients 
+with depression
+Significant improve‑
+ment in depression, 
+BDNF, and serum corti‑
+sol was observed
+3 month yoga interven‑
+tion helped improve 
+BDNF, cortisol, and 
+depression in depressive 
+patients
+Streeter et al., 2012 [70]
+34
+Normal subjects with no 
+prior yoga experience
+Community in USA
+Randomized compara‑
+tive trial
+60-minute yoga inter‑
+vention
+27% increase in GABA 
+levels in yoga group
+Yoga could help a treat 
+disorders with low GABA 
+levels like depression, 
+anxiety
+Shelov et al., 2009 [71]
+46
+Normal staff and 
+students
+Ferkauf Graduate School 
+of Psychology (FGS) 
+and the Albert Einstein 
+College of Medicine 
+(AECOM) in Bronx, New 
+York
+Randomized controlled 
+trial
+8-week yoga interven‑
+tion
+Elevated levels of mind‑
+fulness, per Freiburg 
+Mindfulness Inventory
+Yoga increases mindful‑
+ness and potentially pre‑
+vents later development 
+of negative emotional 
+mood states
+Page 10 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+in patients with congestive cardiac failure [86] and 
+to improve baroreflex sensitivity, peripheral vascu-
+lar resistance, and heart rate variability [87]. It also 
+helps to attenuate catecholamine secretion, which has 
+been implicated in the etiology of severe cardiomyo-
+pathy and heart failure [88]. In one study, 8 weeks of 
+yoga intervention led to significant decrease in IL-6, 
+C-reactive protein, and extracellular superoxide dis-
+mutase, compared with non-yoga controls in patients 
+with heart failure [89]. Thus, evidence indicates that 
+yoga offers multi-faceted protection from cardiac 
+damage mitigated by aberrant cytokine release, such as 
+that seen with COVID-19.
+Limitations
+Our review is up-to-date, and the findings are of sig-
+nificant relevance but the important limitations must 
+be considered. The literature was searched and sum-
+marized thoroughly but our review was not system-
+atic, thus increasing the possibilities of selection and 
+publication bias. Our study included only articles in 
+English thus introducing a language bias. The associa-
+tions and characteristics identified in this review await 
+clearly proven causative mechanisms. Important con-
+founders exist in the cross-sectional studies reviewed 
+in the form of age, medications, and immune strength. 
+Larger randomized controlled trials will provide nec-
+essary insight on the role of yoga in immunomodula-
+tion and mental health during the present pandemic.
+Conclusions
+The aggregation of pathophysiological aberrations, 
+both psychological and somatic, secondary to COVID-
+19 pandemic and its resultant restrictions, may increase 
+the severity of the infection. Accumulated evidence 
+leads us to hypothesize that, for many, yoga practice 
+may attenuate the ill effects of COVID-19–induced 
+immune dysfunction at different stages.
+From a public health perspective, yoga represents a 
+low-cost, noninvasive strategy for alleviating the physi-
+cal and emotional toll of the COVID-19 pandemic. 
+The aforementioned yoga practices can be performed 
+at home, in adherence to social distancing guidelines. 
+Outcomes from an 8-week yoga intervention (asanas, 
+pranayama, and meditation) indicated that medical 
+treatment plus yoga is more effective than medical 
+treatment alone in reducing anxiety [90]. Relaxation 
+techniques like yoga and meditation helps in managing 
+chronic or long term stress by regulating the cytokines, 
+thus assisting people to overcome co-morbidities asso-
+ciated with diseases and improving the quality of life; 
+which is important in COVID-19 and post-COVID 
+illness [2, 21]. Notwithstanding, appropriate clini-
+cal trials are required to document the efficacy of this 
+strategy.
+Abbreviations
+ACE: Angiotensin-converting enzyme; BDNF: Brain-derived neurotrophic 
+factor; COVID-19: Coronavirus disease; CRS: Cytokine release syndrome; HIV: 
+Human immunodeficiency virus; HPA: Hypothalamic-pituitary-adrenal; IFN: 
+Interferon; IgA: Immunoglobulin A; IL: Interleukin; TNF: Tumor necrosis factor.
+Acknowledgements
+Jeanie F. Woodruff, BS, ELS, contributed to the editing of this manuscript.
+Authors’ contributions
+IBR: Hypothesis and concept, KM, DK, RR, KC: Research and Manuscript 
+preparation: KC, AA, IBR, KM, DK, RR, KC, NR, MCM, BP, MS, IVB, AA, SR, DKK, 
+ML, ST, GNL, HC, GF, and NRH: Manuscript review and contribution of critical 
+intellectual content, including figures and tables. The author(s) read approved 
+the final manuscript.
+Funding
+None.
+Availability of data and materials
+The datasets used and/or analyzed during the current study are available from 
+the corresponding author on reasonable request.
+Declarations
+Ethics approval and consent to participate
+Not applicable.
+Consent for publication
+Not applicable.
+Competing interests
+The authors declare that they have no competing interests.
+Fig. 2  Yoga helps to improve various health parameters related to 
+immunity. [Contribution by Mohammad A. Salem, MD; used with 
+written permission]
+Page 11 of 13
+Basu‑Ray et al. BMC Complementary Medicine and Therapies          (2022) 22:191 
+	
+Author details
+1 
+Cardiologist & Cardiac Electrophysiologist, Memphis VA Medical Center, 
+1030 Johnson Ave, Memphis, TN 38104, USA. 2 
+The University of Memphis, 
+Memphis, TN, USA. 3 
+All India Institute of Medical Sciences, Rishikesh, Uttara‑
+khand, India. 4 
+Department of Yoga, Central University of Rajasthan, Bandar 
+Seendri, Rajasthan, India. 5 
+New Cross Hospital, Heart and Lung Centre, Royal 
+Wolverhampton NHS Trust, Wolverhampton, UK. 6 
+Icahn School of Medi‑
+cine at Mount Sinai, New York, NY, USA. 7 
+Department of Internal Medicine, 
+Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA. 
+8 
+Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, Karnataka, 
+India. 9 
+Mahatma Gandhi University of Medical Sciences & Technology, Jaipur, 
+Rajasthan, India. 10 
+University Grants Commission, New Delhi, India. 11 
+Anve‑
+shana Research Laboratories, Swami Vivekananda Anusandhana Samsthana 
+(SVYASA University), Bangalore, Karnataka, India. 12 
+Morarji Desai National Insti‑
+tute of Yoga, Ministry of AYUSH, Govt. of India, New Delhi, India. 13 
+Department 
+of Neurology, Post Graduate Institute of Medical Education and Research, 
+Chandigarh, India. 14 
+Public Health Foundation of India, New Delhi, India. 
+15 
+Department of Physiology, All India Institute of Medical Sciences, New Delhi, 
+India. 16 
+Cardiology Section, Baylor College of Medicine, Michael E. DeBakey 
+VA Medical Center, Houston, TX, USA. 17 
+Department of Internal and Integra‑
+tive Medicine, University of Duisburg-Essen, Essen, Germany. 18 
+Department 
+of Psychiatry, Benson-Henry Institute for Mind-Body Medicine, Massachusetts 
+General Hospital, Boston, MA, USA. 
+Received: 23 December 2020   Accepted: 5 July 2022
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subfolder_0/A qualitative study on the needs of caregivers of inpatients with schizophrenia in India.txt

@@ -0,0 +1,834 @@
+180 
+INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)
+E CAMDEN SCHIZOPH
+A QUALITATIVE STUDY ON THE NEEDS OF CAREGIVERS 
+OF INPATIENTS WITH SCHIZOPHRENIA IN INDIA
+A. JAGANNATHAN, J. THIRTHALLI, A. HAMZA, V.R. HARIPRASAD, 
+H.R. NAGENDRA & B.N. GANGADHAR
+ABSTRACT
+Aim: To explore the needs of caregivers of inpatients with schizophrenia in India.
+Material: Thirty caregivers of inpatients with schizophrenia participated in five focus 
+group discussions (FGD), where the needs of the caregivers were discussed. The 
+FGDs were recorded, transcribed and similar needs were grouped and ranked 
+according to their order of importance. 
+Discussion: The main needs that emerged were regarding: managing the behaviour 
+of patients; managing social-vocational problems of patients; health issues of 
+caregivers; education about schizophrenia; rehabilitation; and managing sexual 
+and marital problems of patients. 
+Conclusion: This study has identified additional needs of caregivers from those 
+found in other studies.
+Key words: needs, caregivers, schizophrenia, focus group discussion, qualitative 
+analysis
+INTRODUCTION
+The importance of the role of family caregivers in the treatment of a person with mental illness 
+cannot be overemphasized. Family caregivers provide considerable support to their ill relatives 
+even while they experience significant burden (Leff, 1994). In a survey conducted by Consumer 
+Health Sciences (CHS) and the National Mental Health Association (NMHA), one third of the 1,328 
+family caregivers surveyed said that the emotional and behavioural symptoms of the illness caused 
+them extreme hardship and was a constant source of anxiety (Consumer Health Sciences, 2008). 
+Caregivers who are in ‘high contact’ with the patient in their daily life often face the highest burden 
+(Winefield & Harvey, 1994). Family coping strategies accounted for a substantial proportion of the 
+variance observed in objective and subjective burden respectively among caregivers of persons with 
+schizophrenia (Magliano et al., 1998). This highlights the fact that studying the needs of family 
+caregivers of patients with severe mental disorders is important from a public health perspective.
+In India, the majority of the people with schizophrenia stay with their families (Thara et al., 
+1998; Murthy, 2006). There have been no systematic scientific Indian studies to assess the needs 
+of caregivers; however, several different opinions have been expressed. Some of the needs opined 
+are the need for awareness about the nature and outcome of mental illnesses in the community, 
+International Journal of Social Psychiatry. © The Author(s), 2011. Reprints and permissions:
+http://www.sagepub.co.uk/journalsPermissions.nav Vol 57(2): 180–194  DOI: 10.1177/0020764009347334
+ 
+JAGANNATHAN ET AL.: A QUALITATIVE STUDY ON THE NEEDS OF CAREGIVERS 
+181
+the need for primary psychiatric and other professional treatment, and psychosocial rehabilitation 
+(Goswami, 2006; Janardhan, 2006). Caregivers of inpatients report experiencing a significantly 
+higher burden than caregivers of outpatients. Unmet needs of the patients have also been found to 
+be significantly related to caregiver burden (Cleary et al., 2005). Meeting these needs would help 
+to enhance the level of functioning of the patient (Solomon & Draine, 1994) and to decrease the 
+emotional problems of family members (Johnson, 1994). 
+Family members of a patient with chronic schizophrenia have multiple needs. The major con-
+cerns and support needs of individuals who assume this stressful role include obtaining support, 
+reducing risks to their own well-being, and promoting the well-being of the mentally ill (Chafetz & 
+
+Barnes, 1989). They often express the need for more support and complain of not having enough 
+opportunities to relieve the burden imposed on them (Angermeyer et al., 2000). Educational 
+needs include gaining information about early warning signs of the illness and relapse, the effects 
+of medication and ways of coping with the patient’s bizarre and assaultive behaviour (Chien & 
+Norman, 2003). Often family members living with ill persons are less aware of the psychiatric nature 
+of the illness (Padmavathi et al., 1998). Thus it is necessary to understand the needs of families 
+of persons with mental illness and to develop specific interventions to meet them in order to help 
+reduce caregiver burden (Cleary et al., 2006; Murthy, 2006).
+The present study was conducted in order to assess the needs of the caregivers of schizophrenic 
+patients in India. India spends a mere 0.83% of its total health budget on mental health compared 
+to England and Wales which spends 13.8% (WHO, 2001); thus, the extent to which the needs of 
+caregivers will be met in India is likely to be different. Furthermore, given the differences in the 
+socio-cultural milieu, the results of the studies done in other cultures may not be relevant in an 
+Indian context. 
+Further, studies using scales to assess caregiver needs have the limitation of forcing the re-
+spondents to answer from a list. For instance, studies either focus on specific needs such as edu-
+cational needs (Chien & Norman, 2003) or on groups of needs such as counselling and support 
+services, education and financial entitlements (Wancata et al., 2006; Barrowclough et al., 1998). We 
+used a qualitative approach to assess the needs of caregivers for several reasons: (a) this approach 
+is useful in tapping a broader range of needs that are specific to the context in which it is used; 
+
+(b) studying the needs of caregivers involves probing of sensitive, emotional and personal themes 
+of needs, which is more suited to a qualitative approach (Hiday et al., 2002; Padget, 1998); and 
+(c) qualitative studies are especially helpful when one intends to generate impressions and to 
+
+develop assessment scales, programmes or services (Stewart et al., 2007).
+METHOD
+Sample
+The participants were 30 caregivers of inpatients with schizophrenia at the National Institute 
+of Mental Health and Neuro Sciences (NIMHANS) in Bangalore, India – a tertiary care centre. 
+NIMHANS has a 900-bed teaching hospital with training and research facilities in psychiatry and 
+other neurosciences. In April 2008, caregivers of all inpatients with schizophrenia were screened. 
+In total, 59 patients with a diagnosis of schizophrenia were admitted to the hospital during this 
+period. Caregivers of patients with a diagnosis of schizophrenia were included in the study if they 
+were to continue to provide care for them following discharge and if they spoke Kannada, Tamil, 
+English or Hindi. Caregivers with psychiatric or neurological disorders and those caring for another 
+182 
+INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)
+relative with psychiatric illness were excluded. Thirty eight caregivers who fulfilled these inclusion 
+and exclusion criteria were approached. Of these 38 caregivers, 30 consented to participate in 
+the study. These included families from different socioeconomic backgrounds, different states of 
+
+India and from different carer roles. The 30 caregivers thus recruited participated in five focus 
+group discussions (FGDs), with approximately six caregivers participating in each of the FGDs. 
+The sociodemographic data of the caregivers who participated in the FGDs and a profile of their 
+ill relatives were compiled (Table 1).
+Focus group discussion 
+From the range of qualitative research methods available, the FGD method was selected (vis-à-
+vis individual interviews), as it is less time-consuming, economical and has the benefits of group 
+processes (Stewart et al., 2007). The discussions followed the recommendations of Stewart et al. 
+(2007) – they involved six to eight individuals who discussed the research question ‘What are the 
+needs of family caregivers of inpatients with schizophrenia?’ for approximately 1.5–2.5 hours. The 
+FGD was conducted under the direction of a moderator (AJ/HVR) who promoted interactions and 
+ensured that the discussions remained focused on the topic of interest. 
+Script
+A standardized script for conducting the FGD was developed on the basis of the aims of the 
+study, literature review and discussion with four experienced focus group researchers. The script 
+
+followed a semi-structured format using open-ended questions in a face-to-face ‘conversational’ style 
+rather than a formal question/answer format. (The script is available from the authors on request.) 
+Although the group discussion script was flexible in nature, some direction was given when the 
+focus was lost and probes were used when necessary. The script included discussion about the felt 
+needs of the caregivers in caring for their relative with schizophrenia, and the grouping and ranking 
+of similar needs according to their order of importance. 
+Procedure
+The study was reviewed and approved by the Institute’s ethics committee. Written informed consent 
+of the family caregivers was obtained to participate in the study and a sociodemographic sheet 
+eliciting information on their age, occupation, monthly income, marital status, patient variables 
+and family constellation was completed. Each FGD was video-recorded and was facilitated by 
+the researcher (psychiatric social worker) and a co-facilitator. The researcher facilitated the group 
+process and the co-facilitator helped in recording the observations of the group session (audio/video 
+and by taking down notes). 
+The FGD involved the researcher asking the caregivers to list their needs (Appendix), group the 
+list of needs into main themes, operationally define the themes and rank them in order of importance. 
+As the methodology of free listing of needs was used, all the needs expressed by the caregivers 
+were noted. Across all five FGDs, the needs of caregivers were found to be largely comparable. 
+Thus, no needs were deleted from the list and all needs were accommodated into either one of the 
+categories/themes. In case of differences of opinion within the group about the grouping and ranking 
+of similar needs, further discussion and cross-clarification (iteration) was conducted among the 
+members who differed in their opinion till a consensus was reached. In groups where consensus 
+could not be reached, the themes were given similar ranking (e.g. in FGD-2, the themes of health 
+of caregivers, rehabilitation options and managing social/behavioural problems of patients were 
+given similar ranking).
+ 
+JAGANNATHAN ET AL.: A QUALITATIVE STUDY ON THE NEEDS OF CAREGIVERS 
+183
+Table 1
+Sociodemographic data of caregivers and patients
+Caregivers (n = 30)
+Patients (n = 29)**
+Variable
+n (%)
+mean (SD)
+Variable
+n (%)
+mean (SD)
+Variable
+n (%)
+mean (SD)
+Age of the caregiver (years)*
+ 
+50.6 (13.4)
+Education	 (years)*
+ 
+10.2  (6.4)
+Age of patient (years)*
+ 
+31 
+ (8.7)
+Gender
+  male
+  female
+ 
+13 
+(43.3)
+ 
+17  (56.7)
+Marital status
+  single
+  married
+  widowed
+ 
+3 (10)
+ 
+25 (83.3)
+ 
+2 
+(6.7)
+Gender
+  male
+  female
+ 
+17 
+ (58.6)
+ 
+12 
+ (41.4)
+Religion
+  Hindu
+  Christian
+ 
+27  (90)
+ 
+3  (10)
+Family type
+  nuclear family
+  joint family
+ 
+23 (76.7)
+ 
+7  (23.3)
+Education in years*
+ 
+11.38  (4.9)
+Economic status
+  low
+  middle
+  high
+ 
+13  (43.3)
+ 
+6  (20)
+ 
+11  (36.7)
+Relationship with the patient
+  parent
+  sibling
+  other relations
+  spouse
+ 
+21  (70)
+ 
+4  (13.3)
+ 
+3  (10)
+ 
+2  (6.7)
+Duration of the illness*
+ 
+103.60 (59.5)
+Occupation
+  unemployed
+  daily-wage labourer
+  professional
+  housewife
+  retired
+  student 
+ 
+1 
+ (3.3)
+ 
+8  (26.7)
+ 
+4  (13.3)
+ 
+8  (26.7)
+ 
+8 
+(26.7)
+ 
+1 
+ (3.3)
+Comorbid physical illness
+  nil
+  diabetes mellitus
+  hypertension
+  others
+ 
+20  (66.7)
+ 
+3  (10)
+ 
+4  (13.3)
+ 
+3  (10)
+Type of schizophrenia
+  paranoid
+  hebephrenic
+  catatonic
+  undifferentiated
+  schizoaffective
+ 
+19 
+(65.5)
+ 
+2 
+(6.9)
+ 
+1 
+(3.4)
+ 
+5 
+(17.2)
+ 
+2 
+(6.9)
+*Mean (SD), ** Two caregivers represented one patient in one of the FGDs.
+184 
+INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)
+Data analysis 
+The first level of data analysis was done during each of the focus group sessions. The researcher 
+made a list of needs during the discussion. The group (caregivers) then divided these needs into 
+themes and sub-themes and ranked them according to their importance. Following the technique 
+of iteration, the group went over these themes and rankings several times before finalizing them. In 
+each FGD the most important theme (based on grouping and ranking at level one and two of data 
+making) was given the highest score (equal to the number of themes listed) and the least important 
+theme was given the a score of 1. If two or more themes were deemed as having equal importance 
+during the FGD, then such themes were given similar scores. If a theme was not represented in a 
+particular FGD, it was given a score of 0 in that FGD.
+Each FGD was transcribed and further data making and analysis was conducted by the researcher 
+(second level of data making). Based on the first level of data making, the researcher reviewed 
+the listing of themes and wherever two or three themes seemed to represent a common theme, 
+they were grouped under an appropriate theme. The theme thus generated was given a score by 
+averaging the scores from the first level of data making. For example, in FGD-5, out of the six 
+themes identified by the caregivers, themes of ‘educational needs’ (score = 6) and ‘information on 
+management of side effects of medicines’ (score = 4) were grouped by the researcher as one main 
+theme of ‘education needs’ and given a score of 5. 
+The researcher then checked the remaining text for leftover lists of needs and put them under the 
+most appropriate theme. The scores for each theme across the five FGDs were totalled. The final 
+ranking of the themes corresponded to these totals; the theme with highest total score was ranked 
+as the most important need (Table 2). 
+The needs under each theme across the five FGDs were listed. A final list of themes and needs 
+under each theme was tabulated for analysis. As the sample size in each FGD was small, no 
+computer-assisted software package was used for the data analysis. Computer software would have 
+been appropriate if 30 individual interviews had been conducted instead of six groups.
+During the entire study period, the ill relative continued to receive the routine treatment prescribed 
+by the doctors at NIMHANS. The treating doctors were consulted and their approval to conduct 
+the FGD was obtained.
+RESULTS
+The main needs that emerged from the analysis of the FGDs are described in Table 2.
+I: Managing illness behaviour
+The areas in which the caregivers needed help to manage the illness behaviour of their relative 
+were: managing their non-compliance with medication; uncooperative behaviour; aggressive and 
+demanding behaviour; dealing with their illness symptoms (hallucinations/delusions, wandering, 
+insomnia, spending behaviour, reduced food intake); increased substance use; handling their 
+unpredictable behaviour; lack of interest in self-care; concentration problems; and lack of daily 
+routine. The following quotes of the caregivers depict the problems they faced in managing the 
+illness behaviour of their relative.
+‘Even when the family members advise or request, my brother says, “No I am not the patient; 
+you have a problem, so why should I take the medication?”’ (Mr S.M. (47 years), FGD-2)
+ 
+JAGANNATHAN ET AL.: A QUALITATIVE STUDY ON THE NEEDS OF CAREGIVERS 
+185
+‘If somebody visits us, and we are talking, my daughter feels as if we are talking about her. 
+Whatever topic we talk about, she tells that we are talking about her. Next when I give her food, 
+she suspects that I have mixed poison or faeces in the food.’ (Mrs J. (36 years), FGD-3)
+‘Suddenly my daughter gets angry, very angry to an extent that she does not get pacified until 
+and unless she hurts someone, even if it were my son or myself.’ (Mrs J. (36 years), FGD-3)
+‘My daughter does not do anything. I have to do everything for her… from combing her hair, 
+washing her clothes. I have to scrub and bathe her also.’ (Mrs J. (36 years), FGD-3)
+II: Managing social-vocational problems 
+Caregivers discussed various areas where they needed professional help in managing the social-
+vocational problems of their ill relative. These were: dealing with patient’s lack of interest in 
+socialization/not going out of the house; relationship problems; uninhibited behaviour; and difficulty 
+in initiating and maintaining activities/job. The following quotes of the caregivers throw light on 
+the social-vocational problems.
+‘My son is always in the home. He never goes out. He does not mix even with our relatives or 
+workers… he finds it difficult to get out of the room.’ (Mrs B.M. (60 years), FGD-2)
+‘My son comes out of the bathroom at times without wearing his clothes. Even when we tell him, 
+he does not listen. It becomes very difficult if there are guests at home.’ (Mr M.S. (45 years), 
+
+FGD-3)
+‘I would want my son to go to a job. He has forgotten about going for the job completely. He 
+does not have a mind to go for a job. (Mr M.R. (65 years), FGD-4)
+My son has changed seven companies. In no company he has worked for more than two to three 
+days… He gets a job easily. Four appointments are in hand. But after joining, he cannot maintain 
+the job.’ (Mr R. (68 years), FGD-4)
+Table 2
+Ranking, rating and percentage of importance of themes across five FGDs
+Rank order Theme
+FGD-1
+FGD-2
+FGD-3
+FGD-4
+FGD-5
+Total
+%*
+I
+Managing illness 
+behaviour of patients
+4
+6
+6
+3
+4
+23
+27.7
+II
+Managing social-
+vocational problems 
+of patients
+3
+4
+5
+2
+3
+17
+20.5
+III
+Health of caregivers
+1
+4
+4
+4
+2
+15
+18.1
+IV
+Education about illness
+5
+1
+1
+1
+5
+13
+15.7
+V
+Rehabilitation
+2
+5
+3
+0
+1
+11
+13.2
+VI
+Managing sexual and 
+marital problems of 
+patient
+0
+2
+2
+0
+0
+4
+4.8
+* Percentage of total needs score represented by the themes. Total needs score = (23 + 17 + 15 + 13 + 11 + 4) = 83. 
+186 
+INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)
+III: Health needs of caregivers
+Caregivers had a number of health needs. They required help in: managing their emotions (anger, 
+depression, fear); handling their stress; taking decisions; dealing with lack of social support; 
+reduced personal life; and balancing work and patient care. The following quotes of the caregivers 
+exemplify their health needs.
+‘I am always worried about the possibility of such events happening at home [violent outburst of 
+the patient]. So we continuously suffer from tension and sadness.’ (Mr M.S. (45 years), FGD-3)
+‘No facility, no neighbours, no relatives or friends came to help us when the patient was violent. 
+We were helpless and did not know what to do. [Mr C.R. is overwhelmed and starts crying.] Even 
+if I called for the ambulance at our place, they do not come. Thus we start getting negative feelings 
+like anger. We need to know how to control these feelings.’ (Mr C.R. (25 years), FGD-2)
+‘For the past 10 years [since my brother’s illness started], the concept of my personal life is 
+completely zero. I am now adjusted to this life and I stopped my studies. I now take care of my 
+brother full-time as my parents are aged.’ (Mr S. (33 years), FGD-4)
+IV: Education
+Education needs of the caregivers included: education about the illness; information on medication/
+side effects/emergency medicine (sedatives); information on available concessions/benefits offered 
+by the government; and information on how to deal with stigma. The following quotes depict the 
+caregiver needs for education.
+‘The medicines have so many side effects. The doctor does not tell us that this medicine will 
+give side effects.’ (Mr I.K. (60 years), FGD-1)
+‘In event of the patient becoming very violent and not responding to us, if there is any pill 
+which can be given to him at that time and if he sleeps… [another group member continues]… 
+one liquid… if by adding a few drops in food, he will be ok, we can then bring him to the 
+hospital. But we don’t know what to give and what not to give [pill]. We need education on that.’ 
+
+(Mr S.M. (47 years) and Mrs B.M. (60 years), FGD-2)
+‘For the patient and caregivers we should know about the concessions available from the gov-
+ernment. For other people [of other disorders] they get reimbursed for their treatment. We are 
+not getting any money from anywhere and we have to spend a lot of money.’ (Mrs B.M. (60 
+years), FGD-2)
+‘There is a lot of stigma about this illness… a lot of misconceptions about mentally ill patients. 
+They do not understand what type of illness this is, what is the problem. So educating society is 
+important.’ (Mr C.R. (25 years), FGD-2)
+V: Rehabilitation
+All caregivers cited these rehabilitation needs: knowing about financial and rehabilitation options; 
+local support groups and helpline services; office/work benefits for caregivers; and local referral 
+systems. The following quotes depict the rehabilitation needs of the caregivers.
+ 
+JAGANNATHAN ET AL.: A QUALITATIVE STUDY ON THE NEEDS OF CAREGIVERS 
+187
+‘Psychiatric patients have very few rehabilitation options… patients who are well… around 70% 
+of them, if some small jobs can be provided for them… small encouragement can be given to 
+them by the government, it would be helpful.’ (Mr I.K. (60 years), FGD-1) 
+‘Development of local support groups in city/hometowns like palliative care groups for cancer 
+patients will be a great relief to all people, wherever we are.’ (Mrs M. (52 years), FGD-2)
+‘At least in medical colleges, connected with this issue a helpline can be opened. The government 
+can do this.’ (Mrs B.M. (60 years), FGD-2)
+‘If we are government employees, at any time, we do not get leave and we can get transferred. 
+Even when I tried to convince my superiors that I had to take care of three mentally ill persons 
+at home [officers] they did not listen. They processed my transfer order. So if certain rules 
+
+and regulations to give leave to us as a caregiver of a patient are made, it would be useful.’ 
+
+(Mr C.R. (25 years), FGD-2)
+‘A small centre should be made available [developed] in our state, in any of the cities or in any 
+place in the state – with one doctor. If patient does not want to come to NIMAHNS, we do not 
+know where to take him. In every crisis situation we cannot come over here [to NIMHANS]. 
+There needs to be a local referral system.’ (Mrs B.M. (60 years), FGD-2)
+VI: Managing the sexual and marital problems of patients
+Caregivers of persons with mental illness faced a number of problems related to the sexual and 
+marital issues of the patient. They needed help in dealing with issues such as: whether to get the 
+patient married; problems in getting patient married; problems in maintaining the patient’s marriage 
+post-illness (separation/divorce issues); and problems of the patient related to sexual activities/
+marital discord. The following quotes of caregivers exemplify some of the above themes.
+‘We have seen a few girls for my son’s marriage. But all the parties we go to see, somebody in 
+our village would have already told them that he is not mentally well and the alliance would be 
+rejected.’ (Mrs B.M. (60 years), FGD-2)
+‘My brother is married but his wife does not stay with him. He has a child and his wife has put 
+the child in a hostel. This is because from 1999 he is getting treatment from NIMHANS and he 
+was not cured. After he goes back home, within a few days the symptoms relapse. So his wife’s 
+father and mother have advised her not to go back to her husband. We do not know how to deal 
+with this situation.’ (Mr S.M. (47 years), FGD-2)
+DISCUSSION
+The needs of the caregivers are extensive and vary across cultures. An in-depth assessment and 
+analysis is of paramount importance in order to develop programmes to cater to the needs of 
+caregivers in a cultural context. The present study explored the needs of caregivers of inpatients 
+with schizophrenia in India. The three main needs that emerged from the analysis of the FGDs, 
+188 
+INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)
+were (in order of importance) help in: (1) managing the illness behaviour of the patients; 
+
+(2) managing social-vocational problems of patients; and (3) health needs of the caregivers. 
+Some published studies have focused on specific needs such as rehabilitation and/or education 
+
+(Chien & Norman, 2003; Winefield & Harvey, 1994). Most other studies have used a standardized 
+needs questionnaire to assess caregiver needs. The Camberwell Assessment of Need (CAN), one 
+of the most widely used, is more often used with persons who are in contact with mental health 
+services and are receiving inpatient, outpatient or day-patient care (Phelan et al., 1995). The Carer’s 
+Needs Assessment (CNA) and the Relatives Cardinal Needs Assessment (RCNS), on the other 
+hand, focus on caregivers’ educational, financial, social and interpersonal, professional support 
+and health needs (Wancata et al., 2006; Barrowclough et al., 1998).
+Assessing the needs through the method of a questionnaire could limit the range of expression 
+of the needs of caregivers. The qualitative assessment method used in this study has been useful 
+in finding in-depth requirements of caregivers in each need area – an additional comprehensive 
+result, different from that of other studies. For example, under ‘health needs’ various caregivers’ 
+requirements were covered such as the need to manage stress and emotions, the need to maintain 
+balance between caregiving and personal life/work and the need to know how to take decisions in 
+stressful situations. 
+The results of the current study could also be interpreted in terms of the sample – how needs of 
+caregivers of inpatients (who had recently become ill or whose illness had exacerbated) could differ 
+from those of caregivers of outpatients (Cleary et al., 2006). The caregivers who participated in 
+this study were more patient-focused rather than carer-focused. This reflects not just the altruistic 
+preoccupations of focus group participants, but also the fact that all these caregivers were taking 
+care of patients who were currently symptomatic and required immediate hospitalization for their 
+symptom control. Managing the symptoms of the patients was always considered as the most 
+important priority. There were differences in opinion between caregivers in some groups about 
+whether rehabilitation, education or their health needs was the next important need. The homogeneity 
+of the sample (all caregivers of inpatients with schizophrenia) could be a reason for all the caregivers 
+having similar priorities in taking care of their patient. 
+Further cultural factors, such as strong family systems, could have a bearing on the results of 
+the study. In India the patient is always accompanied by the family member (who is the caregiver) 
+as compared to other countries where caregivers are not necessarily family members (Thara et al., 
+1998; Leff, 1994). 
+The sociodemographic profile of the caregivers in this study is consistent with that of earlier 
+studies on Indian caregivers of persons with schizophrenia (Srinivasan, 2006; Murthy, 2007). All 
+caregivers were family members. Most of them were parents, especially mothers who had a lower 
+income and were into late adulthood or old age. It may also be noted that the proportion of patients 
+living in nuclear families in this study (76.7%) is comparable to that of the general population of 
+India (70.4%; Office of the Registrar General and Census Commissioner, India, 2001). 
+Caregivers in the study reported that their primary need was help in managing the symptoms of 
+the patient. Due to lack of knowledge, fear and stigma associated with mental illness, caregivers 
+often found themselves at a loss as to how to do this (Gandon et al., 2008). Dealing with the social-
+vocational problems of the patient (second need), was another area of concern for the caregivers. 
+Some expressed more concern about ‘negative’ symptoms of schizophrenia (e.g. social withdrawal) 
+ 
+JAGANNATHAN ET AL.: A QUALITATIVE STUDY ON THE NEEDS OF CAREGIVERS 
+189
+than about positive ones (e.g. hallucinations) (North et al., 1998). Further caregivers seemed to 
+understand that they had to take care of their own health (third need) in order to better care for 
+the patient. 
+Apart from the above three main needs, caregivers also perceived the need for education (fourth 
+need) as important, as it would help reduce stigma in society about mental illness (Murthy, 2006). 
+Caregivers required information not only about the illness, but also about medication/side effects/
+emergency medication (sedatives) and about the available concessions/benefits offered by the 
+government (Cleary et al., 2005; Chien & Norman, 2003). The concept of stigma was discussed 
+by the caregivers who participated in FGD-2 in the context of ‘educating the society to minimize 
+the stigma in society’. Thus, the issue was considered under the category of education as the focus 
+was on educating society – clearing misconceptions, not eradicating stigma. Rehabilitation (fifth 
+need) was expressed as important by the caregivers; as most of the caregivers stayed in nuclear 
+families, they required help in the form of financial and legal concessions, office/work-related 
+benefits for caregivers, rehabilitation centres/day care near home, helpline services and local support 
+groups. Apart from the availability of these services, they also needed information about them and 
+help in accessing these services (Cleary et al., 2005). The sixth need was sexual and marital prob-
+lems and knowing how to deal with them. This was a significant need in the Indian context as 
+marriage and procreation are considered to be important stages in the Indian family life cycle 
+(Madan, 1987). Caregivers wanted to know whether to get their patient married; the stigma of 
+getting the patient married with a mental illness; and how to deal with difficulties post-marriage 
+like relapse of symptoms and marital discord.
+In a country where there are very few psychiatrists, the focus of treatment is more on symptom 
+cure. Even in a tertiary multidisciplinary centre like NIMHANS, the focus is often on needs other 
+than the health needs of the caregivers. Estimates show that 50% of patients approach NIMHANS 
+as a primary care centre (Kare et al., 2008). This makes it difficult to deal with all the needs of the 
+patients and caregivers. Needs like rehabilitation, education and sexual concerns of the patient can 
+be managed at hospital level. However, the health needs of caregivers that are equally important 
+are often not taken as part of the patients’ treatment process at the hospital. As its aim, this study 
+will attempt to develop a structured intervention programme based on the holistic coverage of all 
+the needs of the family caregivers.
+Certain methodological issues of this study need to be mentioned. The method of FGD has certain 
+inherent limitations such as the group members’ responses are not independent of one another, 
+which restricts the generalizability of the results (Stewart et al., 2007). Some of the members were 
+hesitant to talk in a group situation – especially when sharing sensitive issues. Caregivers may 
+have expressed other needs if they had been interviewed individually. Individual interviews could 
+thus have added considerable strength to the results of the study. Any interpretation of the results 
+needs to be done keeping in mind the exclusion of carers who were not comfortable with a group 
+situation. Further, the results obtained from the FGD may have been biased by a very dominant 
+or opinionated member. Future studies could examine the validity of the hierarchy of needs by 
+presenting the findings of this study to another focus group of carers.
+To counter some of these methodological limitations, informed consent of the members to 
+participate in a focus group was taken before the start of the FGD. Those members who were not 
+comfortable with talking in a group situation were not chosen for the study. Further, the moderator 
+bias was minimized by asking the group members themselves to list and rank the needs without 
+consulting the moderator.
+190 
+INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)
+All family caregivers who attended the FGDs emphatically stated that they required help 
+in managing all their needs and expressed their willingness to participate in any training that 
+
+addressed this.
+CONCLUSIONS
+This study is one of the first scientifically researched qualitative needs assessment studies of the 
+caregivers of inpatients with schizophrenia in India. Further, this study gives an holistic view of 
+the needs of caregivers with the list of themes and sub-themes that need to be considered for any 
+future action. It puts significant emphasis on health needs of the caregivers (third important theme), 
+which has often been ignored in other interventions. It must be noted that each patient may have 
+more than one caregiver and help of any kind to manage their health needs may have public health 
+significance.
+Finally, these findings are highly indicative and future studies could test the results in a larger 
+quantitative sample to reconfirm the validity, reliability and generalizability of the results. If validated, 
+it would enable the development of any programme developed for Indian family caregivers based on 
+the needs assessment. As an outcome of this study, the researchers plan to develop a psychosocial 
+and yoga programme for family caregivers of inpatients with schizophrenia in India.
+ACKNOWLEDGEMENTS
+The researchers would like to thank Dr Shekhar P. Seshadri, Dr Prabha S. Chandra, Dr Jayashree 
+Ramakrishnan and Dr K. Subbakrishna for their valuable input, which helped in the development 
+of the focus group script.
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+Srinivasan, N. (2006) Together we rise – Kshema Family Power. In Mental Health by the People (ed. R.S. Murthy). 
+Bangalore: People’s Action for Mental Health (PAMH).
+Stewart, D.W., Shamdasani, P.N. & Rook, D.W. (2007) Focus Groups – Theory and Practice. Second Edition. Applied 
+Social Research Methods Series, Vol 20. New Delhi: Sage Publications. 
+Thara, R., Padmavathi, R., Kumar, S. & Srinivasan, L. (1998) Burden Assessment Schedule: Instrument to assess 
+burden on caregivers of chronically mentally ill. Indian Journal of Psychiatry, 40, 21–29.
+Wancata, J., Krautgartner, M., Berner, J., Scumaci, S., Freidl, M., Alexandrowicz, R. & Rittamannsberger, H. (2006) 
+The ‘Carers’ needs Assessment for Schizophrenia’. Social Psychiatry and Psychiatric Epidemiology, 41, 
+221–229.
+Winefield, H.R. & Harvey, E.J. (1994) Needs of family caregivers in chronic schizophrenia. Schizophrenia Bulletin, 
+20(3), 557–566.
+World Health Organization (2001) Atlas: Country Profiles on Mental Health Resources 2001. Geneva: World Health 
+Organization.
+192 
+INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)
+APPENDIX 
+Table 1
+Needs expressed by caregivers in FGD-1
+  1. Information on how to bring the patient to the doctor
+  2. Skills to motivate patient who is not taking medication
+  3. Contact details of doctors 
+  4. Skills to make patient cooperate with parents at home
+  5. Knowledge to handle sex problems/marriage issues of patients
+  6. Skills to control uncooperative/demanding patient 
+  7. Skills to handle emergency situations (medication, etc)
+  8. Referral to groups in local centres/day homes
+  9. Skills to handle symptoms of patient
+10. Skills to manage patients who are not going outside – e.g. not talking with relatives
+11. Skills to control the anger outbursts of the patient
+12. Need for psychotherapy for the patient
+13. Skills to motivate patient to daily activities
+14. Concessions for caregivers
+15. Knowledge on how to admit violent patients
+16. Knowledge on how to balance work and patient care
+17. Techniques to control caregivers’ anger
+18. Techniques to manage stress of caregivers – negative feelings
+19. Official rules relaxing for caregivers at work
+20. Directives/pamphlets dealing with various situations for other caregivers
+21. Educating society to minimize stigma in society
+Table 2
+Needs expressed by caregivers in FGD-2
+  1. Education about illness/medicines (mass media, school mental health programmes, doctors etc.)
+  2. Multidisciplinary teams to deal with patient(s)/caregiver(s)
+  3. To know how to motivate patient for treatment
+  4. Private services to help caregiver(s)
+  5. Skills to tackle patients if they refuse medication
+  6. Skills to motivate patient(s) to follow daily schedule
+  7. Skills to motivate patient(s) to maintain self-care (e.g. teaching girl children to manage self-care during 
+menstruation)
+  8. Skills to tackling patient(s) in social situations
+  9. Skills to manage demanding patients
+10. Skills to motivate patient(s) to cooperate in household activities
+11. Government policies (economic help)
+12. Rehabilitation centre for patient(s) 
+13. To know how to improve patients’ lack of concentration
+14. Skills to motivate patients to socialize
+15. Skills to tackle symptoms of patient(s) 
+16. Skills to make patient(s) listen to parents at home
+17. Skills to handle unpredictable behaviour of patient(s)
+18. Facilities to help working parents if they need to leave female patients at home alone 
+19. Skills to help parents gain confidence (that they can handle the patient)
+ 
+JAGANNATHAN ET AL.: A QUALITATIVE STUDY ON THE NEEDS OF CAREGIVERS 
+193
+Table 3
+Needs expressed by caregivers in FGD-3
+  1. Skills to manage problems of social behaviour in patient
+  2. Techniques on how to feed patient if they do not eat 
+  3. Techniques to help patient improve peer relationship issues (sister, brother, kids etc.)
+  4. Skills to motivate personal care of the patient
+  5. Skills to deal with difficulty in taking the patient to the doctor
+  6. Skills to deal with difficulty in administering medicines
+  7. Skills to motivating patient who is not going out
+  8. To know how to communicate with the patient 
+  9. To know how to handle problems in marriage 
+10. Patient beating the kids/relatives – how to manage
+11. Skills to manage/balance work – personal life
+12. Skills to control patient from quarrelling with neighbours 
+13. Financial concessions from government/NGO/others
+14. Skills to control angry state of the patient
+15. Skills to manage violent patient
+16. Skills to manage caregivers’ depressive feelings leading to suicidal thoughts
+17. Skills to manage unpredictable behaviour of patient
+18. Techniques to motivate patients who do not like going outside and earning
+19. Skills to manage increased sexual interests of patient 
+20. Knowledge on how to manage symptoms of patient – e.g. self-talk/laughter etc.
+21. Skills to manage caregivers’ emotions: (a) anger; (b) sadness; (c) fear
+Table 4
+Needs expressed by caregivers in FGD-4
+  1. Skills to encourage patients who do not take medicines
+  2. Skills to motivate patients who do not care for self
+  3. Skills to manage aggressive patients
+  4. Techniques to encourage patients who do not take food
+  5. Techniques to encourage patients whose social interaction is low
+  6. Techniques to motivate patient to go for job 
+  7. Skills to bring patient to hospital for treatment
+  8. Techniques to encourage patients who are not active
+  9. Techniques to help patients cope with the demands of the job and maintain it
+10. Techniques to control patient’s increased spending
+11. Techniques to control patient’s increased smoking
+12. Skills to regularize patients who are irregular/have no daily schedule
+13. Skills to immediately control patient in crisis situations
+14. Educate the patient about the illness, if he has no insight
+15. Knowledge on how to control patient symptoms like talking to self
+16. Knowledge on how to handle patient’s sleeplessness
+17. Knowledge on how to handle patient’s wandering behaviour
+18. Techniques to control depressive feeling in caregivers
+19. Skills to manage non-cooperative patient
+20. Financial help
+21. Skills to manage demanding behaviour of patient
+22. Social support
+23. Knowledge on how caregivers can take out time for their personal life 
+194 
+INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)
+Table 5
+Needs expressed by caregivers in FGD-5
+  1. Skills to push patient to do work if lazy
+  2. Skills to motivate patient to do their self-care/activities
+  3. Techniques to motivate patients who do not indulge in writing/reading
+  4. Techniques to motivate patients who do not do any work
+  5. Skills to motivate patients who do not take medicines
+  6. Techniques to reduce bidi (nicotine) intake in patients
+  7. Techniques to control anger outbursts in patient
+  8. Techniques to manage reduced sleep in patient 
+  9. Techniques to manage symptoms like self-talking in patient
+10. Techniques to manage patient behaviour like pacing, restlessness
+11. Skills to manage abnormal behaviours in patient
+12. Techniques to help patients who are not able to sustain a job
+13. Skills to help improve attention/concentration in patients
+14. Self-help centres in villages
+15. Knowledge to deal with increased sleep due to side effects of medication in patient 
+16. Knowledge to deal with weight gain in patients (due to illness/effects of medications)
+A. Jagannathan, PhD Scholar of Department of Psychiatric Social Work, National Institute of Mental Health and 
+Neurosciences (NIMHANS), Bangalore, India.
+J. Thirthalli, Associate Professor of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), 
+Hosur Road, Bangalore – 560029, India.
+A. Hamza, Assistant Professor of Psychiatric Social Work, National Institute of Mental Health and Neurosciences 
+(NIMHANS), Hosur Road, Bangalore – 560029, India.
+V.R. Hariprasad, Senior Research Fellow in Department of Psychiatry, National Institute of Mental Health and 
+Neurosciences (NIMHANS), Bangalore – 560029, India.
+H.R. Nagendra, Vice-Chancellor of Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), Bangalore, India.
+B.N. Gangadhar, Professor of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur 
+Road, Bangalore – 560029, India.
+Correspondence to Jagannathan Aarti, 196 ‘Srinidhi’, 1st Floor, 12th MAIN, 4th Block, Koramangala, Bangalore – 
+
+560029, India.
+Email: [email protected]

subfolder_0/Additional Practice of Yoga Breathing with Intermittent Breath Holding Enhances Psychological Functions in Yoga Practitioners A Randomized Controll.txt

@@ -0,0 +1,615 @@
+TAGEDH1ADDITIONAL PRACTICE OF YOGA BREATHING WITH INTERMITTENT
+BREATH HOLDING ENHANCES PSYCHOLOGICAL FUNCTIONS IN
+YOGA PRACTITIONERS: A RANDOMIZED CONTROLLED TRIALTAGEDEND
+D1X X
+Apar Avinash SaojiD2X X
+,* D3X X
+Raghavendra B.R.D4X X
+, D5X X
+Kshamashree MadleD6X X
+, and D7X X
+Manjunath N.K.D8X X
+Background and objective: The practice of yoga is associated with
+enhanced psychological wellbeing. The current study assessed the
+correlation between the duration of yoga practice with state mindful-
+ness, mind-wandering and state anxiety. Also, we examined if an
+additional 20 min of yoga breathing with intermittent breath holding
+(experimental group) for 8 weeks would affect these psychological
+variables more than regular yoga practice (control group) alone.
+Methods: One
+hundred
+sixteen
+subjects
+were
+randomly
+assigned to experimental (n = 60) and control (n = 56) groups.
+State mindfulness attention awareness scale (SMAAS), Mind-
+Wandering Questionnaire (MWQ) and State anxiety inventory
+were administered at baseline and at the end of 8 weeks.
+Results: Baseline assessment revealed a positive correlation
+between duration of yoga practice with SMAAS scores and nega-
+tive correlation with MWQ and state anxiety scores. At the end
+of 8 weeks, both groups demonstrated enhanced psychological
+functions, but the experimental group receiving additional yoga
+breathing performed better than the group practicing yoga alone.
+Conclusion: An additional practice of yoga breathing with
+intermittent breath holding was found to enhance the psycho-
+logical functions in young adult yoga practitioners.
+Keywords: Mindfulness, Mind-Wandering, Anxiety, Pranayama,
+Psychological well being, Kumbhaka
+(Explore 2018; &:1
6 © 2018 Elsevier Inc. All rights reserved.)
+TAGEDH1INTRODUCTIONTAGEDEND
+Mind-body interventions are found to be useful to managing
+stress.4 Yoga, a noted mind-body intervention has been found
+useful to manage stress and enhance performance.21,22 Among
+various dimensions of yoga practices, Pranayama is an important
+aspect wherein voluntary regulation of the breathing is per-
+formed, while paying mindful attention.23 There are various
+yoga breathing techniques described in the yoga scriptures with
+their potential benefits.17 The regulation of breathing prescribed
+in yoga includes breathing at different pace, alteration of nostrils
+or retention of breath. Earlier reports reveal positive impact of
+mindful breathing on emotional status, through reduction of
+negative affect and emotional volatility.1 There was a reduction
+in perceived stress noted following training in yoga breathing.2,19
+There was also a reduction in test anxiety and improved test per-
+formance following training in Pranayama.18 However, not
+much is known about the impact of yoga and specific yoga
+breathing practices on mindfulness and mind-wandering.
+Mindfulness and Mind-Wandering are two opposing con-
+structs of human psychology.16 Mindfulness is defined by
+Kabat-Zinn as “the awareness that emerges through paying
+attention on purpose, in the present moment, and non-judgmen-
+tally to the unfolding of experience moment by moment”.7
+Recently, mindfulness has been identified as a behavioral para-
+digm that aims at enhancing awareness of the experience at the
+given time, of perceptible mental processes. It is also considered
+as an important aspect of the practice of meditation. Earlier stud-
+ies show mindfulness as an attribute which correlates negatively
+with mind-wandering as well as anxiety.15 Training in mindful-
+ness has been found to reduce mind-wandering and enhance per-
+formance in cognitive tasks involving working memory.14 Such
+training involved practice of attention on breathing and body. A
+recent study shows the brief practice of mindfulness-based inter-
+vention helped children increase the state mindfulness.9 Initial
+reports also suggest a positive role of mindfulness in learning
+and intelligence.5
+Mind-wandering is described as interruption of task-focus by
+task-unrelated thoughts.29 Mind-wandering is a common phe-
+nomenon and is often a sign of unpleasant emotions,8 negative
+mood,27 depression,28 adult Attention Deficit Hyperactivity Dis-
+order12,25 and declined task engagement.20 There is also evidence
+to determine role of anxiety in increased episodes of mind-wan-
+dering through stereotypical threats.13 Due to impairment of
+encoding of information, mind-wandering could lead to failures
+in building a propositional model of a sentence. Thereby, it
+could affect learning abilities by impairing the construction of a
+narrative model having sufficient details to allow generating
+inferences.26 The studies with neuroimaging have demonstrated
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusand-
+hana Samsthana, 19, Eknath Bhavan, Gavipuram Circle, KG Nagar, Ben-
+galuru 560019, Karnataka, India
+* Corresponding author.
+e-mail: [email protected]
+© 2018 Elsevier Inc. All rights reserved.
+ISSN 1550-8307/$36.00
+EXPLORE & 2018, Vol. &, No. &
+https://doi.org/10.1016/j.explore.2018.02.005
+1
+ARTICLE IN PRESS
+ORIGINAL ARTICLES
+a role of activity of the default network of medial prefrontal cor-
+tex, posterior cingulate cortex and left temporoparietal junction
+in mind-wandering, which was also positively correlated to self-
+reporting of the individuals for the tendency to mind wander.6,11
+Although there is a growing interest in the potential role of
+yoga-based practices in modifications of psychological wellbeing,
+research in the area is still in its infancy. Thus, the current study
+was undertaken with the objectives of evaluating if mind-wander-
+ing, state mindfulness and state anxiety could be correlated to the
+duration of experience in yoga; if the practice of yoga modify the
+same constructs with a progressive 8 weeks of training; and whether
+the additional practice of a specific yoga breathing practice could
+modify the constructs more than regular yoga practice alone.
+TAGEDH1MATERIALS AND METHODSTAGEDEND
+Subjects
+143 healthy volunteers studying various long-term residential yoga courses
+at Swami Vivekananda Yoga Anusandhana Samthana (a yoga university),
+Bengaluru, India, were briefed about the study protocol, out of which 130
+consented to participate in the study. The volunteers were screened for
+any major illnesses by a physician who otherwise had no role in the study.
+We excluded participants with a history of respiratory and psychological
+illnesses, use of any medications that could modify mood or cognition.
+We also excluded volunteers who had a history of consumption of alco-
+hol, tobacco or any other habit-forming drugs in any form. Finally, 116
+subjects (44 male + 72 female) were recruited for the study and were ran-
+domly assigned into the experimental group (n = 60) and control group
+(n = 56). The random allocation of the subjects was carried out using ran-
+dom numbers generated using a web-based computer program (www.ran
+domizer.org). The trial profile is illustrated in Fig. 1. The demographic
+data of the subjects is presented in Table 2.
+Ethical Considerations
+The study was approved by the Institutional Ethics Committee of the
+University. Written informed consent forms were obtained from individ-
+ual participants prior to their recruitment to the study.
+Intervention
+Experimental Group: The study was carried out over a period of eight
+weeks. After obtaining the baseline data, the experimental group was
+trained in the Yoga based breathing intervention in addition to routine
+yoga practice of 1 hour/day. The intervention included training for eight
+weeks in the regulated yoga breathing for 20 min incorporating phases of
+inhalation (puraka), internal retention of breath (antarkumbhaka), exhala-
+tion (recaka) and external retention of breath (bahyakumbhaka) in a ratio
+of 1:1:1:1 for 6 s each. The classic yoga texts suggest breath retention in
+varying ratios. We chose this ratio for the intervention since it is consid-
+ered ideal for subjects who are na€
+ıve to the practice of breath holding.
+The intervention was derived from a classical training methodology of
+pranayama suggested in the ancient text of Yoga.23 The duration of 6 s
+was decided based on a previous study which used the similar interval of
+phases of breath hold.30 The duration of 6 s was ensured through verbal
+cues in a pre-recorded audio track.
+Control Group: The control group underwent yoga practices for 1 hour
+practice of Yoga/day for 6 days a week, same as the experimental group.
+The routine yoga practices are listed in Table 1.
+Assessments
+We used three self-report questionnaires viz. Mind-Wandering Question-
+naire (MWD), State Anxiety Inventory-Short Form (STAI-SF) and State
+Mindfulness Attention and Awareness Scale (SMAAS) for the assess-
+ments of the psychological status of the participants. The questionnaires
+were administered at the baseline and following the eight weeks of inter-
+vention.
+Table 1.
+Regular Yoga Practices Followed by the Experimental and Control Groups
+Sl No
+Nature and description of practice
+Duration/rounds of practice
+1
+Loosening practices (mobilizing the major joints)
+5 min
+2
+Surayanamaskara (Sun salutations): a set of 12 postures
+performed in sequence synchronizing with breathing
+12 rounds/10 min
+3
+Asana (physical postures)
+35 min
+A. Standing postures
+a. Ardhakatichakrasana (Lateral bend)
+b. Padahastasnana (Forward bend)
+c. Ardhachakrasana (Backward bend)
+B. Sitting postures
+a. Gomukhasana (Cow pose)
+b. Vakrasana (spinal twisting pose)
+C. Prone postures
+a. Salabhasana (Locust pose)
+b. Bhujangasana (serpent pose)
+c. Dhanurasana (Bow pose)
+D. Supine postures
+a. Sarvangasana (Shoulder stand pose)
+b. Halasana (Plow pose)
+c. Matsyasana (Fish pose)
+d. Setubandhasana (bridge pose)
+4
+Savasana (Corpse pose): Supine rest with
+progressive guided relaxation
+10 min
+ARTICLE IN PRESS
+2
+EXPLORE & 2018, Vol. &, No. &
+Yoga Breathing Enhance Psychological Wellbeing
+Mind-Wandering Questionnaire (MWQ): A reliable and validated five-
+item self-rated questionnaire, in which subjects are asked to fill up
+responses on a scale of 1 (almost never) to 6 (almost always); Cronbach’s
+alpha = 0.850.14
+State Anxiety Inventory-Short Form (STAI-SF): A six-item short form of
+the Spielberger’s State Trait Anxiety Inventory’s (STAI) state anxiety sub-
+scale was administered to assess state anxiety of the subjects. The partici-
+pants rated their present experience using on a scale of 1 (not at all) to 4
+(very much so); Cronbach’s alpha = 0.82.10
+State Mindfulness Attention and Awareness Scale (SMAAS): A reliable
+and validated tool to assess state mindfulness was administered to the
+subjects. The questionnaire contains 5 questions to be answered on a
+scale of 1 (not at all) to 6 (very much); Cronbach’s alpha = 0.92.3
+Data Extraction
+The data were extracted using the standard operating procedures as pre-
+scribed in the manuals.
+Statistical Analyses
+Data analysis was conducted by using SPSS (version 16) statistical soft-
+ware package for Windows (IBM SPSS Statistics. Somers, NY, USA).
+Pearson product-moment correlation coefficient (r) was calculated to
+assess the correlations between the years of experience in yoga and each
+of the constructs assessed in the study. Within and between group analy-
+ses were performed using paired and independent samples t-tests. For the
+t-tests, a confidence interval of 95% was considered significant.
+TAGEDH1RESULTSTAGEDEND
+A total of 112 volunteers completed the study (experimental
+group n = 60, control group n = 52). The correlations between
+the duration of yoga experience and psychological constructs are
+presented in Table 3. The Baseline data from the whole study
+population demonstrated a significant positive correlation with
+Fig. 1. Trial profile.
+Table 2.
+Demographic Data of the Study Population at Baseline
+Experimental group
+(n = 60)
+Control group
+(n = 52)
+Study population
+(N = 112)
+Male/Female
+26/34
+14/38
+40/72
+Age (years)
+21 § 2.7
+20 § 2.9
+21 § 2.4
+Years of yoga experience
+2.63 § 1.71
+2.40 § 1.42
+2.53 § 1.57
+SMAAS score
+4.06 § 0.77
+3.91 § 0.73
+3.99 § 0.75
+State anxiety score
+33.06 § 6.70
+34.04 § 6.31
+33.51 § 6.51
+Mind-wandering score
+2.48 § 0.94
+2.56 § 1.03
+2.52 § 0.98
+ARTICLE IN PRESS
+Yoga Breathing Enhance Psychological Wellbeing
+EXPLORE & 2018, Vol. &, No. &
+3
+the duration of experience in yoga with SMAAS (r = 0.82,
+n = 112, p < 0.001), and negative correlation with the Mind-
+Wandering (r = ¡0.73, n = 112, p < 0.001) and state anxiety
+(r = ¡0.809, n = 112, p < 0.001). SMAAS was negatively corre-
+lated to Mind-wandering (r = ¡0.814, n = 112, p < 0.001) and
+state anxiety (r = ¡0.796, n = 112, p < 0.001), whereas Mind-
+wandering and state anxiety were demonstrated a positive corre-
+lation (r = 0.689, n = 112, p < 0.001).
+For both experimental and control groups, paired-samples
+t-tests were conducted to compare SMAAS, MWQ and state
+anxiety scores at baseline and following the intervention period.
+The group scores (mean and standard deviations) at the baseline
+and post intervention period of the variables are presented in
+Table 4.
+Within Group Comparisons
+In the experimental group, there was a significant difference
+observed in the scores for SMAAS pre (M = 4.058, SD = 0.773)
+and post scores (M = 4.275, SD = 0.747); t(59) = ¡3.364,
+p = 0.001; MWQ pre (M = 2.480, SD = 0.945) and post scores
+(M = 1.980, SD = 0.756); t(59) = 11.580, p < 0.001; and state
+anxiety pre (M = 33.055, SD = 6.703) and post scores
+(M = 28.222, SD = 5.57); t(59) = 9.478, p < 0.001. The control
+group showed a non-significant difference in SMAAS pre
+(M = 3.91, SD = 0.731) and post scores (M = 3.942,
+SD = 0.754); t(51) = ¡0.397, p = 0.693; and significant differ-
+ence in MWQ pre (M = 2.558, SD = 1.035) and post scores
+(M = 2.412, SD = 0.899); t(51) = 2.973, p = 0.004; and state anx-
+iety pre (M = 34.038, SD = 6.308) and post scores (M = 33.013,
+SD = 6.095); t(51) = 2.028, p = 0.048.
+Between Group Comparisons
+Independent-samples t-tests were performed on the post data to
+assess if there was varying effect of additional training in yoga
+breathing with intermittent breath hold to yoga group in modu-
+lating the psychological constructs viz. SMAAS, MWQ and state
+anxiety scores in experimental and control groups. There was a
+significant difference observed in the post scores SMAAS in the
+experimental group (M = 4.275, SD = 0.747) and Control group
+(M = 3.942, SD = 0.754); t(110) = 2.339, p = 0.021; MWQ
+scores in the experimental group (M = 1.980, SD = 0.756) and
+Control group(M = 2.412, SD = 0.899); t(110) = ¡2.759,
+p = 0.007; and state anxiety scores in the experimental group
+(M = 28.222, SD = 5.57) and control group (M = 33.013,
+SD = 6.095); t(110) = ¡4.344, p < 0.001.
+TAGEDH1DISCUSSIONTAGEDEND
+The current study evaluated correlations of state mindfulness,
+Mind-wandering and state anxiety with the duration of yoga experi-
+ence as well as each other. The observations confirmed the initial
+hypothesis, that state mindfulness will be positively correlated to
+duration of yoga experience and negatively to state anxiety and
+Mind-wandering. The study also assessed if an additional practice
+of yoga breathing with intermittent breath holding (experimental
+group) could influence the psychological constructs more than per-
+forming regular yoga practices for one hour/day, 6 days/week alone
+(control group). The findings suggest that regular practice of yoga
+helps to reduce state anxiety and Mind-wandering, whereas an addi-
+tional practice of yoga breathing with intermittent breath holding
+enhances state mindfulness while also reducing the Mind-wander-
+ing and state anxiety. The between group analyses indicate that
+additional yoga breathing with intermittent breath holding could
+lead to better psychological framework than performing regular
+yoga practice alone.
+The scores of the 3 questionnaires at baseline indicate the
+positive influence of yoga practice on psychological state of
+the individuals. The mean score of state anxiety for the study
+population (N = 112) at the baseline (33.52) was slightly
+lower than ‘normal’ score described for the same (34
36).10
+The state anxiety score was found to be negatively correlated
+to the years of yoga experience. Although there is lack of
+normative
+data
+for
+SMAAS
+and
+MWQ
+questionnaires,
+there was a strong positive and negative correlation of the
+duration of yoga practice and scores of SMAAS and MWQ
+respectively.
+Table 3.
+Correlations Between the Duration of Yoga Practice (Years)
+and Baseline Scores of State Mindfulness Attention Awareness Scale
+(SMAAS), State Anxiety Inventory and Mind-Wandering Questionnaire
+(MWQ)
+Variable
+Years of yoga
+SMAAS
+State anxiety
+MWQ
+Years of yoga
+

+SMAAS
+.830**
+

+State anxiety
+¡.789**
+¡.801**
+

+MWQ
+¡.815**
+¡.827**
+.709**
+

+Mean
+2.53
+3.99
+33.51
+2.52
+Standard deviation
+1.57
+0.75
+6.51
+0.98
+** = p < 0.01.
+Table 4.
+The Scores of State Mindfulness Attention Awareness Scale (SMAAS), State Anxiety Inventory and Mind-Wandering Questionnaire (MWQ)
+at Baseline and Following the Intervention Duration of 8 Weeks
+Variables
+Experimental group
+Control group
+Baseline
+Post
+Baseline
+Post
+SMAASa
+4.06 § 0.77
+4.27 § 0.75**
+3.91 § 0.73
+3.94 § 0.75
+State anxietyc
+33.06 § 6.70
+28.22 § 5.57***
+34.04 § 6.31
+33.01 § 6.09*
+MWQb
+2.48 § 0.94
+1.98 § 0.76***
+2.56 § 1.03
+2.41 § 0.89**
+Paired samples t-test within the group analyses comparing the baseline scores with the post scores
+* =p < 0.05.
+** =p < 0.01.
+*** =p < 0.001. Independent samples t-test between group analyses, comparing the post scores of both groups, a = p < 0.05, b = p < 0.01, c = p < 0.001.
+ARTICLE IN PRESS
+4
+EXPLORE & 2018, Vol. &, No. &
+Yoga Breathing Enhance Psychological Wellbeing
+Our findings concur with earlier studies proposing increased
+mindfulness in yoga practitioners31 along with lowered anxiety.32
+There have been no earlier studies eliciting the effects of yoga inter-
+ventions on Mind-wandering as a psychological construct. Yet,
+mindfulness and mind-wandering are known to have negative corre-
+lation.14 Our results are consistent with an earlier study which used
+an attention task, mindfulness and mind-wandering as the outcome
+measures. The findings suggested mindful breathing enhanced the
+performance in the attention task, mindfulness and reduced mind-
+wandering.16 Mindful breathing was proposed to help in reducing
+the thought-unrelated thoughts and improve metacognitive regula-
+tion by increasing awareness of mind-wandering. In our study, we
+used yoga breathing with intermittent breath holding, which needed
+focused attention for synchronization of the breathing with the audi-
+ble cues, thus possibly not allowing the mind-wandering to occur.
+And over time, practice may have led to enhanced mindful state and
+reduced mind-wandering. Mrazek et al. also observed association of
+negative mood with mind-wandering.16 Another study correlates
+negative state of mind leading to mind-wandering.8 Our study
+observed a reduction in anxiety, which may also be contributing to
+elevated mood and thus reduced mind-wandering and enhanced
+mindfulness. Another possible mechanism of action for the observed
+effects could be diminished activity of the default mode network in
+cortical regions that is associated with Mind-wandering. A recent
+study demonstrated such diminished activity of default mode net-
+work following focusing on internal or external objects mindfully.24
+An earlier study on mindful breathing performed on undergrad-
+uate students who were na€
+ıve to the intervention demonstrated
+significantly reduced negative affect following the intervention.1
+The study observed that the subjects were able to approach the
+stimuli in a mindful manner following the breathing intervention,
+signifying better emotional regulation. The subjects in our study
+were yoga practitioners and thus may have better emotion regula-
+tion. Further clinical trials may include the measures of emotion
+regulation for understanding the underlying mechanisms.
+The control group continued to attend the regular yoga sessions
+with an additional 20 min of sports activities/day. There was sig-
+nificant reduction in state anxiety as well as mind-wandering in
+the control group, which may be attributed to anxiolytic effects of
+yoga.32 Yet, the changes observed in the constructs were signifi-
+cantly higher in the experimental group, which performed an
+additional yoga breathing intervention, thus demonstrating the
+beneficial effects of the add on yoga breathing.
+The limitations of the current study include use of self-report
+measures alone. Further trials could estimate if the enhanced
+mindfulness and reduced mind-wandering could affect the per-
+formance of the study population in attention related tasks.
+Also, we lacked an actual control group, since both the groups
+were yoga practitioners and continued to perform regular yoga
+sessions. Further trials may include a non-yoga practitioner
+group for better generalization of the observed results.
+TAGEDH1CONCLUSIONSTAGEDEND
+The findings of the current study are suggestive of a dose-effect
+relationship of duration of yoga enhancing mindfulness and
+reducing mind-wandering and anxiety. The results also indicate
+a negative correlation between mindfulness and mind-wandering
+as well as anxiety. We also observed that an additional practice
+of yoga breathing with intermittent breath holding for 20 min
+has a better influence on the psychological constructs when com-
+pared with regular yoga practice alone. Further trials are war-
+ranted to understand the mechanisms of the observed effects.
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+Yoga Breathing Enhance Psychological Wellbeing

subfolder_0/Aerobic Fitness and Cognitive Functions in Economically Underprivileged Children Aged 7-9 Years.txt

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+100
+International  journal of  Biomedical  science
+Aerobic Fitness and Cognitive Functions in Economically 
+Underprivileged Children Aged 7-9 Years: 
+Apreliminary Study from South India
+Arpitha Jacob
+1, Crystal D. D’Souza1, S. Sumithra1, Sandhya Avadhani2, Chaya Mayasandra 
+Subramanya3, Krishnamachari Srinivasan1
+1St. Johns Research Institute, Bangalore-560034, India; 2St. Johns Medical College and Hospital, Bangalore-560034, India; 
+3Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore-560019, India
+Abstract
+This study examined the relationship between aerobic fitness and cognitive functions in 7-9 year old 
+school going children hailing from a socio-economically disadvantaged background in Bangalore, India. 
+Ninety eight children (51% boys and 49% girls) were assessed on height, weight, BMI, aerobic fitness (multi-
+stage 20 m shuttle test) and cognitive functions (verbal tests: comprehension, arithmetic, vocabulary, analo-
+gies; performance tests: block design, object assembly and coding). Number of shuttles wassignificantly 
+positively correlated with two of the cognitive tests: comprehension (p=0.01) and block design (p=0.005). 
+Multiple linear regression analysis showed that the number of shuttles emerged as an independent predictor 
+of tests of comprehension and block design after adjusting for BMI and gender. The above findings provide 
+preliminary evidence for the association between aerobic fitness and cognitive functions in children from 
+poor socio-economic background. 
+Keywords: aerobic fitness; cognitive functions; economically underprivileged children; South India
+Corresponding author: Krishnamachari Srinivasan, Department of 
+Psychiatry, St. Johns Medical College and Hospital, Vice Dean, St. Johns 
+Research Institute, Opp Koramangala BDA Complex, Bangalore 560 034, 
+India. Tel: +91-80-25532037, 22065059; Fax: +91-80-25501088; E-mail: 
+[email protected].	 	
+	
+	
+	
+Received November 29, 2010; Accepted January 31, 2011
+INTRODUCTION
+A recent meta-analysis on school based physical activ-
+ity and cognitionshowedthat physical activity had a posi-
+tive influence on concentration, memory and classroom 
+behavior (1). Experimental studies using either a cross sec-
+tional design or test-post test comparison demonstrated a 
+significant positive relationship between physical activity 
+and cognitive performance in children (2). A recent review 
+examining the effects of aerobic exercise on various cog-
+nitive tasks found that the optimal intensity for impacting 
+cognitive tasks covered a wide range (~40–80% VO2max) 
+and exercise duration of more than 20 minutes was most 
+efficient in increasing the performance on perceptual and 
+decisional tasks (3). However, a meta-regression analysis 
+concluded that the empirical literature did not support a 
+link between cardiovascular physical fitness and cogni-
+tive performance (4), but the number of studies that had 
+young children as subjects was very small. In the last two 
+decades there has been a resurgence of interest in the area 
+of physical fitness, cognitive and academic performance 
+in children and adolescents. In a recent randomized con-
+trolled trial of aerobic exercise training on cognition in 
+overweight children, there was a significant improvement 
+in executive functions in children in the high dose exer-
+ORIGINAL ARTICLE
+Aerobic fitness and cognitive functions in Indian children
+101
+cise group compared to controls (5). Most of the published 
+studies on physical exercise and cognition in children have 
+come from the West with few published studies from de-
+veloping countries. To the best of our knowledge there are 
+no known published Indian studies examining physical ac-
+tivity and cognition in school children from an economi-
+cally disadvantaged background. In the present study, we 
+examined the association between aerobic fitness and cog-
+nitive functions in 7-9 year old school going children from 
+a socio-economically disadvantaged background living in 
+Bangalore, India.  
+METHODS
+The sample size consisted of hundred, 7-9 year old 
+healthy (as assessed by clinical examination by medical 
+professionals) school going children hailing from a socio-
+economically disadvantaged background (average monthly 
+income of 2000 INR, equivalent to 46 USD approximate-
+ly). All participants were recruited from a single school in 
+Urban Bangalore, India. From a total of 200 children who 
+were part of a larger interventional study on the effects of 
+yogapractices on cognitive performance, physical fitness 
+was assessed in 100 randomly selected children at baseline 
+before the start of yoga intervention. The children gave oral 
+assent while the parents/legal guardian provided written 
+informed consent. The school also provided written per-
+mission to conduct the study on its children, on the school 
+premises. The study was approved by the Institutional Ethi-
+cal Review Board of St. John’s National Academy of Health 
+Sciences. Socio-demographic details were obtained from all 
+children. Height, weight and BMI (Body Mass Index) were 
+recorded. Children underwent a physical examination and 
+apparently healthy children with no history of chronic dis-
+eases, physical or mental handicap and not severely under-
+nourished (<-3SD for weight for age and -3SD height for age 
+z scores of the National center for health statistics / WHO 
+standards) (6) were invited to participate in the study. The 
+Indian adaptation of WISC II, Malin’s Intelligence Scale for 
+Indian Children (7) was used to measure cognitive perfor-
+mance. The test contains both verbal and performance sub-
+tests. For the purpose of the present study, 4 verbal, and 3 
+performance tests from the battery of tests were used. The 
+verbal tests were comprehension, arithmetic, vocabulary 
+and analogies. Block design, object assembly and coding 
+were the performance tasks. The tests were administered by 
+trained psychologists in the morning hours. 
+The multistage 20 m shuttle test described by Leger 
+and Lambert (8) was used as an index of physical fitness. 
+The children were required to run continuously between 
+two points which were 20 m apart. The pace of run-
+ning was indicated by an audio recording which emitted 
+beeps at prescribed intervals. The initial speed was set at 
+4 km/h and increased by 0.5 km/h for each subsequent 
+minute. The test was discontinued when the child vol-
+untarily stopped due to fatigue. The total number of laps 
+completed was used as an index of physical fitness. Pre-
+vious research has shown that the number of laps com-
+pleted positively correlates with VO2 max (9). All study 
+assessments were conducted in the school premises. At 
+the time of conducting test of aerobic fitness all children, 
+as part of the school curriculum, were doing physical ex-
+ercises such as running and stretching exercises for about 
+30 minutes twice a week. 
+Statistical Analysis
+Analyses were done using the SPSS (version 17) soft-
+ware. Continuous variables were reported using mean 
+(SD) and the categorical variables were reported using fre-
+quencies and percentages. Non normal data was log trans-
+formed. Pearson correlation coefficient was computed to 
+assess the association between the cognitive measures and 
+the number of shuttles. Multiple linear regression analysis 
+was computed to identify the predictors of cognitive mea-
+sures. In the regression analysis BMI and sex were adjust-
+ed for since these factors have been reported to influence 
+aerobic functioning.  All analysis was considered statisti-
+cally significant at the 0.05 level of significance.
+RESULTS
+Of the 100 children enrolled in the study, 98 children 
+completed both the assessments (physical fitness and cog-
+nitive tests); both genders were almost equally distributed 
+(boys=51%). The children hailed from the lower socio-
+economic strata with average parental income ofRs, 2000 
+per month (US $46). Most of the parents were employed 
+as daily wage laborers and were illiterate. The mean age of 
+the sample was 7.9 ± 0.9 yrs. The mean height, weight and 
+BMI of the sample were 1.21 ± 0.07 m, 20.4 ± 3.06 Kg and 
+13.8 ± 1.1 respectively. 
+For the analysis the number of shuttles was used as 
+the indicator of physical fitness. The average number of 
+shuttles completed was 46.1 ± 14.2. In the verbal tests of 
+comprehension, arithmetic, analogies and vocabulary the 
+mean scores were 7 ± 2.4, 5.2 ± 1.9, 6.2 ± 3.2 and 13.1 ± 
+4.4 respectively. The mean scores for the various perfor-
+mance tests that included block design, object assembly 
+Aerobic fitness and cognitive functions in Indian children
+102
+and coding were as follows: 6.2 ± 4.1, 4.5 ± 2.5, and 32.4 
+± 8.1 (Table 1).
+The number of shuttles wassignificantly positively 
+correlated with two of the cognitive tests: comprehen-
+sion (P=0.01) and block design (P=0.005) (Table 2). Mul-
+tiple linear regression analysis showed that the number of 
+shuttles is an independent predictor of tests of comprehen-
+sion and block design after adjusting for BMI and gender. 
+Results indicated that number of shuttles explained 8% of 
+the variance in comprehension and block design scores re-
+spectively (Table 3).
+DISCUSSION
+The main objective of the study was to explore the as-
+sociation between aerobic fitness and cognitive functions 
+in 7-9 year old children from a poor socio-economic back-
+ground. The study findings indicated a positive associa-
+tion between aerobic capacity as measured by shuttle tests 
+and cognitive functions in 7-9 year old children. This is 
+corroborated by previous research where children who are 
+physically fit perform better and faster on cognitive testst-
+han children who are less fit (10, 11) and our study extends 
+this finding to school going children from a disadvantaged 
+background. 
+Among the various cognitive tests, significant posi-
+tive association was found between aerobic capacity and 
+cognitive measures of both verbal (comprehension) and 
+performance tasks (block design). Previous studies have 
+shown that particular types of cognitive abilities are sensi-
+tive to benefits of aerobic fitness (2, 12). Though the ex-
+act mechanistic pathways through which physical fitness 
+impacts cognitive functions have not been ascertained, 
+various explanations have been put forward. A child’s fit-
+ness may reflect the child’s overall health, which in turn 
+may positively impact the child’s cognitive performance 
+(13). In addition, movement particularly in young children 
+stimulates cognitive development (14). Recent research 
+has also shed light on the possible neural mechanisms in-
+volved. Animal studies have shown that aerobic activity 
+increased capillary blood flow to the cortex and promote 
+growth of new neurons and synapses, resulting in better 
+performance (15, 16).
+The findings in this small study of a modest positive 
+association between physical fitness and cognitive mea-
+sures among school going children from economically 
+disadvantaged background is in agreement with earlier 
+studies. Future studies on larger sample of children with 
+more comprehensive measures of both physical fitness 
+and cognitive functions are clearly needed including ex-
+ploring dose-effect relationship between physical fitness 
+and cognitive performance. This is especially important 
+given that a large number of children from developing 
+countries fail to reach their optimal cognitive poten-
+Table 1. Descriptive data of sample characteristics, number of 
+shuttles and cognitive variables
+Variables
+Mean
+SD
+Age (years)
+7.9
+0.9
+Height (metres)
+1.21 
+0.07
+Weight (Kg)
+20.4
+3.06
+BMI
+13.8
+1.1
+Number of Shuttles
+46.1
+14.2
+Comprehension
+7
+2.4
+Arithmetic
+5.2
+1.9
+Analogies
+6.2
+3.2
+Vocabulary
+13.1
+4.4
+Block Design
+6.2
+4.1
+Object Assembly
+4.5
+2.5
+Coding
+32.4
+8.1
+Table 2. Correlation between number of shuttles 
+and cognitive variables
+Variable
+Correlation
+P value
+Comprehension
+0.249
+0.01
+Arithmetic
+0.187
+0.06
+Analogies
+0.138
+0.17
+Vocabulary
+0.140
+0.17
+Block Design
+0.283
+0.005
+Object Assembly
+0.126
+0.215
+Coding
+-0.138
+0.176
+BMIa
+0.11
+0.28
+aBody Mass Index.
+Table 3. Results of the multivariate linear regression analysis
+Variable
+B coefficient Adj R2
+P value
+95% C. I.
+LL
+UL
+Comprehension
+0.039
+0.08
+0.025
+0.005
+0. 074
+Block design
+0.009
+0.09
+0.008
+0.002
+0.016
+Aerobic fitness and cognitive functions in Indian children
+103
+tial (17) and introduction of regular physical activity in 
+schools may be a cost effective method of overcoming 
+this significant problem.
+ACKNOWLEDGEMENT
+This study was financially supported by the Ministry 
+of Health, Department of AYUSH, Government of India, 
+4-3/2008-2209/CCRYN/EMR.
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subfolder_0/Assessing Risk and High Risk for Type 2 Diabetes Using Indian Diabetes Risk Score among Adults of Bengaluru An Observation from A Sector Based Survey Study Conducted in Bangalore.txt

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+See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/365449948
+Assessing Risk and High Risk for Type 2 Diabetes Using Indian Diabetes Risk
+Score among Adults of Bengaluru: An Observation from A Sector Based Survey
+Study Conducted in Bengaluru
+Article · November 2022
+DOI: 10.5281/zenodo.7326445
+CITATIONS
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+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
+Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 
+ 
+Assessing Risk and High Risk for Type 2 Diabetes Using Indian Diabetes Risk Score 
+among Adults of Bengaluru: An Observation from A Sector Based Survey Study 
+Conducted in Bengaluru 
+Jintu Kurian*, Ramesh Mavathur Nanjundaiah 
+Division of Yoga and Life sciences, Swami Vivekananda Yoga Anusandhana 
+ Samsthana (S-VYASA), Jigani, 
+Bengaluru, Karnataka, India 
+Citation: Jintu Kurian, Ramesh Mavathur Nanjundaiah. Assessing Risk and High Risk for Type 2 Diabetes Using 
+Indian Diabetes Risk Score among Adults of Bengaluru: An Observation from A Sector Based Survey Study 
+Conducted in Bengaluru. Int Clinc Med Case Rep Jour. 2022;1(8):1-10. 
+DOI: https://doi.org/10.5281/zenodo.7326445  
+Received Date: 08 November, 2022; Accepted Date: 14 November, 2022; Published Date: 16 November, 2022 
+*Corresponding author: Jintu Kurian. Division of Yoga and Life sciences, Swami Vivekananda Yoga 
+Anusandhana Samsthana (S-VYASA), Jigani, Bengaluru, Karnataka, India 
+Copyright: © Jintu Kurian, Open Access 2022. This article, published in Int Clinc Med Case Rep Jour (ICMCRJ) 
+(Attribution 4.0 International), as described by http:// creativecommons.org/licenses/by/4.0/. 
+ 
+ABSTRACT 
+Aim of the study: To apprehend the incidence of pre-diabetes and high risk for Type 2 diabetes mellitus (T2DM) 
+among adults of Bengaluru, South-India. 
+Materials and method: Six week’s house hold sector based survey (N=307; 23-70 years), was conducted in City 
+armed reserve police quarters, Chamrajpet, Bengaluru, Mysore road. Fasting and postprandial blood glucose 
+levels were checked using Hemocue 201+ blood glucose monitor device. In addition, body weight and body mass 
+index were assessed. Categorization of screened subjects based on the risk for T2DM was done using Indian 
+Diabetes Risk Score (IDRS) screening form. Of a total 1250 residents, almost one-fourth of them (n-307) had 
+taken part in the survey. 
+Results: Study resulted in identifying people with normal glucose tolerance or non-diabetes (n=178), impaired 
+fasting glucose or pre-diabetes (n=75), and T2DM (n=49) and newly diagnosed diabetes (n=5). Although, among 
+the screened, the incidence of pre-diabetes was accounted for 24%, with one-half (n=37, 49%) of them found at 
+high risk for type 2 diabetes. Age and gender matched data obtained from the screening postulated higher body 
+mass index (BMI) (p<0.001) and waist circumference (p<0.001) as most contributing factors increasing the 
+incidence of high risk for T2DM among the study population. 
+Conclusion: This survey manifested a higher incidence of pre-diabetes and high risk for T2DM among the study 
+population, which is linked to the anthropometric measures. 
+Key words: High risk for Type 2 Diabetes Mellitus; Pre-diabetes; Body Mass Index; Waist circumference 
+ 
+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
+Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 
+ 
+ 
+INTRODUCTION 
+The incidence and prevalence of type 2 diabetes and prediabetes is increasing worldwide[1] and is found closely 
+associated with industrialization, modernization and socioeconomic factors.[2] Reports also highlight that along 
+with growing incidence and prevalence, cost expenditure of diabetes care is also high[3] which emphasizes the 
+need for early detection and adopting appropriate therapies for prevention and effective management of type 2 
+diabetes mellitus. Few known reasons for such a huge rise in the prevalence is stipulated as low health awareness or 
+ignorance, sedentary life style,[4] abnormalities in the metabolism of carbohydrates, fats and protein, inadequate or 
+impaired secretion[5] and utilization of insulin.[6] In association with the rise in the prevalence, need for regular blood 
+glucose monitoring for early detection of risk for diabetes, the phase also known as prediabetes,[7] characterized by 
+impaired fasting glucose, is inevitable. 
+Madras Diabetes Research Foundation (MDRF), Chennai had developed Indian Diabetes Risk score (IDRS)[8] as 
+a screening tool to identify the risk for diabetes. Studies have been done using IDRS as a simple, [9] non-expensive 
+screening tool comprising of 4 different parameters age, family history, physical activity[10] and abdominal 
+obesity and the current study used IDRS as a screening tool to categorize the screened subjects based on risk for 
+T2DM.[11]  Conclusive evidences suggest that physical inactivity <150 minutes/ week[12] subject an individual to 
+higher anthropometric measures which is a leading cause for metabolic disorders like prediabetes with progressive 
+loss of beta cell activity leading to impaired secretion of insulin,[13] insulin resistance resulting in the onset of 
+T2DM.[14] Dietary changes,[15] sedentary behavior, abdominal obesity[16] and overweight[17] are highest known 
+triggers resulting in inflated incidence and prevalence of prediabetes[18] and T2DM[19] and we used a demographic 
+data sheet involving all these factors to assess the role of the said factors in the incidence of prediabetes and high 
+risk for T2DM. 
+Cross sectional study reports a higher prevalence of prediabetes than T2DM[20] narrowing down the need for such 
+studies exclusively in Southern states of India[21], postulating a need for early detection among Indians, specially 
+among South Indians, to adopt appropriate measures to delay the onset of T2DM. Moreover, 50% of adults with 
+prediabetes[22] and a few percentage even with symptoms of Type 2 Diabetes in India remain unaware[23] and get 
+detected with complications at the time of diagnosis, which extrapolates the importance of early detection through 
+periodic large scale screening. Keeping the above mentioned factors in the background, the present study was 
+conducted to estimate the incidence of prediabetes and the prevailing factors resulting in risk for T2DM among 
+adults of Bengaluru. 
+ 
+MATERIALS AND METHODS 
+The total population of the quarters included 1,250 police personals and family members excluding minors. Among 
+which, one-fourth of them had volunteered to take part in the survey and who found fitting into the set inclusion 
+exclusion criteria ever (N= 307, aged range: 23 and 60 years, with an average age of 41.5 ± 11.2 years) (Figure 1) 
+were screened. The sampling technique used was Quota sampling. 
+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
+Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 
+ 
+ 
+ 
+Data collection 
+Inclusion and Exclusion criteria 
+Male and female adults who are residents of the police quarters for more than 10 years, willing to take part in the 
+survey were included. People who were below 18 and above 70 years of age, physically and mentally challenged, 
+with a history of systemic disorders, diabetes complications, handicapped or amputated, Physically inactive, 
+frequently on night shifts, known alcoholics and consuming more than 5 servings of beverages a day were excluded 
+from the survey. The study protocol was approved by Institutional Ethical Committee of S-VYASA (Deemed-to-be-
+University) and signed informed consent was sought before the data collection. 
+Assessments 
+The assessments included glycemic parameters like Fasting and post prandial capillary blood glucose, 
+anthropometric measures like Body weight, height, Body mass index and waist circumference.  Glycemic 
+parameters were checked on Hemocue glucose 201+ glucose monitoring internally powered equipment 6VDC, 
+catalogue # 1221142161, Sweden). Cuvette boxes were carried by the researchers in ice packs and were opened and 
+used only when the subject indicated that he/she is ready for it, to ensure quality of the Cuvette and to avoid 
+quantitative errors. Risk for diabetes was examined using IDRS: 0-29 low risk; 30-59 medium risk; >60 high risk for 
+T2DM. In addition, demographic data sheet DDS) comprising of information like age, gender, house number, lane, 
+race, duration of stay in the quarters, how many members being with diabetes and known prediabetes, mode and 
+duration of physical activity, diet pattern and preference, sleep quality, and willingness to take part in such surveys if 
+conducted ahead were filled by the eligible subjects. 
+Residents were informed about the survey two weeks in prior through flyer and pamphlets, and the need to be on 
+empty stomach for Capillary Fasting Blood Glucose (CFBG) reading and tentative date and day of data collection 
+upon each of the 18 sectors. In addition, a reminder was given by the researchers through sector wise home visit on a 
+day prior to the data collection. The timing of screening was 6:30 am to 10:30 am on all the days. CFBG was tested 
+after 8-12 hours of overnight fasting and Capillary post prandial blood glucose (however, identifying pre-diabetes 
+was only based on CFBG) was checked within one and a half to two hours of breakfast. 
+Screening process 
+The interested volunteers were also asked to fill up Demographic Data Sheet (DDS) which included questions like 
+the individual’s age, gender, house and lane number, pattern of diet, job, job timings, stress, physical activity (PA), 
+preferred mode of indoor and outdoor activity, duration of PA, health awareness, self-updating with health 
+checkups, sleep, intake of coffee, tea, soft drinks, alcohol and smoking. IDRS screening form was distributed and 
+except for waist circumference and height, subjects filled all other questions by self during their wait to get the 
+fasting blood glucose check done. Prediabetes subjects were identified based on FBG (100 to 125 mg/dl) only. 
+Ethical clearance and informed consent 
+Ethical approval was sought from S-VYASA’s ethical committee and all the rules were followed before, during and 
+post the data collection (coding the data). Data was not collected from the volunteers who denied to sign the consent. 
+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
+Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 
+ 
+ 
+ 
+Data analysis 
+Screening was conducted over a period of six weeks. Data obtained from the survey was entered in Microsoft excel. 
+Descriptive statistics was performed on continuous variables and responses of the screened subjects on IDRS and 
+demographic data sheet were analyzed with logistic and linear regression method on Statistical package for the 
+Social Sciences (Chicago, SPSS Inc.) for Windows, version 23.0. 
+ 
+ 
+                                                      Figure 1: Flow chart 
+ 
+ 
+RESULTS  
+Baseline characteristics  
+Screening resulted in identifying 3 groups based on the glucose tolerance and intolerance. Group 1 comprised of 
+people with impaired glucose tolerance/ T2DM (CFBG: 174.4± 43.9mg/dl; CPPBG 216.9± 55.4mg/dl) among 
+which a few were newly diagnosed as Type 2 diabetes (n=5; CFBG 178.4±37 mg/dl; CPPBG 226.2±58.1 mg/dl) 
+(Table 2). Group 2 consisted of one-fourth of the total screened subjects who were found with impaired fasting 
+glucose/ prediabetes (n=75, CFBG: 113.1±6.7mg/dl) among which except for two all others were newly diagnosed. 
+More than half of the subjects who belonged to Group 3, were found with normal glucose tolerance (n=178; CFBG 
+84.3±8.5mg/dl; CPPBG 111±20.9mg/dl). Demographic data showed more or less same range of age among the 
+subjects of three groups (Table 1). Furthermore, the incidence of prediabetes is estimated as 24%, with an equal 
+distribution across the gender. However, almost half of the total prediabetes (n= 37, 27%) were identified at high 
+risk for T2DM as assessed by IDRS. On the other hand, the incidence of type 2 diabetes was estimated as 9.3% 
+(n=5) (Table 2).  
+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
+Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 
+ 
+ 
+Parameters 
+Group 1 
+Group 2 
+Group 3 
+54 (18) 
+75 (24) 
+178 (58) 
+Age (in years) 
+48.8±8.6 
+43.9±11.1 
+38.1±11.7 
+Male 
+33 (20) 
+40 (24) 
+91 (56) 
+Female 
+21 (15) 
+35 (24) 
+87 (61) 
+Table 1: Data either represented as number of samples (percentage) or as mean ± standard deviation; Demographic, 
+anthropometric and glycemic parameters of the subjects categorized into three groups according to capillary fasting 
+blood glucose (CFBG) range; Group 1: Type Diabetes; Group 2: Prediabetes and Group 3: Normoglycemia. 
+Risk according to Indian Diabetes Risk Score 
+Group 1 
+Group 2 
+Group 3 
+High Risk 
+29 (21) 
+37 (27) 
+71 (52) 
+Medium Risk 
+24 (18) 
+30 (23) 
+77 (59) 
+Low Risk 
+1 (2.5) 
+8 (20.5) 
+30 (77) 
+IDRS factors 
+Age (<30 Years) 
+4 (4) 
+20 (20) 
+78 (76) 
+Age(30-50 years) 
+22 (17) 
+30 (23) 
+80 (61) 
+Age (<50 Years) 
+28 (39) 
+25 (34) 
+20 (27) 
+Vigorously active 
+1 (6) 
+6 (35) 
+10 (59) 
+Moderately active 
+48 (19) 
+54 (22) 
+148 (59) 
+Physically underactive 
+13 (22) 
+15 (28) 
+20 (50) 
+Waist circumference (WC) 
+18 (15) 
+16 (13) 
+86 (72) 
+WC 
+25 (23) 
+26 (24) 
+59 (53) 
+WC 
+11 (14) 
+33 (43) 
+33 (43) 
+No family history of T2DM 
+38 (19) 
+61 (30) 
+105 (51) 
+One parent with T2DM 
+13 (19) 
+10 (14) 
+47 (67) 
+Two parents are with T2DM 
+3 (9) 
+4 (12) 
+26 (79) 
+Table 2: Data represented as sample size (percentage); Categorization of subjects in terms of number of subjects 
+and in bracket percentage distribution in each category according to the scores obtained from Indian Diabetes Risk 
+score (IDRS); WC- Waist circumference, T2DM- Type 2 Diabetes Mellitus, IDRS- Indian Diabetes risk score. 
+ 
+Regression results 
+Linear regression assessment across the groups manifested all the assessed factors with high statistical significance, 
+although, detailed interim analysis denoted, the most contributing factors increasing the incidence of prediabetes and 
+high risk for T2DM as waist circumference and BMI (Table 3). Age as an assessment factors was also found with 
+high statistical significance, even though, as the survey included negligible number of elderly adults, the 
+significance level was not to be considered. 
+ 
+ 
+ 
+ 
+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
+Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 
+ 
+Parameters 
+Adjusted R² 
+RMSE Power (95% CI) 
+t value 
+F value 
+p value 
+CFBG 
+0.718 
+0.409 
+0.93 (4.083-4.355) 
+61.084 
+779.84 
+<0.001 
+CPPBG 
+0.507 
+0.541 
+0.91 (3.699-4.046) 
+43.912 
+316.08 
+<0.001 
+BMI 
+0.155 
+0.709 
+0.91 (4.341-5.716) 
+14.39 
+57.181 
+<0.001 
+Waist Circumference 
+0.106 
+0.729 
+0.89 (3.617-4.787) 
+14.145 
+37.369 
+<0.001 
+Age 
+0.135 
+0.617 
+0.73 (2.651-2.92) 
+10.754 
+48.591 
+<0.001 
+Table 3: Linear regression model with group 2 as Dependent variable; CFBG- Capillary Fasting blood Glucose, 
+CPPBG- Capillary post prandial blood Glucose, BMI- Body Mass Index 
+Identified risk factors 
+Further statistical assessments confirmed waist circumference as the factor of risk, increasing the incidence of 
+prediabetes among the study population (Table 4). In addition to that, two non-modifiable factors age and family 
+history were also strongly imparting the role in surging risk for T2DM. Interestingly, physical activity as one of the 
+modifiable factors, denoted as not considerably contributing (Table 4). 
+IDRS 
+factors 
+Adjus
+ted R² 
+RMSE 
+Power  t value 
+F value 
+Linear regression 
+significance (p value) 
+Χ² 
+Chi-square 
+significance  
+(95% 
+CI) 
+(p value) 
+Age 
+0.135 
+0.717 
+0.93 
+(2.651
+-2.92) 
+40.754 
+48.591 
+<0.001 
+50.75 
+<0.001 
+Physical 
+Activity 
+-0.002 
+0.772 
+0.81 
+(2.198
+-
+2.813) 
+16.021 
+0.458 
+0.499 
+7.226 
+0.124 
+Family 
+History 
+0.24 
+0.762 
+0.75 
+(2.218
+-
+2.423) 
+44.522 
+8.368 
+0.004 
+15.04 
+0.005 
+WC 
+0.36 
+0.857 
+0.94 
+(2.444
+-
+2.696) 
+45.201 
+12.45 
+<0.001 
+29 
+<0.001 
+Total IDRS 
+0.051 
+0.751 
+0.81 
+(2.633
+-3.1) 
+24.167 
+17.486 
+<0.001 
+21.07 
+0.006 
+Table 4: Linear regression and Chi-square (Χ²) test results of IDRS factors among group 2; WC= Waist 
+circumference 
+Logistic regression results 
+Sensitivity of IDRS in identifying risk among people with diabetes is found to be 0.788 whereas the specificity is 
+0.333 with a false positive score of 0.667 with low area under ROC curve (AUC) score of 0.673 (p=0.13. Χ²= 
+7.12). Whereas in case of prediabetes, the sensitivity of the tool was 0.571 with considerably high specificity of 
+0.8 with low false positive score of 0.2, with a fair AUC score of 0.7 and a statistical significance observed 
+through p value (p=0.02, Χ²= 11.093). When checked for people with normal glycemic status, the tool showed a 
+sensitivity of 0.46, specificity of 0.7 with a false positive score of 0.29, showing an accuracy of 0.6 indicated by 
+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
+Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 
+ 
+AUC (p=0.404, Χ²= 10.422). The results summarize that IDRS is identifying the people with prediabetes with the 
+match found with the group formed based on fasting blood glucose reading, whereas not with people who are 
+with Type 2 diabetes and normoglycemia. 
+Correlation results 
+Correlation analysis on total IDRS showed a strong positive correlation with CFBG (r=0.786, p<0.001) cross 
+verifying the grouping of screened subjects based on glycemic parameters. Strong positive co-relation was even 
+found with parameters like age in years with IDRS risk score weighted on age (r=0.9, p<0.001), BMI with Waist 
+Circumference (WC) (r=0.73, p<0.001) and WC scores according to IDRS (r=0.529, p<0.001), and WC 
+according to IDRS with total score of IDRS (r=0.682, p<0.001). 
+ 
+DISCUSSION 
+This survey was conducted with an aim to assess the incidence of prediabetes and high risk for type 2 diabetes 
+among adults of South India. Secondary objectives of the study were to identify the factors increasing the risk for 
+diabetes and incidence of prediabetes among the study population. The results of the study substantially exhibited 
+body mass index and waist circumference as highest contributors increasing the incidence of prediabetes, whereas 
+the non-modifiable factor like age and family history were also found equally significant on a wider view. 
+Logistic regression conducted on the data of this study statistically evaluated the accuracy of IDRS as a screening 
+tool in identifying risk in terms of sensitivity, which indicates the true positive outcome of the data, confirmation of 
+made through the scores of Area of ROC curve (AUC) as low in rightly identifying the risk among group 1 and 3. 
+True negative outcome of the data as shown by the specificity scores and false positive scores are calculated by 
+applying a formula one minus specificity. Confirmation of the result outputs are sought from F and H measures 
+which are based on harmonic mean of precision and recall scores. Study published in 2019 supports the same.[24] 
+Study published in 2020 shows the prevalence of diabetes is 13.2% and that of prediabetes as 15.5%.[25] Whereas, 
+the present study reports the incidence of prediabetes as 27%, and that of the undiagnosed type 2 diabetes as 9.3%, 
+among adults of Bengaluru. This survey outcome thus plights the need for verifying the score distribution towards 
+the factors of IDRS and points out a need for verifying the risk assessments with additional tools along with IDRS.  
+The study is of high social relevance as it could find high risk for incidence of prediabetes among adults of 
+Bengaluru, one of the states in South India. To summarize, this study projects the need for further large scale survey 
+studies to get an estimate of incidence of prediabetes and high risk for diabetes across different states of South India. 
+ 
+CONCLUSION 
+This study orients on the increasing incidence of prediabetes and undiagnosed type 2 diabetes among adults of 
+South India and projects the need for large scale screening involving appropriate screening methods to identify 
+the risk factors too. As this study assessed Body mass index and waist circumference, in addition to the non-
+modifiable factors like family history and age, as most prevailing risk factors further studies should aim at finding 
+other factors as well. The result of this study also highlights the need for awareness programs through interventional 
+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
+Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 
+ 
+studies and to adopt therapeutic ways to manage anthropometric measures helping attain euglycemia, with which, 
+the increasing incidence of prediabetes and Type 2 diabetes can be halted. 
+ 
+ACKNOWLEDGEMENT  
+Deputy Commissioner of Police Mrs. Vartika Katyar, Sister Kala, Mr. Basavaraju; Sister Padma; CAR police 
+quarters, Mysore road, Bangalore; Swami Vivekananda Yoga Anusandhana Samsthana (S VYASA, Deemed-to-be-
+University 
+ 
+CONFLICT OF INTEREST 
+None of the authors have any conflict of interest 
+ 
+SOURCE OF FUNDING  
+Ministry of AYUSH, Government of India, New Delhi 
+ 
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+International Clinical and Medical Case Reports Journal                                             
+                                           
+Research Article (ISSN: 2832-5788) 
+ 
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+ 
+25. Chow CK, Raju PK, Raju R, Reddy KS, Cardona M, Celermajer DS, et al. The prevalence and 
+management of diabetes in rural India. Diabetes Care. 2019;29(7):1717-8. 
+ 
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+8/11/2014
+Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/
+1/10
+Go to:
+J Altern Complement Med. Jan 2013; 19(1): 35–42.
+doi:  10.1089/acm.2011.0282
+PMCID: PMC3546358
+Changes in Autonomic Variables Following Two Meditative States Described in
+Yoga Texts
+Shirley Telles, PhD,  Bhat Ramachandra Raghavendra, MSc, Kalkuni Visweswaraiah Naveen, PhD, Nandi Krishnamurthy
+Manjunath, PhD, Sanjay Kumar, PhD, and Pailoor Subramanya, PhD
+ICMR Center for Advanced Research in Yoga and Neurophysiology, S-VYASA, Bengaluru, India.
+Corresponding author.
+Address correspondence to: Shirley Telles, PhD, Patanjali Research Foundation, Patanjali Yogpeeth, Haridwar, Uttarakhand 249408, India. E-
+mail:Email: [email protected]
+Copyright 2013, Mary Ann Liebert, Inc.
+This article has been cited by other articles in PMC.
+Abstract
+Objectives
+In ancient yoga texts there are two meditative states described. One is dharana, which requires focusing, the second is
+dhyana, during which there is no focusing, but an expansive mental state is reached. While an earlier study did show
+improved performance in an attention task after dharana, the autonomic changes during these two states have not been
+studied.
+Methods
+Autonomic and respiratory variables were assessed in 30 healthy male volunteers (group mean age±SD, 29.1±5.1 years)
+during four mental states described in traditional yoga texts. These four mental states are random thinking (cancalata),
+nonmeditative focusing (ekagrata), meditative focusing (dharana), and effortless meditation (dhyana). Assessments
+were made before (5 minutes), during (20 minutes), and after (5 minutes), each of the four states, on four separate days.
+Results
+During dhyana there was a significant increase in the skin resistance level (p<0.001; post hoc analysis following
+ANOVA, during compared to pre) and photo-plethysmogram amplitude (p<0.05), whereas there was a significant
+decrease in the heart rate (p<0.001) and breath rate (p<0.001). There was a significant decrease in the low frequency
+(LF) power (p<0.001) and increase in the high frequency (HF) power (p<0.001) in the frequency domain analysis of the
+heart rate variability (HRV) spectrum, on which HF power is associated with parasympathetic activity. There was also a
+significant increase in the NN50 count (the number of interval differences of successive NN intervals greater than 50 ms;
+p<0.001) and the pNN50 (the proportion derived by dividing NN50 by the total number of NN intervals; p<0.001) in
+time domain analysis of HRV, both indicative of parasympathetic activity.
+Conclusions
+Maximum changes were seen in autonomic variables and breath rate during the state of effortless meditation (dhyana).
+The changes were all suggestive of reduced sympathetic activity and/or increased vagal modulation. During dharana
+there was an increase in skin resistance. The changes in HRV during ekagrata and cancalata were inconclusive.
+JOURNAL OF ALTERNATIVE AND COMPLEMENTARY
+MEDICINE
+8/11/2014
+Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/
+2/10
+Go to:
+Introduction
+MEDITATION IS RECOGNIZED AS a specific consciousness state in which deep relaxation and increased internalized
+attention co-exist.
+There are widely differing methods, involved in different meditations, though the practices are intended to have a common
+end result (viz., a calm, yet alert mind). This is supported by research from the late 1960s, since when there have been
+investigations on the effects of meditation in experienced as well as inexperienced meditators.
+ In certain cases
+meditators practicing the same technique showed opposite trends of results, particularly for recordings of the
+electroencephalogram (EEG) and autonomic variables. Some studies showed that meditation practice is associated with
+reduced sympathetic activity, whereas other studies reported increased sympathetic activity. For three meditation
+techniques in particular, the results appeared suggestive of both increased arousal (in some cases) and reduced arousal
+(in others). These are Transcendental Meditation (TM), Zazen meditation, and Ananda Marga meditation. These are
+described in detail in following text.
+In a previous study practitioners of TM showed a decrease in oxygen consumption, reduced heart and breath rates,
+lower blood lactate levels, and an increase in slow alpha and occasional theta in the EEG after 20 minutes of practice,
+suggestive of a quietening effect.  In fact most of the studies on TM reported changes suggestive of increased autonomic
+stability and sympathetic withdrawal.  In addition, Dillbeck and Orme-Johnson,  carried out a meta-analysis of 31
+studies evaluating the effect of meditation on reducing somatic arousal. The studies showed reduced somatic arousal with
+some physiological changes suggestive of increased alertness. The findings of increased alertness was supported by a
+study by Lang et al.  In this study meditators who had 2 to 3 years of experience practicing TM had lower 24-hour
+urinary catecholamines compared to meditators with an average experience of 4.1 years. The findings contradict the idea
+that meditation is simply a state of reduced sympathetic activity but supports the idea of it being a “calm yet alert” state.
+Similar findings (increased as well as decreased arousal) were also reported for the eyes open, Zazen meditation. In
+1960, Hirai reported an increase in heart rate during Zazen meditation,  whereas Sugi and Akatsu  found a decrease in
+oxygen consumption in Zazen meditators. Hence the first report was suggestive of activation while the second report was
+suggestive of relaxation.
+Similarly, two reports were also found for Ananda Marga meditation, which involves intense concentration. In one report
+during the meditation, the expert meditators showed an increase in skin conductance and absence of a deceleratory heart
+rate orienting response.  These findings challenged a relaxation model for Ananda Marga meditation, which showed an
+increase in galvanic skin resistance, a decrease in breath rate, and a more stable EEG in another study.
+Hence, these early studies on different meditation techniques did not support a single model of meditation as either
+activating or relaxing. Findings like these gave rise to meditation being described as a state of “alertful rest,” a description
+first used by researchers studying TM, and later used for other meditation techniques as well.
+Relatively recently there was a report which described three broad categories of meditation techniques and their EEG
+patterns.
+ The three categories were (1) focused attention, which involves voluntary and sustained attention on the
+chosen object, (2) open monitoring meditation in which there is nonreactive monitoring of the moment-to-moment content
+of experience, and (3) automatic self-transcending, which includes techniques intended to transcend their own activity.
+Overall the report suggests that there exist differences in objective assessments in meditation techniques which differ in
+their methods and principles.
+The concept of meditation described in ancient yoga texts fits in with the categories of meditation experience mentioned
+above. In Patanjali's Yoga Sutras (circa 900 BC), there are two meditative states described, one leading to the other.
+The first stage is dharana (or focusing with effort), confining the mind within a limited mental area (“desha-
+bandhashchittasya dharana”; Patanjali's Yoga Sutras, Chapter III, Verse 1).
+ The next stage is dhyana or effortless
+expansion (“tatra pratyayaikatanata dhyanam”; Patanjali's Yoga Sutras, Chapter III, Verse 2).
+ This state is
+characterized by the uninterrupted flow of the mind towards the object chosen for meditation. The practice of dharana is
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+Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts
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+supposed to precede dhyana.
+Dharana and dhyana may be considered as the last two of four stages which form a continuum in the process and
+practice of meditation. The first two stages are described in another ancient text (the Bhagavad Gita, compiled circa
+500 BC). The first stage is cancalata, which is a stage of random thinking.
+ The second stage is ekagrata, during
+which the attention is directed to a series of associated thoughts.
+ If a person chooses to think thoughts related to
+meditation, the person would then be able to progress to the next two stages, dharana and dhyana.
+The performance in a cancellation task was compared in 70 normal healthy male volunteers at the beginning and end of
+the four types of sessions (viz., cancalata, ekagrata, dharana, and dhyana).
+ The performance in this task improved
+significantly after dharana (which can be considered a state of meditative focusing) and was worse after cancalata (or
+random thinking), suggesting better attention after dharana.
+There has been no study comparing the four mental states using autonomic and respiratory variables. Hence, the present
+study was planned to assess the changes in autonomic and respiratory variables in normal healthy volunteers before,
+during, and after the four types of sessions (cancalata, ekagrata, dharana, dhyana) on separate days. These mental
+states are descriptions from the ancient yoga texts and studying them was hoped to increase the understanding about
+meditation including differences seen in earlier studies.
+Materials and Methods
+Participants
+There were 30 male volunteers with ages ranging from 20 to 45 years (group mean age±SD, 29.1±5.1 years) who were
+residing at a yoga center in south India. All of them had normal health based on a routine case history and clinical
+examination. An electrocardiogram (EKG) recording showed that none of them had extra systoles or any abnormality in
+the EKG. They were not on any medication or using any other wellness strategy. The other predetermined conditions to
+exclude participants from the trial were any chronic illness, particularly psychiatric or neurological disorders. Male
+volunteers alone were selected as autonomic and respiratory variables are known to vary with the phases of the
+menstrual cycle.
+ All the meditators had been practicing meditation on the Sanskrit syllable Om for 30 minutes each
+day, 4 days a week. They had a minimum of 6 months of experience in meditation on the syllable Om (group average
+experience±SD, 20.95±14.21 months). Apart from their prior experience of meditation on Om, they were given a 3-
+month orientation program under the guidance of an experienced meditation teacher.
+All participants expressed their willingness to take part in the experiment. The study was approved by the institution's
+ethics committee. The study protocol was explained to the subjects, and their signed consent was obtained.
+Design of the study
+Each participant was assessed in four sessions. Two of them were meditation sessions (dharana [meditative focusing]
+and dhyana [meditative defocusing or effortless meditation]) and two of them were control sessions (ekagrata
+[nonmeditative focused thinking] and cancalata [random thinking]). All four sessions consisted of three states: pre (5
+minutes), during (20 minutes), and post (5 minutes). Assessments were made on four different days, which were not
+necessarily on consecutive days, but at the same time of the day. The allocation of participants to the four sessions was
+random using a standard random number table. This was done so as to prevent the influence of being exposed to the
+laboratory for the first time, from influencing the results. In the cancalata session participants were asked to allow their
+thoughts to wander freely. This was facilitated as they were listening to a compiled audio CD consisting of brief periods
+of conversation on multiple subjects recorded from a local radio station. In the ekagrata session, participants were
+asked to focus on a single topic (i.e., listening to a lecture on meditation). In the dharana session participants were asked
+to focus on the Sanskrit syllable Om, whereas in the dhyana session participants moved effortlessly from thinking about
+Om, to quiet absorption in the single thought of Om (i.e., dhyana). Instructions for dharana and dhyana were played
+from compiled audio CD. The duration of all the four sessions was 20 minutes. The study design is schematically
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+4/10
+Respiration
+Heart rate and heart rate variability
+Photo-plethysmogram amplitude
+Skin resistance
+Random thinking (cancalata)
+Nonmeditative focused thinking (ekagrata)
+Meditative focusing (dharana)
+Meditative defocusing or effortless meditation (dhyana)
+presented in Figure 1.
+FIG. 1.
+Schematic representation of the study.
+Assessments
+Autonomic variables and respiration were assessed in the four sessions using a four-channel polygraph (Polyrite D,
+Recorders and Medicare Systems, Chandigarh, India).
+Respiration was recorded using a volumetric pressure transducer fixed around the trunk about 8 cm below
+the lower costal margin as the participants sat erect.
+The EKG 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 (ADC) at a sampling rate of 1024 Hz and was analyzed off-line to obtain the heart rate variability
+(HRV) spectrum.
+The photo-electric transducer was placed on the volar surface of the distal phalanx of
+the left thumb with the light emitting diode facing the volar surface. The digit pulse volume was recorded and presented as
+microvolts. The amplitude of the pulse wave was used to record digit pulse volume which was presented as microvolts.
+Skin resistance was recorded using Ag/AgCl electrodes with electrode gel placed in contact with the
+volar surfaces of the distal phalanges of the index and middle fingers of the left hand. A low level DC preamplifier was
+used and a constant current of 10 μA was passed between the electrodes.
+Interventions
+Throughout all sessions participants sat cross legged and kept their eyes closed following prerecorded instructions. An
+emphasis was placed on carrying out the practices slowly, with awareness of physical and mental sensations, and
+relaxation. Participants were given a 3-month meditation orientation program under the guidance of an experienced
+meditation teacher. The purpose of this orientation was for all participants to practice the two different states of
+meditation, viz., dharana and dhyana based on specific instructions. The evaluation of the participants' practice of
+dharana and dhyana was based on their self-report as well as consultations with the meditation teacher. A brief
+description of each session is given in the following sections.
+Participants were asked to allow their thoughts to wander freely as they listened to a
+compiled audio CD consisting of brief periods of conversation, announcements, advertisements, and talks on multiple
+topic recorded from a local radio station transmission. All these conversations were unconnected and were believed to
+induce a state of random thinking.
+Participants listened to a prerecorded lecture on meditation. This was not
+about meditation, on the Sanskrit syllable Om, but about meditation, in general. It was speculated that listening to a
+lecture on a particular topics could induce the state of nonmeditative focused thinking.
+Participants were asked to follow the audio instructions for the practice of dharana. The
+meditative focusing on the Sanskrit syllable Om consisted of mental visualization of the symbol Om. Dharana involves
+conscious effort to keep the thoughts restricted to those given in the instructions.
+Participants were asked to follow the audio instruction for the
+practice of dhyana. They were supposed to absorb with the object of meditation without any effort. Dhyana involves
+effortless defocusing induced by mental chanting of Om.
+8/11/2014
+Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/
+5/10
+Go to:
+After each session participants were asked to rate their ability to comply with instructions on a scale from 0 to 10. Only
+those who achieved 7.5 (75%) and more were included in the study. None of the sessions had to be excluded for this
+reason.
+Data extraction
+The following data were extracted from the polygraph. The respiratory rate in cycles per minute (cpm) was calculated by
+counting the breath cycles in 60-second epochs, continuously. The heart rate in beats per minute (bpm) was calculated
+by counting the R waves of the QRS complex in the EKG in 60-second epochs, continuously. The skin resistance was
+obtained at 20-second intervals, continuously and expressed in kilohms (kΩ). The amplitude of the digit pulse volume
+was sampled from the peak of the pulse wave at 30-second intervals and presented in microvolts.
+Frequency domain and time domain analysis of HRV data was carried out for 5-minute recordings for each of the
+following sessions (cancalata, ekagrata, dharana, dhyana). These 5-minute epochs were recorded for pre, during,
+and post sessions. Pre and post sessions had one epoch of 5 minutes, whereas during had four similar epochs (viz. D1,
+D2, D3, D4). The data recorded were visually inspected off-line and only noise-free data were included for analysis. The
+data were analyzed with an HRV analysis program developed by the Biomedical Signal Analysis Group (University of
+Kuopio, Finland).
+ The energy in the HRV series in the following specific frequency bands was studied viz., the very
+low frequency band (0.0–.05 Hz), low frequency (LF) band (0.05–0.15 Hz), and high frequency (HF) band (0.15–0.5
+Hz). The LF and HF band values were expressed as normalized units.
+ The following components of time domain HRV
+were analyzed: (1) mean RR interval (the mean of the intervals between adjacent QRS complexes or the instantaneous
+heart rate), (2) RMSSD (the square root of the mean of the sum of the squares of differences between adjacent NN
+intervals), (3) NN50 (the number of interval differences of successive NN intervals greater than 50 milliseconds), and (4)
+pNN50 (the proportion derived by dividing NN50 by the total number of NN intervals).
+Data analysis
+Statistical analysis was done using SPSS Inc. (Chicago, USA) (Version 16.0). Repeated measures analysis of variance
+(ANOVA) were performed with two “within subjects” factors (i.e., Factor 1: Sessions; cancalata, ekagrata, dharana,
+and dhyana, and Factor 2: States; Pre, During [D1, D2, D3, D4], and Post). This was followed by a post hoc analysis
+with Bonferroni adjustment for multiple comparisons between the mean values of different states (Pre, During and Post)
+and all comparisons were made with the respective Pre state.
+Results
+The group mean values±SD for breath rate, heart rate, photo-plethysmogram amplitude, and skin resistance are given in 
+Table 1. Frequency domain and time domain measures of HRV are given in Table 2 and Table 3, respectively.
+Table 1.
+Changes in Autonomic and Respiratory Variables Recorded Pre, During, and
+Post Four Sessions. Values Are Group Mean±SD
+Table 2.
+Changes in Frequency Domain Analysis of the Heart Rate Variability
+Components; Values Are Group Mean±SD
+Table 3.
+Time Domain Analysis of the Heart Rate Variability Components; Values Are
+Group Mean±SD
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+Repeated measures ANOVA
+The significant changes in breath rate, heart rate, photo-plethysmogram amplitude, skin resistance, LF power, HF power,
+LF/HF ratio, the mean RR, the RMSSD, the NN50, and the pNN50 are given in Table 4.
+Table 4.
+Summary of the Repeated Measures Analysis of Variance (ANOVA) Showing
+Statically Significant Results
+Post hoc analyses with Bonferroni adjustment
+Post hoc analyses with Bonferroni adjustment were performed and all comparisons were made with respective pre
+states. These have been summarized in Table 5.
+Table 5.
+Summary of the Level of Significance and Direction of Change for Post-hoc
+Analyses with Bonferroni Adjustment Comparing During and Post with the
+Respective Pre Values
+Discussion
+Autonomic variables and the breath rate were recorded during random thinking (cancalata), nonmeditative focusing
+(ekagrata), meditative focusing (dharana), and meditative defocusing or effortless meditation (dhyana).
+Maximum changes in autonomic variables and the breath rate occurred during the stage of effortless meditation (dhyana).
+The changes were all suggestive of reduced sympathetic activity and/or increased vagal modulation. These were a
+decrease in heart rate, an increase in digit pulse volume (based on the photo-plethysmogram amplitude), an increase in
+skin resistance, a decrease in the LF power of HRV, and an increase in the HF power, also an increase in NN50 and
+pNN50, with a reduction in breath rate.
+The main difference between dharana and dhyana sessions was apparent in the autonomic variables and breath rate. As
+described above, most of the changes during dhyana were suggestive of reduced activity in the different subdivisions of
+sympathetic nervous system activity, though some variables are regulated by several factors. The heart rate for example,
+is regulated by dual innervation (sympathetic and vagal), as well as humoral factors.
+ This makes the decrease in heart
+rate less easy to interpret (i.e., it could be due to increased vagal tone or due to sympathetic withdrawal). This also
+applies to HRV components.
+There was a general understanding that the LF band of the HRV is an index of cardiac sympathetic activity.
+ However,
+this has been debated. Neither the LF band (<0.15 Hz) nor the HF band (>0.15 Hz) are considered exclusive markers of
+sympathetic or parasympathetic tone, respectively.
+ The HRV represents the integrated end-organ response to the
+complex nonlinear interaction between the two divisions of the autonomic nervous system as well as other factors. This
+particularly applies to the relationship between the LF power and cardiac sympathetic tone. It was found that the LF
+power was reduced by selective cardiac parasympathectomy and was not totally removed when β-adrenoceptor
+blockade was combined with denervation.
+ Also activities that were expected to increase sympathetic activity failed to
+increase the LF power and actually significantly reduced the LF power. In fact sympathetic activity can also modulate 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. However the association is qualitative rather than
+quantitative. Hence the HRV provides a qualitative marker of cardiac parasympathetic regulation and changes in the LF
+power and LF/HF ratio have to be viewed with caution.
+The LF power significantly increased during random thinking (cancalata) and nonmeditative focusing (ekagrata), while
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+there was a significant decrease during meditation (dhyana). Conversely, the HF power increased during meditation
+(dhyana), while it was decreased during nonmeditative focusing (ekagrata). The increase in LF during ekagrata and
+cancalata could reflect either a change in sympathetic or parasympathetic activity as described above. Given the
+complexity in interpreting these changes, at this stage it may be said that the change in LF in ekagrata and cancalata
+reflects a change in autonomic activity that would need further investigation. The frequency domain analysis indicated a
+possible increase in parasympathetic activity based on the increase in HF power in dhyana alone. This is supported by
+the changes in the HRV with time domain analysis. The pNN50 and the NN50 are both indicative of vagal tone.
+ Both
+values increased during dhyana, which was also suggestive of parasympathetic dominance. Hence during dhyana there
+was a shift in the autonomic balance towards vagal dominance.
+The skin resistance level is an indicator of the level of activity in the cholinergic sudomotor sympathetic nerves supplying
+the eccrine sweat glands.
+ This is believed to be the main contributor to changes in the spontaneous electrodermal
+activity.
+ The increase in the skin resistance level in all four sessions suggests relaxation during all of them.
+An increase in photo-plethysmogram amplitude correlates with decreased noradrenergic vasomotor sympathetic control
+of the cutaneous blood vessels.
+ Hence during the dhyana session there was decreased activity in the sympathetic
+nerves supplying the cutaneous blood vessels.
+Unlike these variables the breath rate depends upon numerous factors ranging from the level of physical activity to
+psychological stress.
+ A decrease in breath rate is generally associated with relaxation, which can explain the decrease
+seen during dhyana. The increase in breath rate during cancalata could suggest that participants found the diverse
+auditory inputs (taken from a local radio station and put together at random) stressful.
+Taken together the results suggest that effortless meditation or dhyana is associated with changes in the autonomic
+nervous system suggesting vagal dominance. Hence earlier studies that gave contrasting results (i.e., of sympathetic
+withdrawal in some studies, while other studies showed sympathetic activation), when meditators practiced the same
+technique may have been due to some meditators being in the dharana phase, while others were in the dhyana phase.
+Examples for this are Ananda Marga Meditation, for which one study reported sympathetic withdrawal,
+ while another
+study reported increased sympathetic activity in meditators.  Similarly there were conflicting reports for Zazen
+meditation.
+A TM session has been shown to consist of phenomenologically and physiologically distinct substates.
+ The three
+qualitatively different substates that have been described are (1) the inward stroke in which there is progressive reduction
+of all activity, (2) transcendental consciousness in which thoughts are absent yet consciousness is maintained, and (3) the
+outward stroke in which mental and physical activity progressively increase.
+ These three substates or phases have
+easily measured markers.
+ It was observed that meditators went through the three phases several times in a session.
+However, it was possible to note that the inward stroke was characterized by less heart rate deceleration and lowered
+skin conductance compared to the state of transcendental consciousness. Hence, in different phases of meditation,
+sympathetic activity may differ. This is similar to the present results. These differences during a meditation session could
+also be the reason for the apparently contradictory results seen in Ananda Marga and Zazen meditators. Also the
+differences could be due to the fact that different techniques are often given the same name.
+In summary, the changes were hence suggestive of reduced activation in dhyana. However dhyana is not the ultimate
+stage described in the ancient texts. Following dhyana, the eighth step in the astanga (eight limbs) yoga of Patanjali is
+samadhi which means, the state of ultimate realization. Samadhi has two stages, sabija samadhi (bija=seed, in
+Sanskrit), which means realization in its seed or unmanifest form (Patanjali's Yoga Sutras, Chapter I, Verse 50). With
+continued practice this leads to nirbija samadhi or the manifest state of ultimate realization (Patanjali's Yoga Sutras,
+Chapter I, Verse 51).
+There have been studies that have attempted to find objective physiological correlates for the experience of pure
+awareness as in samadhi. In 40 meditators practicing the TM technique, 11 participants were chosen to press a button
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+after an episode of pure consciousness experience. There was a significant relationship between button presses and
+breath suspension.
+Breath suspension periods when experiencing pure consciousness in TM were correlated with increased total EEG
+coherence with implications for functional integration and better mind–body health, along with reduced heart rate and
+phasic skin conductance responses.
+In summary, the present results show that when meditation is divided as two traditionally described stages, meditative
+focusing (dharana) and meditative defocusing (dhyana), the changes in the autonomic nervous system are distinct and
+different. The present findings make it apparent that studying yoga practices using present-day scientific methods may be
+made more meaningful if the techniques are understood based on the descriptions in the traditional texts.
+Conclusions
+Maximum changes were seen in autonomic variables and breath rate during the state of effortless meditation (dhyana).
+The changes were all suggestive of reduced sympathetic activity and/or increased vagal modulation. During dharana
+there was an increase in skin resistance. The changes with HRV during ekagrata and cancalata were inconclusive.
+Acknowledgment
+The authors gratefully acknowledge the funding from the Indian Council of Medical Research (ICMR), Government of
+India, as part of a grant (Project No. 2001-05010) towards the Center for Advanced Research in Yoga and
+Neurophysiology (CAR-Y&N).
+Author Disclosure Statement
+The authors declare that they have no competing financial interests.
+References
+1. Murata T. Takahashi T. Hamada T, et al. Individual trait anxiety levels characterizing the properties of Zen meditation.
+Neuropsychobiology. 2004;50:189–194. [PubMed]
+2. Wallace RK. Benson H. Wilson AF. A wakeful hypometabolic physiologic state. Am J Physiol. 1971;221:795–799.
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+Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/
+9/10
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+Articles from Journal of Alternative and Complementary Medicine are provided here courtesy of Mary Ann Liebert,
+Inc.

subfolder_0/Changes in lung function measures following Bhastrika Pranayama (bellows breath) and running in healthy individuals..txt

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+Int J Yoga. 2019 Sep-Dec; 12(3): 233–239.
+doi: 10.4103/ijoy.IJOY_43_18
+PMCID: PMC6746052
+PMID: 31543632
+Changes in Lung Function Measures Following Bhastrika Pranayama
+(Bellows Breath) and Running in Healthy Individuals
+Rana Bal Budhi, Sandeep Payghan,  and Singh Deepeshwar
+Department of Yoga and Life Science, S-VYASA Yoga University, Bengaluru, Karnataka, India
+Department of Yoga, Dev Sanskrit University, Haridwar, Uttarakhand, India
+Address for correspondence: Mr. Rana Bal Budhi, S-VYASA University, No. 19, Eknath Bhavan, Gavipuram
+Circle, KG Nagar, Bengaluru - 560 019, Karnataka, India. E-mail: [email protected]
+Received 2018 Jul; Accepted 2019 Feb.
+Copyright : © 2019 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:
+The purpose of this study was to observe the effect of bhastrika pranayama (bellows breath) and
+exercise on lung function of healthy individuals.
+Materials and Methods:
+A total of thirty male participants were recruited and randomly divided into two groups, i.e., yoga
+breathing group (YBG, n = 15) and physical exercise group (PEG, n = 15), and the participants’ ages
+ranged between 18 and 30 years (group age mean ± standard deviation, 22.5 ± 1.9 years). YBG
+practiced bhastrika pranayama for 15 min, whereas PEG practiced running for 15 min, 6 days in a
+week, over a period of 1 month. The participants were assessed for (i) forced vital capacity (FVC), (ii)
+forced expiratory volume in the first second (FEV1), (iii) peak expiratory flow rate (PEFR), and (iv)
+maximum voluntary ventilation (MVV) functions of lungs.
+Results:
+Repeated-measures analyses of variance with Bonferroni adjustment post hoc analyses of multiple
+comparisons showed that there was a significant increase in YBG for all variables, i.e., FVC, FEV1,
+PEFR, and MVV (P < 0.001, P < 0.001, P < 0.01, and P < 0.001, respectively), whereas there was a
+significant increase in PEFR and MVV (P < 0.05 and P < 0.01, respectively) only, among PEG.
+However, the change in PEG was less of magnitude as compared to YBG.
+Conclusions:
+These findings demonstrate that incorporating pranayama in sports can enhance the efficiency of
+healthy individuals and athletes by enhancing the ventilatory functions of lungs, especially for those
+who partake in aerobic-based sports and require efficient lungs to deliver sufficient oxygen uptake.
+Keywords: Bellows breath, running, ventilatory function, yogic breathing exercise
+1
+1
+Introduction
+Breath regulation or control is crucial to the practice of yoga and is emphasized in later six out of the
+eight aspects, or “limbs” of yoga as follows: yama (universal ethics), niyama (individual ethics), asana
+(physical postures), pranayama (breath control), pratyahara (control of the senses), dharana
+(concentration), dhyana (meditation), and samadhi (bliss).[1] Breath can be considered as the most
+important function of the body for indeed all the other functions depend on it.[2] When the breath stops
+permanently, life ends. Hence, prana (chi) or the breath is thus rightly called the life force energy.
+Moreover, the technique of manipulation of the normal pattern of prana (breath) through its conscious
+control is known as pranayama (yogic breathing exercise).[1] In view of its importance, the yogis from
+times immemorial developed this special system “Pranayama” and emphasized on the need of its
+regular practice. Its practice helps to reap maximum benefits by controlling the life force in a superior
+and extraordinary way by harmonizing body, mind, and spirit.[3] Schünemann et al.[4] reported in their
+study that pulmonary function is a long-term predictor of overall survival rates in both genders and
+could be used as a tool in general health assessment.
+In a previous study, Pramanik et al.[5] revealed that after slow bhastrika pranayamic breathing
+(respiratory rate [RR] 6 breath/min) for 5 min, both the systolic and diastolic blood pressure decreased
+significantly with a slight fall in heart rate. Raju et al.[6] studied pranayama effect among athletes in
+two phases on exercise tests. Both phases, i.e., submaximal and maximal exercise tests revealed that
+the participants practicing pranayama could achieve significantly higher work rates with a reduction in
+oxygen consumption per unit work and without an increase in blood lactate levels. Another study
+assessing the combined effect of both anulom vilom and bhastrika pranayama reported significant
+improvement in vital capacity and maximal ventilator volume.[7]
+Prakash et al.[8] in a cross-sectional study found that the yogis and athletes had significantly better
+forced expiratory volume in the first second (FEV1). Further, yogis’ peak expiratory flow rate (PEFR)
+was reported to be significantly better than that of both athletes and sedentary workers. Joshi et al.[9]
+reported that 6 weeks of pranayama improved ventilatory functions by lowering RR, increasing the
+forced vital capacity (FVC), FEV1, maximum voluntary ventilation (MVV), PEFR, and prolonging the
+breath holding time. Similarly, another study demonstrated a significant increase in FVC, FEV1, PEFR,
+and forced expiratory flow by 25%–75% after the practice of pranava, nadishuddi and savitri
+pranayama.[10] Apart from this, there was a comparative study between slow (Nadisohana, Pranav
+pranayama, and Savitri pranayama) and fast group pranayama (kapalabhati, bhastrika, and kukkriya)
+after training of 12 weeks on pulmonary function in young healthy volunteers reporting improvement
+in ventilatory functions.[11] Additionally, other comparative studies on slow and fast pranayama,
+bhastrika was included as one of the practices of fast group had reported improvement in hand grip
+strength and endurance,[12] reduced perceived stress and enhanced cognitive functions in healthy
+subjects.[13] Furthermore, fast pranayama's additional effects on the executive function of
+manipulation in auditory working memory, central neural processing, and sensory motor performance
+were observed. Apart from this, there are also studies on mukha bhastrika (a bellow-type pranayama)
+reporting decreased reaction time.[14]
+However, all the previous studies had been limited to certain points such as (i) either combined effects
+of slow/fast group pranayama were explored or pranayama effect was cumulatively investigated with
+other multiple techniques of yoga practices, (ii) most studies were either done without a control group
+or rarely control group was present, and (iii) retrospective studies were reported. And eventually, there
+was no study which has examined bhastrika pranayama alone compared with exercise (running) on
+ventilatory functions of the lung. Higher lung capacity has been speculated to be a key variable for
+marathon performance in amateur runners in a previous study.[15] Hence, the present study aimed to
+assess the impact of 4-week (1 month) bhastrika pranayama compared with running as active control
+on four parameters of lung function, i.e., (i) FVC, (ii) FEV1, (iii) PEFR, and (iv) MVV on healthy
+volunteers, who were actively involved in sport activities.
+Materials and Methods
+Participants
+Thirty healthy male participants with ages between 18 and 30 years (group average age ± standard
+deviation, 28.8 ± 7.8 years) were selected from North India. Only male participants were recruited in
+the study as pulmonary capacity varies with gender due to the influence of the reproductive hormones
+in females.[16] The sample size was calculated based on the FEV1 mean and standard deviation values
+of a previous study.[17] The G*Power software,[18] Version 3.0.10 (Heinrich Heine Universität
+Düsseldorf) was used, where alpha, power, and effect size were 0.05, 0.95, and 1.99 respectively,
+which generated a sample size of 7 in each group. It was decided to recruit 15 participants in each
+group to compensate for possible dropouts. Participants were randomly allocated using the web-based
+Research Randomizer[19] into yoga breathing group (YBG; n = 15) and physical exercise group (PEG;
+n = 15) after baseline data recording of the pulmonary function test (PFT). All participants were
+healthy, based on a routine case history and clinical examination, and none of them were on
+medication. They were actively involved in sports activities and ready to volunteer in the current study.
+The participants were excluded who had a history of major medical illness such as tuberculosis,
+hypertension, diabetes mellitus, bronchial asthma, history of major surgery in the recent past, smoking,
+alcohol consumption, and nonvegetarian diet. The study design was explained to all the participants,
+and their signed informed consent form was obtained. The study was approved by the Institutional
+Ethics Committee of Dev Sanskriti University, Haridwar, India.
+Design
+It is difficult to assess yoga practices in double-blind trials because the intervention requires the active
+participation of the individual and hence, the identities of the interventions become known after
+allocation.[18] However, the investigator who did the PFT was blind to the intervention. Therefore, it
+was a simple randomized controlled study. Consort flow diagram is explained in Figure 1.
+Figure 1
+CONSORT flow diagram
+Assessments
+Forced vital capacity
+Forced expiratory volume in the first second
+Peak expiratory flow rate
+Maximum voluntary ventilation
+Baseline data of each participant for the PFT were measured using a precalibrated computerized
+spirometer-MEDSPIROR (RMS recorders and Med Sys Pvt. Ltd., Chandigarh, India) instrument by an
+expert lab technician. Participants were properly familiarized with the testing procedure before each
+test. The baseline and postdata recording was carried out in sitting position following a standard
+procedure[20] during morning hours (6:30 am to 8:00 am). While performing a test, participants were
+adequately encouraged to perform at their optimum level. The test was repeated three times, and the
+highest value was used for the statistical analyses. All readings were recorded at saturated body
+temperature and pressure.
+For each measure, the maintenance of a tight seal between the lips and mouthpiece of the spirometer
+was ensured. All participants were assessed on the following parameters:
+In assessing FVC, participants were made to sit comfortably with normal
+breathing, with the mouthpiece of a spirometer placed into the mouth. The participants were instructed
+to inspire to their maximum effort and blow all the air through the mouthpiece as rapidly, forcefully,
+and completely as possible.
+FEV1 was the value in the first second of forceful
+expiration derived from FVC.
+For the PEFR, participants were instructed to perform forceful expiration
+immediately after a full inspiration (i.e., with no postinspiratory pause). It is the maximum velocity in
+liters per minute with which air is forced out of the lungs.[21]
+For MVV assessment, participants were instructed to inhale and exhale
+with a maximum voluntary effort by breathing as quickly and deeply as possible for 10–20 s, and
+finally the highest volume from 10 to 20 s was corrected to 1 min.
+Intervention
+The YBG practiced bhastrika pranayama for 15 min, 6 days in a week for a month, in morning hour
+approximately at 8 “o” clock. There was no training or orientation before the intervention as
+participants were occasional practitioner of yogic practices. Bhastrika pranayama imitates the action of
+the bhastra or “bellows” and fans the internal fire heating the physical and subtle bodies. Inhalation
+and exhalation in this pranayama are equal and are the result of systematic and equal lung movements.
+The inhalation and exhalation were performed with little force.[3] All participants were asked to sit in
+any comfortable meditation pose, and bhastrika pranayama practice was started with Om chanting and
+ended with pacifying chanting called shantipatha. Every day, participants were asked to practice three
+rounds of bhastrika pranayama of 4–5 min each with approximately 1 min rest after each round. All
+the participants were trained and monitored by a certified yoga trainer.
+The practice of bhastrika pranayama with medium or fast pace continuously for longer duration is not
+possible or very difficult, so volunteers were asked to start the practice with slow pace and gradually
+increase the speed with full efforts toward the ending of approximately 5 min.
+Similarly, participants in the PEG were asked to run for 5 min thrice in an open environment and
+instead of complete rest, they were asked to walk as a rest in between approximately 1 min, after every
+5 min. PEG practiced running like YBG for 15 min, 6 days in a week for a month, in morning hour
+approximately at 8:30 am. Initially, each participant was asked to run slowly and gradually increase
+their speed to full effort toward the end of approximately 5-min practice. PEG was also monitored by
+an investigator who was not involved in the analysis part.
+Statistical analysis
+Statistical analyses were performed using the Statistical Package for the Social Sciences (Version 18.0.
+SPSS Inc., Chicago, IL, USA). Data of (i) FVC, (ii) FEV1, (iii) PEFR, and (iv) MVV recorded were
+tested by Shapiro–Wilk test for normality, which showed that data were normally distributed.
+Therefore, repeated-measures analyses of variance (ANOVA) were performed. There was one within-
+subject factor, i.e., state (baseline and post) and one between-subjects factor, i.e., groups (YBG and
+PEG). Post hoc analyses with Bonferroni adjustment were used to detect significant differences
+between the mean values. Cohen's d effect size was calculated using G-power software (3.0.10
+version).
+Results
+The baseline and postgroup mean and standard deviation for data obtained in the FVC, FEV1, PEFR,
+and MVV are shown in Table 1.
+Table 1
+Baseline and postdata obtained in lung function for yoga breathing group and physical exercise
+group
+Open in a separate window
+Values are in group mean±SD. Repeated-measures ANOVA with Bonferroni adjustment post hoc analyses was
+performed for multiple comparisons, *P<0.05, **P<0.01, ***P<0.001, *Depicts comparison between post with
+respective pre means, P<0.05 depicts comparison between post states of both groups. FVC=Forced vital
+capacity, SD=Standard deviation, FEV1=Forced expiratory volume in the first second, PEFR=Peak expiratory
+flow rate, MVV=Maximum voluntary ventilation, ES=Cohen’s d effect size, ANOVA=Analysis of variance
+Forced vital capacity
+The repeated-measures ANOVA showed a significant difference between the states for FVC (F
+ =
+10.37, P < 0.003). Post hoc analyses with Bonferroni adjustment were performed for multiple
+comparisons. After yoga sessions, there was a significant increase in FVC (P < 0.001; Cohen's d =
+1.05) compared to baseline; in contrary to this, there was no significant increase in physical exercise
+sessions.
+Forced expiratory volume in the first second
+The repeated-measures ANOVA showed a significant difference between states for FEV1 (F
+ =
+22.65, P < 0.001). Post hoc analyses with Bonferroni adjustment were performed, and there was a
+significant increase in FEV1 (P < 0.001; Cohen's d = 1.10) compared to baseline in YBG, whereas
+there were no significant changes in PEG.
+Peak expiratory flow rate
+Parameters
+Group
+P
+Yoga (n=15)
+Percentage
+change
+Running (n=15)
+Before
+(mean±SD)
+After (mean±SD)
+ES
+Before
+(mean±SD)
+After
+(mean±SD)
+ES
+FVC (L)
+2.52±0.61
+3.48±1.22**
+0.91
+38.10
+2.54±0.65
+2.73±0.75
+0.27
+FEV1 (L/s)
+2.37±0.59
+2.95±0.46***
+1.1
+24.47
+2.37±0.61
+2.47±0.60
+0.17
+PEFR (L/s)
+5.11±1.39
+5.79±1.34**
+0.5
+13.31
+4.87±1.39
+5.48±1.64*
+0.4
+MVV
+(L/min)
+114.0±32.44
+157.67±24.23***
+1.5
+38.31
+116.20±28.78
+135.13±31.18**
+0.63
+,†
+,†
+†
+1, 28
+1,28
+The repeated-measures ANOVA showed a significant difference between states for PEFR (F
+ =
+15.17, P < 0.001). Post hoc analyses with Bonferroni adjustment for both yoga and physical exercise
+showed significant increase in PEFR (i.e., P < 0.01 and P < 0.05 and Cohen's d = 0.50 and 0.40 for
+YBG and PEG, respectively). However, a magnitude of change was more in YBG compared to PEG as
+shown in Figure 1.
+Maximal voluntary ventilation
+The repeated-measures ANOVA showed a significant difference between states for MVV (F
+ =
+79.96, P < 0.001). Post hoc analyses with Bonferroni adjustment for yoga and physical exercise
+practice showed significant increase in MVV (P < 0.001 and P < 0.01 and Cohen's d = 1.54 and 0.63
+for YBG and PEG, respectively) compared to baseline; in this parameter also, the magnitude of change
+was more in YBG as compared to PEG as shown in Figure 2.
+Figure 2
+Graph showing the percentage change. *P < 0.05, **P < 0.01, ***P < 0.001. FVC = Forced vital capacity,
+FEV1 = Forced expiratory volume in the first second, PEFR = Peak expiratory flow rate, MVV =
+Maximum ventilation volume, YBG = Yoga breathing group, PEG = Physical exercise group
+Discussion
+In the present study, FVC, FEV1, PEFR, and MVV increased significantly after the 1-month practice of
+bhastrika pranayama (YBG) as compared to a physical exercise (PEG). The PEG also showed an
+increase in PEFR and MVV, but the magnitude of change was less compared to YBG. These findings
+are in line with earlier studies. However, the present study attempted to explore single bhastrika
+pranayama effect on healthy individuals in comparison with physical exercise. The regular breathing
+practices in yoga training[22] and Sudarshan Kriya[23] studies had reported significant improvement in
+all PFTs such as FVC, FEV1, PEFR, and MVV. The current study also showed improvement in FVC
+by 38.1% after 4 weeks’ practice of bhastrika. The finding is in consistent with the previous study that
+has reported that pranayama training for 6-week improves ventilatory functions in the form of lowered
+RR and by increasing FVC, FEV1, MVV, and PEFR.[9]
+One of the previous studies conducted on bhastirka pranayama had showed significant improvement in
+pulmonary function after 12 weeks of practice compared with baselines values. This study was limited
+with no control group.[22] In addition to this, there are studies reporting improvements in pulmonary
+1, 28
+1, 28
+function which investigated the effect of multiple pranayamas.[9,10,11] Whereas the current study
+observed only the single pranayama (bhastrika) practice effect on pulmonary functions compared with
+running.
+FVC is an index of the state of elastic properties of the respiratory apparatus.[24] Whereas FEV1 is the
+expelling rate of breath from the lungs in the 1  s. It reflects the flow-resistive properties to air flow in
+airways that are >2 mm in diameter. FVC has been considered as a critical component of good health
+and survival important for the evaluation of normal subjects and patients with respiratory and
+cardiovascular conditions.[25] Kondam et al.[26] had reported that consistent practice of a variety of
+asanas constantly recruits muscles of the thoracic cavity. This recruitment may lead to greater
+musculature involvement and thereby result in improved FVC. Further, a study reported that yoga
+exercises improve respiratory breathing capacity by increasing chest wall expansion and forced
+expiratory lung volumes.[27] In both the studies, asanas were the intervention used, whereas in the
+present study, asanas were not at all practiced by the participants, and only bhastrika pranayama was
+intervened. Hence, improvement in the FVC and FEV1 could be due to recruitment and strengthening
+of respiratory muscles that might have enhanced elastic properties of the lungs and chest, incidental to
+the regular practice of bhastrika pranayama.[28] In contrast to this, there were no significant changes
+observed in the above variables among PEG.
+PEFR is a measure of elastic recoil pressure changes or the resistance of small airways.[24] In several
+previous studies,[9,10,11,29] significant improvement in PEFR after yoga practice has been reported.
+An improvement in PEFR was also observed in the present study, but in both YBG and PEG, where
+YBG had a relatively greater magnitude of change [Table 1]. Although earlier PEFR was believed to be
+effort dependent, now it is accepted to be effort independent and is mainly dependent on lung volume
+and airway mechanics.[30] The “Bhastrika Pranayama” is one of the yogic well-regulated breathing
+exercises that involves the use of lung spaces that are not used up in normal shallow breathing, thereby
+it may increase the depth of breathing. Forceful or deep yogic breathing (pranayama) expands the
+lungs more than normal breathing that may recruit previously closed alveoli, resulting in an increased
+surface area of the respiratory membrane and air diffusion across the membrane.[31] The improved
+breathing pattern may widen respiratory bronchioles, leading to effective perfusion of alveoli in a large
+number.[32] Therefore, the increased PEFR in a higher magnitude of YBG than PEG might be a
+consequence of the opening of a small airway in lungs and decrease in airway resistance.
+MVV is respiratory apparatus measuring the status of respiratory muscles, i.e., mechanical properties
+of lungs and chest, representing the flow-resistive properties of the system. MVV has a wide variability
+with the subject and is an effort-dependent test.[24] In the present study, during bhastrika pranayama
+practice, participants were asked and trained to inflate and deflate the lungs and chest to the fullest and
+deepest possible extent as in previous pranayama studies.[9] Hence, the practice of bhastrika
+pranayama in YBG may have helped to use diaphragmatic and abdominal muscles efficiently, leading
+to significant increase in MVV in higher magnitude than PEG.[33]
+In addition to this, regular inspiration and expiration during yoga and pranayama practices for a
+prolonged period lead the lungs to inflate and deflate maximally that causes strengthening and
+enhancement of endurance of the respiratory muscles.[8] And further, maximal lung inflation is the
+major stimulus for releasing the lung surfactants[10] from the epithelial lining of alveoli and
+prostaglandins into the alveolar spaces by the parenchyma of the lungs.[34] This may have increased
+lung compliance and decreased bronchiolar smooth muscle tone, respectively. In other words,
+decreased bronchiolar smooth muscle tone or increased bronchiolar smooth muscle relaxation may
+increase the caliber of airways, leading to more airflow and less airway resistance. These all could be
+the possible mechanism for increasing the pulmonary function in a higher magnitude of YBG
+compared to PEG in the current study. Clinically, there are also few studies that have reported the
+beneficial effects of yoga and breathing practices on respiratory disorders such as asthma[31,35,36] and
+chronic obstructive pulmonary disease.[37,38]
+This study assessed the direct effect of one particular breathing practice called bhastrika pranayama on
+lung functions and compared it with physical exercise. An important thing to be noticed in this study
+was that YBG had more significant effect than PEG. However, the study had the following limitations:
+st
+(i) latest version equipment was not used for measurement, so lung volumes such as functional residual
+capacity and inspiratory capacity were not measured at rest and during exercise in the study; (ii)
+intensity is a crucial part of training and it would have been ideal to strictly control this parameter by
+monitoring energy expenditure while training sessions. As the study was comparing the effects of two
+different streams of training; (iii) the sample size was small, and further studies with larger sample size
+and longer duration can validate the findings with the underlying mechanism; (iv) combined practice of
+yogic breathing and running as third group as well as control group as fourth added, would have been
+more ideal; and (v) demographic details of all participants were self-reported. In addition, the present
+study only recruited male participants; future studies can recruit both the genders in equal numbers for
+generalization of outcome.
+Conclusions
+The results of the study conclude that the practice of bhastrika pranayama can recruit normally
+unventilated lung spaces and help strengthen the respiratory muscles and increase the elastic properties
+of lungs and chest, thereby improving its ventilatory functions.
+It was interesting to find that there was a more significant increase in YBG than the PEG. Therefore,
+yoga breathing, particularly bhastrika pranayama, may have a promising factor for those who partake
+in aerobic-based sports (such as athletes, swimmers, and trekkers) and require efficient lungs to deliver
+sufficient oxygen uptake.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgment
+The help given by Lalan Bhaiya (expert/senior lab technician) and Brahmavarchasva Sodsansthan,
+Haridwar, India, in carrying out the assessments is gratefully acknowledged.
+In addition to this, Swami Vivekananda Anusandan Samsthana, Bengaluru, India, is also highly
+acknowledged for providing all the facilities to compose the research article.
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+Publications

subfolder_0/Complimentary effect of yogic sound resonance relaxation technique in patients with common neck pain.txt

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+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+18
+Complimentary effect of yogic sound resonance relaxation 
+technique in patients with common neck pain
+Bali Yogitha, R Nagarathna, Ebnezar John, HR Nagendra
+Department of Orthopaedics, Ebnezar Orthopedic Centre, Parimala Hospital, Bengaluru, India
+Address for correspondence: Dr. Yogitha Bali,
+No.164, Nandikeshwara Nilaya, Doctor’s Layout, Arakere, 
+ 
+Bannerghatta Road, Bengaluru - 76, India. 
+E-mail: [email protected]
+DOI: 10.4103/0973-6131.66774
+Original Article
+Background: Studies have shown that conventional treatment methods with drugs, physiotherapy and exercises for common 
+neck pain (CNP) may be inadequate. Yoga techniques have been found to be effective complimentary therapies in chronic 
+low back pain and also for stress reduction in other diseases.
+Objective: The aim of the study was to examine the complimentary role of a yogic relaxation called mind sound resonance 
+technique (MSRT) in non-surgical management of CNP.
+Materials and Methods: In this randomized controlled study, 60 patients with CNP were assigned to two groups (yoga, 
+n=30) and (control, n=30). The yoga group received yogic MSRT for 20 minutes in supine position after the conventional 
+physiotherapy program for 30 minutes using pre-recorded audio CD and the control group had non-guided supine rest for 20 
+minutes (after physiotherapy), for 10 days. MSRT provides deep relaxation for both mind and body by introspective experience 
+of the sound resonance in the whole body while repeating the syllables A, U, M and Om and a long chant (Mahamrityunjaya 
+mantra) several times in a meaningful sequence. Both the groups had pre and post assessments using visual pain analog 
+scale, tenderness scoring key, neck disability score (NDS) questionnaire, goniometric measurement of cervical spinal flexibility, 
+and state and trait anxiety inventory-Y1 (STAI-Y1).
+Results: Mann-Whitney U test showed significant difference between groups in pain (P<0.01), tenderness (P<0.01), neck 
+movements (P<0.01). NDS (P<0.01) and state anxiety (STAI-Y1) showed higher reduction in yoga (P<0.01) than that in the 
+control group. Wilcoxon’s test showed a significant improvement in both groups on all variables (P<0.01).
+Conclusions: Yoga relaxation through MSRT adds significant complimentary benefits to conventional physiotherapy for CNP 
+by reducing pain, tenderness, disability and state anxiety and providing improved flexibility.
+Key words: Neck pain; mind sound resonance technique; physiotherapy; stress; yoga
+ABSTRACT
+intROductiOn
+Neck pain is one of the very common complaints across 
+the globe, with a prevalence of nearly 13%[1,2] and a lifetime 
+prevalence of nearly 50% and women are more prone than 
+men with an incidence ratio of 1.67 (women are more likely 
+than men to develop neck pain; incidence rate ratio=1.67, 
+95% confidence interval 1.08-2.60).[3-5] Neck and shoulder 
+pain has also become an increasingly common health 
+complaint among adolescents, where the prevalence is found 
+to be higher in girls than in boys.[6] It is one of the frequent 
+causes for sickness absenteeism that could disrupt a nation’s 
+economy apart from disrupting the personal and professional 
+life of a victim.[7] Though the exact cause is unknown, 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 are some of the etiological factors.[8] “Common neck 
+pain” (CNP) which is not due to any organic lesion accounts 
+for more than 80% of neck pains.[9] Psychological stress 
+that may be associated in any of these factors cannot be 
+undermined.[10] Depression and anxiety are well-known 
+undesirable side effects of chronic neck pain.[11,12]
+Since the underlying pathology of neck disorders remains 
+unclear, the treatments are aimed at relief of pain and 
+stiffness. The conventional conservative methods include 
+non-steroidal anti-inflammatory drugs, physical measures 
+such as heat, ultrasound, manipulation and exercises.[13]
+www.ijoy.org.in
+19
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+Moffett et al, compared a brief physiotherapy intervention 
+on 268 patients (for 7 days) with usual physiotherapy 
+(for 14 days) for CNP and showed that latter may be only 
+marginally better than the former.[14]
+Spray and stretch (vapo-coolant spray followed by passive 
+stretching) was compared to laser therapy and a placebo, 
+with no significant difference between the groups and 
+no significant reduction in pain.[15] A study conducted 
+to investigate the use of traction in two randomized 
+controlled trials revealed the difference between the groups 
+to be small and not significant.[16,17] Loy et al, showed that 
+symptomatic improvement was better with a combination 
+of cervical traction, short wave diathermy and electro 
+acupuncture, than a combination of TENS, collar, rest and 
+education in moderate quality neck pain.[18] With growing 
+dissatisfaction with these conventional therapies, there 
+is a pressing need for complementary measures and yoga 
+seems to hold promise through its multifaceted approach 
+to healing. Studies have established the role of yoga in 
+decreasing the pain and disability in chronic low back 
+pain, along with improved flexibility within 1 week to 4 
+months of yogic intervention with no adverse effects.[19]
+Yoga has also been found to be an effective tool in reducing 
+stress levels.[20,21] Mind sound resonance technique 
+(MSRT) is one of the advanced guided yoga relaxation 
+techniques that can be practiced in supine or sitting 
+posture for achieving the goal of positive health, will 
+power, concentration and deep relaxation.
+This tool [Table 1] was developed using the concepts from 
+traditional texts that talk about the power of Om (Mandukya 
+Upanishad) and Nadanusandhana (Hatha Yoga Pradipika) 
+for achieving internal mastery over the modifications of 
+the mind (Patanjali’s definition of yoga).[22] MSRT opens 
+up the secret of traditional chants called Mantras. MSRT 
+was one of the components of the intensive integrated yoga 
+program that was used as the intervention for low back 
+pain study.[23] Although MSRT has been used routinely as a 
+component of the integrated approach to yoga therapy for 
+treatment of neck pain and back pain at our yoga therapy 
+health home and the orthopedic center with encouraging 
+results, the results of these studies were not published. 
+Hence, this study was planned with an aim to evaluate 
+the efficacy of an add-on program of this yoga-based 
+relaxation technique and compare it with the conventional 
+physiotherapy technique. The hypothesis was that the yoga 
+group would show better improvement than the control 
+group in measures of pain, tenderness, disability, flexibility 
+and state anxiety.
+mateRials and methOds
+The sample size was derived by calculating the effect 
+size based on the mean and standard deviation (SD) of 
+an earlier unpublished interventional study done at this 
+center using the same design for chronic low back pain, 
+by Anupritha et al.[23] Eighty-seven consecutive patients 
+who came to the Ebenezer’s orthopedic unit of Parimala 
+hospital, Bengaluru, India, for treatment of neck pain 
+were screened. Of these, 60 who needed physiotherapy 
+and consented to be in the study were randomized into 
+two groups of 30 each using a computer-generated random 
+number table on the “randomizer.com” software. There 
+were 28 females and 32 males.
+The institutional ethical committee of SVYASA approved 
+the study. Signed informed consent was obtained from all 
+the participants.
+Patients with CNP due to spasm (myalgia) or strain of 
+the neck muscles, ligament strain, cervical spondylosis 
+without any neurological impairment and who were 
+advised physiotherapy by the consulting orthopedic 
+surgeon were included in the study. It was ensured that 
+these were literate patients in the age group of 20–70 years 
+with no previous exposure to yoga.
+Those with uncommon neck pains (UCNP) due to organic 
+causes such as congenital conditions like wry neck, 
+infective conditions like tuberculosis, inflammatory 
+conditions like rheumatoid arthritis, metabolic disorders 
+like osteoporosis, neoplastic conditions and post-traumatic 
+conditions with ligament or bone injuries were excluded.
+The study design was as follows. This was a randomized 
+parallel two-armed control design. Sixty subjects who were 
+advised conventional treatment including physiotherapy 
+for CNP at the orthopedic centre were selected for the 
+study and were randomized into two groups after obtaining 
+the informed consent. Yoga group received yoga-based 
+relaxation technique that included MSRT after a short 
+Table 1: Steps of MSRT
+Practice
+Duration
+Prayer – salutation to the divine (Maha 
+Mrityunjaya Mantra)
+1 minute
+Quick relaxation technique – observe the abdominal 
+breathing internally with closed eyes
+3 minutes
+Loud chanting (Ahata) of A, U, M and AUM 
+(three rounds)
+16 minutes
+Alternate loud (Ahata) and mental (Anahata) chanting 
+of A, U, M and AUM (three rounds)
+Ahata of a long chant invoking fearlessness – Maha 
+Mrityunjaya Mantra (three rounds)
+Alternate Ahata–anahata of Mahamrityunjaya mantra 
+(three rounds)
+Anahata of AUM (three rounds)
+Silence
+Resolve
+Closing prayer for peace
+MSRT in CNP
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+20
+Bali, et al.
+movements of the neck: flexion (F), extension (E), lateral 
+flexion (to right = LFR and to left = LFL), and lateral 
+rotation (LRR and LRL).
+Secondary outcome measures included blood pressure (BP), 
+pulse rate (PR) and state anxiety inventory (STAI-Y1). BP 
+was measured using a sphygmomanometer on day 1 and 
+day 10 after the treatment. PR was counted manually for 1 
+minute before the treatment was started on 1st and 10th day.
+STAI developed by Spielberger et al (1970) consists of 
+two forms (Y1 and Y2) each comprising 20 items rated 
+on a 4-point scale. and was used for assessing the anxiety 
+levels. Form Y1 used to assess state anxiety is defined 
+as “a transitory emotional state that varies in intensity, 
+fluctuates over time and is characterized by feelings of 
+tension and apprehension and by heightened activity of the 
+autonomic nervous system”. It evaluates how respondents 
+feel “right now” at this moment. Form Y2 evaluates trait 
+anxiety, which is defined as “a relatively stable individual 
+predisposition to respond to situations perceived as 
+threatening”. It assesses how the respondents feel most of 
+the time. The scores for each of the forms range from 20 
+to 80, with high scores indicating presence of high levels 
+of anxiety. We used Y1 in our study.
+Data sheets marked by all patients for PAS, NDS and 
+STAI-Y1 were coded and kept aside for future assessment. 
+All measurements were taken before the intervention on 
+1st day and 10th day.
+intervention
+Conventional schedule of physiotherapy that was 
+common to both the groups included (a) intermittent 
+cervical traction treatment (one-sixth of the body weight) 
+for 10 minutes, using the Cervical Traction instrument, 
+Electrocare (2001), Chennai, India (b) interferential 
+therapy for 10 minutes using IFT Technomed (2003) and 
+(c) ultrasound massage for 10 minutes using Ultrasound 
+Technomed 408 (2003). 
+An add-on intervention for the control group was a non-
+guided supine rest for a period of 20 minutes after the 
+conservative treatment (physiotherapy) for 30 minutes. 
+Add-on yoga relaxation for the study group was used. 
+After the physiotherapy, the study group received the yoga 
+relaxation therapy called MSRT done in supine position. 
+MSRT is one of the advanced yoga techniques for achieving 
+deep relaxation. MSRT involves experiencing with closed 
+eyes the internal vibrations and resonance developed while 
+chanting the syllables A, U, M, Om and Mahamrityunjaya 
+mantra sounds.
+Instructions were given in the recorded tape to feel the 
+quick relaxation technique, by way of a prerecorded audio 
+tape played with head phones for a period of 20 minutes, 
+after 30 minutes of conventional physiotherapy. Control 
+group had non-guided supine rest for 20 minutes after 
+the conventional physiotherapy. After randomization, 
+the pre-data on all variables were recorded. The role of 
+stress and the value of relaxation in general after the 
+conventional physiotherapy were explained to both the 
+groups by the research officer. The yoga group had a 
+separate session to explain the meaning and other details 
+of the intervention and was taught the technique through 
+personal instructions by the yoga therapist for half an hour 
+on the 1st day. From the second day onward, they were 
+asked to practice the same in supine position by listening 
+to the prerecorded audio tape on head phones in the annex 
+room of the physiotherapy department of the hospital.
+The subjects in the control group were asked to relax 
+comfortably and calm down their mind in the supine rest 
+on their own in the annex room similar to the study group. 
+Post data were obtained on all subjects on the 10th day.
+As this was an interventional study, there was no 
+possibility of blinding. The pain analog scale (PAS) sheets 
+and the answer sheets of State Trait Anxiety Inventory 
+(Form1) (STAI Y1) were kept aside for data extraction until 
+the completion of both pre and post data.
+Assessments through the clinical examination by the 
+orthopedic surgeon before recruitment included (a) 
+history of all health problems followed by examination 
+for assessment of the degree and type of neck pain, (b) 
+neurological examination to look for any motor or sensory 
+deficit, (c) X-rays of the cervical spine in antero-posterior 
+and lateral views.
+The primary outcome measures used were visual pain 
+analog scale (PAS), neck muscle tenderness, neck disability 
+score (NDS) and movements of the neck. The subjects 
+were asked to mark the degree of their present pain on 
+a numerical PAS by placing a dot on a 10-cm line drawn 
+on a white paper with centimeter markings, with 0 = “nil 
+pain” and 10 = “the worst possible pain the person can 
+imagine”.[24] Neck muscle tenderness grading of tenderness 
+was done using the following key: Grade 1 = tenderness on 
+deep palpation of para-cervical muscles, Grade 2 = patient 
+winces on pressure, Grade 3 = patient winces and withdraws 
+and Grade 4 = patient does not allow one to touch.[25] The 
+NDS developed by Vernon et al., was used.[26] It consists 
+of 60 questions related to pain intensity, personal care, 
+work, concentration, lifting, reading, driving, recreation, 
+headache and sleeping. The patients were asked to 
+complete the answers to these questions on a 6-point 
+scale ranging from 0 to 5. Cervical spinal flexibility was 
+measured by using a Lenthon Goniometer for the following 
+21
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+resonance all over the body both during loud (Ahata: heard) 
+and mental chanting (Anahata: unheard). This is done 
+alternately starting from Ahata ‘
+A
+’ followed by Anahata ‘
+A
+’ 
+repeated three times. This is followed by similar repetitions 
+of all other chants. Resonance generated by MSRT helps in 
+revitalizing the internal energy in the body. It takes to deeper 
+layers of silence, wards off all fears and stresses. It can lead to 
+an experience of tremendous expansion and rest that forms 
+the basis of the healing power of these traditional chanting 
+called Mantras.[27] This type of mindfulness techniques that 
+involve deep levels of mind and body relaxation have the 
+ability to reduce the sympathetic nervous system activation 
+and increase parasympathetic nervous system activity and 
+restore homeostasis.
+data extraction
+Pain analog scale
+The distance of the point marked by the patient on the 
+PAS line was measured by using a measuring scale and 
+expressed in centimeters.
+Spinal flexibility
+The values for F
+, E, RLF
+, LLF
+, RLR and LLR were expressed 
+in degrees.
+Neck disability score
+The total score was obtained by taking the sum of the 
+scores for all 60 questions.
+state and trait anxiety inventory-y1
+The scoring of the STAI-Y1 was carried out as per the 
+manual. The sum of the scores on the 5-point scale for the 
+12 questions marked on the answer sheets was considered 
+as the total score for state anxiety.
+data analysis
+Data were analyzed using statistical package for social 
+sciences (SPSS, version 10.0). The base line values of 
+the two groups were checked for normal distribution by 
+using Shapiro-Wilk’s Test. Since the parameters were not 
+normally distributed, non-parametric tests were used. 
+Wilcoxon’s signed ranks test was done to compare the 
+means before and after intervention. The differences 
+between the two groups for all variables were assessed by 
+Mann-Whitney U test.
+ethics
+Ethical clearance was obtained from the ethical committee.
+Results
+[Table 2 shows results of both between and within groups] 
+Sixty subjects who satisfied the selection criteria were 
+registered for the study of which 32 (15 in control, 17 in 
+yoga) were females and 28 (15 in control, 13 in yoga) were 
+males. Table 3 shows the baseline characteristics  which 
+were similar between groups. There were six dropouts 
+(two in yoga and four in control group). The reasons for 
+dropping out are mentioned in trial profile [Figure 1]. The 
+mean and SD of age in yoga group was 41.03 ± 15.54 and 
+that of control group was 42.23 ± 14.30 years. Duration 
+of neck pain was 6.8 + 3.16 and 5.40 + 2.66 years for 
+control group and yoga group, respectively. There was no 
+significant difference between groups for baseline values 
+on any of the variables. Table 4 shows the results within 
+the groups after 10th day of the intervention.
+Non-parametric Wilcoxon’s test showed a significant 
+MSRT in CNP
+Table 2: Table of results
+Variables
+Yoga group (%)
+Control group (%)
+Effect size
+Pre (M ± SD)
+Post (M ± SD)
+% change
+Pre (M ± SD)
+Post (M ± SD)
+% change
+PAS
+8.27 ± 1.14
+0.37 ± 0.67
+95.5*+
+7.93 ± 1.14
+3.07 ± 1.98
+61.29*
+1.83
+Tenderness
+2.37 ± 0.89
+0.17 ± 0.38
+92.82*+
+2.23 ± 0.68
+0.83 ± 0.65
+62.78*
+1.24
+NDS
+45.30 ± 21.49
+3.93 ± 5.36
+91.32*+
+43.47 ± 19.82
+13.90 ± 10.03
+68.02*
+1.24
+Flexion
+10.13 ± 7.94
+44.60 ± 7.12
+–340.27*+
+7.67 ± 5.93
+29.93 ± 5.42
+–290.22*
+2.32
+Extension
+8.40 ± 7.37
+44.73 ± 7.16
+–432.5*+
+7.40 ± 5.51
+29.10 ± 6.74
+–293.24*
+2.25
+RLF
+7.73 ± 4.92
+37.23 ± 5.29
+–381.63*+
+7.30 ± 6.10
+30.67 ± 5.49
+–320.13*
+0.94
+LLF
+8.13 ± 4.95
+38.33 ± 5.20
+–371.46*+
+6.70 ± 5.93
+30.90 ± 4.99
+–361.19 (*)
+1.46
+RLR
+8.60 ± 5.83
+45.37 ± 7.58
+–427.55*+
+9.07 ± 5.51
+29.87 ± 7.42
+–229.32*
+2.07
+LLR
+8.77 ± 5.07
+44.13 ± 6.74
+–403.19*+
+10.30 ± 6.35
+29.87 ± 7.16
+–190*
+1.9
+STAI
+56.80 ± 8.10
+45.83 ± 10.66
+19.31*+
+58.13 ± 9.32
+53.37 ± 5.64
+8.18
+0.88
+BPS
+132.30 ± 12.31
+111.60 ± 9.31
+15.64*+
+134.53 ± 14.29
+127.13 ± 15.28
+5.50*
+1.23
+BPD
+86.50 ± 8.12
+72.93 ± 6.80
+15.68*+
+83.60 ± 16.62
+83.30 ± 8.18
+0.35
+1.38
+Pulse
+75.30 ± 6.59
+67.70 ± 5.54
+10.09*+
+76.23 ± 6.25
+74.13 ± 6.66
+2.75
+1.05
+*P<0.01 for Wilcoxon’s test (within groups); +P<0.01 for Mann-Whitney U test (between groups);
+M = Mean, SD = Standard deviation, percentage and EF = Effect size of yoga and control groups, PAS = Pain analog scale, NDS = Neck disability score,  
+RLF = Right lateral flexion, LLF = Left lateral flexion, RLR = Right lateral rotation, LLR = Left lateral rotation, STAI = State trait anxiety inventory, BPS = Blood 
+pressure systolic, BPD = Blood pressure diastolic
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+22
+Bali, et al.
+Figure 1: Trial profile
+Number screened
+85
+Randomized
+60
+30
+PT + MSRT
+30
+PT + SR
+YOGA
+28
+CONTROL
+26
+2–complete relief of pain 4th and
+5th day–stopped treatment
+DROP OUTS YOGA
+Number satisfied selection criteria
+60
+2–complete relief of pain-stopped
+treatment on 7th day
+2–advised complete bed rest due to
+pain aggravation
+DROP OUTS CONTROL
+improvement in both the groups in pain (P<0.01), 
+tenderness (P<0.01), NDS (P<0.01), spinal flexibility 
+including flexion (P<0.01), extension (P<0.01), RLF 
+(P<0.01), LLF (P<0.01), RLR (P<0.01) and LLR (P<0.01) 
+movements of the neck and state anxiety (P<0.01). There 
+were significant (P<0.05) differences between groups on 
+all these variables studied, with higher percentage changes 
+in yoga than control group. Systolic BP showed significant 
+reduction in both the groups (P<0.01) but the diastolic 
+BP and the PR showed significant reduction only in yoga 
+group (P<0.01) with non-significant difference between 
+groups.
+In yoga group there was reduction in pain by 95.5%, 
+tenderness by 92.82% and NDS by 91.32%. The spinal 
+flexibility increased in movements of flexion by −340.27%, 
+extension by −432.5%, RLF by −381.63%, LLF by 371.46%, 
+RLR by −427.55%, and LLR by −403.19%.
+In conclusion, it is observed that there is significant 
+improvement in all variables in both the groups with 
+significantly better improvement in yoga than control 
+group.
+discussiOn
+This prospective randomized control study was designed 
+to assess the efficacy of addition of a yoga-based relaxation 
+technique called MSRT to the conventional physiotherapy 
+program for 10 days in patients with CNP
+. Analysis of 
+outcomes indicated significant difference between the 
+groups (Mann-Whitney test) and within groups (Wilcoxon’s 
+test) for all variables including PAS (P<0.01), tenderness 
+(P<0.01), flexion (P<0.01), extension (P<0.01), RLF 
+(P<0.01), LLF (P<0.01), RLR (P<0.01), LLR (P<0.01), 
+NDS (P<0.01) and state anxiety (STAI-Y1) of state and trait 
+anxiety inventory (P<0.01).
+Meaning and comparison of a few earlier studies suggest 
+the usefulness of relaxation techniques in reduction of 
+pain and improvement of flexibility by reduction in muscle 
+tension in patients with chronic neck pain. Kabat–Zinn 
+showed that 65% of the patients felt lesser pain after 
+practicing mindfulness meditation for 10 weeks in patients 
+with chronic pain, who had not improved with traditional 
+medical care.[28] There are three randomized trial controls 
+on yoga for chronic low back pain. RCTs using Viniyoga 
+and Iyengar yoga therapy showed reduction in pain and 
+functional disability with non-significant changes in the 
+control group. In a study done on patients with chronic low 
+Table 3: Demographic data
+Characteristics
+Yoga (n=30)
+Control (n=30)
+Age (M ± SD)
+41.03 ± 15.54
+42.23 ± 14.30
+Gender
+Males
+17
+15
+Females
+13
+15
+Causes
+Non-specific
+14
+13
+Spondylosis
+16
+17
+Height
+157.45 ± 7.40
+158.35 ± 5.97
+Weight
+60.37 ± 11.07
+59.23 ± 13.16
+BMI
+24.60 ± 4.15
+23.90 ± 4.51
+23
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+MSRT in CNP
+Table 4: Results after intervention
+Variable
+Yoga
+Control
+Pre (M ± SD)
+Pre (M ± SD)
+Pre (M ± SD)
+Post (M ± SD)
+PAS
+8.27 ± 1.14
+0.37 ± 0.67*
+7.93 ± 1.14
+3.07 ± 1.98*
+TN
+2.37 ± 0.89
+0.17 ± 0.38*
+2.23 ± 0.68
+0.83 ± 0.65*
+F
+10.13 ± 7.94
+44.60 ± 7.12*
+7.67 ± 5.93
+29.93 ± 5.42*
+E
+8.40 ± 7.37
+44.73 ± 7.16*
+7.40 ± 5.51
+29.10 ± 6.74*
+RLF
+7.73 ± 4.92
+37.23 ± 5.29*
+7.30 ± 6.10
+30.67 ± 5.49*
+LLF
+8.13 ± 4.95
+38.33 ± 5.20*
+6.70 ± 5.93
+30.90 ± 4.99*
+RLR
+8.60 ± 5.83
+45.37 ± 7.58*
+9.07 ± 5.51
+29.87 ± 7.42*
+LLR
+8.77 ± 5.07
+44.13 ± 6.74*
+10.30 ± 6.35
+29.87 ± 7.16*
+NDS
+45.30 ± 21.49
+3.93 ± 5.36*
+43.47 ± 19.82
+13.90 ± 10.03*
+STAI-Y1
+56.80 ± 8.10
+45.83 ± 10.66*
+58.13 ± 9.32
+53.37 ± 5.64
+BPBS
+132.30 ± 12.31
+111.60 ± 9.31*
+134.53 ± 14.29
+127.13 ± 15.28*
+BPBD
+86.50 ± 8.12
+72.93 ± 6.80*
+83.60 ± 16.62
+83.30 ± 8.18
+PB
+75.30 ± 6.59
+67.70 ± 5.54*
+76.23 ± 6.25
+74.13 ± 6.66
+*P < 0.01 for Wilcoxon’s test (within groups)
+back pain by Tekur et al, a short-term intensive residential 
+yoga program was compared with intensive residential 
+physical exercise program.
+The yoga group showed significantly better improvement 
+in pain-related disability and spinal flexibility.[19] There 
+is no study that has used MSRT for chronic pain. One 
+unpublished study at this institution (dissertation for 
+MSc degree of Shetty A., 2006) on the role of MSRT 
+in chronic low back pain showed reduction in back 
+pain, improvement in spine flexibility and decrease 
+in stress on using this relaxation technique. Sripada 
+Swamy and Vasudha in a dissertation for M.Sc., Yoga, 
+on Nādānusandāna have compiled information on the 
+practice of nādānusandhāna, benefits and its application 
+from ancient Indian scriptures as well as from the experts 
+in the field of yoga and spiritual lore.[29]
+A review on the evidence for mind body therapies such 
+as guided relaxation, meditation, imagery and cognitive-
+behavioral therapy in the treatment of pain-related medical 
+conditions concluded that these strategies may be an 
+appropriate adjunctive treatment for chronic neck and low 
+back pain as they offer better stress management techniques, 
+coping skills training and cognitive restructuring.[30]
+As for the mechanism, a research conducted by Linton, to 
+review the psychological risk factors in back and neck pain 
+indicated a clear link between psychological variables with 
+neck and back pain. Results of the prospective studies showed 
+that the psychological variables were related to onset of pain, 
+acute, subacute and chronic pain. Stress, distress or anxiety 
+as well as mood and emotions, cognitive functioning and pain 
+behavior were found to be significant factors.[31]
+As quoted in one study, tension that is associated with 
+stress is stored mainly in the neck muscles, diaphragm and 
+the nervous system. If these areas are relaxed, stress gets 
+reduced, minimizing the impact of stress on the individual. 
+It has also been suggested that the presence of depressive 
+symptoms predicts future musculoskeletal disorders but 
+not vice versa.[19] Stress can cause spasms by interfering 
+with co-ordination of different muscle groups involved in 
+the functioning of the neck.
+Yoga is an ancient Indian science and way of life which 
+includes the practice of specific postures, regulated 
+breathing and meditation.[32] Yoga texts mention that the 
+root cause of many diseases can be traced to lifestyle and 
+amplified likes and dislikes at the mind level .The distressful 
+emotional surges (called aadhi)[33] may percolate into the 
+physical frame manifesting as diseases.[24] Hence, yoga is 
+fast advancing as an effective therapeutic tool in physical, 
+psychological and psychosomatic disorders.[34] In a study 
+by Vempati et al. on healthy adults, the yoga-based guided 
+relaxation was shown to reduce the sympathetic activity as 
+measured by autonomic parameters, oxygen consumption 
+and breath volume.[21] Medical and pre-medical students 
+showed lesser anxiety and stress during an examination 
+period after 8 weeks of meditation.[35] Transcendental 
+meditation (TM) was compared to muscle relaxation in its 
+effectiveness in controlling stress with significantly better 
+reduction in blood pressure in the TM group.
+Brain imaging studies have shown that meditation shifts 
+the brain activity in the prefrontal cortex from the right 
+hemisphere to the left indicating that the brain is re-
+oriented from a stressful fight or flight mode to one of 
+acceptance, a shift that may indicate better contentment.[29]
+Thus, the etiology of CNP being multifactorial, there is 
+sufficient evidence in the literature to demonstrate a 
+requirement to draw treatment options from many sources 
+in order to achieve a favorable pain relief outcome.
+The RCT design demonstrated several methodological 
+strengths: (a) CNP of both the categories, physical 
+(cervical spondylosis) and psychological (muscle spasm) 
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+24
+were included in the study; (b) it used a standardized 
+randomization procedure; (c) there was baseline matching 
+of confounding factors such as age, sex, height, weight 
+and BMI; (d) assessment was multidimensional including 
+both objective and subjective parameters; (e) because 
+the duration of the yoga intervention was short, the 
+acceptability and adherence to the therapy was good; 
+(f) As MSRT was played using a cassette in the therapy 
+sessions, it could be reproduced in the exact way for all 
+cases.
+cOnclusiOn
+This randomized control study has shown that yoga 
+relaxation through MSRT adds significant complimentary 
+benefits to conventional physiotherapy for CNP by 
+reducing pain, disability and state anxiety and improving 
+flexibility.
+limitations of the study
+This was a study from one orthopedic unit in Bengaluru 
+city only. The MSRT technique used involved chanting of 
+Indian mantra which may be unacceptable and difficult 
+for non-Indian community. Follow up of these cases are 
+required for compliance and recurrences.
+suggestions for future Work
+Future studies should be done in other study groups from 
+different orthopedic centers in India and other countries 
+to establish the generalizability. In addition, there is a 
+need for clinical studies to determine whether yoga-based 
+relaxation technique can decrease medication requirement. 
+Basic physiological studies to understand the mechanisms 
+responsible for therapeutic effects of MSRT on CNP may 
+be undertaken.
+implications and recommendations
+An integrative holistic model incorporating psychological 
+and physical therapies for CNP will strengthen the 
+rationalistic approach to treatment of CNP
+. We recommend 
+that this simple procedure of using relaxation during 
+and after the physiotherapy may be incorporated in 
+all conventional therapy units round the globe in the 
+management of CNP
+.
+acknOWledGements
+We thank Dr. Ravi Kulkarni and Dr. Vadiraj for their statistical 
+support in analyzing the data. We also thank Dr. Deshpande S 
+for his active guidance in the making of this dissertation and 
+paper. We thank all the staff members of SVYASA and Ebenezer 
+Orthopedic Center for their co-operation in conducting and 
+funding this study
+abbReviatiOns
+PAS1
+Pain analog scale 
+1st day
+NDS10
+Neck disability score 
+10th day
+PAS10
+Pain analog scale 
+10th day
+STAI1
+State trait anxiety  
+1st day
+TN1
+Tenderness  
+1st day 
+STAI10
+State trait anxiety  
+10th day
+TN10
+Tenderness  
+10th day
+F1
+Flexion 1st day
+BPB1
+Blood pressure 1st day, 
+before intervention
+F10
+Flexion 0th day
+BPB2
+Blood pressure 1st day, 
+during intervention
+E1
+Extension 1st  
+day
+BPB3
+Blood pressure 1st day, 
+after intervention
+E10
+Extension  
+10th day
+BPA1
+Blood pressure 1st day, 
+before intervention
+RLF1
+Right lateral 
+flexion, 1st day
+BPA2
+Blood pressure 1st day, 
+during intervention
+RLF10
+Right lateral 
+flexion, 10th day
+BPA3
+Blood pressure 1st day, 
+after intervention
+LLF1
+Left lateral 
+flexion, 1st day
+LLF10
+Left lateral 
+flexion, 10th day
+PB 1
+Pulse rate 1st day, 
+before intervention
+RLR1
+Right lateral 
+rotation,  
+1st day
+PB 2
+Pulse rate 1st day, 
+during intervention
+RLR10 Right lateral 
+rotation, 
+10th day
+PB3
+Pulse rate 1st day, after 
+intervention
+LLR1
+Left lateral 
+rotation 1st day
+PA1
+Pulse rate 10th day, 
+before intervention
+LLR10
+Left lateral 
+rotation 10th day
+PA2
+Pulse rate 10th day, 
+during intervention
+NDS1
+Neck disability 
+score 1st day
+PA3
+Pulse rate 10th day, 
+after intervention
+RefeRences
+1. 
+Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine 
+(Phila Pa 1976) 1994;19:1307-9.
+2. 
+van der Donk J, Schouten JS, Passchier J, van Romunde LK, Valkenburg 
+HA. The associations of neck pain with radiological abnormalities of the 
+cervical spine and personality traits in a general population. J Rheumatol 
+1991;18:1884-9. 
+3. 
+Horal J. The clinical appearance of low back disorders in the city of 
+Gothenburg, Sweden. Comparisons of incapacitated probands with matched 
+controls. Acta Orthop Scand Suppl 1969;118:42-5.
+4. 
+Hult L. Cervical, dorsal and lumbar spinal syndromes; a field investigation 
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+special reference to disc degeneration and so-called muscular rheumatism. 
+Acta Orthop Scand Suppl 1954;17:175-277.
+5. 
+Hult L. The Munkfors investigation; a study of the frequency and causes 
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+observations on certain signs and symptoms from the dorsal spine and the 
+joints of the extremities in industrial and forest workers. Acta Orthop Scand 
+Suppl 1954;16:12-29.
+6. 
+Côté P, Cassidy JD, Carroll LJ, Kristman V. The annual incidence and course 
+Bali, et al.
+25
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+of neck pain in the general population: A population-based cohort study. 
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+7. 
+Harrison. Back and Neck pain. In: Wilson, Braunwald, Petersdorf, Martin, 
+editors. Harrison’s Principles of Internal Medicine. 22nd ed, Vol. 2. New York: 
+MacGraw-Hill Health Professionals Division; 2003. p. 1991.
+8. 
+Ebnezar J. You and Your Neck Pain. Bangalore: Karnataka Orthopedic 
+Academy (R); 2007. p. 25-34.
+9. 
+Ebnezar J. Textbook of Orthopedics. 3rd ed, New Delhi: Jaypee Brothers 
+Publications; 2006. p. 341-3.
+10. Linton SJ. Spine. Sweden: Orebro Medical centre; 2000.
+11. 
+Iyengar BK. Yoga-The Path to Holistic Health. London, England: Dorling 
+Kindersley; 2001. p. 25. 
+12. Leino P, Magni G. Depressive and distress symptoms as predictors of low 
+back pain, neck-shoulder pain, and other musculoskeletal morbidity: A 10-
+year follow-up of metal industry employees. Pain 1993;53:89-94. 
+13. Ramani PS. Textbook of Cervical spondylosis. 1st ed. New Delhi: Jaypee 
+Brothers Publications; 2005. p. 111.
+14. Moffett J, McLean S. The role of physiotherapy in the management of non-
+specific back pain and neck pain. Rheumatology (Oxford) 2006;45:371-8.
+15. Foley-Nolan D, Moore K, Codd M, Barry C, O’Connor P, Coughlan RJ. Low 
+energy high frequency pulsed electromagnetic therapy for acute whiplash 
+injuries. A double blind randomized controlled study. Scand J Rehabil Med 
+1992;24:51-9.
+16. Goldie I, Landquist A. Evaluation of the effects of different forms of 
+physiotherapy in cervical pain. Scand J Rehabil Med 1970;2:117-21.
+17. Pennie BH, Agambar LJ. Whiplash injuries. A trial of early management. J 
+Bone Joint Surg Br 1990;72:277-9.
+18. Loy TT. Treatment of cervical spondylosis: Electroacupuncture versus 
+physiotherapy. Med J Aust 1983;2:32-4.
+19. Tekur P, Singphow C, Nagendra 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 Complement 
+Med 2008;14:637-44.
+20. Michaels RR, Huber MJ, McCann DS. Evaluation of transcendental 
+meditation as a method of reducing stress. Science 1976;192:1242-4. 
+21. Vempati RP, Telles S. Yoga-based guided relaxation reduces sympathetic 
+activity judged from baseline levels. Psychol Rep 2002;90:487-94.
+22. Galantino ML, Bzdewka TM, Eissler-Russo JL, Holbrook ML, Mogck EP, 
+Geigle P, et al. The impact of modified Hatha yoga on chronic low back pain: 
+A pilot study. Altern Ther Health Med 2004;10:56-9.
+23. Anuprita S. Complementary effect of MSRT as add on program in patients 
+undergoing Traction and Interferential therapy for chronic low back pain. 
+Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, Karnataka: 
+2007.
+24. Pollard CA. Preliminary validity study of the pain disability index. Percept 
+Mot Skills 1984;59:974.
+25. Swash M, Glynn M. Hutchinson clinical manual, 22nd ed. London: Elsevier 
+Publications; 2005.
+26. Vernon H, Mior S. The Neck Disability Index: A study of reliability and 
+validity. J Manipulative Physiol Ther 1991;14:409-15.
+27. Nagendra HR. Mind sound resonance technique. Bangalore: Swami 
+Vivekananda Yoga Prakashana; 2001. p. 51.
+28. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic 
+pain patients based on the practice of mindfulness meditation: Theoretical 
+considerations and preliminary results. Gen Hosp Psychiatry 1982;4:33-47.
+29. Sripada Swamy DS, Vasudha MS dissertation for M.Sc., Yoga; on 
+Nādānusandāna. Swami Vivekananda Yoga Anusandhana Samsthana, 
+Bangalore, Karnataka: 2006.
+30. Wolsko PM, Eisenberg DM, Davis RB, Phillips RS. Use of mind-body medical 
+therapies. J Gen Intern Med 2004;19:43-50.
+31. Taimini IK. The science of yoga. Madras: The Theosophical Publishing 
+House; 1961. p. 7.
+32. Nagarathna R. Yoga Health and disease. Kaohsiung J Med Sci 1999;2:96-104.
+33. Nagarathna R, Nagendra HR. Therapeutic applications of yoga, a report. J 
+Exp Med 1,9.
+34. Bonadonna R. Meditation’s Impact on Chronic Illness. Holist Nurs Pract 
+2003;17:309-19.
+35. Sorgeon C. Treating Hypertension ‘Naturally’. Web MD Health April 2, 2002.
+MSRT in CNP
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subfolder_0/Decoding the integrated approach to Yoga therapy.txt

@@ -0,0 +1,201 @@
+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
+166
+A number of studies conducted in India  have shown that 
+yoga practice improves weight, blood pressure, insulin, 
+triglycerides,[3] blood pressure,[4,5] FBS and PPBS levels,[6,7] 
+pulse rate.[5] In most of the above studies the period of 
+yoga intervention was anywhere between 40  days to 
+a maximum of 90 days to observe the desired effects. 
+The yoga intervention also differed from Hatha yoga to 
+Yoga nidra. The fact that in our study we have observed 
+changes in all outcome variables after 2 weeks of in‑patient 
+stay shows that the IAYT is effective in the treatment of 
+diabetes ‑ where all the components of the IAYT model are 
+integrated and provided to have a desired effect on each of 
+the five levels of existence in a controlled and monitored 
+environment ‑ asanas and pranayama comprise only a 
+minuscule part of the entire program. In this context, in 
+most of the above research studies, yoga was possibly 
+equivalent to “asana, pranayama and/or meditation 
+practice.” Hardly any studies mentioned controlling for 
+extraneous factors which could have status played an 
+integral role in the effectiveness of the program (diet, stress 
+and medication compliance).
+The challenge would be to replicate this holistic 
+model of IAYT for diabetes actively in community and 
+out‑patient settings, as it would require controlling for 
+medication compliance, adherence to yoga and stress 
+in a nonresidential set‑up. A  three‑arm randomized 
+controlled study with:  (1) In‑patient IAYT model, 
+(2) out‑patient IAYT model and (3) control group could 
+be an important and interesting step in understanding 
+the factors determining effectiveness and replicability of 
+the IAYT model in the Indian community setting, which 
+in turn would help reduce the overall burden of diabetes 
+in Indian community.
+Aarti Jagannathan, Yuman Bishenchandra
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga 
+Anusandhana Samasthana, Bengaluru, Karnataka, India
+Sir,
+In continuation to the article published in your esteemed 
+journal titled, “Decoding the integrated approach to 
+yoga therapy: Qualitative evidence based conceptual 
+framework” by Villacres et al.,[1] we would like to add 
+supportive quantitative data to understand and explain 
+the mechanism of the integrated approach to yoga 
+therapy (IAYT) model developed by Swami Vivekananda 
+Yoga Anusandhana Samasthana (SVYASA),[2] based on 
+the Pancha Kosa concept. As mentioned by Villacres 
+et al.,[1] the IAYT can be understood as a holistic model, 
+which corrects the imbalances at physical, mental 
+and emotional levels through application of multiple 
+components such as asanas, diet, loosening exercise, 
+breathing exercises, pranayama, cyclic medication, mind 
+sound resonance technique, devotional sessions and yogic 
+counselling (lectures). Rightly as the author put it, “no 
+component singularly can claim to be the IAYT, nor could 
+possibly have the same effects as the whole model,”[1]
+A look at retrospective quantitative data of 560 patients 
+with diabetes (who presented to primary treatment 
+center – Arogyadhama, Prashanti, SVYASA, Jigani between 
+2008 and 2010) who underwent the IAYT helps us 
+further understand the workings of this model. The 
+patients stayed for a minimum of 6 days to a maximum of 
+15 days (mean [standard deviation] duration of in‑patient 
+stay: 12.38  [6.10] days), during which the IAYT for 
+diabetes was imparted to them. The four important factors 
+that could affect their diabetes status:  (1) Medication 
+compliance, (2) diet, (3), stress and (4) adherence to yoga, 
+were monitored and controlled. Medication compliance 
+and adherence to yoga was controlled by the medical 
+doctor and yoga therapist in‑charge in the section; diet was 
+controlled as standard saatvik food is usually provided at 
+Prashanti, SVYASA to all patients admitted; the ambience 
+of Prashanti campus (away from city life, silence and 
+amidst nature) could be considered as a calming factor 
+to combat stress. Assessment and analysis of diabetes 
+related parameters in the above mentioned controlled 
+environment showed that though the baseline values of 
+all variables were not normally distributed (P < 0.01), 
+nonparametric test analysis of pair wise time effect using 
+the Wilcoxon signed ranks test showed a significant 
+improvement in respiratory rate, pulse rate, systolic 
+blood pressure, diastolic blood pressure, weight, breath 
+holding rate, fasting blood sugar (FBS), and postprandial 
+blood sugar  (PPBS) from before yoga to after yoga 
+practice [P < 0.001, Table 1].
+Decoding the integrated approach to yoga therapy
+Table  1: Wilcoxon signed rank test
+Variable rate (before 
+yoga-after yoga)
+Median (range)
+Z
+p value
+Before yoga
+After yoga
+Respiratory rate
+20.00 (24)
+17.00 (18)
+−12.089 <0.001 
+Pulse rate
+80.00 (62)
+78.00 (80)
+−8.449
+<0.001 
+Systolic blood pressure 128.00 (143) 126.00 (106)
+−6.220
+<0.001 
+Diastolic blood 
+pressure
+80.00 (100)
+78.00 (80)
+−5.844
+<0.001 
+Breath holding time
+12.00 (20)
+14.00 (30)
+−14.118 <0.001 
+Weight
+68.04 (87)
+67.00 (82)
+−14.563 <0.001 
+FBS
+120.50 (251) 109.00 (362)
+−8.239
+<0.001 
+PPBS
+201.00 (506) 185.00 (455)
+−6.242
+<0.001 
+FBS = Fasting blood sugar; PPBS = Postprandial blood sugar
+Letter to Editor
+Letter to Editor
+167
+International Journal of Yoga • Vol. 7 • Jul-Dec-2014
+Address for correspondence: 
+Dr. Aarti Jagannathan, 
+Division of Yoga and Life Sciences, 
+Swami Vivekananda Yoga Anusandhana Samasthana, 
+19, Gavipuuram, KG Nagar, Bengaluru ‑ 560 019, 
+Karnataka, India. 
+E‑mail: [email protected]
+REFERENCES
+1.	
+Villacres MC, Jagannathan A, Nagarathna R, Ramakrsihna J. Decoding the 
+integrated approach to yoga therapy: Qualitative evidence based conceptual 
+framework. Int J Yoga 2014;7:22‑31.
+2.	
+Nagarathna R, Nagendra HR. Integrated Approach of Yoga Therapy for 
+Positive Health. Bangalore: Swami Vivekanand Yoga Prakashana; 2004.
+3.	
+Yang L, Brozovic S, Xu J, Long Y, Kralik PM, Waigel S, et al. Inflammatory 
+gene expression in OVE26 diabetic kidney during the development of 
+nephropathy. Nephron Exp Nephrol 2011;119:e8‑20.
+4.	
+Cohen RM, Smith EP. Frequency of HbA1c discordance in estimating blood 
+glucose control. Curr Opin Clin Nutr Metab Care 2008;11:512‑7.
+5.	
+Kerr D, Gillam E, Ryder J, Trowbridge S, Cavan D, Thomas P. An eastern 
+art form for a western disease: Randomised controlled trial of yoga in 
+patients with poorly controlled insulintreated diabetes. Pract Diabetes Int 
+2002;19:164‑6.
+6.	
+Amita S, Prabhakar S, Manoj I, Harminder S, Pavan T. Effect of yoga‑nidra 
+on blood glucose level in diabetic patients. Indian J Physiol Pharmacol 
+2009;53:97‑101.
+7.	
+Singh S, Malhotra V, Singh  KP, Sharma  SB, Madhu  SV, Tandon OP. 
+A  preliminary report on the role of yoga asanas on oxidative stress 
+in non‑insulin dependent diabetes mellitus. Indian J Clin Biochem 
+2001;16:216‑20.
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.133935

subfolder_0/Development and Testing of an Audio-Visual Self-Help Yoga Manual for Indian Caregivers of Persons with Schizophrenia Living in the Community_ A Single-Blind Randomized Controlled Trial.txt

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+Int J Yoga. 2020 Jan-Apr; 13(1): 62–69.
+doi: 10.4103/ijoy.IJOY_70_18
+PMCID: PMC6937882
+PMID: 32030023
+Development and Testing of an Audio-Visual Self-Help Yoga Manual for Indian Caregivers of
+Persons with Schizophrenia Living in the Community: A Single-Blind Randomized Controlled Trial
+Ameer Hamza, Aarti Jagannathan, Sudarshan Hegde, Naresh Katla, Shree Raksha U Bhide,  Jagadisha Thirthallli,  Shivarama Varambally,  and
+HR Nagendra
+Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
+Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
+Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Aarti Jagannathan, Department of Psychiatric Social Work, Room No: 106, Govindaswamy Building, 1  Floor,
+National Institute of Mental Health and Neurosciences, Hombegowda Nagar, Hosur Road, Bengaluru, Karnataka, India. E-mail: [email protected]
+Received 2018 Sep 29; Revised 2019 May 3; Accepted 2019 Jun 6.
+Copyright : © 2019 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:
+To test the feasibility and effectiveness of an audio-visual self-help audio-visual yoga manual on burden of Indian caregivers of persons with
+schizophrenia, living in the community.
+Methods:
+1
+1
+1
+2
+1
+2
+st
+An earlier developed yoga program for caregivers of schizophrenia was remodeled into an audio-visual self-help manual in three languages
+and validated by mental health and yoga experts. 48 consenting primary family caregivers of outpatients with schizophrenia were screened,
+recruited, and allotted randomly to Yoga or Care as Usual Group. Participants in Yoga group were taught yoga from the self-help manual (1
+session of 1 h every month for 5 months). The caregivers were asked to follow the manual for the remaining month at home. Assessments of
+burden, perceived stress, quality of life, and anxiety-depression were conducted by a rater blind to the group status at baseline and at the end
+of every month.
+Results:
+Post factoring for missing data, Repeatedmeasure ANOVA was conducted; which showed that there was no significant difference between
+the group that practiced the selfhelp yoga manual and the care as usual group. The caregivers who practiced yoga at home maintained an
+average of 50% attendance and “very well” level of yoga performance.
+Conclusion:
+The audio-visual self-help yoga manual was found to be feasible to use by the caregivers even though its effectiveness could not be
+ascertained due to high attrition.
+Keywords: Caregivers burden, feasibility testing, self-help yoga manual
+Introduction
+In India, majority of the family caregivers take on the burden of caring for their relative with schizophrenia at their home in the community.
+Due to the stressful demands of caring, they often experience significant burden[1] and sometimes border close to clinical depression. Yoga
+has been found to be effective in the management of stress.[2] Further yoga, which originated in India, is seen to be a more practical
+intervention for caregivers to practice in the community.
+Jagannathan et al.,[3] in a randomized controlled study provided caregivers of in-patients with schizophrenia yoga intervention. It was
+noticed that irrespective of the intervention, with reduction in patient symptoms, the burden of the caregivers also reduced. Further, the yoga
+intervention given was provided only for a period of 7 days, which experts in the field of yoga believed to be insufficient. Varambally et al.
+[4] in another controlled study found that caregivers of outpatients with psychosis were able to learn and retain yoga practices for a period
+of 1 month, leading to reduced burden and improved quality of life. However, a large proportion of caregivers were unable to enroll and
+adhere to the study protocol due to inability to attend yoga sessions at centers far away from their community.
+Based on the results of the above two studies, the current study was designed, with the aim of testing the feasibility of a self-help audio-
+visual yoga manual on burden of Indian caregivers of persons with schizophrenia, living in the community. The researchers believe that this
+self-help audio-visual yoga manual would be a novel and viable option to encourage caregivers to adopt yoga at their homes in the
+community.
+Methods
+This study was funded by the Indian Council of Medical Research, New Delhi, India. It was reviewed and approved by the Institute Ethics
+Committee, at National Institute of Mental Health and Neurosciences, Bengaluru. Written informed consent was obtained from the mental
+health professionals and yoga therapist who helped in the remodeling of the self-help manual and family caregivers who participated in the
+feasibility study.
+The research was conducted in three phases. In Phase I, the earlier developed and validated yoga program for caregivers of schizophrenia[5]
+was remodeled into a self-help written manual with an audio-visual digital versatile disc (DVD). In Phase II, this redeveloped and validated
+self-help manual was tested for its feasibility on five caregivers of outpatients with schizophrenia. In Phase III, the self-help yoga manual
+was tested for its effectiveness on burden of Indian caregivers of persons with schizophrenia, living in the community.
+Phase 1 – Redevelopment and validation of self-help manual
+The earlier developed and validated yoga program for caregivers of schizophrenia[5] was successfully remodeled into a self-help manual
+and DVD and validated (Face and content). The job of developing the self-help yoga manual and DVD was outsourced to a private vendor
+outside the institute. The videoshooting for the DVD took place at S-VYASA campus. S-VYASA provided technical expertise as well as a
+trained yoga therapist as a model for the whole shooting. The entire process, i.e., video and photo shoot of the yoga procedures and editing
+of the video was monitored and supervised by (Co-I) and his team from S-VYASA. Parallel to video shooting, the manual was developed as
+a self-help format and translated into Kannada and Hindi Languages by respective language translators. Both the language translations
+content were edited and validated by the yoga experts (n = 7). Once the video editing and content of the manual in all three languages were
+finalized and validated by the experts, the voice over to the video was initiated using the content of respective language's manual. The final
+draft of the video with voice over and manual in all three languages was presented to all coinvestigators of the study as well as to the experts
+from S-VYASA for their feedback. After 2–3 iterations, the manual and DVD was approved. The final manual and DVD was in English,
+Kannada, and Hindi languages, with an aim to help reach out to a large section of caregivers living in rural/semi-urban/urban India.
+Phase 2 – Feasibility Testing of the manual
+Primary caregivers of outpatients diagnosed with schizophrenia (according to ICD 10, F20, F25, and F29) with a minimum of 3 months
+duration of illness, with a Clinical Global Inventory–Severity Scale[6] score of 4 and below, between 18 and 60 years of age, who continued
+to care for the patient even after discharge from the hospital, who were willing to participate weekly once in a yoga training for a period of 1
+month, who knew Kannada, English, or Hindi languages and were ready to provide consent to participate in the study were recruited.
+Participants were excluded if the caregivers were diagnosed with severe psychiatric or neurological disorders. Caregivers also were
+excluded if they had another relative with psychiatric or neurological illness and/or if their patient relapsed with psychiatric symptoms
+during the course of the study. Caregivers who have undergone formal yoga training (certificate course from a recognized institute) and who
+were practicing yoga regularly for the past 1 month or who had undergone yoga training program from SVYASA University were not
+included in the study.
+This redeveloped and validated self-help manual was tested for its feasibility on five caregivers of outpatients with schizophrenia for the
+period of 1 month. The five caregivers were taught the yoga practices by a trained yoga therapist, from the self-help manual in three parts (1
+session of 1 h every week for 3 weeks) during their weekly follow-up visits followed by the fourth session inclusive of all three parts as a
+concluding session. The caregivers were asked to follow the manual and practice the exercises taught to them for the remaining days till the
+next follow-up date. The yoga therapist maintained a log of the caregiver's practice schedule and attendance at home to check their
+adherence. The yoga instructor also recorded the performance of caregivers at each follow-up visit.
+At every weekly follow-up Burden, (Burden Assessment Schedule),[7,8,9,10,11,12,13,14,15,16,17] Quality of Life (WHO Quality of Life–
+Brief Questionnaire),[7] Stress using (Perceived Stress Scale [PSS])[8] and Anxiety and depression (Hospital Anxiety and Depression Scale
+[HADS])[9] was assessed. All the assessment tools were administered by a Research Scientist 1 (RS1) in the local language (Kannada or
+Hindi) for the benefit of clients who spoke and understood only the vernacular language. A feedback form to assess the Program, Handouts
+(Yoga Manual and Video), and Trainer (a mix of qualitative and quantitative data) was taken during the time the first, second, and third
+assessments were conducted.
+Data were analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY:
+IBM Corp). The sociodemographic data were analyzed using descriptive statistics, the results were analyzed using nonparametric statistics
+(Friedman's Chi-square test) and the qualitative feedback was content analyzed.
+Phase 3 –- Testing for effectiveness
+To test the effectiveness of the self-help yoga manual, a directional hypothesis was adopted: (H1): Self-help yoga manual (Y) independently
+enables caregivers of outpatients with schizophrenia to reduce burden of caregiving than caregivers who are not provided any yoga manual
+(Care as Usual; CAU) (YT > CAU).
+To achieve a target sample of 60 (30 in each group: Yoga Therapy – YT and Care As Usual – CAU), a sample of 1040 participants were
+screened with predefined inclusion and exclusion criteria, as mentioned in Phase 2. The caregivers who met the inclusion and exclusion
+criteria were screened using the Self-Reporting Questionnaire[10] and whoever scored 8 and below (having no mental health problems)
+were offered to participate in the study. The CONSORT diagram detailing the process of screening is given in Figure 1
+Open in a separate window
+Figure 1
+Consort diagram depicting the detailed process of screening
+This study used a two-group single-blind, randomized control design. RS1 explained the content of the consent and study process to the
+participants, including the randomization process. Whoever accepted and agreed to participate in the study by signing the written consent,
+were recruited into the study and their sociodemographic details were procured along with baseline assessments by RS1, who was blind to
+the randomization status. To maintain rater blinding, assessment was conducted by RS1 and group allocation status was managed by
+Research Staff 2 (RS2) (yoga therapist), and this was done in two separate places. The randomization was made in opaque sealed envelopes
+by the principal investigator and managed by RS2. Once the baseline assessments were completed, the participants were sent to yoga center
+to meet RS2 for the randomized allotment. For each patient, RS2 opened one opaque-sealed envelope having the group allocation. He was
+thus unaware of the group status of the next recruited patient (allocation concealment). RS2 would tear the group allocation envelope in
+front of the participant and let them know in which group they were allotted, i.e., YT or CAU.
+Participants who were allotted to Yoga group (YT) were taught the yoga exercises from the self-help manual in three parts (1 session of 1 h
+every month for 3 months) during their monthly follow-up visits. The manual contained step-wise details of the yoga asanas/pranayama
+along with pictures for ease of practice. Further, a DVD of the yoga practices was attached to the written manual to help the caregivers to
+follow the practices through audio-visual medium. The caregivers were asked to follow the manual and practice the exercises taught to them
+for the remaining month till the next follow-up date.
+Participants who were allotted to waitlist control group (CAU) did not receive yoga training. Instead, they were available for assessments
+for the 5-month period and were called for follow-up to the outpatient Department once in a month. Normal consultation time spent with the
+caregiver/patient at the initial contact was 3 h. The caregivers in this group (CAU) were however taught the yoga exercises from the self-
+help manual in three parts (1 session of 1 h every month for three months) during their monthly follow-up visits only postcompletion of the
+data collection timelines (after completion of their day 150 assessments).
+At every monthly follow-up, Burden, (Burden Assessment Schedule),[6] Quality of Life (WHO Quality of Life–Brief Questionnaire),[7]
+Stress using (PSS),[8] and Anxiety and depression (HADS)[9] along with yoga performance was assessed.
+Data were analyzed using the Statistical Package for the Social Sciences (SPSS, Version: IBM-SPSS 24). The socio-demographic data were
+analyzed using descriptive statistics, and the results were analyzed using parametric statistics (Repeatedmeasure ANOVA [RMANOVA]) as
+the data was normally distributed. Missing data analysis was also conducted.
+Results
+Phase I
+Theme 1: What caregivers I valued in the program
+Theme 2: Suggestions to improve the programme
+Theme 3: Caregiver's overall experience of the programme
+The manual contained step-wise details of the yoga asanas/pranayama along with pictures for ease of practice. The audio-visual format of
+the yoga practices was added to the written manual to help the caregivers to follow the practices through audio-visual medium. The entire
+yoga program consisted of Yoga practices and Satsang (Philosophy of Yoga) which was broken down into three parts (The final manual is
+can be obtained from the authors on request).
+Phase II
+Five caregivers gave their consent for the feasibility study and all of them completed the 4 weeks follow-up assessments except the 5
+person who missed the last follow-up. Although all the outcome variables were normally distributed at baseline, as the sample size was
+small (n = 5), nonparametric tests were used to analyze the data. The results of Friedman Chi-square test across the timelines showed
+significant improvement in burden and stress scores of the caregivers over the period of 4 weeks. All the caregivers were able to follow-up
+the instructions given and practices taught by the yoga therapist and were practicing the same in their houses regularly, i.e., average of 20
+days in a given month.
+The caregivers provided feedback that the overall pace and length of program was neutral to excellent with scores ranging from 3 to 5. With
+respect to usefulness and ease of understanding the video and manual, rating ranged between Excellent and Good, with scores of 4–5.
+Overall rating of trainer was Good–Excellent with scores ranging between 4 and 5. The qualitative feedback supported the quantitative
+Likert ratings and could be divided into three broad themes with supporting quotes of the caregivers:
+”It is short, easy to learn and good” (C1, 26 years, female)
+Suryanamaskara and other exercises were good” (C4, 27 years, female)
+”I liked the way the yoga teacher taught and explained the details of the practices” (C5, 42 years, female).
+”The contact sessions can be conducted at different locations in Bangalore if possible” (C1, 26 years, female)
+”Group session rather individual would be better” (C3, 20 years, male)
+”Want little more information of the practices if possible” (C4, 27 years, female).
+It is a very good initiative with easy and effective yoga techniques (C1, 26 years, female)
+”It helped relieve stress and tension and made me feel healthy to take care of my patient” (C2, 55 male)
+th
+”I felt calm–peace of mind and had relief” (C3, 20 years, male)
+”This programme is very good. It totally relaxed me gave me more peace of mind” (C5, 42 years, female).
+Phase III
+A total of 48 samples were recruited into the study, i.e., 23 in yoga group and 25 in care as usual (control) group. There were different
+strategies used, to track, contact. and inform recruited caregivers to come for regular follow-ups. Even after regular follow-up calls, sending
+postal reminders, checking the recruited caregiver's patient file once in month at medical record section, the follow-up rates were poor [
+Figure 1]. The sociodemographic details of the caregivers in Yoga and CAU group are detailed in Table 1.
+Table 1
+Sociodemographic details of the caregivers in yoga and care as usual
+Open in a separate window
+SD=Standard deviation
+Variable
+Mean (SD)*/n (%)
+Yoga (n=23)
+Care as usual (n=25)
+Age of caregiver (years)*
+39.96 (10.45)
+36.24 (12.89)
+Education (years)*
+9.95 (4.97)
+10.92 (4.63)
+Monthly income (rupees)*
+12,934.78 (12,299.57)
+20,283.96 (24,879.53)
+Distance from host institution (km)*
+62.304 (85.93)
+39.44 (34.09)
+Change of transport (number of times)*
+1.52 (0.89)
+1.2 (1.00)
+Number of family members*
+4.52 (1.62)
+4.48 (1.93)
+Caregiver gender
+ Male
+17 (73.9)
+17 (68)
+ Female
+6 (26.1)
+8 (32)
+Caregiver religion
+ Hindu
+22 (95.7)
+23 (92)
+ Others
+1 (4.3)
+2 (8)
+Caregiver occupation
+ Employed
+18 (78.3)
+17 (68)
+ Unemployed
+5 (21.7)
+8 (32)
+Caregiver marital status
+ Never married
+4 (17.4)
+9 (36)
+ Ever married
+19 (82.6)
+16 (64)
+Region
+Shapiro–Wilk normality test was conducted for both the group's, for all the four variables at baseline. Burden Assessment Scale, PSS, and
+WHO-QOL-Brief were normally distributed, whereas the data of the HADS were not normally distributed. There were no baseline
+differences between the groups across all the outcome variables.
+Due to high rates of dropouts over the study timelines, it was decided to do missing data analysis, where the mean scores of the latest
+follow-up that the client attended was considered as the data for the subsequent follow-ups that he/she missed. Using this method of missing
+data analysis, further statistical analysis was conducted.
+RMANOVA, a parametric test to find the interaction effect over the period of 6 months, was performed for BAS, WHO-QOL-Brief, and
+PSS. From Table 2, it can be observed that there is no significant difference between those who practiced the self-help yoga manual and
+those who received care as usual in either of the outcome variables. To understand the effect of the intervention in the two groups on HADS
+(data not normally distributed) over a period of time, Friedman Chi-square, a nonparametric test was performed. From Table 3, it can be
+observed that there is no significant difference in the outcome of HADS between those who were doing yoga and those who got care as
+usual, indicating that both the interventions had an equal effect.
+Table 2
+Effect of intervention over period of 6 months (interaction effect – repeated measure ANOVA)
+Assessments
+Mean (SD)
+F3
+P
+Yoga (n=23)
+Care as usual (n=25)
+Baseline
+1  F/U
+2
+ F/U
+3
+ F/U
+4
+ F/U
+5
+ F/U
+Baseline
+1  F/U
+2
+ F/U
+3
+ F/U
+4
+ F/U
+5
+ F/U
+BAS
+64.43
+(13.65)
+63.21
+(13.79)
+64.34
+(13.43)
+63.86
+(13.55)
+63.30
+(13.83)
+62.95
+(14.55)
+60.68
+(12.28)
+58.72
+(12.37)
+58.36
+(12.17)
+57.08
+(12.28)
+56.56
+(12.43)
+57.28
+(13.31)
+0.34
+0.88
+WHO-QOL
+- Brief
+88.52
+(8.96)
+88.47
+(9.43)
+88.21
+(9.74)
+88.65
+(8.51)
+88.82
+(8.44)
+89.04
+(8.45)
+89.36
+(9.34)
+91.12
+(9.67)
+90.92
+(8.53)
+91.4
+(9.12)
+88.96
+(14.09)
+91.4
+(14.06)
+1.57
+0.15
+PSS
+17.26
+(5.37)
+17.56
+(5.40)
+17.09
+(4.81)
+16.52
+(5.70)
+17.04
+(5.50)
+17.17
+(5.12)
+17.44
+(2.86)
+16.80
+(5.09)
+17.64
+(3.90)
+17.64
+(3.710)
+17.80
+(3.42)
+16.88
+(4.31)
+1.03
+0.11
+Open in a separate window
+F3=F value indicating interaction effect in RMANOVA. RMANOVA=Repeated-measure ANOVA, SD=Standard deviation, F/U=Follow-up, BAS=Burden
+Assessment Scale, QOL=Quality of life, PSS=Perceived Stress Scale
+st
+nd
+rd
+th
+th
+st
+nd
+rd
+th
+th
+Table 3
+Effect of intervention over a period of 6 months (time effect – Friedman Chi-square)
+HADS assessment
+Mean (SD)
+Friedman χ
+P
+Baseline
+1  F/U
+2
+ F/U
+3
+ F/U
+4
+ F/U
+5
+ F/U
+Yoga (n=23)
+7.86 (6.69)
+8.34 (7.02)
+8.56 (6.90)
+7.08 (6.94)
+7.04 (6.85)
+7.00 (6.88)
+8.531
+0.129
+Care as usual (n=25)
+5.56 (5.40)
+5.56 (6.22)
+5.96 (6.30)
+6.4 (6.64)
+4.96 (5.23)
+3.8 (4.15)
+3.816
+0.576
+SD=Standard deviation, HADS=Hospital Anxiety and Depression Scale, F/U=Follow-up
+Analysis of the yoga attendance at home out of 30 days ranged between 14 days of practice to 16 days of practice (approximately half the
+number of days of yoga practice). Yoga performance of the caregivers as rated by the yoga therapist when they attended the yoga session at
+the Yoga Centre showed that out of a total score of 32 (8 domains with minimum score of 1 and maximum score of 4), the average
+performance score of the caregivers ranged from 23 to 26, which was considered as performed “very well.” Further analysis showed no
+significant correlations between yoga attendance and any of the outcome variables or yoga performance and any of the outcome variables
+possibly due to low number of sample at every follow-up.
+Discussion
+The goal of the study was to help reduce the burden and stress of the caregivers of persons with schizophrenia by training them to self-
+practice yoga in their homes. This was done essentially to help reach yoga to the community and for reducing the logistic barriers to
+attending and practicing yoga in a tertiary care center.[11] The qualitative and quantitative results of the feasibility testing phase of the study
+depict that the audio-visual self-help yoga manual for Indian caregivers of persons with schizophrenia is feasible to practice, helps reduce
+stress and burden of the caregivers (objectively and subjectively), and can be tested for its efficacy in the future.
+2
+st
+nd
+rd
+th
+th
+The effectiveness of the self-help manual could not be established as no significant difference was observed between those who practiced
+the self-help yoga manual and those who received care as usual in any of the outcome variables. These results need to be interpreted in the
+background of poor follow-rates (high attrition) which was as low as 35% at the end of 1 -month follow-up and which dropped further to
+14% follow rate. The reasons for dropout (barriers to yoga) as expressed by the caregivers included loss of work day, long distance of travel
+from their homes, no alternative caregiver to take care of patient, patient getting symptomatically better, and hence caregivers not
+experiencing burden nor feeling the need for yoga. Most yoga studies depict a yoga adherence rate of 50%[12] in a community setting. As
+there was hardly any data to analyze at the end of the 6 -month follow-up, it would be false to interpret that the self-help manual was not
+more effective than the care as usual group. Both the Pilot Phase and the main study results depicted significant reduction in burden and
+stress scores at the end of 1 month in those who practiced the self-help manual for the period of the 1 month. If attrition rates in yoga studies
+can be controlled, the true effectiveness of yoga intervention could be depicted.
+Caregivers seemed to be more motivated to attend sessions in the feasibility phase, once week sessions, as compared to the Main study
+phase, sessions conducted once a month. Thus, a more regular follow-up may be required to maintain follow-rates and adherence to yoga.
+Even if our study with a longer training period (of 5 months) had shown effectiveness, its wider application in routine clinical practice
+would have been a daunting task as only a minuscule proportion of caregivers were able to go through longer periods of training. There are
+many barriers to convince people to travel long distances from their homes to a center for yoga therapy[11] once they are discharged. In this
+context, we believe that possible the yoga training programs should be developed for not more than a period of 1 month to help reduce
+attrition rates. Traditional yoga therapists may argue that a 1 month program could be too short to perceive any effects of yoga.
+Studies have time and again discussed the importance of the length of yoga practice[13,14,15,16] to observe desirable effects. Caregivers
+who reported that they had practiced yoga, did they practice yogasana at home as well as they did under supervision? This is indeed a
+genuine concern. Given the long duration of illness, there could well be certain degree of cynicism and lack of interest in the caregivers. The
+seriousness with which they would have adhered to any interventions is doubtful. This observation in vindicated by the fact that <50% of
+the caregivers in the yoga group reported practicing yoga daily.
+Scales used may not have been sensitive in tapping the efficacy of the interventions. The burden scales provide a total burden score which
+encompasses all components of burden including financial, occupation, family routine, family leisure, family interaction, social relations,
+and emotional–physical–mental health. Yoga therapy may not necessarily have a bearing on all these components of burden and stress.
+Although we realized this limitation in the beginning of this study itself, we still decided to use these scales because: (1) they were widely
+used scales which had no good alternatives and (2) they were clinically meaningful outcomes and we had hypothesized that the
+interventions would ultimately lead to a reduction in burden through different methodologies (e.g.,: through developing a sense of
+equanimity by practicing yoga; understanding patient behavior using the skills taught in the psychosocial program). Thus, instead of
+discounting the effectiveness of the program, any negative result could be viewed as a possible inability of the structured instruments to tap
+the effectiveness of the program in reducing the burden of the caregivers.
+st
+th
+Expectation of the caregivers was to “cure the patient.” Hence, caregivers found it difficult to relate their participation in the yoga
+intervention. Further as most of the caregivers did not consider the caretaking process to be burdensome or stressful (they considered it as
+their family responsibility), interventions could have been effective for those caregivers who expressed a felt need for these interventions.
+Resilience of Indian caregivers could be higher than reported in the Western studies. A reason for this is the strong family system present in
+the country which helps the patient and caregivers cope with the illness effectively. By providing interventions to all caregivers, we may be
+falsely assuming that they all equally burdened by the caretaking process and have poor resilience.
+This is one of the first studies in India to have systematically tested the feasibility and effectiveness of audio-visual self-help yoga manual
+for Indian caregivers of persons with schizophrenia. The self-help yoga manual developed in this study was observed to be feasible to use
+by the caregivers qualitatively and quantitatively in reduction of their burden. This manual can thus be provided to caregivers of persons
+with schizophrenia in the community and can also act as a guide for mental health professionals and yoga therapists in the future. The
+effectiveness of this manual however could not be conclusive arrived at, due to the poor follow rates (high attrition). In this background, it
+would be false to interpret that the self-help manual was not more effective than the Care as usual group, as in the Feasibility Phase, time
+effect results depicted significant reduction in burden and stress scores at the end of 1 month in those who practiced the self-help manual for
+the period of the 1 month. If attrition rates in yoga studies can be controlled, the true effectiveness of yoga intervention could be depicted. In
+this context, we believe that future yoga research should provide yoga training for not more than a period of 1 month to help reduce attrition
+rates. Also as attrition was mainly because of the inability of caregivers to travel to a tertiary care center for yoga training, testing the
+feasibility and effectiveness of virtual yoga sessions should be the next research questions that should be addressed by yoga researchers.
+Conclusion
+The self-help audio-visual yoga manual was found to be feasible to use by the caregivers even though its effectiveness could not be
+ascertained due to high attrition.
+Financial support and sponsorship
+This study was finally supported by the Indian Council of Medical Research has funded for this research project.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgments
+The authors would like to thank the Indian Council of Medical Research, New Delhi, for funding this project.
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+Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow Publications

subfolder_0/Development and Validation of a Need-Based Integrated yoga program for cancer patients_unlocked.txt

@@ -0,0 +1,1712 @@
+Journal of Stem Cells 
+ 
+ISSN: 1556-8539 
+Volume 7, Number 4 
+ 
+© Nova Science Publishers, Inc. 
+ 
+ 
+ 
+ 
+Development and Validation of a Need-Based Integrated 
+Yoga Program for Cancer Patients: A Retrospective Study 
+ 
+ 
+ 
+Amritanshu Ram1,  
+Nagarathna Raghuram1**,  
+Raghavendra M. Rao 2,  
+Hemant Bhargav1, Prasad S. Koka1,3,4,5, 
+Satyam Tripathi1,  
+Raghuram V. Nelamangala 1,  
+Gopinath S. Kodaganur6,  
+and Nagendra Hongasandra Ramarao1 
+1Swami Vivekananda Yoga Anusandhana Samsthana 
+(S-VYASA) University, Kempegowda Nagar, 
+Bangalore, Karnataka, India 
+2Health Care Global (HCG), Bangalore, India 
+3Department of Biological Sciences, Poornaprajna 
+Institute of Scientific Research, Sadashivnagar, 
+Bangalore, India 
+4Laboratory of Stem Cell Biology, Torrey Pines Institute 
+for Molecular Studies, General Atomics Court, San 
+Diego, California, USA 
+5Haffkine Institute for Training, Research and Testing, 
+Acharya Donde Marg, Parel, Mumbai, India 
+6Bangalore Institute of Oncology, Bangalore, India
+                                                        
+ Correspondence Email: [email protected] 
+** Correspondence Email: [email protected] 
+Abstract 
+ 
+Context and Aim: Complementary and alternative therapies 
+(CAM) are gaining popularity amongst patients as add on to 
+conventional medicine. Yoga stands third amongst all CAM 
+that is being used by cancer patients today. Different 
+schools of yoga use different sets of practices, with some 
+using a more physical approach and many using meditation 
+and/or breathing. All these modules are developed based on 
+the needs of the patient. This paper is an attempt to provide 
+the basis for a comprehensive need based integrative yoga 
+module for cancer patients at different stages of treatment 
+and follow up. In this paper, the holistic modules of the 
+integrated approach of yoga therapy for cancer (IAYTC) 
+have been developed based on the patient needs, as per the 
+observations by the clinicians and the caregivers. Authors 
+have attempted to systematically create holistic modules of 
+IAYTC for various stages of the disease and treatment. 
+These modules have been used in randomized trials to 
+evaluate its efficacy and have shown to be effective as add-
+on to conventional management of cancer. Thus, the 
+objective of this effort was to present the theoretical basis 
+and validate the need based holistic yoga modules for 
+cancer patients.  
+Materials and Methods: Literature from traditional texts 
+including Vedas, Ayurveda, Upanishads, Bhagavat Gita, 
+Yoga Vasishtha etc. and their commentaries were looked 
+into for references of cancer and therapeutic directives. 
+Present day scientific literature was also explored with 
+regards to defining cancer, its etiopathology and its 
+management. Results of studies done using CAM therapies 
+were also looked at, for salient findings. Focused group 
+discussions (FGD) amongst researchers, experienced gurus, 
+and medical professionals involved in research and clinical 
+cancer practice were carried out with the objectives of 
+determining needs of the patient and yoga practices that 
+could prove efficient. A list of needs at different stages of 
+conventional 
+therapies 
+(surgery, 
+chemotherapy 
+and 
+radiation therapy) was listed and yoga modules were 
+developed accordingly. Considering the needs, expected 
+side effects, the energy levels and the psychological states 
+of the participants, eight modules evolved. 
+Results: The results of the six steps for developing the 
+validated module are reported. Step 1: Literature review 
+from 
+traditional 
+yoga 
+and 
+ayurveda 
+texts 
+on 
+etiopathogenesis and management of cancer (arbuda), and 
+Amritanshu Ram, Nagarathna Raghuram, Raghavendra M. Rao et al. 
+ 
+270 
+the recent literature on cancer stem cells and immunology 
+of cancer. Step 2: Focused group discussions and 
+deliberations to compile the needs of patients based on the 
+expected side effects, energy levels and the psychological 
+state of the patient as observed by the caregivers and the 
+clinicians. Step 3: Content validation through consensus by 
+the experts for the eight modules of IAYTC that could be 
+used as complimentary to conventional management of 
+cancer at different stages during and after the diagnosis was 
+created. Step 4: Field testing for safety and feasibility of the 
+modules through pilot studies. Step 5: Compilation of the 
+results of efficacy trials through RCTs and step 6: A review 
+of our studies on mechanisms to offer evidence for action 
+of IAYTC on psycho-neuro-immunological pathways in 
+cancer.  
+Conclusion: The evidence from the traditional knowledge 
+and recent scientific studies validates eight modules of 
+integrated approach of yoga therapy for cancer that can be 
+used safely and effectively as complimentary during all 
+conventional cancer therapies.  
+ 
+Keywords: yoga; cancer; traditional knowledge; cancer 
+stem cells 
+ 
+ 
+Introduction 
+ 
+Cancer is a leading cause of death worldwide. [1] 
+Research to eradicate the tumor burden without 
+harming the host has progressed with many success 
+stories that have resulted in cure (in a few cancers), 
+improved longevity and quality life. In spite of these 
+advances, it is intriguing that the prevalence of the 
+disease has not reduced. The world statistics indicates 
+that in India alone, 22.2% of women presently suffer 
+from cancer which is expected to increase to almost 
+30% in the next five years. [2] This has led patients to 
+resort to complementary and alternative medicine 
+(CAM). 
+According 
+to 
+a 
+previous 
+survey, 
+approximately 21% of cancer survivors in the United 
+States had engaged in CAM practices. [3] Among 
+these, yoga was the third most commonly accepted 
+therapy [3]. 
+Malignant tumors are known to consist of a stem 
+cell population that exhibits both the tumor markers 
+and the stem cell markers. Thus these are called 
+cancer stem cells (CSCs). Cancer stem cells (CSCs) 
+are stem-like tumor populations that are reported to 
+contribute towards tumor growth, maintenance, and 
+recurrence after therapy. Recent reports also link 
+resistance to conventional therapies and the metastatic 
+potential to CSCs. [4] A review by Mimeault and 
+Batra (2006) emphasizes the interactions among 
+certain developmental signaling factors and their 
+pathways which are involved in the regulation of the 
+self-renewal and/or differentiation of adult stem cells. 
+They describe that aberrant expression and activities 
+of hormones, cytokines and chemokines which 
+include estrogens, androgens, TGF-Notch etc., and 
+tumorigenic signaling elements such as telomerase, 
+NF-B and Myc-1 may enhance cancer stem cell 
+survival and contribute towards the malignant 
+potential of tumors. [5] In this context, preliminary 
+evidences suggest that Yoga modulates neural, 
+endocrine and immune functions at the cellular level 
+to bring about a balance. [6–8] 
+A study on 45 caregivers of dementia patients 
+showed that a brief daily yoga meditation intervention 
+may reverse the pattern of increased NF-κB-related 
+transcription of pro-inflammatory cytokines and 
+decreased Interferon response factors (IRF1) related 
+transcription of innate antiviral response genes. [9] 
+Another study on 49 patients with breast cancer 
+patients and 10 with prostate cancer has shown the 
+efficacy of mindfulness based yoga practices in 
+shifting the immune profile from one associated with 
+depressive symptoms to a more normal profile via 
+modulating T cell production of cytokines such as IL-
+4 (increased) and IFN-gamma (reduced) in addition to 
+reduced production of IL-10 by natural killer (NK) 
+cells. [10] Similarly another recent study on 86 
+patients with chronic inflammatory diseases has 
+shown that an intervention program which includes 
+asanas (postures), pranayama (breathing exercises), 
+stress management, group discussions, lectures, and 
+individualized advice can lead to reduction in stress 
+(plasma cortisol and β-endorphin) and inflammation 
+(interleukin [IL]-6 and tumor necrosis factor [TNF]-α 
+within a short duration of 10 days. [11] We had 
+shown that Yoga therapy enhances natural killer cells 
+[12], and also modulates stress and DNA damage in 
+breast cancer patients receiving radiotherapy. [13] In 
+another RCT that recruited 98 recently diagnosed 
+stage II and III breast cancer patients, compared the 
+effects of a yoga program with supportive therapy and 
+exercise rehabilitation on postoperative outcomes and 
+wound healing following breast surgery. A significant 
+decrease in plasma TNF alpha levels was observed 
+following surgery in the yoga group (P < 0.001), as 
+compared to the controls [13]. A study performed on 
+Development and Validation of a Need-Based Integrated Yoga Program for Cancer Patients 
+ 
+271
+60 medical students demonstrated that integrated yoga 
+practices for 35 minutes daily for 12 weeks results in 
+better tolerance of stress and prevents the rise in 
+serum cortisol and INF- during exams, which is not 
+seen in the control group who did not undergo any 
+kind of yoga practice. [14]. A similar study conducted 
+on 50 healthy females to address the mechanisms 
+underlying hatha yoga's potential stress-reduction 
+benefits compared inflammatory and endocrine 
+responses of novice and expert yoga practitioners 
+before, during, and after a restorative hatha yoga 
+session, as well as in two control conditions 
+(movement control, and passive-video control). 
+Importantly, even though novices and experts did not 
+differ on key dimensions, including age, abdominal 
+adiposity, and cardio-respiratory fitness, the novices' 
+serum interleukin (IL)-6 levels were 41% higher than 
+those of experts across sessions, and the odds of a 
+novice having detectable C-reactive protein (CRP) 
+were 4.75 times as high as that of an expert. In 
+addition, experts produced less lipopolysaccharide-
+stimulated IL-6 in response to the stressor than 
+novices. They concluded that Yoga may minimize 
+inflammatory responses to stressful encounters which 
+influences the burden that stressors place on an 
+individual [15] Thus, yoga therapy may bring about 
+moderation and balance in the expression and 
+activities of various hormones, cytokines and 
+tumorigenic signaling elements to reduce cancer stem 
+cell survival and thus may complement conventional 
+therapies in reducing cancer progression and 
+recurrence. 
+Yoga offers several techniques to restore 
+normalcy by introspection and self-knowledge. 
+Different schools use different set of these practices, 
+some using more of physical practices [16] and many 
+using meditation and/or breathing. All these practices 
+can be classified and compiled as need based 
+modules. In a meta-analytical review [17] Lin et al. 
+has compiled the techniques and the benefits used by 
+different researchers. Speca et al., 2000 [18] used 
+gentle Mindfulness based stress reduction program; 
+Cohen et al., 2004 [19] used Tibetan yoga which 
+included controlled breathing, mindfulness, postures 
+from Tsa lung (channels and vital breath), Trul khor 
+(magical wheel) in cases of lymphoma; Monti et al., 
+2006 [20] used gentle yoga (MBAT); Danhauer et 
+al.2009 [21] used asanas, pranayama, and deep 
+relaxation. Moadel et al., 2007 [22] used Hatha yoga 
+that included physical stretches, breathing and 
+meditation. The researchers from our institution 
+[Raghavendra rao [12,23–25], Banerjee [26], and 
+Vadiraja [12,23–25,27–29] used integrated yoga that 
+included the modules described in this study. This 
+article is an attempt to present the process of 
+development 
+of 
+holistic 
+modules 
+called 
+the 
+‘Integrated Approach of Yoga Therapy for Cancer 
+(IAYTC)’ aimed at correcting the imbalances at 
+physical, mental, emotional and spiritual levels. 
+ 
+ 
+Methods 
+ 
+Focus group discussions with experts 
+ 
+The discussion group consisted of eight members 
+with varied expertise. Three members were yoga 
+experts capable of providing guidance based on 
+ancient scriptures and its interpretations; two 
+scientists who had been involved in CAM research 
+and have had salient publications in the field of yoga 
+for cancer; one post graduate physician who is also a 
+practitioner of yoga for several years and two 
+oncologists 
+who 
+have 
+had 
+extensive 
+clinical 
+experience in the field of oncology. The Focused 
+group discussions (FGDs) were organized with a two 
+point agenda.(a) To assess the needs of the patient at 
+several phases of the treatment (surgery, RT, CT, HT, 
+post treatment) and (b) to evolve the modules of 
+integrated yoga intervention that could address these 
+needs. The team was involved at all stages of 
+discussion and development of the modules.  
+Table 1 shows the stages in the development of 
+need based yoga modules for cancer.  
+ 
+Table 1. Stages in the development for a cancer 
+specific yoga module 
+ 
+1. References to Cancer from Traditional Scriptures 
+2. Focused group discussions-  needs of cancer 
+patients  
+3. Content validation of eight modules 
+4. Field testing 
+5. Efficacy trials 
+6. Mechanism studies  
+ 
+Amritanshu Ram, Nagarathna Raghuram, Raghavendra M. Rao et al. 
+ 
+272 
+Ancient References to Cancer 
+ 
+Detailed review of literature, both traditional and 
+modern, in the field of yoga and mind body medicine 
+was conducted. Ancient yoga texts like Upanishads, 
+Bhagavat Gita, Patanjali Yoga Sutra, Yoga Vasishta, 
+Hatha Yoga Pradipika and Hatha Ratnavali were 
+reviewed to look for descriptions of mind body 
+diseases including cancer. Popular commentaries of 
+these texts were also reviewed to find interpretations 
+that could prove helpful in understanding cancer and 
+similar disorders. Citations from salient texts of the 
+ayurveda system of medicine were also looked into to 
+provide perspective to the disorder and treatment 
+mechanisms. A thorough search of scientific literature 
+shed light on the recent developments in the 
+understanding of cancer and its treatment modalities. 
+Published studies on alternative therapies used as 
+adjunct to conventional treatment were collected as 
+part of the literature review. The authors went on to 
+compile all the major theories that attempted to 
+explain the etiology of cancer, and made an attempt to 
+suggest a suitable remedy for the same. The 
+compilation of therapeutic modalities described in 
+Ayurveda and yoga included yoga postures, breathing 
+practices (pranayama), mind modulation techniques 
+(meditation), 
+and 
+lifestyle 
+advice. 
+Other 
+complementary alternative therapies were also looked 
+into, to find relevant practices, which had shown to 
+influence various aspects of cancer positively. A 
+master list of all these were compiled and presented to 
+the experts in a checklist form. The check list 
+included questions about all the psychological and 
+physical needs at different stages of Conventional 
+therapies (surgery or chemotherapy or radiation). 
+Inputs, with regards to the needs of a cancer 
+patient, as opined by oncologists, caregivers and 
+cancer patients, were collected based on the checklist 
+provided. Thus a need-based CAM module could be 
+designed and put forth as modules that could be used 
+as adjunct to conventional treatment. 
+ 
+ 
+Procedure 
+ 
+The study used the in-depth discussion method of 
+data collection with the purpose of compiling yoga 
+based traditional knowledge available in all yoga 
+scriptures. The process involved several small group 
+meetings, correspondences, visiting the experts in the 
+field and sitting together to practice and experience 
+the techniques that were prescribed. Using a 
+humanized method, rather than a restricted checklist 
+or questionnaire scoring method, offered flexibility 
+for the evolution of the concepts. Despite it’s time 
+consuming characteristics it helped the researchers to 
+interact as contributors in order to develop the 
+module. The extensive questions and discussion 
+sessions facilitated the development of the modules 
+by sharing each other’s experiences and developing 
+the steps of the modules that evolved. 
+The eight modules that evolved from these FGDs 
+were field tested through pilot studies. Further 
+revisions based on the feedbacks from the therapists 
+and the patients during these pilot studies helped in 
+finalizing the modules. These were used as the 
+interventions in our randomized control studies on 
+breast cancer that formed the material for the eight 
+publications on the complimentary role of IAYT in 
+breast cancer [13,23–29]. 
+ 
+ 
+Results 
+ 
+Considering the need, expected side effects, the 
+energy levels and the psychological states of the 
+participants, eight modules evolved, the results of 
+which are described below. 
+ 
+ 
+Figure 1. Five Layers of the Human system. 
+ 
+Step1 – Literary Basis for IAYTC Modules  
+at Five Aspects of Personality  
+ 
+According to yoga texts (30), the human system 
+consists of five components (panca kośa - five bodies) 
+Development and Validation of a Need-Based Integrated Yoga Program for Cancer Patients 
+ 
+273
+1. Physical (Annamaya Kośa) 
+2. Prana or subtle energy (Prānamaya Kośa) 
+3. Instinctual mind (Manomaya Kośa) 
+4. Intellectual 
+or 
+discriminative 
+mind 
+(Vignānamaya Kośa) and 
+5. The blissfully silence state (Ānandamaya 
+Kośa) 
+ 
+Shvetashvatara Upanishad [31] describes that a 
+human being is in perfect health when he is 
+established in Ānandamaya Kośa which is the 
+unchanging state of being, the self. The living body is 
+a flux of continuous changes that is programmed to 
+live a full life span of about a century in perfect heath 
+if it is not disturbed by major calamities. Mind is the 
+most highly evolved and the most powerful entity of 
+the manifest universe. Disease begins in manomaya 
+kośa, the instinctual mind which is characterized by 
+likes and dislikes (Verse 49) [32] Due to wrong 
+notion of happiness the mind goes on seeking 
+relentlessly for objects of happiness; fear of failures 
+leads to distress and violent emotions; emotions are 
+defined as uncontrolled rewinding speed of thoughts 
+(chapter 5 verse 26) [33]; this becomes a habit; 
+suppressed emotions manifests as uncontrolled speed 
+in prānamaya kośa; speed and constriction of prana 
+flow to different organs result in violent activity in 
+Annamaya Kośa. As man goes through the ups and 
+downs of life (be it exposure to external onslaughts 
+like injury or infection, or emotionally challenging 
+situations), it sets off an imbalance.  
+The goal of treatment is to establish in a state of 
+complete mastery over all Kośas; this is possible by a 
+training to dwell in the state of alertful inner silence, 
+the Vignanamaya Kośa which is a state of total 
+contentment and freedom from all distress and 
+disease. (Chapter 2 Verse 12) [31] This is a state in 
+which one develops the ability to manipulate the laws 
+of nature within the body and outside the body. 
+(Chapter 1 Verse 4) [34] The integrated approach of 
+yoga provides a means to recognize and reverse the 
+damage by techniques at all these five levels. 
+ 
+References to Cancer (Arbuda ) in Āyurveda 
+Texts 
+Āyurveda, that evolved as a system of medicine 
+takes over from the understanding provided in yoga 
+texts. The imbalance due to excessive uncontrolled 
+speed in the prānamaya kośa that goes on to manifest 
+as physically visible symptomatic carcinomatous 
+mass in the annamaya kośa level has been elaborated. 
+Ayurveda is a highly developed system of medicine 
+that has descriptions of classification, progression, 
+manifestations and medical prescriptions for cancer. 
+According to āyurveda, the imbalance or vitiation of 
+any one of the three factors (vata, pitta and kapha) 
+results in disease and the balance can be restored by 
+holistic 
+life 
+style 
+modification 
+along 
+with 
+administration of drugs. Cancer is referred to as 
+Adhimāmsa and/or Arbuda under māmsa dhātu 
+pradośaja 
+(vitiated 
+muscle 
+tissue) 
+disorders. 
+Localization of the vitiated dośa to one part of the 
+body followed by metastasis (Prasara) is also 
+mentioned by Caraka. [35] The texts go on to explain 
+the stages of progression of arbuda. (Table 2) Arbuda 
+is considered to be due to vitiation with predominance 
+of Kapha Dośa that results in toxins (āma correlated 
+to free radicals) which get localized predominantly in 
+tissues, such as Rakta (blood), Māmsa (Muscle) and 
+Meda (Adipose). The treatment administered should 
+reduce the kapha dośa (Kaphahara), cleanse the 
+toxins of tissues, and reduce the āma (Māmsa and 
+Medo duñtihara). 
+ 
+Table 2. Stages of progression of imbalances in cancer (arbuda) according to Ayurveda [36] 
+ 
+1. Sanchaya (starting of imbalance) 
+In benign tumors: Abnormal cells confined to this stage only within the tissue of 
+origin. In malignant tumors: The process proceeds to further stages.  
+2. Prakopa (aggravation) 
+Stage of uncontrolled growth. 
+3. Prasara (spread) 
+Distant metastasis 
+Primary prasara  
+Invading adjacent tissues. 
+Secondary prasara 
+Migration to other parts away from the tissue of origin. 
+4. Sthāna samśraya (localization) 
+Localization in other tissues after metastasis. 
+ 
+Amritanshu Ram, Nagarathna Raghuram, Raghavendra M. Rao et al. 
+274 
+We find detailed decriptions of the clinical 
+manifestations 
+(Vyakta 
+arbuda) 
+and 
+also 
+the 
+complications (Bheda) of cancer in ayurveda texts. 
+Management of arbuda according to ayurveda 
+consists of two components:  
+ 
+a. Improving the immune stamina which is of 
+foremost importance and  
+b. Restore the balance of the three dośās by 
+drugs and life style modification.  
+ 
+The specific treatment for arbuda is classified 
+under 
+Bhaishajiya 
+Chikitsa, 
+the 
+conservation 
+therapies to revert the disease and Śalya Chikitsa 
+(Surgery). Surgical (Śastra Karma) procedures that 
+include Chhedana (partial or complete removal of 
+tissue), Lekhana (scraping or dissolving) and 
+Viśravaëa Aëuśastra Karma (draining with Para-
+surgical methods). Ayurveda also describes radical 
+surgeries to clear the area of residual malignant cells. 
+Anuśastra Karma is the specialty of surgeons (Śalya 
+Chikitsaka) 
+which 
+includes 
+Agni 
+Karma 
+corresponding to radiation therapy and Kśāra Karma 
+that involves threading i.e. ligation of the tumor by 
+medicated threads. It has been mentioned that there is 
+possibility of recurrence of arbuda even after all 
+procedures are completed (37) and hence the need for 
+continued vigilance and administration of Rasāyana 
+therapies. This rasāyana therapy appears to be of 
+great value as an add-on to present day management 
+of cancer. Four groups of drugs that have Rasāyana 
+functions 
+have 
+been 
+mentioned: 
+(a) 
+Balya 
+(restoratives), 
+(b) 
+Jeevaniya 
+(vitalizers), 
+(c) 
+Brahmaëeeya (nutritious) and (d) Vayas-sthapana 
+(age stabilizers). 
+Rasāyana drugs correct the dośā’s disturbed 
+equilibrium and nourish the tissues (Dhātus). Many 
+scientific studies on rasāyana drugs such as āmalaki, 
+Aśwagandha, Guduchi, Yashtimadhu, Jivanti, Tulasi 
+and Pippali have shown their beneficial effects. Based 
+on some experimental studies in animal and human 
+subjects, it is proposed that rasāyanās may have 
+several rejuvenating properties such as anti-oxidant, 
+adaptogenic, immuno modulatory, cytoprotective, 
+neurotropic and or anabolic activities [38]. 
+ 
+ 
+Step 2 –The Needs of Cancer Patients 
+ 
+All modules have the common purpose of 
+correcting the imbalances at all five aspects of the 
+personality through alert rest to the mind-body-
+complex in general and to the effected organ in 
+particular. Each module consists of eight steps and 
+takes about 30 minutes to perform. All modules begin 
+with a selected prayer followed by Introspective 
+Perception/recognition and end with a resolve 
+followed by a closing prayer. The practices are to be 
+taught in ten sessions of one and half hours each.  
+ 
+Table 3. Needs of a cancer patient – results of a discussion with clinicians, caregivers and patients 
+ 
+Treatment phase 
+Patients’ concerns 
+Clinician’s needs 
+Caregivers’  feedback 
+Surgery 
+Fear, anxiety, success of surgery. 
+Fear of Complications. 
+Wound healing, drain 
+retention, better prognosis 
+Hospital stay,  
+Follow up visits, Functional 
+independence, 
+Reduce economic burden 
+Radiation Therapy 
+Fatigue, pain, nausea, physical 
+appearance, 
+Fear of Complications 
+Efficiency of RT,  
+ prevent fibrosis, 
+ lymph edema,  
+Superficial tissue damage 
+Tolerance to scheduled dose 
+Quality of life, Vomiting 
+Chemo-therapy 
+Fear of side effects Fatigue, pain, 
+nausea, physical appearance, 
+Problems of repeated venepuncture. 
+ Manitainence of chemoport. 
+completion of treatment and 
+adherence, Anemia (Hb), 
+Immune suppression, 
+Energy level 
+Functional independence, 
+Negative emotions 
+Depression,  
+Nausea /vomiting 
+Hormone Therapy 
+Side effects 
+Loss of reproductive functions. 
+Treatment adherence 
+Hospital visits,  
+Mood 
+Post treatment 
+Supportive medication,  
+Long term side effects 
+Immune status, 
+Long term side effects  
+Functional independence, 
+Quality of Life 
+ 
+ 
+Development and Validation of a Need-Based Integrated Yoga Program for Cancer Patients 
+ 
+275
+After a lecture for about 30 minutes to understand the 
+principle and back ground of the technique, the 
+participants 
+learn 
+the 
+module 
+under 
+guided 
+instructions for 50 minutes; this is followed by 10 
+minutes of interaction to check the experience. All 
+participants begin with basic modules based on the 
+abilities and needs. The therapist and the yoga 
+clinician assess the experience of the participant using 
+a check list before moving on to more advanced level. 
+[39]. 
+ 
+ 
+Step 4 –Field Testing for Safety and Feasibility 
+of the Modules through Pilot Studies 
+ 
+Pilot studies were conducted (1995 to 2005) on 
+several cancer patients (breast, stomach, esophagus, 
+uterine cervix, colon, brain etc.) who were admitted 
+for IAYTC therapy at Arogyadhama, the residential 
+health home of VYASA. The modules were 
+introduced to these patients with regular follow up 
+and assessments. The feedbacks from the therapists, 
+about the feasibility, and from the patients, about their 
+experiences during the practices were documented. 
+This formed the basis for improvising the module of 
+IAYTC for the planned RCT for breast cancer.  
+A second level FGD was planned to finalize the 
+module by taking the inputs from the eight experts 
+who were involved initially in developing the 
+modules using a semi structured discussion method.  
+ 
+ 
+Step 5 –Efficacy trials through RCTs  
+ 
+Results of RCTs for efficacy  
+In our first RCT [13], 69 women with stage II or 
+III breast cancer were recruited to study the effect of 
+different modules of yoga during different stages of 
+conventional treatment starting from the first day of 
+diagnosis until the treatment was completed. During 
+the period of 2005-2008 when all our RCTs were 
+planned, the protocol of management at Bangalore 
+institute of oncology where the studies were 
+conducted, the standard conventional protocol was 
+surgery, 
+followed 
+by 
+radiation 
+therapy 
+and 
+chemotherapy (six cycles at an interval of three weeks 
+with changes depending on the side effects) which 
+changed by the end of the study. 
+ 
+Table 4. Eight modules of the IAYTC grouped into five categories 
+ 
+Personality 
+Aspects 
+Modules 
+Phase of cancer 
+Surgery 
+RT 
+CT 
+HT 
+Survival 
+Annamaya  
+1. 
+Sukshmavyayamas (SKYM) 
+ 
+ 
+ 
+ 
+ 
+2. 
+Self-Management Of Excessive Tension (SMET) 
+ 
+ 
+ 
+ 
+ 
+Prānamaya  
+3. 
+Pranic Energization Technique (PET) 
+ 
+ 
+ 
+ 
+ 
+Manomaya  
+4. 
+Mind sound resonance technique (MSRT) 
+ 
+ 
+ 
+ 
+ 
+5. 
+Mind emotions management technique (MEMT) 
+ 
+ 
+ 
+ 
+ 
+6. 
+Mind imagery technique (MIRT) 
+ 
+ 
+ 
+ 
+ 
+Vignānamaya  
+7. 
+Vignana Sadhana Kaushala (VISAK) 
+ 
+ 
+ 
+ 
+ 
+Ānandamaya  
+8. 
+Ananda Amrta Sinchana (ANAMS) 
+ 
+ 
+ 
+ 
+ 
+ 
+Effects of IAYTC after surgery 
+All participants were taught SKYM (in part) and 
+SMET in two days before surgery either as inpatients 
+or outpatient. They practiced DRT (ten minutes) 
+component of SMET four times a day for two days in 
+immediate post-operative period in the hospital; 
+SKYM practice was revised with a few additions 
+during their stay. They were asked to continue the full 
+practice (SKYM and SMET) daily for 30 minutes at 
+home. The results showed lesser number of days of 
+drain retention which resulted in lesser duration of 
+hospital stay after surgery implying economic 
+advantages (ref). They also showed significant 
+reduction in the number and severity of other 
+distressful symptoms after surgery (ref). 
+ 
+Effects of IAYTC during radiation therapy 
+As they moved on to radiation therapy when the 
+wound had healed they went on to learn PET and 
+MSRT. During radiation therapy, the level of 
+perceived stress anxiety and depression were lesser in 
+the yoga group(ref); the DNA damage as measured by 
+Amritanshu Ram, Nagarathna Raghuram, Raghavendra M. Rao et al. 
+ 
+276 
+comet assay was significantly lesser in the yoga group 
+as compared to the control group [26]. 
+ 
+Effects of IAYTC during and after 
+chemotherapy  
+As they moved on and were preparing for 
+chemotherapy (CT) they went on to learn MIRT and 
+MEMT; they were given prerecorded audio CDs for 
+home practice; they were made to listen and practice 
+MSRT followed by PET during the hour long 
+chemotherapy infusion. As the CT progressed (six 
+cycles at an interval of three weeks between the 
+intravenous infusion therapy), the patients were taught 
+the other practices of VISAK and ANAMS which are 
+meant to allay the fear at subtler levels.  
+The results showed significant reduction in both 
+State and Trait anxiety (STAI); the CT related 
+distressful symptoms were significantly lower in the 
+yoga group [25]; the frequency and severity of post-
+chemotherapy nausea and the anticipatory nausea 
+reduced 
+significantly. 
+There 
+were 
+significant 
+correlations 
+between 
+nausea, 
+vomiting 
+and 
+psychological variables such as anxiety, depression, 
+symptom distress, quality of life and toxicity [24]. 
+There was also reduction in depression and increase 
+in quality of life during the course of treatment (p= 
+<0.001). 
+ 
+ 
+Table 5. Results of efficacy trials conducted with IAYTC as intervention 
+ 
+Author 
+BENEFITS 
+PHYSICAL 
+(Annamaya kosha) 
+VITAL ENERGY 
+(Pranamaya kosha) 
+PSYCHOLOGICAL 
+(Manomaya kosha) 
+QOL 
+(anadamaya kosha) 
+Rao 2006 EJCC 
+↓Emesis intensity  
+↓Nausea  frequency  
+↓Symptom Numbers  
+↓Symptom Severity 
+↓Emesis ant intensity 
+↓Nausea intensity  
+↓Symptom distress  
+↓ Anticipatory 
+Nausea frequency   
+↓ Anticipatory 
+Nausea Intensity   
+↓Anxiety  
+↓Depression  
+ 
+Banerjee 2007 ICT 
+↓DNA Damage  
+↓Perceived Stress  
+↓Anxiety  
+↓Depression  
+↑Overall QOL  
+Rao 2008 IJOY 
+↑CD8+   
+↑CD56+  
+↓Symptom Severity  
+↓Trait anxiety  
+↓Depression  
+General QOL ↑ 
+Rao 2008 IJOY 
+↓Drain Retention  
+Suture Removal: 
+↓Duration ↓Hospital 
+Stay  
+ 
+ 
+ 
+Rao 2009 CTIM 
+ 
+↓Symptom Distress  
+↓ State Anxiety 
+↓ Trait Anxiety 
+ 
+Vadiraj 2009 IJOY 
+↓Physical Distress  
+↓Pain  
+↑Physical Activity  
+↓Appetite Loss  
+↓Fatigue 
+↓ Distress 
+↓Insomnia  
+ 
+Vadiraj 2009 ICT 
+↓6am cortisol 
+↓ Pooled cortisol 
+ 
+Anxiety ↓ 
+Depression ↓ 
+ 
+Vadiraj 2010 CTIM 
+ 
+ 
+↓Negative Affect  
+↑ Emotional QOL  
+Positive Affect↑ 
+QOL: Cognitive ↑ 
+ 
+ 
+Effects after Completing the Therapy 
+At the end of the entire therapy perceived stress 
+level was lower with better emotional and cognitive 
+functions of quality of life, and positive affect in the 
+yoga group [28].  
+ 
+Step 6– Evidence for Mechanism:  
+Benefits of the Modules on Psycho-Neuro-
+Humero-Immunological Pathways 
+ 
+Psycho-Humeral Pathway- Salivary Cortisol 
+Vadiraja et al [29] observed significant decrease 
+in the psychological and physical distress, fatigue, 
+Development and Validation of a Need-Based Integrated Yoga Program for Cancer Patients 
+ 
+277
+pain, insomnia, appetite loss and negative affect with 
+improved activity levels and positive affect (ref) in 
+patients with stage 2 and 3 breast cancer after IAYTC. 
+There were positive correlations between the physical 
+and psychological symptoms. The activity levels were 
+correlated with fatigue, nausea and vomiting, 
+constipation and diarrhea. The perceived stress (PSS), 
+anxiety (STAI) and depression (HADS) were also 
+lower in the yoga group.  
+The salivary cortisol at 6am and the overall 
+pooled cortisol levels were significantly lower in the 
+yoga group of patients with stage II and III breast 
+cancer; and the scores for anxiety and depression 
+were correlated with 6am cortisol levels. [27]  
+ 
+Psycho-Immune Pathway- Immunoglobulin, 
+Cytokines and T Cells 
+Measurement of serum IgA, CD8+ and CD56+ 
+counts and TNF-α were undertaken which provided 
+evidence to the immune system normalizing effects of 
+the integrated yoga modules [23]. The Plasma TNF-α 
+levels were significantly lower in the immediate post 
+operative period (7th day) in yoga group as compared 
+to control group (Mann-Whitney p<0.001) indicating 
+lower pro-inflammatory activity which could explain 
+faster healing. [13] Serum IgA were significantly 
+lower, %CD8+ and %CD56 counts were significantly 
+higher in yoga group pointing to better immune 
+adaptability towards the stressor [23]. 
+Rao et al also went on to show a predictive 
+relationship between the emotional states (anxiety and 
+depression) and the outcome of surgery. The yoga 
+intervention played an important role in predicting the 
+number of days for drain retention, suture removal 
+interval, duration of hospital stay and post surgery and 
+TNF-α levels [13]. There were also significant 
+correlations 
+between 
+nausea, 
+vomiting 
+and 
+psychological variables such as anxiety, depression, 
+symptom distress, quality of life and toxicity 
+[24].This may be considered to be supportive 
+evidence for the hypothesis of a downward causative 
+relationship between the mind and cancer. 
+ 
+ 
+Discussion 
+ 
+This paper presents the six steps of developing 
+and providing the validity for the IAYTC modules 
+and also the proof of concept for their psycho-neuro-
+humero-immunological basis. The concepts about the 
+origin and progression of disease that had evolved as 
+an introspective science in the east by yoga masters 
+were compiled. Eight feasible need based modules 
+were developed after several exchanges between the 
+experts. These were tested by pilot studies on patients 
+with cancer at different sites. The efficacy was proved 
+through high grade (pedro scoring of 6) [17] 
+randomized control trials in breast cancer patients. 
+Step 6 showed the predictive relationships between 
+the psyche with the humoral and immunological 
+measures.  
+ 
+ 
+Comparisons 
+ 
+Since 
+the 
+first 
+published 
+research 
+article 
+evaluating the benefits of a support group therapy 
+[40] in 1981, several researchers have used techniques 
+like mindfulness-based stress reduction (MBSR), 
+progressive muscle relaxation, Tibetan yoga as 
+alternative forms of mindful and proactive non-
+pharmacological methodologies in combination with 
+conventional treatment and seen a plethora of benefits 
+in cancer care.  
+There are many schools of yoga that are being 
+practiced today in the world. These range from simple 
+body postures either with or without the use of props 
+to meditation. Iyengar yoga is one such school of 
+yoga that prescribes simple asanas with supportive 
+aids like pillows, wooden blocks and ropes that assist 
+in reaching final position of difficult postures. Also 
+breath modulation (pranayama) and meditation are 
+practiced in these final postures. Other schools like 
+Sudarshan Kriyā Yoga, Hatha Yoga, and Patanjali 
+yoga have varying proportions of physical, breath and 
+mind 
+activities 
+implemented 
+through 
+diverse 
+techniques. As the premise for calling any practice 
+‘yoga’ is clearly defined in ancient Indian literature as 
+‘chitta vritti nirodhah’ (voluntary mastery over the 
+modifications of the mind)(chapter 1 verse 2) [34] and 
+offered eight or more practices to achieve this, 
+researchers have the freedom to select and modify the 
+intervention to suit the desired objectives.  
+Studies 
+using 
+Tibetan 
+yoga 
+[19], 
+MBSR 
+[18,41,42] and simple awareness [43] techniques have 
+shown benefits to cancer patients at physical, 
+Amritanshu Ram, Nagarathna Raghuram, Raghavendra M. Rao et al. 
+ 
+278 
+psychological, psychosocial levels and consistently 
+reported an improvement in quality of life outcomes. 
+Physical benefits included reduction in fatigue 
+[21,44,45], pain [44,46] and symptoms [46,47]. Also 
+improvements in sleep measures [19] and immune 
+parameters [18] have been reported. Research has also 
+shown that a spectrum of psychological abnormalities 
+like distress [17,46], stress [17,18,48], anxiety 
+[17,21,46,48], depression [17,21,46], affect[21] and 
+mood [47], can be corrected through mind body 
+interventions.  
+Psychosocial variables like mental adjustment 
+[48] and acceptance [44] are also affected by 
+inculcating restorative yoga related techniques into 
+the treatment process. Quality of life as measured by 
+several sub scales relating to physical QOL, 
+psychological QOL, Health related QOL and overall 
+QOL have shown consistent improvements [21,49]. A 
+review article suggests that these QOL measures need 
+to play a more important role in planning treatment 
+regimen for cancer patients [50].  
+ 
+ 
+Mechanism -Yoga and Cancer Stem Cells 
+ 
+Recent reports link resistance to conventional 
+therapies and the metastatic potential to a stem-cell-
+like tumor population, termed cancer stem cells 
+(CSCs) [51,52]. CSC population survives injury due 
+to radiations and chemotherapy through their ability 
+to restrict DNA damage by reducing reactive oxygen 
+species and thus, continues to propagate the tumor by 
+preventing DNA damage [52]. It appears that the 
+elimination of this minority of cancer progenitor cells 
+with stem cell-like properties [53] is essential for the 
+development of more effective curative treatments 
+against cancer.  
+Two factors which facilitate cancer stem cell 
+survival are; aberrant expression of tumor signaling 
+pathways [52] and hypoxia [54]. Hypoxia induced 
+signaling is mediated by Hypoxia-inducible factor 
+(HIF), which is critical for stem cell survival and self-
+renewal [4]. Apart from balancing the neuro-
+endocrino-immunological 
+pathways 
+[7], 
+Yoga 
+practices especially pranayamas have been proven to 
+increase blood oxygen saturation levels [55]. 
+Proposed IAYTC Module thus, has the potential to 
+make CSCs more susceptible to radiation and 
+chemotherapy 
+induced 
+damage 
+probably 
+by 
+harmonizing tumor signaling pathways and by 
+reducing Hypoxia-induced transcription of HIFs, 
+thereby reducing the progression and recurrence of 
+cancer. 
+ 
+ 
+Summary 
+ 
+The yoga texts propose a psycho-physical model 
+of cancer. It is an imbalance caused by persistent 
+uncontrolled speeded up recycling of thoughts 
+(emotions) in the psyche that manifests as cancer at 
+the physical level. The aim is introspective self-
+correction of the inner violence and reaches a blissful 
+silent state of the mind. Eight modules of practices to 
+correct the imbalances evolved through focused group 
+discussions. Corrections in the modules were 
+implemented after getting feedbacks from field testing 
+through pilot studies. Randomized control studies 
+provided more evidence to the value of these IAYTC 
+modules 
+as 
+add-on 
+therapy. 
+Predictive 
+and 
+correlational relationship between psychological with 
+immunological and humoral variables was considered 
+as supportive evidence for the scriptural basis for the 
+modules. 
+ 
+ 
+Limitations of the Study 
+ 
+The study is a retrospective presentation of the 
+steps that were followed over the years and not a 
+prospective planned study to assess the validity and 
+reliability of the modules. Statistically acceptable 
+scoring for the check list was not used during all 
+group discussions as the format was semi structured. 
+Not all members of the focused group met during all 
+discussions and some of the meetings were not 
+documented. Statistical calculations of split half 
+reliability were not planned. 
+ 
+ 
+Strengths and Recommendations from the 
+Study 
+ 
+Eight published articles that have tested the 
+feasibility, safety and efficacy of these eight modules 
+of IAYTC is the major strength of this work. These 
+Development and Validation of a Need-Based Integrated Yoga Program for Cancer Patients 
+ 
+279
+modules developed on the basis of time tested 
+knowledge base of 2000 to 7000 years by the eastern 
+introspective researchers offers many more tools to 
+modern 
+cancer 
+management 
+protocols. 
+The 
+uniqueness of these modules is that these can be 
+added on safely to any of the protocols of 
+management of cancer of different stages at any site. 
+We recommend incorporation of these tested modules 
+in all cancer management protocols to reduce the 
+toxicity and side effects which has been one of the 
+major limitations of most of the therapeutic tools 
+available today. This would add on to better 
+acceptability through improved quality of life.  
+ 
+ 
+Suggestions for Future Work 
+ 
+More studies to establish the validity and 
+reliability using structured approach is recommended. 
+These modules have to be tested in different races; 
+this is now going on as a NIH funded project at MD 
+Anderson’s center for cancer, Houston, USA. Can 
+these techniques replace the existing modalities of 
+management is a major question that has to be 
+addressed 
+by 
+innovative 
+ethically 
+acceptable 
+experimental designs. 
+ 
+ 
+Conclusion 
+ 
+Among the various CAM treatments available, 
+yoga has proved to be useful in management of 
+cancer. Eight modules of IAYTC to be introduced 
+systematically as add-on to conventional therapies 
+(surgery, radiation, and chemo) of cancer with 
+additional benefits of improved quality of life, stress 
+reduction, correction of HPA axis and immune system 
+imbalances offers many more tools to the existing 
+protocols of cancer management. 
+ 
+ 
+Acknowledgments 
+ 
+We thank CCRYN (central council of research in 
+yoga and naturopathy), department of AYUSH, 
+ministry of health and family welfare, government of 
+India, New Delhi for funding the projects of RCTs. 
+We are grateful to SVYASA for supporting research 
+through its divisions of ‘yoga and spirituality’ and 
+‘yoga and life sciences’. We thank the Bangalore 
+institute of oncology and health care global for their 
+continued support to conduct these studies. We thank 
+all the participants of the focused group discussion.  
+ 
+Dr. Prasad Koka is supported by 
+Ramalingaswami Re-entry Scheme Fellowship of the 
+Department of Biotechnology, Government of India, 
+New Delhi, India. 
+ 
+ 
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+ 

subfolder_0/Development and feasibility of need based yoga program for.txt

@@ -0,0 +1,708 @@
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+42
+Context and Aim: Yoga has been found to be effective in the management of stress. This paper describes the development 
+of a yoga program aimed to reduce burden and improve coping of family caregivers of inpatients with schizophrenia in India.
+Materials and Methods: Based on the assessment of caregiver needs, literature review, and expert opinion, a ten-day group 
+yoga program was initially developed using the qualitative inductive method of inquiry. Each day’s program included warm-up 
+exercises, yogic asanas, pranayama, and satsang. A structured questionnaire eliciting comments on each day’s contents was 
+given independently to ten experienced yoga professionals working in the field of health for validation. The final version of 
+the program was pilot-tested on a group of six caregivers of in-patients with schizophrenia admitted at NIMHANS, Bangalore.
+Results: On the question of whether the program would help reduce the burden of caregivers, six of the ten experts (60%) 
+gave a rank of four of five (very much useful). Based on comments of the experts, several changes were made to the program. 
+In the pilot-testing stage, more than 60% of the caregivers assigned a score of four and above (on a five-point Likert scale, five 
+being extremely useful) for the overall program, handouts distributed, and performance of the trainer. Qualitative feedback of 
+the caregivers further endorsed the feasibility and usefulness of the program.
+Conclusion: The developed yoga program was found to be acceptable to caregivers of in-patients with schizophrenia.
+Key words: Family caregivers; need; schizophrenia; yoga.
+ABSTRACT
+Development and feasibility of need-based yoga program for 
+family caregivers of in-patients with schizophrenia in India
+Aarti Jagannathan, Ameer Hamza, Jagadisha Thirthalli1, HR Nagendra2, R Nagarathna3, BN Gangadhar1
+Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), 1Department of Psychiatry, 
+National Institute of Mental Health and Neurosciences (NIMHANS), 2Vice-chancellor, Swami Vivekananda Yoga Anusandhana Samasthana 
+(SVYASA), 3Dean, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samasthana (SVYASA), Bangalore, India
+Address for correspondence: Dr. Aarti Jagannathan, 
+No: 10, ‘JAGRATI’, 5th Cross, MR Gardens, Vishwanatha Naganahalli, RT Nagar Post – 560 032, India. 
+E-mail: [email protected]
+Original Article
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.91711
+INTRODUCTION
+Yoga models described by earlier authors have provided 
+their own rationale behind the choice of yoga asanas/
+program.[1-3] However, there is no mention whether these 
+programs have been endorsed by other specialists in the 
+field than the researcher themselves. Also, there is no 
+literature which discusses the development of a yoga 
+program which attempts to match the expressed needs of 
+the participants.
+Only two studies have looked at development and 
+feasibility testing of yoga programs for caregivers of 
+persons with disability. Puymbrock et al.[4] tested the 
+feasibility of a yoga program on the physical health and 
+coping of informal caregivers who cared for a person 
+with a disease or disability in USA. Waelde et al.[5] 
+conducted a pilot study of a yoga and meditation 
+intervention called “Inner Resources” for dementia 
+caregiver stress in USA.
+The above studies focus more on feasibility testing rather 
+than on the development of a yoga program. The cultural 
+applicability of the studies in an Indian setting would 
+also require testing. Furthermore, the needs expressed 
+by the caregivers of persons with dementia[6-9] is different 
+from that of the needs of caregivers of persons with 
+schizophrenia.[10] As there were no Indian studies which 
+explored the development and feasibility testing of yoga 
+program based on the needs of caregivers, we undertook 
+the systematic development of a yoga program based on the 
+needs of caregiver of persons suffering from schizophrenia.
+43
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Jagannathan, et al.: Need-based yoga program for caregivers of patients with schizophrenia
+MATERIALS AND METHODS
+The study was reviewed and approved by the Institute’s 
+ethics committee. Written informed consent of the mental 
+health professionals who helped in validation of the 
+program and family caregivers who participated in the pilot 
+study was obtained. A sociodemographic sheet eliciting 
+information on their age, occupation, monthly income, and 
+marital status was filled up by the researcher for both the 
+mental health professionals and family caregivers.
+The inductive method of inquiry (quintessence of 
+qualitative research) in which general principles (theories/
+programs) are developed from specific observations was 
+used to develop and test the feasibility of the program. The 
+development of the yoga program was conducted in two 
+stages. Stage-one involved development of the content and 
+methodology for the yoga program. Stage-two involved face 
+and content validation of the program. The feasibility of the 
+program was tested in Stage-three of the study where the 
+program was pilot-tested and feedback from the caregivers 
+who participated in the program was elicited. The process 
+involved in each stage of the development and feasibility 
+testing of the program is delineated below [Figure 1].
+Stage-One: Program development
+Initially, a yoga program was developed by matching 
+the needs of the caregivers.[10] Classical texts such as 
+Patanjali Yoga Sutra,[11] Rigveda,[12] Gheranda Samhita,[13] 
+Hatharatnavali,[14] and Hathayogapradipika[15] were 
+reviewed to understand the asanas/practices that would 
+help directly or indirectly deal with each of the needs.
+To help warm up the body to practice the asanas and 
+pranayama, jogging, cycling, and hands in and out 
+breathing was incorporated in the beginning of each day’s 
+program (Nagendra, 2008).
+Suryanamaskara a set of yogic postures done in a sequence 
+of postures routinely followed in several yoga schools, 
+helps in bringing about general flexibility of the body and 
+improving mental health as a preparation for asanas and 
+pranayama (Satyananda Saraswati, 2008; Yogendra., 1997). 
+Even the foremost classical text (Rigveda, 1st Mandala, 
+50th Sukta) emphasizes the benefits of the practice in 
+destroying physical illnesses and the diseases of the 
+heart (mind) [‘udyannadya mitramaha arohannuttaram 
+divam /Hrdrogham mamasurya harimanam ca nasaya // 
+(1st  Rucha). “Rising this day, O rich in friends, ascending 
+to the loftier heaven, Surya remove my hearts disease, take 
+from me this yellow hue…”].
+The goal of yoga practices in context of the needs expressed 
+by the caregivers (such as managing illness behavior, 
+managing socio-occupational concerns, physical and 
+mental health, and managing marital and sexual issues of 
+the patient) was to enable the caregivers to think clearly, 
+have equanimity in emotions, improve their decision 
+making as well as their response to a situation, and 
+improve their attention. A review of classical yoga texts 
+(Gheranda Samhita, Hatharatnavali, Hathapradipika) and 
+contemporary yoga textbooks (Yogendra., 1997, Satyananda 
+Saraswati, 2008; Nagendra, 2008) showed that asanas such 
+as Padahastasana, ardhachakrasana, Vajrasana, Vakrasana, 
+Salabhasana Bhujangasana, Savasana, Nadanusandana, 
+Matsyasana, Nadishuddhi, Bhramhari, and Kapalabhatti 
+had direct or indirect benefits in improving caregiver’s 
+ability to think clearly, improve their decision making/
+response to a situation/attention, and equanimity of 
+emotions.
+The satsang was used to educate the caregivers on how yoga 
+could help tackle their needs and help in rehabilitation 
+of the patient.
+Table 1 depicts the details of the yoga program developed 
+in accordance with the assessed needs of caregivers. The 
+table enlists practices that are applicable/not applicable in 
+fulfilling the six assessed needs of the caregivers.
+The ultimate aim of the yoga program was to reduce the 
+burden of the caregivers either by addressing their needs 
+or by developing yoga program which in turn would equip 
+them with the ability and skills to reduce their burden—
+irrespective of the fulfillment of needs. As not all needs 
+could be theoretically addressed by teaching yoga, we 
+focused on the reduction of burden (aim of the study), 
+irrespective of the expressed needs.
+Thus, the framework of the yoga program was based on 
+Integrated Yoga Therapy (IAYT) model developed by 
+Swami Vivekananda Yoga Anusandhana Samasthana[3] 
+(SVYASA). This model incorporated the “Self Management 
+of Excessive Tension (SMET)/ Cyclic meditation” approach 
+which reflected not only the aim of the current study 
+of reducing burden and improving coping among the 
+caregivers, but also directly or indirectly dealt with the 
+Figure 1: Process of Inductive method of program development
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+44
+Jagannathan, et al.: Need-based yoga program for caregivers of patients with schizophrenia
+six broad categories of assessed needs elucidated in the 
+first phase of this study.[10]
+Stage-Two: Face and content validation
+For the purpose of content validation of the program, the 
+researcher developed a structured questionnaire eliciting 
+dichotomous responses such as Yes/No and qualitative 
+comments on the appropriateness of each exercise and 
+asana selected as a component of the entire yoga program. 
+Ten experienced yoga therapy and research professionals 
+(in and around Bangalore) were approached individually 
+for the validation. The average number of years of work 
+experience (SD) of the experts after their formal education 
+was 14.8 (14.1) years. Through this methodology of content 
+- validation, the researcher accumulated a list of comments 
+for incorporating into yoga program. For face validation of 
+the program, the researcher asked each of the professionals 
+to rate the likelihood of the program achieving its objective 
+of helping the caregivers reducing their burden and stress 
+- on a five point Likert scale.
+To arrive at a consensus on the contents and methodology of 
+the yoga program, three rounds of iteration was conducted 
+among the yoga professionals, i.e., the researcher made 
+changes to the program based on comments given by the 
+professionals and went back (iteration) to them for their 
+further inputs on the modified program, three times before 
+all the ten experts agreed on the contents and methodology 
+(data saturation).
+A standardized script of the final version of the yoga 
+program was developed on incorporating the comments 
+of the ten experts. The script included list of practices and 
+asanas along with their step-wise procedure and pictures, 
+detailed notes on each satsang topic (seven topics – one 
+topic for each day; the script is available from the authors 
+on request). A handout explaining the contraindication of 
+practicing certain asanas during ailments along with the 
+order and list of yogic practices and their pictures was 
+developed in four languages (English, Hindi, Kannada, 
+and Tamil) for distribution to the participants. Each 
+satsang topic and notes was converted into power point 
+slides in the four languages for ease of presentation to the 
+participants.
+Stage-Three: Pilot study and feasibility
+The final version of the yoga program was pilot-tested on 
+a group of eight in-patient family caregivers who were 
+residing at National Institute of Mental Health and Neuro 
+Sciences (NIMHANS) in Bangalore, India (NIMHANS has 
+a 900-bed teaching hospital with training and research 
+facilities in psychiatry and other neurosciences) during 
+the period of the study.
+Caregivers of patients with a diagnosis of schizophrenia 
+were included in the study if they were to continue to 
+provide care for them following discharge. Caregivers with 
+psychiatric or neurological disorders and those caring for 
+another relative with psychiatric illness were excluded. 
+Of the eight caregivers recruited in the pilot study, three 
+caregivers dropped out during the intervention. The mean 
+age (SD) of the caregivers who completed the program 
+Table 1: Yoga program in accordance to needs of caregivers [Practices applicable (A)/not applicable (NA)]
+Practice
+Duration 
+(minutes)
+Need 1 
+managing 
+illness 
+behavior
+Need 2 
+managing 
+socio-vocation 
+problems
+Need 3 
+health of the 
+caregiver
+Need 4 
+education about 
+the illness
+Need 5 
+rehabilitation
+Need 6 
+managing 
+marital 
+and sexual 
+problems
+Jogging
+5
+A
+A
+A
+NA
+NA
+A
+Cycling
+3
+A
+A
+A
+NA
+NA
+A
+Suryanamaskar
+3
+A
+A
+A
+NA
+NA
+A
+Hands in and out breathing
+3
+A
+A
+A
+NA
+NA
+A
+Padahastasana
+1
+A
+A
+A
+NA
+NA
+A
+Ardhachakrasana
+1
+A
+A
+A
+NA
+NA
+A
+Vakrasana
+2
+A
+A
+A
+NA
+NA
+A
+Vajrasana
+1
+A
+A
+A
+NA
+NA
+A
+IRT
+1
+A
+A
+A
+NA
+NA
+A
+Bhujangasana
+1
+A
+A
+A
+NA
+NA
+A
+Shalabhasana
+2
+A
+A
+A
+NA
+NA
+A
+Sarvangasana
+2
+A
+A
+A
+NA
+NA
+A
+Matsyasana
+2
+A
+A
+A
+NA
+NA
+A
+QRT
+3
+A
+A
+A
+NA
+NA
+A
+KB
+2
+A
+A
+A
+NA
+NA
+A
+NS
+2
+A
+A
+A
+NA
+NA
+A
+Bhramari
+3
+A
+A
+A
+NA
+NA
+A
+Nadanusandhana
+5
+A
+A
+A
+NA
+NA
+A
+Satsang
+3
+NA
+NA
+NA
+A
+A
+NA
+TOTAL
+45
+45
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Jagannathan, et al.: Need-based yoga program for caregivers of patients with schizophrenia
+was 49.6 (19.5) years. They had an average of 10.4 (3.8) 
+years of education. All of them were females and three of 
+the caregivers were parents. The average (SD) duration of 
+illness of their patients was 12.2 (8.2) years and none of 
+them had not received any prior structured training on 
+how they should take care of their patient.
+Participants were trained in performing yoga asanas 
+under the guidance of a trained yoga therapist (based on 
+the script developed; therapist trained by SVYASA). The 
+intervention included sessions of about one hour daily for a 
+period of seven days. During the entire period of the study, 
+the ill relative continued to receive the routine treatment 
+prescribed by the doctors at NIMHANS. At the end of the 
+seven days, the caregivers were asked to fill a structured 
+feedback form on their overall rating of the program, 
+trainer, and the handouts distributed during the sessions.
+Descriptive analysis of the quantitative (Likert ratings) 
+feedback and content analysis of the qualitative feedback 
+received from the caregivers was conducted. Each and 
+every comment was given importance and the researcher 
+tried to accommodate all of it into the yoga program.
+RESULTS
+As the main objective of the study was to develop and test 
+the feasibility of a need-based yoga program for inpatient 
+caregivers, the results reflect the qualitative data acquired 
+at two levels: at the validation stage and at the pilot stage.
+At validation stage
+For content validation, experts were asked for their 
+feedback on the components that should be added in 
+the IAYT model [incorporating the ‘Self Management of 
+Excessive Tension’ (SMET)/ Cyclic meditation approach]. 
+The suggestions given by the experts are elicited below:
+• 
+Breathing exercises (like ‘Bhujangasana breathing’ and 
+‘Salabhasana breathing’) need to be included.
+• 
+Chanting either with the breathing exercises or 
+separately (Nadanusandana) should be included 
+as it would increase the exhalation: inhalation 
+ratio and hence (in all probability) stimulate the 
+parasympathetic tone, which would be useful in stress 
+reduction.
+• 
+Emphasis on awareness of calmness and silence from 
+within during asana practice is of vital importance. 
+For this reason, explanations of the purpose of the 
+asanas should be done in the introduction or during 
+‘Satsang’ at the end.
+• 
+Teach the full round of 13 practices of ‘suryanamaskara’ 
+with invocation at the beginning of each for at least 
+six minutes.
+• 
+I am personally used to ‘Padahastasana’ at the end, 
+once the body and legs are softened. It is a good 
+preparation for final ‘Savasana’ (or Quick Relaxation 
+Technique - QRT).
+• 
+‘Paschimuttanasana’ or ‘Halasana’ can feature in 
+the list as these two (possibly in combination with 
+Sarvangasana) are ideal for loosening up the region 
+of the ‘Muladhara chakara’ and inducting the shakti 
+to flow more strongly.
+• 
+Twist poses are excellent for refreshing blood flow 
+to all the inner organs in the abdomen, from which 
+the renewed flow of the various pranas in the nadis/
+meridians transform how a person feels. In this 
+context, even the rotating swings performed during 
+loosening exercises could be useful as a 1-minute 
+practice during the warm-up period.
+• 
+Sarvangasana is the best position for becoming 
+aware of the inner silence and could well be put at 
+the beginning.
+• 
+To add deep breathing, nadishodhana and Kapalabhatti 
+in the program which should be practiced frequently, 
+example: while attending satsang.
+• 
+Caregivers need to consciously focus on the ‘stretch’ 
+which maintains easy and relaxed breathing during 
+asana performance. This has the most powerful 
+calming and integrating effect.
+Based on the comments given by the experts, the yoga 
+program was appropriately modified and developed for a 
+seven-day period of one hour each (inclusive of 45 minutes 
+of practices and 15 minutes of satsang). The program 
+started with loosening exercises, five rounds of 13 step 
+‘suryanamaskara’ excluding invocation (due to lack of 
+time), cyclic meditation, ‘Kapalabhatti’, ‘Nadishuddhi’ 
+pranayama, and chanting (Nadanusandana). Emphasis 
+was on awareness of calmness and silence from within 
+during asana practice. For this reason, explanations about 
+the benefits of each asana was given during the practice 
+and included as topics for the ‘Satsang’ at the end of each 
+day’s program. Caregivers were consciously taught to 
+focus on the ‘stretch’ with maintaining easy and relaxed 
+breathing during asana performance. Paschimuttanasana’, 
+‘Halasana’, and Sarvangasana were excluded from the 
+program as the authors felt that it would be challenging 
+for the caregivers to learn and practice these asanas due 
+to their age.
+For face validation, on asking whether the overall yoga 
+program would achieve its objective of helping the 
+caregivers reduce their burden and stress, six of the ten 
+experts (60%) gave a rank of four (very much useful). 
+At pilot stage
+Of the five caregivers who underwent the pilot yoga 
+program, four of them assigned a score of four or five (on a 
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+46
+Jagannathan, et al.: Need-based yoga program for caregivers of patients with schizophrenia
+five-point Likert scale, five being extremely useful) for the 
+overall program, handouts distributed, and performance of 
+the trainer. Qualitative feedback of the caregivers further 
+endorsed the feasibility and usefulness of the program 
+(M: Member):
+• 
+“The entire program was good as it taught us the 
+importance of taking care of our own health. I liked 
+to attend the program” (M1).
+• 
+“I liked the program as it helped to reduce my physical 
+problem (leg pain) and gave me a relaxed feeling” (M2).
+• 
+“The program helped me to understand the problem 
+(of my health) and find a way to get relief. I liked the 
+chanting of slokas the best.”(M3)
+• 
+“The instructor and her way of teaching were very 
+good. Also I feel Suryanamskar benefitted me the 
+most.” (M5).
+DISCUSSION
+The challenges faced by caregivers in dealing with their 
+relative who is suffering from schizophrenia are varied 
+and extensive. A number of interventions offered to 
+family members with patients of schizophrenia have 
+been developing to help deal with the burden and stress 
+of caring. The current study in an attempt to develop a 
+need-based yoga program describes the steps involved in 
+the program development, content and face validation, 
+and pilot testing of the program.
+There is hardly any research study that discusses the 
+development and effectiveness of standardized training 
+programs based on the assessed needs of caregivers of 
+persons suffering from schizophrenia in India. This 
+attempt to develop a structured intervention program 
+based on the holistic coverage of all the needs of the 
+family caregivers—via a participatory approach (i.e., the 
+caregivers themselves opined their needs and areas they 
+required training in which was incorporated to develop 
+the program) is of significant importance, even though we 
+were unable to match all the needs of the caregivers to the 
+contents of yoga program (where the focus was more to 
+reduce burden of the caregivers).
+The yoga program was developed after a lot of collective 
+thought and scientific rigor. The possible effects of each 
+asana and exercise on the physiology and mental health of 
+the caregiver was weighed to retain the asana/exercise in 
+the program (whether it physiologically reduced the stress 
+and mentally reduced burden and improved coping). A 
+number of related factors such as age and possible health 
+conditions of the caregiver were taken into consideration 
+before incorporating a particular asana/exercise into the 
+program. Experts had opined the importance of educating 
+the caregivers about the benefits of the asanas/exercises at 
+the onset or during the satsang—incorporation of which 
+helped caregiver gain greater awareness of the subtle 
+changes in the physical and mental state over the period 
+of the program.
+Though a few experts were skeptical of the effects of yoga 
+in helping caregivers relieve their burden and stress, 
+majority of them felt that the overall yoga program would 
+achieve its objective. Skepticism could be valid, as both 
+concepts of burden and stress are complex. Varied practical 
+issues could weigh on the caregivers’ mind when asked to 
+rate their burden—example, financial burden and stress 
+in caregivers is a prolonged effect of enduring certain 
+unresolved practical problems.
+Another critique of the above program was that it was too 
+short to enable the caregivers to imbibe the yoga techniques 
+into daily practice. Traditional yoga therapists would 
+argue that the seven-day program could be too short to 
+perceive any effects of yoga. However, development of an 
+elaborate program in the current setting would have its 
+own limitations, mainly being that of high drop-outs and 
+inability to reach out to majority of the caregivers. This 
+is mainly because the average period of stay of a patient 
+and his caregiver in any psychiatric setting is less than one 
+week. The statistics at NIMHANS depict the average stay of 
+in-patients and their caregivers as three weeks. However, 
+as the patient is usually acutely symptomatic in the first 
+week, it is challenging to conduct any intervention with 
+the caregiver alone, as there is no one else to take care of 
+the patient. There are many barriers like convincing people 
+to travel long distances from their homes to a center for 
+yoga therapy/psychosocial interventions[16] once they are 
+discharged. In this context, we believe that our seven-day 
+program was pragmatic in its timeline and achieved its goal 
+of reaching out to maximum caregivers who were admitted 
+in the wards along with their patients at NIMHANS, during 
+the study period.
+The sociodemographic profile of the caregivers who 
+participated in the programs was consistent with that 
+of earlier studies on Indian caregivers of persons with 
+schizophrenia.[17,18] All caregivers were family members. 
+Most of them were parents, who were working and were 
+into late adulthood or old age.
+The feasibility and usefulness of the yoga program was 
+endorsed by the caregivers. The fact that the caregivers 
+were able to perform all the asanas properly, understand 
+its benefits, and feel relaxed indicates that the program 
+was feasible and could be tested on a larger population.
+CONCLUSION
+This study is one of the first studies to use a sound 
+methodology of inductive enquiry model for the 
+47
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Jagannathan, et al.: Need-based yoga program for caregivers of patients with schizophrenia
+development of a need-based yoga program for caregivers 
+of in-patients with schizophrenia in India. These findings 
+are highly indicative and future studies could test the 
+efficacy of the program with a larger quantitative sample 
+to reconfirm its validity, reliability, and generalizability. 
+The researchers plan to test the efficacy of this validated 
+yoga program for family caregivers of inpatients with 
+schizophrenia in India in a larger randomized control trial, 
+as an outcome of this study.
+ACKNOWLEDGEMENT
+The team would like to thank Dr. Hariprasad VR (Senior Research 
+Fellow, Advanced Centre for Yoga, NIMHANS) and Meghna S 
+Deshpande (Yoga instructor) for their contribution in designing 
+the yoga program.
+REFERENCES
+1.	
+Yogendra. Yoga Asanas simplified. Yogendra Publication Fund – The yoga 
+Institute, Mumbai, India; 1997.
+2.	
+Satyananda Saraswati. Asana Pranayama Mudra Bandha. Munger, Bihar, 
+India: Yoga publications trust; 2008.
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+Nagendra HR, Nagarathna R. New perspectives in stress management. 
+Vivekananda Yoga Research Foundation, Bangalore: Swami Vivekanand 
+Yoga Prakashana; 2008.
+4.	
+Puymbroeck MV, Payne LL, Hsieh PC. A phase I feasibility study of yoga 
+on the physical health and coping of informal caregivers. Evid Based 
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+Waelde LC, Thompson L, Gallagher-Thompson D. A pilot study of a yoga 
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+6.	
+Peeters JM, Van Beek AP, Meerveld JH, Spreeuwenberg PM, Francke AL. 
+Informal caregivers of persons with dementia, their use of and needs for 
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+BMC Nurs 2010;9:9.
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+Rosa E, Lussignoli G, Sabbatini F, Chiappa A, Di Cesare S, Lamanna L, 
+et al. Needs of caregivers of the patients with dementia. Arch Gerontol 
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+Lai CK, Chung JC. Caregivers’ informational needs on dementia and dementia 
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+Colantonio A, Cohen C, Pon M. Assessing support needs of caregivers 
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+2001;37:231-43.
+10.	 Jagannathan A, Thirthalli J, Hamza A, Hariprasad VR, Nagendra HR, 
+Gangadhar BN. A qualitative study on the needs of caregivers of inpatients 
+with schizophrenia in India. Int J Soc Psychiatry 2011;57:180-94.
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+Iyengar BK. Light on the yoga sutras of patanjali. London: Harper Collins 
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+Rigveda-Samhitā: Śrimat-Sāyanāchārya virachita-bhāṣya-sametā (First ed.). 
+Pune, India: Vaidika Samśodhana Mandala; 1933.
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+Kaivalyadhama S.M.Y.M Samiti; 1978.
+14.	 Gharote ML, Devnath P, Jha VK. Hatharatnavali (A treatise on Hathayoga) 
+of Srinivasayogi. Lonavala: The Lonavala Yoga Institute; 2002.	
+15.	 Svatmarama. Hatha Yoga Pradipika of Svatmarama. 4th ed: Adyar (Madras, 
+India): Adyar Library and Research Centre; 1994.
+16.	 Baspure S, Jagannathan A, Varambally S, Thirthalli J, Nagendra HR, 
+Venkatasubramanian G, et al. Barriers to yoga therapy as an add on treatment 
+for schizophrenia - data from a clinical trial. Paper presented by Dr. Shubhangi 
+B at the National Conference on Naturopathy and Yoga, Recent Research 
+Trends, Jindal Nature Cure Hospital, Jindal Nagar Tumkur Road Bangalore, 
+January 2009.
+17.	 Srinivasan N. Together we rise-kshema family power. In: Murthy RS (Editor). 
+Mental Health by the People. Bangalore: Peoples Action for Mental Health 
+(PAMH); 2006.
+18.	 Murthy RS. Mental health by the people. Bangalore: Peoples Action for 
+Mental Health (PAMH); 2006.
+How to cite this article: Jagannathan A, Hamza A, Thirthalli J, 
+Nagendra HR, Nagarathna R, Gangadhar BN. Development and 
+feasibility of need-based yoga program for family caregivers of in-
+patients with schizophrenia in India. Int J Yoga 2012;5:42-7.
+Source of Support: Nil, Conflict of Interest: None declared
+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.
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subfolder_0/Development and validation of yoga module for Parkinson’s Disease.txt

@@ -0,0 +1,578 @@
+See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/315650406
+Development and validation of a yoga module for Parkinson disease
+Article  in  Journal of Complementary and Integrative Medicine · January 2017
+DOI: 10.1515/jcim-2015-0112
+CITATIONS
+7
+READS
+831
+5 authors, including:
+Some of the authors of this publication are also working on these related projects:
+Yoga for MS View project
+InSTAR - Schizophrenia Research Program @ NIMHANS View project
+Kashinath Metri
+Central University of Rajasthan
+48 PUBLICATIONS   168 CITATIONS   
+SEE PROFILE
+Shivarama Varambally
+National Institute of Mental Health and Neuro Sciences
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+Hr Nagendra
+SVYASA Yoga University
+144 PUBLICATIONS   4,806 CITATIONS   
+SEE PROFILE
+All content following this page was uploaded by Kashinath Metri on 07 February 2018.
+The user has requested enhancement of the downloaded file.
+DE GRUYTER
+Journal of Complementary and Integrative Medicine. 2017; 20150112
+Noopur Kakde1 / Kashinath G. Metri1 / Shivarama Varambally2 / Raghuram Nagaratna3 /
+H.R. Nagendra4
+Development and validation of a yoga module
+for Parkinson disease
+1 Swami Vivekananda Yoga Anusandhana Samsthana University, Yoga and Life Sciences, Bangalore, India, E-mail:
+[email protected], [email protected]
+2 Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS] Bangalore, Bangalore, India,
+E-mail: [email protected]
+3 Holistic Health Centre, S-VYASA Bangalore, Bangalore, India, E-mail: [email protected]
+4 S-VYASA University, Bangalore, Bangalore, India, E-mail: [email protected]
+Abstract:
+Background: Parkinson’s disease (PD), a progressive neurodegenerative disease, affects motor and nonmotor
+functions, leading to severe debility and poor quality of life. Studies have reported the beneficial role of yoga in
+alleviating the symptoms of PD; however, a validated yoga module for PD is unavailable. This study developed
+and validated an integrated yoga module(IYM) for PD.
+Methods: The IYM was prepared after a thorough review of classical yoga texts and previous findings. Twenty
+experienced yoga experts, who fulfilled the inclusion criteria, were selected validating the content of the IYM.
+A total of 28 practices were included in the IYM, and each practice was discussed and rated as (i) not essential,
+(ii) useful but not essential, and (iii) essential; the content validity ratio (CVR) was calculated using Lawshe’s
+formula.
+Results: Data analysis revealed that of the 28 IYM practices, 21 exhibited significant content validity (cut-off
+value: 0.42, as calculated by applying Lawshe’s formula for the CVR).
+Conclusions: The IYM is valid for PD, with good content validity. However, future studies must determine the
+feasibility and efficacy of the developed module.
+Keywords: neurological disorders, Parkinson disease, stiffness, tremors, yoga
+DOI: 10.1515/jcim-2015-0112
+Received: December 15, 2015; Accepted: January 17, 2017
+Introduction
+Parkinson’s disease (PD) is one of the most common progressive neurodegenerative disorders and is character-
+ized by various motor symptoms such as resting tremors, bradykinesia, rigidity, and imbalance. As the disease
+progresses, additional symptoms, such as autonomic dysfunction, cognitive impairment, neurobehavioral ab-
+normalities, and sensory abnormalities, such as anosmia, paraesthesia, and pain, also develop [1, 2].
+A survey reported that 6.3 million persons had PD [3]. PD is predominantly observed in men [4, 5]; it affects
+the financial aspects and quality of life of patients and makes them dependent on others [6]. Levodopa is the
+most potent drug used in the conventional management of PD [7]. However, this drug has various adverse
+effects such as psychosis, motor fluctuations, and dyskinesia. Dopamine resistance can cause several motor
+difficulties, such as speech impairment, abnormal posture and gait, and balance problems, and non-motor
+symptoms such as autonomic dysfunction, mood and cognitive impairment, sleep problems, and pain [8]. A
+survey reported that 40 % of patients with PD used at least one alternative therapy [5].
+Yoga
+Yoga is a mind–body intervention and comprises physical practices (asanas), breathing techniques
+(pranayama), and meditation and relaxation techniques. Yoga is a popular complementary and alternative
+medicine modality worldwide. Studies have reported several health benefits of yoga for clinical conditions such
+as asthma [9], coronary artery disease [10], diabetes mellitus [11], pulmonary tuberculosis [12, 13], epilepsy, fi-
+bromyalgia, and arthritis [14].
+Kashinath G. Metri is the corresponding author.
+© 2017 Walter de Gruyter GmbH, Berlin/Boston.
+Authenticated | [email protected] author's copy
+Download Date | 6/16/17 1:17 PM
+Kakde et al.
+DE GRUYTER
+Furthermore, studies have reported a positive role of yoga in chronic neurological conditions such as mul-
+tiple sclerosis [15], carpal tunnel syndrome [16], migraine [17], and stroke [18].Yoga was reported to improve
+strength and flexibility [19].
+Yoga and neurological disorders
+The practice of yoga improves the measures of gait, fatigue, quality of life, and physical function in several
+neurological conditions [15, 20–22].
+Yoga is beneficial in several neurological conditions such as multiple sclerosis and stroke [23]. It improves
+fatigue, cognitive function [24], balance, and quality of life in multiple sclerosis [15, 25] and improves the balance
+confidence and quality of life of patients with stroke [18, 22, 26].
+PD and yoga
+In a randomized controlled trial, 13 patients with PD were divided into the Iyengar yoga (intervention) and
+waitlist-control groups. The intervention group performed 60 min of Iyengar yoga daily for 12 weeks. At the
+end of 12 weeks, marked improvement was observed in the United PD Rating Scale scores; motor performance;
+Berg Balance Scale scores; and gait, hip, knee, ankle, and shoulder range of motion in the intervention yoga
+group compared with the control group [27].
+In another single-group prepost study, 10 adults with PD performed a 60-min session of Hatha Yoga weekly
+for 8 weeks, following which considerable improvements were observed in anxiety, depression, functional
+strength, and leg flexibility [28].
+In a similar pre-post study, 17 participants with PD underwent a 10-week Iyengar yoga program consisting
+of 2-h yoga classes and a daily 30-min home practice session. After the intervention, marked improvements
+were noticed in walking speed, Short Physical Performance Battery scores, balance, and Falls Efficacy Scale
+scores [29].
+Another study assessing nine adults with PD, who participated in a twice weekly Hatha yoga program
+(75-min duration) for 12 weeks, reported remarkable improvements in physical measures (chair stand and sit-
+and-reach test) and depression [30].
+A systematic review on PD concluded that yoga alleviates PD-related symptoms, including motor function,
+muscle strength, flexibility, balance, gait difficulties, poor balance, and lower-body weakness. It also improves
+depression, sleep, and quality of life of patients with PD [31].
+Apart from these studies, three single-case studies of patients with PD aged 57, 59, and 69 years who un-
+derwent yoga interventions for 6 months (90-min daily), 3 weeks (60-min daily), and 8 months (60-min daily),
+respectively, reported improvements in the body awareness and motor function of these patients [32].
+Other alternative therapies in PD
+Approximately 40 % of patients with PD use alternative therapies. Ayurveda, Tai Chi, mindfulness, massage
+therapy, and acupuncture are the most commonly used alternative therapies for PD [33, 34]. Most of these
+therapies have promising roles in PD management [34]. An ayurvedic herb called Mucuna prureins was used as
+an herbal dopamine supplement, and it played important role in improving the motor function and quality of
+life of patients with PD [35].
+However, the strong recommendations by previous studies for using yoga in PD have not been confirmed
+with a well-designed and validated yoga module [31]. This study developed and validated an integrated yoga
+module (IYM) for patients in the first three stages of PD (without comorbidities such as hypertension and
+diabetes). The basic module was designed such that improvisations could be made according to the participant
+requirements (e. g., if they require support or assistance).
+Materials and methods
+The IYM was developed as follows.
+Authenticated | [email protected] author's copy
+Download Date | 6/16/17 1:17 PM
+DE GRUYTER
+Kakde et al.
+Step 1: Compilation of literature on PD
+a. In this phase, we reviewed traditional [36, 37] and contemporary yoga texts [38–40].
+b. Research papers on the use of yoga in neurological conditions, including modern scientific reviews of PD,
+were identified using different search engines such as PubMed and Google Scholar. Indexing terms such as
+“yoga,” “Parkinson’s disease,” “movement disorders,” “pranayama,” and “Hathayoga” were used in the
+search. All experimental studies that only used yoga as the therapy for PD were included.
+Step 2: Sorting the literature on PD
+The compiled literature was searched to identify the common and unique features described in each study.
+Studies published in scientific journals were extracted, which provided scientific support to the literary search.
+Step 3: Preparing a yoga module based on previous literature on PD
+A customized protocol was developed, which comprised practices supported by classical texts and research
+evidence. This preliminary module comprised 28 practices.
+Step 4: Validation of the yoga module by experts
+For validation, the complete module was presented to yoga experts with clinical experience [who had either a
+doctorate or Doctor of Medicine degree in Yoga, with a minimum of 5 years’ experience or a Masters degree
+in yoga (MSc Yoga)/yoga therapist, with a minimum of 7 years’ experience]. These experts were requested to
+validate the practices in the proposed module on a three-point scale as follows.
+1. Not essential: has no role in improving any symptoms or the quality of life of patients with PD
+2. Useful but not essential: useful in improving general wellbeing, but the benefits are not specific to PD symp-
+toms
+3. Essential: very important for improving PD symptoms
+A panel comprising 20 experts with the aforementioned qualifications was assembled for determining the con-
+tent validity. Experts in yoga therapy with clinical experience (≥5 years) were also considered yoga experts.
+Among the 20 experts, more than seven had previously applied yoga therapy in patients with PD and were
+already using most of the practices included in this module. For calculating the content validity ratio (CVR),
+the expert panel was asked to comment on the necessity of the included items.
+The CVR for the total scale was computed based on the experts’ validation. According to Lawshe’s formula,
+if more than half of the panelists indicate that an item is essential, then that item has the minimum content
+validity. The CVR for our scale was ≥0.42, which was considered satisfactory for a panel of 20 experts.
+Statistical analysis
+The cut-offvalue of 0.42 was calculated by applying Lawshe’s formula for the CVR (Lawshe CH, 1975). The
+mean CVR across the items may be used as an indicator of the overall test content validity.
+Lawshe’s formula:
+CVR = (Ne −N/2)
+N/2
+where
+Ne = total number of panelists indicating “essential” for each practice
+N = total number of panelists
+Authenticated | [email protected] author's copy
+Download Date | 6/16/17 1:17 PM
+Kakde et al.
+DE GRUYTER
+Results
+Of the 28 IYM practices selected for validation, 21 had a CVR score of ≥0.49, indicating high content validity.
+These practices are listed in Table 1. Seven practices (Table 2) had a CVR score of <0.49, indicating low content
+validity.
+Table 1: Practices with a CVR score of ≥0.49.
+SI. no.
+Practice
+CVR
+1.
+Griva Shithilikarana
+0.9
+2.
+Bhuja Shithilikarana
+0.8
+3.
+Kati Shithilikarana
+0.7
+4.
+Janu Shithilikarana
+0.7
+5.
+Gulpha Shithilikarana
+0.6
+6.
+Hands In and Out Breathing
+1
+7.
+Hand Stretch Breathing
+0.9
+8.
+Shashankasana Breathing
+0.6
+9.
+Quick Relaxation Breathing
+0.8
+10.
+Ardha Kati Chakrasana
+0.5
+11
+Setubandhasana
+0.8
+11.
+Suptaudarakarshanasana
+0.8
+12.
+Ardha Pavanamuktasana
+0.6
+13.
+Bhujangasana
+0.8
+14.
+Ardha Shalabhasana
+0.7
+15.
+Deep Relaxation Technique
+0.9
+16.
+Kapalabhatti
+0.5
+17.
+Vibhagya Pranayama
+0.9
+18.
+Nadi Shuddi
+1
+19
+Bhramari Pranayama
+0.9
+20.
+Nadanusandhana
+1
+21.
+Om Dhyana
+0.5
+SI. no.
+Practice (Sanskrit)
+Practice (English)
+Rounds
+Time, minutes
+1. Specific loosening practices for Parkinson disease
+a.
+Grive Shithilikarana
+Neck exercises
+3
+1
+b.
+Bhuja Shithilikarana
+Shoulder rotation
+3
+1
+c.
+Kati Shithilikarana
+Waist rotation
+3
+1
+d.
+Janu Shithilikarana
+Knee tightening
+3
+1
+e.
+Gulpha Shithilikarana
+Ankle rotation
+3
+1
+2. Specific breathing practices for Parkinson disease
+a.
+Shvasa Kriya
+Hands in and out
+3
+2
+b.
+Shvasa Kriya
+Hand stretch breathing
+3
+2
+c.
+Shashankasana with “m” Kara
+Moon pose breathing
+3
+2
+3. Specific relaxation after breathing
+a.
+Shavasana (with chanting of “A”)
+Quick relaxation technique
+1
+3
+4. Specific standing Asanas for Parkinson disease
+a.
+Ardha Kati Chakrasana
+Lateral arc pose
+Right side
+1
+1
+Left side
+1
+1
+Authenticated | [email protected] author's copy
+Download Date | 6/16/17 1:17 PM
+DE GRUYTER
+Kakde et al.
+5. Specific Supine Asanas for Parkinson Disease
+a.
+Setubandhasana
+Bridge pose
+3
+2
+b.
+Suptaudarakarshanasana
+Folded leg stretch
+Right side
+3
+3
+Left side
+3
+c.
+Ardhapavanamuktasana
+Half wind releasing pose
+Right side
+1
+1
+Left side
+1
+1
+6. Specific Supine practices for Parkinson disease
+a.
+Bhujangasana
+Serpent pose
+3
+2
+b.
+Ardha Shalabhasana
+Half locust pose
+Right side
+3
+1
+Left side
+3
+1
+7. Specific relaxation after Asanas for Parkinson disease
+a.
+Shavasana
+Deep relaxation technique
+1
+5
+8. Specific Kriya practices for Parkinson disease
+a.
+Kapalabhatti
+Skull brightening breath
+Daily:60 counts
+1
+9. Specific pranayama practices for Parkinson disease
+a.
+Vibhagya
+Sectional breathing
+Pranayama
+Abdominal
+3
+Thoracic
+3
+4
+Shoulder
+3
+b.
+Nadi Shuddi
+Alternate nostril breathing
+9
+4
+c.
+Bhramari Pranayama
+Bumble bee chant
+5
+2
+10. Specific meditation practices for Parkinson disease
+a.
+Nadanusandhana
+Sound resonance technique
+AA kara
+9
+UU kara
+9
+5
+MM kara
+9
+AUM kara
+9
+b.
+Om Dhyana
+Om meditation
+5
+Table 2: Practices with a CVR score of <0.49.
+SI. no.
+Practice
+CVR
+1.
+Tiger Breathing
+0.2
+2.
+Ardha Chakrasana
+0.2
+3.
+Pashchimottanasana
+0
+4.
+Gomukasana
+0
+5.
+Trataka
+0.3
+6.
+Ujjayi Pranayama
+0.4
+Authenticated | [email protected] author's copy
+Download Date | 6/16/17 1:17 PM
+Kakde et al.
+DE GRUYTER
+Discussion
+In the present study, we developed a valid yoga module for PD. We selected different yoga practices, including
+loosening practices, breathing practices, yoga postures, and yoga-based relaxation and meditation techniques,
+from classical yoga texts and previous research findings. Twenty qualified experts, who fulfilled the study
+criteria, validated this module. Of the 28 practices subjected to validation, 21 had a CVR score of ≥0.49 and
+were included in the final validated yoga module.
+To date, no previous studies have focused on the validation of a yoga module for PD.
+This study was conducted in two phases: (a) designing the yoga module for PD and (b) expert validation of
+the module for PD.
+In the first phase, the IYM was designed based on literature reviews of traditional textual references and
+recent research publications. We did not find any direct references for yogic practices capable of improving
+PD symptoms. However, recent Hatha yogic texts [41, 42] have increasingly emphasized on improving health
+through different yogic practices.
+In addition, recent findings on PD reported by several schools of yoga have helped in formulating a
+yoga module for PD. The CVR was calculated for all 28 practices in our yoga module. Of these, 21 practices
+(CVR≥0.42) were included in the validated yoga module (Table 3). The remaining seven practices (CVR≤0.42),
+namely Tiger Breathing, Ardha Chakrasana (0.2), Tiger Breathing (0.2), Pashchimottanasana (0), Gomukasana
+(0), Trataka (0.3), and Ujjayi Pranayama (0.4), were used as complimentary poses for important postures to align
+the body and mind. These practices were slightly challenging for patients with PD at a beginner level.
+Therefore, most experts did not consider them as essential for PD therapy. Apart from these seven practices,
+the 21 practices were considered essential for PD therapy; thus, the final CVR satisfied the minimum value, as
+per Lawshe’s CVR.
+Similar to any other exercise protocol, an ideal yoga module consists of modes (types), frequencies, inten-
+sities, durations, and progression. Determining the appropriate mode depends upon patient preference and
+safety issues associated with the stage of PD or other conditions. The frequency, intensity, and duration are
+specific to the type of activity and should be customized according to the patient’s ability to safely perform the
+activity.
+The loosening practices (Shithilikarna Vyayamas) included in this module helped in loosening the joints
+and reducing the stiffness, which consequently helped in easy mobility.
+The standing yoga asana (Ardhakti Chakrasana) helped in improving balance and strengthened the hip
+extensor, quadriceps, hamstring, and calf muscles.
+Other supine and prone postures helped in improving flexibility and strength and reducing the stiffness in
+the back, hip, and lower limb muscles, thereby aiding mobility [27].
+All relaxation techniques helped in reducing stress and anxiety and improving the relaxation of the body
+and mind. This facilitated the improvement of anxiety, depression, and stress caused by PD [31].
+Conclusions
+The present IYM is a valid module for PD. However, future studies must determine the feasibility and efficacy
+of the IYM.
+Acknowledgement
+The authors thank Swami Vivekananda Yoga Anusandhana Samsthana University for granting permission
+to conduct this study and the experts for participating in this study. We also acknowledge Dr. Pramod Pal,
+Professor of Neurology at NIMHANS Bengaluru for his inputs regarding Parkinson’s Disease.
+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.
+Authenticated | [email protected] author's copy
+Download Date | 6/16/17 1:17 PM
+DE GRUYTER
+Kakde et al.
+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.
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+View publication stats
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subfolder_0/Diet enriched with fresh coconut decreases blood glucose levels and body weight in normal adults.txt

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+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Journal of Complementary and Integrative Medicine. 2018; 20170097
+Short Communication
+Venugopal Vijayakumar1 / Nagashree R.Shankar1 / Ramesh Mavathur1 / A.Mooventhan2,3 /
+Sood Anju4 / NK Manjunath5
+Diet enriched with fresh coconut decreases blood
+glucose levels and body weight in normal adults
+1 Division of Yoga and Life Sciences,S-VYASA University,Bengaluru,Karnataka,India
+2 All India Institute of Medical Sciences (AIIMS),Department of Yoga,Center for Integrative Medicine and Research (CIMR),
+New Delhi,India,E-mail: [email protected]
+3 Division of Yoga and Life Sciences,Department of Research and Development,S-VYASA University,Bengaluru,Karnataka,
+India,E-mail: [email protected]
+4 S-VYASA University,and MD,Diet and Weight Management Health Centre,Division of Yoga and Life Sciences,Bengaluru,
+India
+5 Division of Yoga and Life Sciences,and Head,Department of Research and Development,S-VYASA University,Bengaluru,
+Karnataka,India
+Abstract:
+Background: There exist controversies about the health effects of coconut. Fresh coconut consumption on hu-
+man health has not been studied substantially. Fresh coconut consumption is a regular part of the diet for many
+people in tropical countries like India, and thus there is an increasing need to understand the effects of fresh
+coconut on various aspects of health.
+Aim: To compare the effects of increased saturated fatty acid (SFA) and fiber intake, provided by fresh coconut,
+versus monounsaturated fatty acid (MUFA) and fiber intake, provided by a combination of groundnut oil and
+groundnuts, on anthropometry, serum insulin, glucose levels and blood pressure in healthy adults.
+Materials: Eighty healthy volunteers, randomized into two groups, were provided with a standardized
+diet along with either 100 g fresh coconut or an equivalent amount of groundnuts and groundnut oil for a pe-
+riod of 90 days. Assessments such as anthropometric measurements, blood pressure, blood sugar and insulin
+levels were performed before and after the supplementation period.
+Results: Results of this study showed a significant reduction in fasting blood sugar (FBS) in both the groups.
+However, a significant reduction in body weight was observed in the coconut group, while a significant increase
+in diastolic pressure was observed in the groundnut group.
+Conclusions: Results of this study suggest that fresh coconut-added diet helps reduce blood glucose levels and
+body weight in normal healthy individuals.
+Keywords: blood glucose level, body weight, coconut, groundnut, insulin
+DOI: 10.1515/jcim-2017-0097
+Received: July 24, 2017; Accepted: January 5, 2018
+Background
+Many ancient philosophies on food and alternate therapies of medicine have enumerated multiple health bene-
+fits of coconut [1, 2, 4]. However, medical research has associated coconut fats with dyslipidemia and increased
+body weight, disturbed glucose metabolism and insulin resistance due to its rich saturated fat 92%% [5] and
+saturated fatty acids (SFA) content [6]. All the above listed factors contribute to lifestyle disorders/noncom-
+municable diseases (NCDs) which are major global health challenges of the twenty-first century. According to
+latest data, out of 56 million deaths worldwide, 86%% are due to NCDs [7]. South Asians have a higher risk of
+developing NCDs at a lower body mass index (BMI) and waist circumference (WC) than other ethnic groups
+[8]. Hence, it is important to resolve the controversy surrounding coconuts which most Indians and Asians
+consume every day, in either the fresh or dry form as an ingredient in their food as most traditional recipes de-
+mand addition of fresh coconut. Studies on the effect of coconut oil consumption are contradictory, with some
+showing deleterious effects [9–11] and others showing neutral effects [12, 13]. However, the available literature
+on the health effects of fresh coconut on human subjects is too small and inconclusive. Fresh coconuts not only
+A.Mooventhan is the corresponding author.
+© 2018 Walter de Gruyter GmbH,Berlin/Boston.
+1
+Brought to you by | University of California - Santa Barbara
+Authenticated
+Download Date | 2/27/18 5:46 PM
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+Vijayakumar et al.
+DE GRUYTER
+contain SFA but are rich in fiber, protein, and a number of vitamins, minerals and electrolytes along with 40–50
+% moisture [14]. Many studies report that increased consumption of fiber improves glucose metabolism, glu-
+cose–insulin homeostasis, endothelial functioning and weight loss and also reduce inflammation [6, 15, 16]. On
+the other hand, there are studies showing evidence that consuming SFA negatively affects the whole metabolic
+profile by decreasing the particle size of high-density lipoprotein (HDL) and low-density lipoprotein (LDL),
+increasing triglycerides and plasma glucose [11]. The present study evaluates the influence of daily consump-
+tion of fresh coconut on anthropometry and physical and biochemical parameters in comparison to groundnut
+which is rich in monounsaturated fatty acid (MUFA) in healthy adults.
+Materials and methods
+Subjects
+The present study was carried out on 80 healthy adults who were recruited following advertisement of the
+study within a residential university campus. Sample size was calculated using G-power 3.1.9.2 software us-
+ing alpha = 0.05, power = 0.95 and effect size = 0.570. A sample size of (n = 27) in each group was obtained.
+Healthy individuals between 18 and 40 years were recruited for the study. Accounting for possible dropouts,
+40 subjects were recruited for each group. Subjects were aged 23.8 ± 4.8 years and BMI 21.29 ± 2.07-kg/m2.
+Subjects intolerant to nuts were excluded. Subjects were nonsmokers and were teetotalers. All subjects signed
+a written consent to participate in the study and were free to withdraw at any time. The study protocol was
+approved by the institutional ethics committee. The study was registered with Clinical Trial Registry of India
+(CTRI/2016/07/007071).
+Study design
+The study was a randomized comparative study of 90-day duration. The subjects were randomized into two
+groups – coconut group and groundnut group. The randomization was done using a computer-generated ran-
+dom number table (www.randomizer.org). Subjects were trained and requested to abstain from consuming any
+other food apart from the food and snacks provided by the coconut project kitchen, set up exclusively for the
+study. Compliance to the diet was ensured by serving specific portion sizes for each individual based on their
+calorie requirement and maintenance of individual log book.
+Assessments
+Anthropometry: Subjects’ weight and height were recorded by the same person on day 1 and day 90. Waist–hip
+ratio (WHR) and BMI (weight in kg/height in meter squared) were determined. Body weight was measured
+using a digital scale. Height, waist and hip circumference were measured using a standard measuring tape.
+The systolic and diastolic blood pressures were recorded manually with a sphygmomanometer in lying-down
+position.
+Biochemical data and fatty acid analysis
+Fasting blood sugar (FBS) was measured using fully automated Biochemistry Analyzer (Mindray BS-390,
+China). Insulin was measured with commercially available human enzyme immunoassay ELISA kits (USCN
+Biotech, Houston, Texas, USA) using Perkin Elmer Multimode plate reader (EnSpire, Waltham, Massachusetts,
+USA).
+Intervention
+All subjects received a balanced diet and consumed this standard meal plus intervention for a period of 90
+days. Along with the standard diet, the coconut group consumed 100 g of fresh coconut per day, while the
+groundnut group consumed 45 g of groundnuts and 22 g of groundnut oil per day daily for a period of 90
+days. A combination of groundnut and oil was used to make the two study interventions isocaloric, and to
+2
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+ensure similar macronutrient composition. The coconut group consumed 2,689 kcal, 392 g of carbohydrates
+(58.3 % of Energy (E), 77 g of proteins (11.4 % of E) and 90 g (30.3 % of E) of fat and the groundnut group
+consumed 2,699 kcal, 384 g of carbohydrates (57 % of E), 89 g protein (13 % of E) and 90 g of fat per day (30 % of
+E). The fiber content of the interventions was 13.6 g of total fiber (12.7 g insoluble dietary fiber and 0.9 g soluble
+dietary fiber) in coconut diet and 11 g total fiber (8.5 g insoluble dietary fiber and 2.5 g soluble dietary fiber)
+in groundnut diet. Details on the fatty acid compositions of the coconut and groundnut meals are provided in
+Table 1.
+Table 1: Fatty acid composition of the two meals measured through gas chromatography.
+Fatty acid type
+Lipid numbers
+Coconut meal
+Groundnut meal
+Lauric acid (MCFA)
+12:0
+27.3
+0
+Myristic acid (MCFA)
+14:0
+11.7
+0
+Palmitic acid (LCFA)
+16:0
+14.3
+14.4
+Stearic acid (LCFA)
+18:0
+4.4
+4.7
+Vaccenic acid (MUFA)
+18:1
+17.9
+40.6
+Linoleic acid (PUFA)
+18:2 n-6
+23.1
+36.7
+Linolenic acid (PUFA)
+18:3 n-3
+1.2
+0.8
+Total SFA
+58
+22
+MCFA, Medium-chain fatty acid; LCFA, Long-chain fatty acid; MUFA,Monounsaturated fatty acid; PUFA, Polyunsaturated fatty acid;
+SFA, Saturated fatty acid.
+Fresh coconut was generally added to snacks such as boiled or sprouted grams or/and in chutney (a sauce in
+the cuisines of the Indian subcontinent, a side dish made with coconut, coriander, roasted bengal gram, green
+chilies and salt). Groundnuts were added to snacks or powdered and added to a dish in meals. Groundnut oil
+was used during cooking of groundnut group meals. The dietary intake of SFA was almost 2.6 times higher in
+the coconut group as compared to the groundnut group (Table 1).
+Data analysis
+Data were checked for normality using Kolmogorov–Smirnov test. Within-group analysis was performed using
+a paired-sample t test and between-group analysis was performed using independent sample t test with the
+use of Statistical Package for the Social Sciences (SPSS) for Windows, Version 16.0. Chicago, SPSS Inc. p < 0.05
+was considered as significant.
+Results
+Of the 80 subjects recruited, 58 subjects [27 in the coconut group and 31 in the groundnut group] completed the
+study. Both the groups at baseline were comparable. Table 2 shows the mean score and standard deviation of all
+the variables measured before and after the intervention. Results of this study showed a significant reduction
+in FBS in both the groups, but no difference was seen between the groups (p > 0.05). However, a significant
+reduction in body weight was observed in the coconut group unlike the groundnut group, while a significant
+increase in diastolic blood pressure was observed in the groundnut group (p = 0.01) unlike the coconut group.
+There were no significant changes in insulin levels, BMI, mid-upper-arm circumference, WC and WHR in both
+the groups.
+Table 2: Baseline and posttest assessments of coconut group and groundnut group.
+Variable
+Coconut group
+Groundnut group
+Independent t test
+Pretest
+Posttest
+Pretest
+Posttest
+t value
+p value
+Weight, kg
+59.8 ± 10.18
+59.05 ± 9.58a
+56.79 ± 7.29
+56.2 ± 7.9
+1.24
+0.22
+BMI, kg/m2
+21.61 ± 2.24
+21.38 ± 2.1
+21.02 ± 2.03
+20.8 ± 1.96
+1.03
+0.31
+MUAC, m
+0.2735 ± 0.02
+0.27 ± 0.02
+0.26 ± 0.03
+0.26 ± 0.02
+1.53
+0.13
+WC, m
+0.77 ± 0.07
+0.76 ± 0.07
+0.76 ± 0.09
+0.73 ± 0.11
+1.08
+0.28
+WHR
+0.82 ± 0.07
+0.79 ± 0.12
+0.82 ± 0.06
+0.81 ± 0.06
+0.86
+0.40
+SBP,mmHg
+111.04 ± 8.69
+110.59 ± 7.56
+107.23 ± 8.57
+107.68 ± 7.7
+1.45
+0.15
+3
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+DBP, mmHg
+75.63 ± 6.75
+76.07 ± 6.48
+72.58 ± 7.16
+75.48 ± 6.37b
+0.35
+0.73
+FBS, mmol/L
+4.63 ± 0.32
+4.23 ± 0.37c
+4.65 ± 0.43
+4.06 ± 0.57c
+1.31
+0.19
+Insulin, pmol/L
+72.66 ± 125.2
+41.57 ± 24.07
+132 ± 253
+69 ± 90
+0.46
+0.64
+All values are in mean ± standard deviation. ap < 0.05, bp < 0.01, cp < 0.001 within-group analysis using paired-sample t test. BMI, Body
+mass index; MUAC, Mid-upper-arm circumference; WHR, Waist–hip ratio; SBP, Systolic blood pressure; DBP, Diastolic blood pressure;
+FBS, Fasting blood sugar.
+Discussion
+In the present study, an attempt was made to understand the impact of fiber and high SFA from fresh coconut
+in comparison with fiber and fat (MUFA) from groundnuts when used in addition to a regular balanced meal.
+Results of this study showed a significant decrease in body weight in the coconut group unlike the ground-
+nut group. As early as 1987, Blundell et al. reported that fiber influences the body weight by influencing the
+control over the food consumption [17]. Fiber brings about satiety and hence ensures reduced quantity of con-
+sumption and reduces hunger for longer periods of time. This has been reported in many earlier studies [18–20].
+Another study reported consuming >25 g of fiber per day may help to decrease the prevalence of obesity [20].
+Mechanisms underlying this effect of fiber are due to a reduction in the energy density of the meal and prolong-
+ing the intestinal phase of nutrient processing and absorption [18]. Another study reported that the effectiveness
+of dietary fiber depends on the source and its chemical structure responsible for their physical properties [21].
+Coconut has high insoluble dietary fiber of 58.71 % (63.25 % total dietary fiber) [22]. A food is considered to
+be an “excellent source of fiber” if it contains 20 % of the recommended amount (5 g/serving) [23] and thus
+we can call fresh coconut as an excellent source of dietary fiber. Coconut fiber shows highest water retention
+and swelling capacity when compared to other dietary fibers [22]. But, the concern in increasing dietary fiber
+is its negative effect on the bioavailability of minerals like calcium, iron, zinc and magnesium. This is due to the
+property of dietary fiber to bind nonspecifically and reduce their absorption [24–26]. However, reports from
+medium-chain fatty acid (MCFA)-rich diets showed increased absorption of calcium and magnesium [27]. Not
+just fiber but also MCFA in coconut contributes to decrease in body weight. MCFAs in coconut oil contribute
+to decrease in body weight [28] by increasing daily energy expenditure through increased rate of oxidation of
+MCFA in liver. MCFA also induces satiety. Hormones including cholecystokinin, peptide YY, gastric inhibitory
+peptide, neurotensin and pancreatic polypeptide have been proposed to the underlying mechanisms by which
+MCFA may induce satiety; however, the exact mechanisms have not been established [29]. Another 4-week ran-
+domized double-blind study reported a decrease in body weight and body fat and showed a sparing effect on
+fat-free mass [30].
+Higher intake of saturated fat adversely affects glucose metabolism and insulin resistance [6]. But, in our
+study, high saturated fat content from fresh coconut did not have any negative effect on blood glucose. This is
+possibly due to the presence of fiber and the MCFA in coconut. Many earlier studies on fiber have reported this
+phenomenon [23, 31, 32]. Fiber-rich diets have proved to reduce glycosylated hemoglobin and day-long blood
+glucose by 16 % [33, 34]. The effect of fiber on glucose metabolism can be attributed to slow absorption and
+digestion of carbohydrates (slow gastric emptying), leading to a reduced demand for insulin [35] and improved
+glycemic index of the diet [16, 36]. Another reason for lowering of FBS could be due to the coconut protein.
+Coconut kernel protein has a potential effect in lowering the oxidative stress associated with diabetes, and this
+was attributed to the presence of high amount of biologically potent arginine [37].
+We also found trends of reduction in insulin levels in our study, although it was not significant. It is well
+understood that hyperinsulinemia is most often caused by insulin resistance where pancreas tries to compen-
+sate by making more insulin. Insulin resistance may eventually lead to the development of type 2 diabetes.
+Similar results were seen in another study which reported decreased insulin with increased fiber intake [38].
+MCFA also have been reported to have a positive impact on blood sugar and preserve insulin sensitivity by
+suppressing fat deposition through enhanced thermogenesis and fat oxidation [39]. After a single oral dose of
+MCFA, a slight hypoglycemia was observed way back in 1982 and was reported to be as a result of decrease in
+the hepatic glucose output and increase in concentration of insulin. Insulin secretion seems to increase because
+of stimulation of islets of Langerhans by either ketone bodies produced by MCFAs or MCFA themselves [27].
+Obesity [40], inflammation and oxidative stress are attributed to the pathogenesis of cardiovascular diseases
+including hypertension and atherosclerosis [41]. Consumption of fresh virgin coconut oil is reported to be ben-
+eficial in preventing cardiovascular diseases by reducing body weight, insulin resistance, hypertension, total
+cholesterol, triglycerides, phospholipids, LDL and very low-density lipoprotein (VLDL) levels, while improv-
+ing HDL and antioxidant status [9, 40, 41]. Similarly, it also prevents lipid and protein abnormality, without
+producing any detrimental effects on blood pressure and inflammatory biomarkers [41].
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+Coronary heart disease (CHD) is common in India and, recently, an increase in the incidence of CHD was
+reported from the South Indian state of Kerala (literally known as “land of coconut palms”), where the people
+consume a large amount of coconuts and coconut oil in their diet [12]. Consumption of coconut and coconut
+oil that contains high amounts of saturated fats were believed to be strongly associated with high incidence of
+CHD in Kerala. But, a case–control study revealed that there is no significant difference in coconut consumption
+between CHD patients and age- and sex-matched healthy individuals [12]. This indicates that there is no specific
+role for coconut or coconut oil in the causation of CHD of Indian patients from Kerala. Another study reported
+that the intake of coconut, fruits and vegetables was negatively associated with hypertension in the urban
+population of Trivandrum, Kerala, South India [42]. Presence of hyperlipidemia and heart diseases are reported
+to be uncommon among high coconut-consuming populations [43].
+India is facing an “epidemic” of NCDs resulting in substantial socioeconomic burden. Nutrition transition
+over the past few decades coupled with declining levels of physical activity due to rapid urbanization have re-
+sulted in escalating levels of obesity, dyslipidemia, subclinical inflammation, type 2 diabetes mellitus and CHD
+in Indians. Hence, a preventive approach like consumption of fresh coconut might help in preventing the escala-
+tion of NCDs in India [44]. Because, fresh coconuts are nutritious, which are not only rich in SFA, but also rich in
+fiber, protein, vitamins, minerals, electrolytes and moisture. Interestingly, the composition of the SFA found in
+the coconut consists of >50 % of MCFA, whose properties and metabolism differ from the long-chain SFA com-
+monly found in animal products [40]. Moreover, it has been reported to have numerous medicinal properties
+including antibacterial, antifungal, antiviral, antiparasitic, antidermatophytic, antioxidant [45], hypoglycemic
+[45, 46], cytoprotective [46], hepatoprotective and immunostimulant [45]. Previous studies also support the ev-
+idence that the consumption of coconut is effective in reducing body weight [40] and in improving increasing
+beneficial effect in the treatment of obesity, dyslipidemia, insulin resistance and hypertension [47].
+Strengths of the study: Daily consumption of fresh coconut has no negative impact on any markers discussed
+in the paper and could reduce blood glucose and body weight. This impact might reduce the risk of developing
+lifestyle disorders in healthy men and women. Moreover, this is one of the very few studies to report the effect
+of coconut consumption in a raw and fresh form on blood glucose levels, when compared to most other trials
+looking at the effect of coconut oil, and none of the subjects reported any adverse effect throughout the study
+period. Limitations of the study: The present study was conducted in healthy individuals aged 23.8 ± 4.8 years;
+thus, application of the results of this study either in elderly or in individuals with pathological conditions
+is limiting the scope of the study. Hence, further studies are required in elderly and in various pathological
+conditions for better understanding of the effect of fresh coconut intake.
+Conclusions
+Daily consumption of 100 g of fresh coconut, containing high levels of fiber and MCFA, is found to be beneficial
+in reducing body weight and blood glucose levels and showed no significant negative impacts on biochemi-
+cal, anthropometric and physical measures. Further research with larger sample size and long-term follow-up
+including more specific parameters would throw better light in understanding the beneficial effects of fresh
+coconut consumption.
+Author contributions: All the authors have accepted responsibility for the entire content of this submitted
+manuscript and approved submission.
+Research funding: Coconut Development Board, Kochi, Government of India, India and S-VYASA University,
+Bengaluru, India.
+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.
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+DE GRUYTER
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+DE GRUYTER
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subfolder_0/Distribution of glycated haemoglobin and its determinants in Indian young adults.txt

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+Distribution of glycated haemoglobin and its
+determinants in Indian young adults
+Raghuram Nagarathna a,*,1, Navneet Kaur b,c,1, Akshay Anand c,*,2, Kanupriya Sharma c,
+Rima Dada d, Palukuru Sridhar a, Purnendu Sharma a, Amit Kumar Singh a, Suchitra Patil a,
+Hongasandra R. Nagendra a
+a Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India
+b Department of Physical Education, Panjab University Chandigarh, India
+c Neuroscience Research Lab, Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
+d Department of Anatomy, Laboratory of Molecular Reproduction & Genetics, All India Institute of Medical Sciences, New Delhi, India
+A R T I C L E
+I N F O
+Article history:
+Received 21 October 2019
+Received in revised form
+23 November 2019
+Accepted 12 December 2019
+Available online 14 December 2019
+Keywords:
+Indian Diabetes Risk Score
+Diabetes
+Prediabetes
+Glycated haemoglobin
+Risk factors
+A B S T R A C T
+Aim: The aim of the present study is to understand the distribution of A1c in four different
+age groups in young adults and its relation to other co-variants.
+Methods: The countrywide data was collected in 2017 in Individuals with high risk analysed
+by Indian Diabetes Risk Score (IDRS) and self-declared diabetics were identified after
+screening a sample of 240,968 individuals from rural (4 villages of about 500 adults each)
+and urban (4 census enumeration blocks of about 500 adults each) population spanning
+65 districts of 29 states/UTs of Indian subcontinent. Blood tests and other detailed assess-
+ments were carried out on this selected group. This study presents the analysis of the A1c
+values of 2862 young adults (<35 years).
+Results: In the age group of 31–34 years, the proportion of Diabetes (22.36%) and Prediabetes
+(9.86%) was higher in comparison with younger age groups. Also, Diabetes (7.3%) and Pre-
+diabetes (22%) were highest among those who had parental history of DM in both parents
+as compared to those with Diabetes history in one parent [Diabetes (7.1%) or Prediabetes
+(19.0%)] and no Diabetes Parental History (Diabetes (7.3%) and Prediabetes (18.3%) cases.
+BMI was found to play a significant positive correlation with Diabetes and Prediabetes
+(p < 0.001) with range of A1c.
+Conclusion: Age, BMI and parental history were found to be correlated with A1c levels in
+IDRS screened high-risk population. With increasing age, the proportion of Diabetics and
+Prediabetics also increased with positive correlation of age with A1c levels.
+
 2019 Published by Elsevier B.V.
+https://doi.org/10.1016/j.diabres.2019.107982
+0168-8227/
 2019 Published by Elsevier B.V.
+* Corresponding authors.
+E-mail addresses: [email protected] (R. Nagarathna), [email protected] (A. Anand).
+1 Equal first.
+2 Co-corresponding author.
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+Contents available at ScienceDirect
+Diabetes Research
+and Clinical Practice
+journal homepage: www.elsevier.com/locate/diabres
+1.
+Introduction
+Diabetes Mellitus affects people of all ages. There is a dra-
+matic increase in the prevalence of Type 2 Diabetes (T2DM)
+in young adults globally and also in India [1] which led to
+increasing prevalence of long term complications of Diabetes
+[2]. Almost 50% of the Indian population is unaware of their
+Diabetes status [3].
+Indian Diabetes Risk Score (IDRS) is often used as an ini-
+tial, cost effective, simple tool to assess the risk of Diabetes
+(T2DM) and it can also be used in combination with A1c
+and BMI so that preventive measures can be taken at early
+stages [1,4,5]. There are other scales similar to IDRS, like FIN-
+RISK [6] and Framingham Offspring Diabetes Risk Score, Uni-
+ted States [7], AUSDRISK [8] and many others [9] which are
+used as an assessment tools in various countries for assess-
+ment of T2DM risk. But IDRS is more specific for Indian pop-
+ulation with sensitivity of 62.2% and specificity of 78.7% [10].
+However Glycosylated Haemoglobin (A1c) is used as a gold
+standard for detection of T2DM and Prediabetes [57,58]. It is
+used in evaluation of the long term of glycemic control and
+aids in prediction of risk for development of complication
+associated with Diabetes. A1c level is known to have positive
+correlation with age, gender, ethnicity, IDRS, BMI, and Waist-
+hip ratio (WHR) [11,12]. Early identification of risk of T2DM
+through IDRS can create an early awareness of the risk of
+development of T2DM, which can be assured with A1c evalu-
+ation. There is an increasing incidence of T2DM in adoles-
+cents and young adults in countries like UK, USA, Japan and
+Korea [25,61,62]. However very limited studies have focused
+on the Young adult population with A1c assessment in India,
+therefore, similar will provide an estimation about the distri-
+bution of A1c levels among the Indian Young adults along
+with the major risk factors contributing to this condition.
+BMI, Lipid profile, Obesity are some risk factor’s which are
+directly correlated with the development of T2DM [13–15],
+hence assessment of these factors also gives an idea about
+the glycemic control of the participant population. These fac-
+tors along with enhanced A1c levels, also indicate involve-
+ment of micro vascular diseases [16], which highlights the
+need of lifestyle modification.
+India’s T2DM prevalence has been expected to increase
+upto 266% by 2030, with the urban population considered at
+a higher risk than the rural population [17]. This highlights
+an urgent need to highlight the importance of the need to
+undertake lifestyle modification among young adults. For this
+there is a dire need to adopt suitable public action so that the
+enhanced burden of T2DM does not hurt health or develop-
+ment budgets of developing countries. This is the first study
+from India revealing a high prevalence of T2DM in young
+adults based on both IDRS and A1c.The study calls for control
+of A1c by nationwide public health intervention model.
+2.
+Material and methods
+2.1.
+Study population
+The countrywide study was carried out in 2017 in which
+house to house survey was carried out for screening of high
+risk individuals in the community under the Niyantarita
+Maduhmeha Bharat (NMB-2017, F.No.16-63/2016–17/CCRYN/RE
+S/Y&D/MCT) multi cluster population based survey. The
+detailed methodology is previously published [18,19].
+This included various states and Union Territories of India.
+Additionally, for the detection of high risk individuals from
+the community, NMB screening form was used for collection
+of data by Yoga Volunteers for Diabetes Mellitus (YVDMs).
+The screening form contained information regarding the fol-
+lowing parameters: Age, marital status, information about
+Diabetes, Level of Physical activity, Genetic History, Anthropo-
+metric parameters (consist of Weight, height, waist circum-
+ference, Hip Circumference), socio-economic information
+like education of Head of family, Occupation and Family
+income/month etc. During the screening as well as at the
+time of the registration, informed consents were obtained
+from every participant.
+The total number of 240,968 individuals were registered
+with door to door visit out of which complete screening data
+of 162,230 individuals was available. This screening was done
+on the basis of IDRS i.e. 
 60 (High Risk). And 69,717 partici-
+pants were invited for biochemical assessmentstelephoni-
+cally. The total young adult population within the age range
+(19–34 years) was 2862 (Male-1664, Female-1198).
+The selected subjects were analyzed for biochemical and
+anthropometric assessments. Further, the age was divided
+into four age groups (4 equal intervals) i.e. 19–22, 23–26, 27–
+30 and 31–34 years.
+2.2.
+Measures
+IDRS was used to determine the level of risk for Diabetes
+among Indian population. This was proposed by Mohan
+et al. [24]. It is one of the most simple, cost effective and easy
+technique to use for mass screening. It mainly uses four crite-
+ria for detection of high-risk individuals from the community,
+namely Age, Waist Circumference, Genetic History and Level
+of Physical Activity of the subject. Further, the cumulative
+scores of these four risk factors enables detection of risk sta-
+tus (High risk 
 60, Moderate 30–50, low risk < 30) of the indi-
+vidual. Diabetes (T2DM) is a condition characterized by high
+blood sugar, insulin resistance and relative lack of Insulin
+with A1c value 
 6.5 and Prediabetes is a condition where
+blood sugar level is above normal but not as high as Diabetes
+(5.7 - 6.4) [59,60].
+The detailed procedure for biochemical assessments has
+been previously published [18]. The BMI was calculated by
+using the formula (of weight divided by height in squares)
+and WHR was measured by using the formula waist divided
+by hip (W/H).
+2.3.
+Statistical analysis
+The statistical analysis was carried out by using the SPSS
+Statistics, version 22.0 (IBM Corp., Armonk, New York, United
+States of America). For the assessment of data, continuous
+data was given in the form of mean ± SD and n (%) was given
+in as discrete categorical data; suitably matched percentiles,
+range and median was used. Furthermore, for the assessment
+of differences between actual and predicted A1cvalues paired
+2
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+t-test was used. To analyze the normalcy of data, Kolmogorov
+Smirnov test was used. In addition, to find out the relation-
+ship among different parameters Spearman and Pearson
+coefficient correlation test was administered. The appropriate
+test i.e. Chi square or Fisher’s exact test was used as compar-
+ison between different proportions. To find out independent
+risk factors for different risk factors, Multivariate Regression
+analysis was performed. Multivariate regression analysis
+was used to predict the A1c levels in Young adult population
+with perfect fitted model. The independent variables included
+age, gender, family history, BMI, WHR and IDRS. The Age fac-
+tor shows the higher significant value (0.000).
+3.
+Results
+3.1.
+Clinical characteristics of participants
+The data used in this study was collected under the National
+Survey Niyantrita Madhumeha Bharat (NMB, 2017) program, a
+national survey. The Table 1 shows the mean and SD values
+of biochemical parameters in young adults. The data was
+analyzed in four different groups: 19–22 years of age, 23–
+26 years, 27–30 years, and 31–34 years.
+3.2.
+Distribution of age wise Diabetics and Pre diabetics
+Based on A1c level estimates, the young adult population
+included 7.2% Diabetic and 18.6% Pre Diabetics, which after
+being categorized in age groups showed that 5.1% males
+and 9.8% females were Diabetic, and 12.0% males 26.3%
+females were pre diabetic. The age group categorization of
+which is shown in Table 2.
+There were more male young adults in the T2DM group
+(12.8% in 31–34yrs) while there were more female young
+adults in the Pre Diabetes range (23.7% in 31–34yrs) with
+increasing age as shown in Table 2.Therefore, with growing
+age, increased prevalence of diabetes in males was seen as
+compared to females. In the Prediabetes group, it was found
+to be higher in females.
+3.3.
+Distribution of Diabetics and Pre-diabetics by A1c
+The distribution of A1c among four age groups is shown in
+Table 2. Based on A1c, the prevalence of T2DM and Predia-
+betes increased with age. In the age group of 19–22 years,
+the prevalence of T2DM was 5.3% and that for Prediabetes
+was 13.0%. This further increases with the growing with age
+viz: between the age groups of 23–26 years (Diabetes-4%,
+Prediabetes-12.5%), 27–30 years (Diabetes-5.6%, Prediabetes-
+18.9%) and 31–34 years (Diabetes-9.9%, Prediabetes-22.4%)
+respectively.
+3.4.
+Role of family history in distribution of Diabetes and
+Prediabetes on the basis of A1c
+Parental diabetic history revealed that 7.7% of Diabetics and
+21% of Pre Diabetics were more associated with a Diabetic
+father than a Diabetic mother. The proportion of Diabetes
+(7.3%) and Prediabetes (22%) together with both Diabetic par-
+ents was expectedly higher (Table 2). Furthermore, it was
+found that Diabetic mother (10.0%) and father (9.1%) resulted
+in a higher prevalence of Diabetic male young adults in com-
+parison to female young adults (Father-6.9%, Mother-3.8%).
+Additionally, age group, gender and family history wise differ-
+ences are shown in Table 2.
+3.5.
+Role of demography in distribution of Diabetes and
+Prediabetes by A1c
+Urban young adults were more prone to Diabetes (9.9%) and
+Pre Diabetes in comparison to rural (5.1%) young adults at a
+significant level.
+3.6.
+Role of physical activity in distribution of Diabetes
+and Prediabetes by A1c
+Surprisingly, it was found that highest number of diabetes
+(7.6%) and Prediabetes (18.7%) prevalence was found among
+the moderate physical activity group in comparison with
+the mild (Diabetes-7.4%,Pre Diabetes-17.5%) physical activity
+group. Expectedly, the vigorous physical activity group had
+lower incidence of Diabetes (5.1%), and Prediabetes (11.5%).
+3.7.
+Role of biochemical parameters in distribution of
+Diabetes and Prediabetes by A1c
+According to A1c, 58.2% were Diabetics in the group with
+PPBG (
200) whereas 82.7% were pre diabetics in the normal
+PPBG (<140 mg/dl) range. And 64.7% Diabetics were in the high
+FBG range (
125) and 69.9% pre diabetics were in the normal
+FBG (<100 mg/dl) range. About 73.2% Diabetics and 80.3% Pre-
+diabetics had normal cholesterol levels, whereas 51.9% of dia-
+betic and 36.8% of prediabetic cases showed high risk triglyc-
+erides levels.
+However, 63.9% of women with low HDL were found to be
+associated with Diabetes, 62.7% with Pre Diabetes in compar-
+ison to the normal HDL range amongst which 36.1% were Dia-
+betic and 37.3% were pre diabetics. In males, 69.4% were
+Diabetic and 63.3% were pre diabetic in normal HDL level
+group as compared to health risk category with 30.6% Diabetic
+and 36.7% pre diabetic cases.
+In case of LDL, the higher number of Diabetes (85.6%) and
+Prediabetes (87.8%) cases were found in the normal category
+Table 1 – Mean and SD values of different Biochemical factors among Indian young adults.
+PPBG (mg/dl)
+FBG (mg/dl)
+A1c (%)
+Cholesterol (mg/dl)
+Triglyceride (mg/dl)
+HDL (mg/dl)
+LDL (mg/dl)
+Mean
+116.36
+96.40
+5.51
+162.50
+137.04
+49.91
+88.66
+SD
+55.48
+32.33
+1.10
+35.85
+84.67
+15.24
+31.57
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+3
+Table 2 – Clinical characteristics of study participants: Showing T2DM and Pre Diabetes (5.7–6.4 = Prediabetes, 
6.5 = Dia-
+betes) status through different parameters. Data are expressed in the percentage and statistical significance (**p < 0.008,
+***p < 0.001).
+Variable
+Subgroups
+A1c
+Age groups (in Years)
+Significance
+Chi Test
+Over All
+19–22
+23–26
+27–30
+31–34
+Overall
+N = 2862
+DM
+198(7.2%)
+5.3%
+4.0%
+5.6%
+9.9%
+<0.001
+Pre DM
+516(18.6%)
+13.0%
+12.5%
+18.9
+22.4%
+Gender
+Males
+N =1664
+DM
+86(5.1%)
+6.7%
+0.8%
+4.7%
+12.8%
+0.417
+Pre DM
+200(12.0.%)
+10.4%
+12.2%
+19.9%
+20.3%
+Females
+N=1198
+DM
+117(9.8%)
+3.9%
+6.6%
+6.3%
+8.0%
+Pre DM
+316(26.3%)
+15.6%
+12.8%
+18.2%
+23.7%
+Area
+Rural
+N = 1577
+DM
+80(5.1%)
+3.9%
+2.2%
+5.2%
+10.5%
+0.008
+Pre DM
+229(14.5%)
+11.7%
+11.5%
+21.0%
+23.5%
+Urban
+N = 1190
+DM
+117(9.9%)
+6.7%
+5.4%
+5.8%
+9.4%
+Pre DM
+287(24.1%)
+14.2%
+13.4%
+17.3%
+21.6%
+Parental H/of DM
+No Diabetes Parents
+N = 2192
+DM
+160(7.3%)
+4.9%
+3.8%
+35.5%
+10.5%
+Pre DM
+402(18.3%)
+13.6%
+12.0%
+19.5%
+21.4%
+One parent
+N = 368
+DM
+26(7.1%)
+10.8%
+4.3%
+5.0%
+8.7%
+0.942
+Pre DM
+70(19.0%)
+10.8%
+10.1%
+15.8%
+26.7%
+Both parents
+N = 82
+DM
+6(7.3%)
+0%
+0%
+10.0%
+8.8%
+Pre DM
+18(22.0%)
+0%
+15.4%
+23.3%
+26.5%
+Father
+N = 310
+DM
+24(7.7%)
+6.7%
+3.5%
+8.5%
+9.2%
+0.446
+Pre DM
+65(21%)
+3.3%
+10.5%
+20.7%
+29.1%
+Mother
+N = 222
+DM
+14(6.3%)
+11.8%
+2.6%
+5.1%
+8.0%
+0.868
+Pre DM
+41(18.5%)
+17.6%
+13.2%
+16.5%
+22.7%
+Father
+N = 310
+Male
+N = 121
+DM
+11(9.1%)
+12.5%
+4.2%
+7.1%
+11.3%
+0.578
+Pre
+DM
+17(14.0%)
+0.0%
+4.2%
+17.9%
+20.8%
+Female
+N = 189
+DM
+13(6.9%)
+0.0%
+3.0%
+9.3%
+8.0%
+0.095
+Pre
+DM
+48(25.4%)
+7.1%
+15.2%
+22.2%
+34.1%
+Mother
+N = 222
+Male
+N = 90
+DM
+9(10.0%)
+12.5%
+0.0%
+6.9%
+15.8%
+0.555
+Pre
+DM
+17(18.9%)
+12.5%
+6.7%
+27.6%
+18.4%
+Female
+N = 132
+DM
+5(3.8%)
+11.1%
+4.3%
+4.0%
+2.0%
+0.144
+Pre
+DM
+24(18.2%)
+22.2%
+17.4%
+10.0%
+26.0%
+Physical activity
+Mild
+N = 685
+DM
+51(7.4%)
+4.5%
+2.9%
+4.9%
+11.4%
+0.642
+Pre DM
+120(17.5%)
+6.4%
+10.2%
+18.2%
+20.6%
+Moderate
+N = 198
+DM
+15(7.6%)
+10.5%
+5.9%
+6.3%
+8.5%
+Pre DM
+37(18.7%)
+10.5%
+8.9%
+23.8%
+20.7%
+Vigorous
+N = 78
+DM
+4(5.1%)
+0%
+5.9%
+15.4%
+2.6%
+Pre DM
+9(11.5%)
+0%
+17.6%
+7.7%)
+13.2%
+Cholesterol
+Normal
+(h2 0 0)
+N = 2343
+DM
+142(73.2%)
+4.5%
+3.5%
+30(4.6%)
+8.7%
+<0.001
+Pre DM
+412(80.3%)
+12.7%
+12.8%
+17.0%
+21.5%
+Health risk
+(
200)
+N = 375
+DM
+52(26.8%)
+30.0%
+10.8%
+9.9%
+15.4%
+Pre DM
+101(19.7%)
+30.0%
+10.8%
+31.7%
+27.3%
+Triglyceride
+Normal
+(h1 5 0)
+N = 1811
+DM
+90(48.1%)
+4.8%
+3.5%
+3.2%
+6.9%
+<0.001
+Pre DM
+311(63.2%)
+14.5%
+10.3%
+17.0%
+21.3%
+Health risk
+(>150)
+N = 746
+DM
+97(51.9%)
+9.8%
+8.1%
+10.6%
+15.8%
+Pre DM
+181(36.8%)
+12.2%
+20.2%
+25.1%
+26.1%
+LDL
+Normal
+(h1 3 0)
+N = 2319
+DM
+154(85.6%)
+5.9%
+3.7%
+5.3%
+9.0%
+<0.001
+Pre DM
+423(87.8%)
+13.1%
+12.7%
+18.3%
+21.9%
+Health risk
+(>130)
+N = 217
+DM
+26(14.4%)
+0.0%
+8.7%
+4.8%
+17.1%
+Pre DM
+59(12.2%)
+37.5%
+4.3%
+31.7%
+28.5%
+(continued on nnext page)
+4
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+group in comparison with health risk 14.4% diabetic 12.2% pre
+diabetic.
+3.8.
+Role of other related constituents in distribution of
+Diabetes and Prediabetes by A1c
+As per BMI, 11.4% young obese adults were Diabetic and 28.1%
+were pre diabetic as compared to normal young adults
+(p < 0.01). Additionally, according to WHR (an indicator of
+abdominal obesity) 7.7% high risk females were Diabetics
+and 23.2% low risk females were Pre Diabetics. Similarly, in
+case of males, 9.3% males were Diabetics among the low risk
+group while 17.8% cases among the high risk group were Pre
+Diabetic.
+3.9.
+Dispersal of glycosylated haemoglobin values
+In the Table 3, the percentile mean values, standard error for
+A1cis shown with age, gender, parental history, diet, BMI,
+abdominal obesity. In comparison to all the age groups, on
+Table 2 – (continued)
+Variable
+Subgroups
+A1c
+Age groups
+Significance
+Chi Test
+Over All
+19–22
+23–26
+27–30
+31–34
+FBG
+Normal
+(<100 mg/dl)
+N = 1964
+DM
+32(18.8%)
+3.0%
+1.7%
+0.9%
+1.7%
+<0.001
+Pre DM
+336(69.9%)
+12.9%
+10.4%
+18.5%
+20.7%
+Prediabetes
+(100–125 mg/dl)
+N = 341
+DM
+28(16.5%)
+0.0%
+7.3%
+3.4%
+11.3%
+Pre DM
+127(26.4%)
+29.4%
+34.1%
+33.0%
+40.5%
+Diabetes
+(
125 mg/dl)
+N = 159
+DM
+110(64.7%)
+50.0%
+53.3%
+69.0%
+73.4%
+Pre DM
+18(3.7%)
+0.0%
+26.7%
+7.1%
+11.7%
+PPBS
+Normal
+(<140 mg/dl)
+N = 1220
+DM
+32(26.2%)
+3.4%
+3.3%
+2.5%
+2.3%
+<0.001
+Pre DM
+239(82.7%)
+16.4%
+12.1%
+19.4%
+23.1%
+Prediabetes
+(140–199 mg/dl)
+N = 93
+DM
+19(15.6%)
+0.0%
+33.3%
+25.0%
+18.8%
+Pre DM
+43(14.9%)
+0.0%
+33.3%
+30.0%
+54.7%
+Diabetes
+(
200 mg/dl)
+N = 87
+DM
+71(58.2%)
+66.7%
+70.0%
+86.7%
+83.1%
+Pre DM
+7(2.4%)
+0.0%
+10.0%
+6.7%
+8.5%
+BMI
+Normal (<25kg/m2)
+N = 1854
+DM
+119(6.4%)
+4.3%
+4.0%
+4.8%
+9.0%
+<0.001
+Pre DM
+157(15.6%)
+10.8%
+8.4%
+16.2%
+19.6%
+Obese (
25 kg/m2)
+N = 367
+DM
+42(11.4%)
+15.8%
+5.6%
+10.3%
+13.4%
+Pre DM
+103(28.1%)
+15.8%
+24.1%
+24.3%
+32.6%
+WHR
+Male
+Low Risk
+(<0.90)
+N = 204
+DM
+19(9.3%)
+9.4%
+0.0%
+6.8%
+18.6%
+0.064
+Pre DM
+22(10.8%)
+3.1%
+6.9%
+11.4%
+17.1%
+High Risk
+(>0.90)
+N = 516
+DM
+42(8.1%)
+6.7%
+1.1%
+3.7%
+14.0%
+Pre DM
+92(17.8%)
+10.0%
+11.8%
+20.1%
+21.0%
+WHR
+Female
+Low Risk
+(<0.85)
+N= 224
+DM
+11(4.9%)
+0.0%
+7.5%
+3.9%
+5.3%
+0.092
+Pre DM
+52(23.2%)
+21.4%
+12.5%
+21.1%
+29.8%
+High Risk
+(<0.85)
+N = 874
+DM
+67(7.7%)
+6.3%
+6.0%
+7.4%
+8.6%
+Pre DM
+156(17.8%)
+9.4%
+10.7%
+16.9%
+22.2%
+HDL
+Male
+Normal
+(>40)
+N = 746
+DM
+26(69.4%)
+8.9%
+0.0%
+3.0%
+12.7%
+0.525
+Pre DM
+72(63.3%)
+2.2%
+17.3%
+27.7%
+19.3%
+Health Risk
+(<40)
+N = 377
+DM
+59(30.6%)
+5.7%
+1.3%
+5.2%
+13.4%
+Pre DM
+124(36.7%)
+14.9%
+9.7%
+15.6%
+21.1%
+HDL
+Female
+Normal
+(>50)
+N = 735
+DM
+69(36.1%)
+2.9%
+6.9%
+8.2%
+9.5%
+<0.001
+Pre DM
+198(37.3%)
+20.3%
+15.0%
+22.0%
+28.1%
+Health Risk
+(<50)
+N = 854
+DM
+39(63.9%)
+5.7%
+6.4%
+2.5%
+6.4%
+Pre DM
+118(62.7%)
+11.3%
+10.4%
+14.2%
+19.7%
+DM- Diabetes Mellitus; Pre DM- Pre Diabetes Mellitus; PPBG- Glucose Tolerance Test; FBG: Fasting Blood Glucose; IDRS: Indian Diabetes Risk
+Score; WHR-Waist Hip ratio, BMI -Body Mass Index; H/of DM – History of Diabetes Mellitus.
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+5
+the basis of A1c, the age group of 31–34 years showed higher
+A1c values in all percentiles. The mean values (5.68) were also
+higher in this age group (p < 0.001). According to the gender,
+the females had higher mean (5.53) and percentile values of
+A1c (p < 0.01).
+Additionally, those individuals who had parental history of
+both Diabetes parents had higher mean (5.55) and percentile
+values in comparison with nil and one diabetic parent. On
+the basis of Body mass index (BMI), the mean (5.74) values
+and the different percentile values were advanced among
+the obese group in comparison with normal BMI.
+In females, there was a marginal difference in mean and
+percentile values of waist hip ratio among low (5.49) and high
+(5.50) risk females with no statistical difference. In case of
+males, low risk (5.54) individuals show marginally higher
+A1c. Expectedly, at 95th percentile high risk (7.20) group
+shows higher A1c values than low risk (6.47) groups at
+p < 0.001 level of significance.
+Fig. 1 – Multivariate regression model predicted glycated haemoglobin (%) confidence intervals by age and sex (adjusted
+R2 = 0.069), P 0.078). Age group 1: 19–22 years, Age group 2: 23–26 years, Age group 3: 27–30, Age group 4: 31–34 years.
+Table 3 – Dispersion of Glycosylated Haemoglobin values: Dispersion of glycosylated haemoglobin (A1c) values by age, sex,
+parental history and other related factors showing mean,SEM and A1c percentiles. Statistical significance (**p < 0.01,
+***p < 0.001).
+Mean
+SEM
+Percentile of A1c
+P value
+5
+10
+25
+50
+75
+90
+95
+Total
+5.51
+0.02
+4.50
+4.70
+5.00
+5.30
+5.70
+6.20
+7.10
+Age (years)
+19–22
+5.30
+0.06
+4.31
+4.50
+4.90
+5.15
+5.50
+5.90
+6.67
+<0.001
+23–26
+5.31
+0.03
+4.50
+4.70
+4.90
+5.20
+5.50
+5.90
+6.26
+27–30
+5.46
+0.03
+4.50
+4.70
+5.00
+5.30
+5.60
+6.00
+6.60
+31–34
+5.68
+0.03
+4.60
+4.80
+5.10
+5.40
+5.80
+6.40
+8.03
+Gender
+Male
+5.50
+0.02
+4.58
+4.70
+5.00
+5.30
+5.70
+6.20
+6.91
+<0.01
+Female
+5.53
+0.036
+4.50
+4.70
+5.00
+5.30
+5.60
+6.18
+7.50
+Parental History
+No Diabetes parents
+5.52
+0.02
+4.50
+4.70
+5.00
+5.30
+5.70
+6.10
+7.20
+0.797
+One Diabetes parent
+5.50
+0.06
+4.40
+4.70
+5.00
+5.30
+5.70
+6.20
+7.10
+Both Diabetes parents
+5.55
+0.11
+4.50
+4.70
+5.10
+5.30
+5.70
+6.30
+7.44
+BMI
+Normal
+5.46
+0.02
+4.50
+4.70
+5.00
+5.30
+5.60
+6.00
+7.00
+0.126
+Obese
+5.74
+0.06
+4.70
+4.80
+5.20
+5.50
+5.90
+6.60
+7.70
+Waist-hip ratio
+Low risk
+Female
+5.5
+0.05
+4.60
+4.80
+5.10
+5.40
+5.70
+6.10
+6.47
+0.057
+Male
+5.54
+0.09
+4.50
+4.65
+4.92
+5.20
+5.60
+6.30
+9.45
+<0.001
+High risk
+Female
+5.49
+0.034
+4.50
+4.70
+5.10
+5.40
+5.70
+6.20
+7.20
+<0.001
+Male
+5.53
+0.05
+4.40
+4.70
+5.00
+5.30
+5.70
+6.30
+7.53
+<0.001
+6
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+3.10.
+Multivariate regression model
+The multivariate regression model was used to predict the
+A1c values in young adult population. The perfect fitted
+model was selected after multivariate regression analysis
+and adjusted R-square value was 0.069 which was statistically
+significant (0.078) (Fig. 1) and (Table 4). The assumed (Table 4)
+structure for multivariate regression was as given:
+Fig. 2 – Prevalence of Glycated haemoglobin (A1c) with age (A) and gender (B).
+Table 4 – Multivariate Regression analysis: Multivariate regression analysis predicting level of glycated haemoglobin (%)
+(adjusted R2 = 0.069), P 0.078). Age – 19–22 years, Age1 – 23–26 years, Age2 – 27–30, Age 3 – 31–34 years, **>0.003.
+Variables
+Standardized Coefficients
+Beta
+P value
+Gender
+0.015 (0.245 to 0.183)
+0.777
+Age
+0.051 (0.89 to 0.067)
+0.783
+Age 1
+0.199 (1.744 to 0.399)
+0.218
+Age 2
+0.238(0.672 to.070)
+0.111
+Age 3
+0.190 (0.285 to 0.006)
+00.61
+One Parent Diabetes
+0.165 (0.330 to 0.069)
+0.003
+Both parent Diabetes
+0.025 (0.123 to 0.197)
+0.649
+Body Mass Index
+0.042 (0.002 to 0.001)
+0.429
+Waist Hip Ratio
+0.039 (1.668 to 0.747)
+0.454
+Indian Diabetes Risk Score
+0.102 (0.001 to 0.014)
+0.078
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+7
+A1cð%Þ ¼ 5:62  :015  age  :199  age1
+:238  age2  :190  age3
+:015  Gender  :165  ðone parent diabetesÞ
+þ:025  ðBoth Parent DiabetesÞ  :042  BMI
+0:39  WHR þ :102  IDRS
+One parent Diabetes History was significantly associated
+with A1c.
+4.
+Discussion
+Diabetes is a complex disease and occurs due to cumulative
+effect of genetics and environmental factors like diet, dys-
+functional eating habits, levels of physical activity, levels of
+endocrine disrupting chemicals like arsenic and psychologi-
+cal stress. Worldwide, 451 million people have Diabetes and
+its prevalence is growing due to our stressful lifestyle and ever
+increasing intake of fast food rich in trans fats, sugars and
+salt. It occurs mainly due to insulin resistance and insuffi-
+cient insulin secretion and is predominantly caused due to
+oxidative stress and damage, inflammation and endoplasmic
+reticulum stress. Our study examined the distribution of A1c
+among 2862 Indian young adults along with other factors and
+biochemical parameters for the risk of T2DM.
+It was shown in a study that the occurrence of Diabetes in
+young adults could make them more vulnerable to other co-
+morbidities and poor quality of life, leading to unfavorable
+long-term outcomes thus raising the possibility of future pub-
+lic health calamity [1]. It has been found in many studies that
+younger onset of Diabetes leads to early development of other
+vascular complications than those with later onset [20]. Thus,
+simple lifestyle interventions like enhanced physical activity
+and Yoga may help to reduce the prevalence of this epidemic
+and its sequelae like cardiometabolic effects. One of the key
+factors which play a role in Diabetes type 2 onset is dysfunc-
+tional eating habits and stress. Yoga helps to regulate both
+and is known to enhance insulin sensitivity. As age is one
+the acknowledged risk factors for Diabetes, this is also true
+for young Indian adults. The proportion of young Diabetes
+and Prediabetes young adults has been found to increase with
+increase in the age [21] (Fig. 2A) Age is one of the risk factors
+for Diabetes and similar results were found in other studies
+[22]. T2DM prevalence also depends upon the ethnic back-
+ground, as described in various studies [12,23,24]. Further-
+more, it was found that male young adults had higher rate
+of Diabetes, with advancing age, is consistent with the study
+done by Seo et al in Korean population[25]. [25]. This study
+shows that proportionately more male were Diabetic in the
+age group 31–34 indicating that with advancing age male
+become more prone to Diabetes which is consistent with cer-
+tain studies Seo et al. [25–27]. Moreover, with advancing age,
+female also show some risk of development of Type 2 Dia-
+betes Mellitus as 23.7% females had Prediabetes in the age
+group of 31–34 years. However, the reason for more female
+subjects in Pre Diabetic group remains unclear. Fig. 3 shows
+the elevated values of A1c with age [28,29] among young male
+[30] adults. On the other hand, there were marginal gender
+differences between both genders on the A1c levels. The
+females had slightly higher A1c values than males (Fig. 2B).
+In this study, urban adults were found to have more Dia-
+betes and Pre Diabetes in comparison with rural adults.
+Higher physical activity and a diet rich in whole plant based
+foods, which is predominantly unrefined and unprocessed,
+could account for the lower prevalence of Diabetes in rural
+Indians. A study by Mohan et al has also reported the preva-
+lence of self-reported Diabetes to be higher in urban areas
+[31]. Presence of more diagnostic facilities in urban setup
+could further explain higher prevalence of self-reported Dia-
+betes amongst urban Indians. However, a study done by
+Anjana et al. revealed that prevalence of Diabetes and
+Prediabetes was equally high in
+both rural and urban
+localities [32].
+Table 4 describes the prediction values of A1c based on
+multivariate regression model and shows the significant asso-
+ciation of Parental history with A1c. Furthermore, the propor-
+tion of Diabetes and Prediabetes has been found to be more
+among those young adults who had both parents as Diabetics.
+This suggests that there is higher risk of Diabetes when both
+parents are affected. In addition, it has been found that dia-
+betic father had higher probability of having diabetic kids in
+comparison with diabetic mother. However, contradictory
+results were found in another study where Diabetes was more
+prevalent in the case of Diabetic mother than father [33].
+Additionally, it was also found that sons are more prone to
+Diabetes if any of the parents from Diabetes, in comparison
+with their daughters. On the other hand, some studies
+described association of Diabetes among fathers and their
+Diabetic sons [34,35]. Diabetes is a complex disease and thus
+no role of holandric inheritance to account for higher
+prevalence in sons of Diabetic fathers. However, abdominal
+obesity with higher levels of abdominal fat (visceral fat-
+mesentric and omental fat) plays a critical role in etiopatho-
+genesis of metabolic syndrome and Diabetes. Dysregulation
+in lipids and glucose are associated with visceral adiposity
+rather than subcutaneous fat accumulation. Accumulation
+of visceral fat shows a positive correlation with levels of C
+peptide, insulin and glucose levels but Testosterone levels
+show negative association. Although Diabetes is not a risk
+factor for hypogonadism, it is associated with lower levels
+of testosterone. In women too, insulin and C peptide levels
+Fig. 3 – Difference in Glycated haemoglobin (weighted Mean
+and Standard Error) According to age group and gender.
+(P < 0.001 between Genders, P < 0.001 between different age
+groups).
+8
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+correlate with abdominal obesity and not mid-thigh fat.
+While ovulation, clinical or biochemical hyperandrogenism,
+polycystic ovaries and insulin resistance are the hallmarks
+of polycystic ovarian disease (PCOD) these women have a
+higher susceptibility to develop T2DM and gestational Dia-
+betes. It affects 4–7% of pregnancies and is characterized by
+carbohydrate intolerance at onset of pregnancy. Women with
+PCOD have higher pre-gestational levels of insulin and
+develop derangements of glycemic control during this time
+despite increased levels of insulin due to placental hormones.
+This could lead to hyperglycemia and gestational Diabetes. It
+has been found in a study that the family history of T2DM is
+inversely related with age. This implies that those having
+strong family history of Diabetes have earlier onset of Dia-
+betes Weerarathna and Dissanayake [36]. A strong family his-
+tory increases susceptibility to develop Diabetes if there is
+sedentary lifestyle and dysfunctional eating habits.
+The levels of FBG and PPBG were found increased in Dia-
+betics and Prediabetes. The PPBG Diabetes (
200) and FBG
+Diabetes (
125) constituted more Diabetes cases when fur-
+ther analyzed by A1c, showing higher correlation between
+A1c and other biochemical parameters. Specifically, 58.2% of
+participants with PPBG 
 200 were found to be T2DM as per
+A1c criteria. This could be ascribed to inconsistencies in cor-
+relation between PPBG and A1c. Several studies have shown a
+strong correlation of PPBG and FBPG Weerarathna and Dis-
+sanayake [36,37]. Biochemical analysis has also revealed that
+individuals with normal cholesterol and LDL levels may also
+develop Diabetes and Prediabetes. Raised Triglycerides are
+also health risks with strong association with Diabetes. Dys-
+lipidemia is one of the major co morbidity associated with
+insulin resistance characterized by increased plasma triglyc-
+erides concentration, decreased HDL increased LDL concen-
+tration [38]. Abnormal lipids in Diabetes patients include
+elevated VLDL, LDL and Triglycerides and reduced levels of
+HDL, low levels of HDL levels in T2DM patients. This is almost
+double as compared to non-diabetics [39]. In our study, it was
+found that the young female adults with low HDL levels were
+found prone to Diabetes and Prediabetes (who had health
+risk). In contrast, Diabetics and Prediabetics males had nor-
+mal HDL levels.
+The result of the study showed that Obesity is the one of
+the contributing factors for Diabetes (11.4%) and Prediabetes
+(28.1%). Moreover, obesity is a major factor for the develop-
+ment of insulin resistance. According to WHO, obesity in
+childhood and adolescence increases at a higher rate in devel-
+oping countries of Asia and Africa [40]. Association between
+abdominal obesity and Diabetes has also been reported in
+number of studies [41–43]. The prevalence of Diabetes and
+Prediabetes was found reduced among vigorous exercise
+group in our study [44–46].There is a marginal difference in
+diabetic cases among the mild (7.4%) and moderate (7.6%)
+physical activity group. Apart from the level of physical activ-
+ity, there are various factors which contribute to Diabetes.
+This includes the dietary pattern. Although the current litera-
+ture [47] is consistent with moderate exercise group to have
+low propensity to develop Diabetes as compared to mild exer-
+cise group [48], we report this finding to be not significantly
+different. Regardless, mild physical activity is also effective
+in improving glycemic parameters [49].
+The strength of the study derived from the unique applica-
+tion of A1c for prediction and distribution of Diabetes among
+young adults is hitherto unreported from India. Also, there
+are very few studies available on the basis of A1c. This may
+be due to high costs associated with this test. This is the first
+study from India which represents 24 states and 2 union ter-
+ritories and 5 zones to analyze the status of Diabetes and
+Prediabetes in Indian young adults. Therefore, this study
+paves way to understand the risk of Diabetes in young adults
+and suggests timely management and prevention of the
+same. The limitation that it does not take into account indi-
+viduals below an age of 19 years can be addressed in future
+studies. Furthermore, physical inactivity group were not
+included in the study. Psychological stress also plays a major
+role in etiology of T2DM but Psychological assessments,
+socioeconomic status (like family income and parental educa-
+tion) were not incorporated in this study.
+The present study describes the glycosylated A1c levels
+from a large cohort of individuals sampled equally across
+urban and rural areas from India, and also highlights the util-
+ity of IDRS for identifying individuals at high risk for T2DM
+which correlate to these levels. The results from the current
+study highlights a high prevalence of T2DM in young Indian
+adults which indicates the need of lifestyle modification
+[41,50] in order to halt or delay the onset of Diabetes among
+in Young adults. Thus, it is imperative to institute public
+health measures like exercise and Yoga [51,52–54] along with
+dietary modifications [55,56]. We also recommend a similar
+analysis on regular intervals in order to understand the
+changing patterns of A1c among the community.
+5.
+Ethics statement
+The study was approved by the Indian Yoga Association Insti-
+tutional Ethics Committee via reference no: RES/IEC-IYA/001.
+The written consent form was obtained from the participants.
+Declaration of Competing Interest
+The authors declare that they have no known competing
+financial interests or personal relationships that could have
+appeared to influence the work reported in this paper.
+Author contribution statement
+RN: Writing, Conceptualization and analysis; NK: Writing,
+Data Collection for Chandigarh and analysis; AA: Conceptual-
+ization of the manuscript; KS: Writing and Data Analysis; RD:
+Modification and inputs for analysis; PS: Data Collection and
+analysis; PS: Data Collection and analysis; AS: Data Collection
+and analysis; SP: Statistical Analysis; HS: Project implementa-
+tion and conceptualization of the study.
+Acknowledgments
+The authors acknowledge the support of CCRYN for man
+power, MOHFW for support the cost of investigations and
+IYA for the overall project implementation. Mr. Saurabh
+Kumar and Ms. Chanda Devi for their valuable inputs.
+d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 5 9 ( 2 0 2 0 ) 1 0 7 9 8 2
+9
+Funding
+The Project was funded by Ministry of Ayush, Government of
+India.
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+11

subfolder_0/Dyadic yoga program for patients undergoing thoracic radiotherapy and their family caregivers results of a pilot randomized controlled trial.txt

@@ -0,0 +1,783 @@
+P A P E R
+Dyadic yoga program for patients undergoing thoracic
+radiotherapy and their family caregivers: Results of a pilot
+randomized controlled trial
+Kathrin Milbury1
+| Zhongxing Liao1 | Vickie Shannon1 | Smitha Mallaiah1 |
+Raghuram Nagarathna2 | Yisheng Li1 | Chunyi Yang1 | Cindy Carmack1 | Eduardo Bruera1 |
+Lorenzo Cohen1
+1The University of Texas MD Anderson
+Cancer Center, Houston, Texas, USA
+2Swami Vivekananda Yoga Anusandhana
+Samsthana, Bengaluru, India
+Correspondence
+Kathrin Milbury, The University of Texas MD
+Anderson Cancer Center, Department of
+Behavioral Science, 1414 Pressler St.,
+Houston, TX 77230‐1439, USA.
+Email: [email protected],
+Funding information
+National Center for Complementary and Inte-
+grative Health, Grant/Award Number: K01
+AT007559
+Abstract
+Objective:
+Thoracic radiotherapy (TRT) may result in toxicities that are associated
+with performance declines and poor quality of life (QOL) for patients and their family
+caregivers. The purpose of this randomized controlled trial was to establish feasibility
+and preliminary efficacy of a dyadic yoga (DY) intervention as a supportive care strategy.
+Methods:
+Patients with stage I to III non‐small cell lung or esophageal cancer under-
+going TRT and their caregivers (N = 26 dyads) were randomized to a 15‐session DY or
+a waitlist control (WLC) group. Prior to TRT and randomization, both groups com-
+pleted measures of QOL (SF‐36) and depressive symptoms (CES‐D). Patients also
+completed the 6‐minute walk test (6MWT). Dyads were reassessed on the last day
+of TRT and 3 months later.
+Results:
+A priori feasibility criteria were met regarding consent (68%), adherence
+(80%), and retention (81%) rates. Controlling for relevant covariates, multilevel modeling
+analyses revealed significant clinical improvements for patients in the DY group com-
+pared with the WLC group for the 6MWT (means: DY = 473 m vs WLC = 397 m,
+d = 1.19) and SF‐36 physical function (means: DY = 38.77 vs WLC = 30.88; d = .66)
+and social function (means: DY = 45.24 vs WLC = 39.09; d = .44) across the follow‐up
+period. Caregivers in the DY group reported marginally clinically significant improve-
+ments in SF‐36 vitality (means: DY = 53.05 vs WLC = 48.84; d = .39) and role perfor-
+mance (means: DY = 52.78 vs WLC = 48.59; d = .51) relative to those in the WLC group.
+Conclusions:
+This novel supportive care program appears to be feasible and bene-
+ficial for patients undergoing TRT and their caregivers. A larger efficacy trial with a
+more stringent control group is warranted.
+KEYWORDS
+cancer, dyadic intervention, family caregivers, oncology, physical function, quality of life, thoracic
+radiotherapy, yoga
+1
+|
+BACKGROUND
+Thoracic radiotherapy (TRT), particularly when delivered concurrently
+with chemotherapy, may result in acute and late toxicities (eg,
+dyspnea, reduced lung function).1-4 Chemoradiation is often the
+definitive treatment for patients with thoracic malignancies (eg, lung
+and esophageal cancers) because they tend to be diagnosed with
+unresectable, locally advanced or even metastatic disease.5 Due to
+Received: 12 July 2018
+Revised: 8 January 2019
+Accepted: 11 January 2019
+DOI: 10.1002/pon.4991
+Psycho‐Oncology. 2019;28:615–621.
+© 2019 John Wiley & Sons, Ltd.
+wileyonlinelibrary.com/journal/pon
+615
+the adverse effects of aggressive multimodal cancer treatment, a gen-
+erally poor prognosis, and common comorbidities, patients with tho-
+racic cancers are at high risk of experiencing physical function
+declines, physical and psychological symptoms, and overall poor qual-
+ity of life (QOL).3,4,6 Consequently, patients have a high need for tan-
+gible care and emotional support from their families.7 Caregiving is
+taxing, however, and family caregivers often report feeling helpless
+and overwhelmed and having low caregiving efficacy.8,9 Given the
+high rates of distress in both cancer patients and their family care-
+givers, and the interdependent nature of distress in families coping
+with cancer, a dyadic approach to supportive care may be advanta-
+geous
+over
+traditional,
+patient‐oriented
+interventions.10-12
+The
+psychosocial literature includes reports of a handful of dyadic
+randomized controlled trials (RCTs) including those with lung and
+esophageal cancer patients, with two of these trials providing
+evidence of preliminary efficacy in improved psychological distress
+or relationship outcomes.13,14 Of note, previously reported dyadic
+psychosocial interventions have not targeted physical function as a
+study outcome.
+Considering the need to address physical decline and the mixed
+evidence regarding improved symptoms and QOL in thoracic cancer
+patients and their caregivers, a dyadic yoga (DY) intervention that
+integrates gentle movements with breathing exercises and relaxation
+techniques focusing on the needs of the patient‐caregiver dyad may
+be a promising supportive care strategy. Although researchers have
+extensively studied yoga in women with breast cancer, little is known
+regarding the feasibility of implementing an RCT of yoga in patients
+undergoing TRT.15,16 In our formative research, we developed a DY
+intervention to improve QOL during and after TRT.17
+Building on this previous study, we sought to examine the feasibil-
+ity of implementing an RCT of this intervention and expand our proce-
+dures to include the 6‐minute walk test (6MWT), an objective,
+clinically relevant measure of patients' physical function found to pre-
+dict survival in patients with lung cancer.18 Based on previous dyadic
+psychosocial RCTs, we hypothesized that at least 60% of eligible
+dyads would consent to participate, participants randomized to the
+DY group would attend at least 75% of the intervention sessions,
+and 60% of the dyads would be retained at the 3‐month follow‐up
+assessment.13,14,19 Additionally, we sought to establish the preliminary
+efficacy for the intervention regarding clinically significant improve-
+ments in patients' 6MWT results and patients' and caregivers' depres-
+sive symptoms and overall QOL relative to those of dyads in a waitlist
+control (WLC) group at the end of treatment and 3 months later.
+2
+|
+METHODS
+2.1
+|
+Participants
+Patients with stage I to IIIB non‐small cell lung or esophageal cancer
+undergoing at least 5 weeks of TRT having a consenting family care-
+giver (eg, spouse, sibling, adult child) were eligible to participate. Both
+patients and caregivers had to be at least 18 years old, proficient in
+English, and able to provide informed consent. Patients were excluded
+if they were not oriented to time, place, or person; practiced any form
+of yoga on a regular basis (self‐defined) in the year prior to diagnosis;
+and had a physician‐rated Eastern Cooperative Oncology Group
+(ECOG) performance status of greater than 2.
+2.2
+|
+Procedure
+Prior to starting the trial, the MD Anderson Institutional Review Board
+approved all of the procedures. Research staff identified potentially
+eligible patients
+in the institution's
+electronic
+medical
+records,
+approached patients and caregivers during routine clinic visits, con-
+firmed their study eligibility, and obtained their written informed con-
+sent to participate prior to data collection. If a caregiver was not
+present during a clinic visit, the patient's permission to contact the
+caregiver was obtained. Prior to randomization, both patients and
+caregivers completed paper‐pencil survey measures (baseline/T1)
+and then again on the last day of TRT (T2), and 3 months later (T3).
+Surveys were returned either in person during a clinic visit or via
+pre‐postage paid return envelops. Patients also completed the
+6MWT at T1 to T3. Participants were enrolled for a duration of 18
+to 20 weeks. The trial was completed between November 2014 and
+October 2016.
+2.3
+|
+Randomization
+Dyads were randomized to either the DY or WLC group through a
+form of adaptive randomization called minimization ensuring that the
+groups were balanced on patients' stage, sex, age, and cancer type
+(non‐small cell lung cancer [NSCLC] vs esophageal cancer) using a
+computerized system (Filemaker).20
+2.4
+|
+DY group
+The manualized yoga program was developed in collaboration with
+Swami Vivekananda Yoga Anusandhana Samsthana. Two certified
+instructors (International Association of Yoga Therapists; C‐IAYT)
+who had also completed a 200‐hour instructor course in Vivekananda
+yoga implemented the sessions. All sessions were delivered to individ-
+ual patient‐caregiver dyads either in a designated space for behavioral
+interventions or a family consult room in the radiation treatment area
+based on participants' preference. Dyads had to attend all sessions
+together over the course of patients' standard TRT (2‐3 times per
+week for a total of 6 weeks; 60 minutes per session).
+The program consisted of four main components: (1) joint
+loosening with breath synchronization; (2) postures (asanas) including
+partner‐poses
+followed
+by
+relaxation
+techniques;
+(3)
+breath
+energization (pranayama) with sound resonance; and (4) guided
+imagery/meditation focusing on dyadic concepts (eg, love, accep-
+tance).17 Sessions 1 to 4 focused on gradually introducing the various
+practices. The remaining sessions (5‐15) focused on practicing the
+components and answering questions pertaining to the techniques
+and participants' experiences. Starting with session 1, instructors con-
+veyed the notion that each practice is intended to target the needs of
+both members of the dyad, with a focus on their interconnectedness.
+Participants received printed materials and a compact disc containing
+616
+MILBURY ET AL.
+the program at sessions 1 and 5, respectively, and were encouraged to
+practice the techniques on their own on the days when they did not
+meet with their instructor.
+To ensure treatment fidelity, all sessions were video‐recorded
+(with the participants' permission obtained during the informed
+consent process) and reviewed on an ongoing basis using a fidelity
+checklist.
+2.5
+|
+WLC group
+The WLC group received the usual care as provided by their health
+care team and were offered the intervention after they completed
+the T3 assessment. No additional data were collected.
+2.6
+|
+Measures
+Demographic and medical factors. Demographic items (eg, age, marital
+status) were included in the baseline questionnaires. Patients' medical
+data were extracted from their electronic medical records.
+Feasibility data. Tracking data regarding consent rates, class atten-
+dance, completion of questionnaires, and attrition were kept. Partici-
+pants in the DY group completed an evaluation of the intervention
+to assess their satisfaction. The frequency of home yoga practice
+was assessed weekly with a paper‐pencil practice log over the course
+of TRT. Instructors monitored for adverse events, and participants
+completed perceived exertion during the yoga session on the 0 to
+10 Borg scale on a weekly basis to ascertain patient safety.21
+Patient physical function was assessed using the 6MWT following
+the guidelines of the American Thoracic Society (ATS).22 A research
+assistant who was blinded to group assignment implemented the tests
+on a straight, long, and flat hospital corridor. For patients with thoracic
+malignancies, 42 meters (m) has been identified as the cut‐off value
+for clinically relevant differences.23 Patients were asked to indicate
+their level of perceived exertion during the task on the 0 to 10 Borg
+scale and their shortness of breath on the 0 to 10 modified Borg
+Scale.21,24 A 1‐point between‐group difference has been identified
+as the minimally clinically important difference.25
+Depressive symptoms were assessed using the Center for Epidemi-
+ologic Studies‐Depression Scale (CES‐D), a 20‐item self‐reported
+instrument focusing on the affective component of depression.26 A
+score of at least 16 is the cutoff for further psychological evaluation
+for a depressive disorder.
+QOL was assessed with the Medical Outcomes Study 36‐item
+short‐form survey (SF‐36) assessing eight distinct domains: physical
+functioning, physical impediments to role functioning, bodily pain,
+general health perceptions, vitality, social functioning, emotional
+impediments to role functioning, and mental health.27 A group
+difference of 5 points is considered clinically significant.
+2.7
+|
+Statistical analyses
+To examine feasibility, we calculated descriptive statistics of consent,
+class attendance, assessment completion, and program satisfaction.
+To establish preliminary efficacy, we used an intent‐to‐treat analysis
+when performing multilevel modeling (MLM) using PROC MIXED
+(SAS, 9.4 version). We used separate analyses for patients and
+caregivers and controlled for baseline level of the given outcome.
+Because age, gender, smoking status, and patients' stage at diagnosis
+have been associated with outcomes in thoracic cancers,28,29 we
+included these factors as a priori covariates when examining group
+means. In the caregiver models, we controlled for age and sex as they
+were associated with the outcomes at P < .05. We examined each
+dimension of the SF‐36 separately to identify which QOL domain
+may serve as a primary outcome in the future efficacy trial. Because
+the current study is a pilot trial and not adequately powered, we
+interpreted least square mean (LSM) differences for the 6MWT and
+SF‐36 domains based on clinical relevance as opposed to inferential
+significance testing. We also calculated the effect size (Cohen's d)
+associated with each between‐group comparison interpreting effects
+as small (d = .2), medium (d = .5), and large (d = .8) and recorded 95%
+confidence intervals (CI).30 Because too few participants met the
+CES‐D caseness criterion, we did not examine change in caseness
+to identify clinical relevance. Instead, we examined the between‐
+group effect size to establish preliminary efficacy. We followed up
+the MLM analyses with cross‐sectional between group tests to
+examine LSM for time point. We determined sample size based on
+Whitehead et al's recommendation of n = 30 for a two arm‐pilot
+trial detecting a medium effect size with 90% power and two‐sided
+5% significance.31 (We consented an additional two dyads because
+two of the consented patients became ineligible as mentioned
+below).
+3
+|
+RESULTS
+3.1
+|
+Participant characteristics
+Baseline demographic and medical data are listed in Table 1. Briefly,
+patients mostly were male (62%), White (88%), educated with at least
+some college credits (69%), elderly (mean = 66.7 years, range = 33‐
+88), and retired (62%); and had NSCLC (80%), and stage III disease
+(92%). Caregivers mostly were female (62%), educated with at least
+some college credits (54%), middle aged (mean age = 60 years;
+range = 24‐78), fulltime employed (31%), and married (81%) to the
+patient. CES‐D caseness was low for both patients (19%) and care-
+givers (15%). There were no significant group differences regarding
+baseline participant characteristics. See supplemental Table 1 for
+baseline dyadic results.
+3.2
+|
+Feasibility results
+3.2.1
+|
+Recruitment and sample retention
+We screened 144 patients, 47 of whom were eligible for study
+participation. Ineligibility was mainly due to lack of a caregiver or
+consenting caregiver (n = 73). Of the eligible dyads, 32 (68%)
+consented. Refusal reasons were lack of interest (n = 7) and time
+(n = 5), feeling too sick or distressed to participate (n = 2), and not
+wanting to risk being in the control group (n = 1). Four patients
+MILBURY ET AL.
+617
+withdrew prior to randomization, and two became ineligible due to
+disease
+progression
+and
+discontinuation
+of
+treatment
+prior
+to
+randomization so that we randomized 26 of the 32 dyads that had
+consented. Regarding the questionnaires and 6MWT, 26 dyads
+completed the T1 assessment, 25 completed the T2 assessment,
+and 18 (70%) completed the T3 assessment. See Figure 1 for
+Consort Chart.
+3.2.2
+|
+Adherence and acceptability
+Dyads randomized to the DY group attended a mean of 12 sessions
+(SD = 4.0; range: 4‐15; 80% of all sessions) and practiced on average
+2.17 times (SD = 1.63; range: 0‐5 times) per week outside of class.
+All participants in the DY group rated each component of the inter-
+vention as either “beneficial” or “very beneficial” and the overall
+TABLE 1
+Baseline patient and caregiver characteristics (N = 26 dyads)
+Yoga Group (N = 13 Dyads)
+Control Group (N = 13 Dyads)
+Variable
+Patient
+Caregiver
+Patient
+Caregiver
+Male sex n (%)
+8 (62)
+5 (38)
+8 (62)
+3 (17)
+Mean age, years ±SD, (range)
+66.15 ± 5.48 (58‐76)
+62.01 ± 11.37 (29‐75)
+65.54 ± 12.53 (32‐87)
+56.9 ± 15.17 (24‐78)
+Non‐Hispanic white, n (%)
+11 (85)
+11 (85)
+13 (100)
+13 (100)
+Spousal caregiver
+12 (92)
+10 (77)
+Highest level of education, n (%)
+Some college or higher
+10 (77)
+11 (85)
+10 (77)
+9 (69)
+Household income, n (%)
+50 000 or more
+12 (92)
+11 (85)
+11 (85)
+9 (69)
+Employment status, n (%)
+Retried
+9 (69)
+7 (54)
+8 (62)
+5 (38)
+Full‐time
+2 (15)
+4 (31)
+3 (23)
+4 (31)
+Medical leave
+2 (15)
+1 (8)
+2 (15)
+1 (8)
+Part‐time/homemakers
+1 (8)
+3 (23)
+Cancer type, n (%)
+Non‐small cell lung cancer
+10 (77)
+10 (77)
+Stage at diagnosis, n (%)
+III
+9 (69)
+8 (62)
+Resection, n (%)
+Yes,
+4 (31)
+3 (23)
+Chemoradiation, n (%)
+Yes
+12 (92)
+12 (92)
+ECOG performance status at recruitment
+0
+3 (23)
+5 (38)
+I
+8 (62)
+7 (54)
+Time since diagnoses, weeks ±SD, (range)
+4.93 ± 2.00 (1‐12)
+8.51 ± 8.44 (2‐34)
+Abbreviations: ECOG, Eastern Cooperative Oncology Group; SD, standard deviation.
+FIGURE 1
+Consort flow diagram
+618
+MILBURY ET AL.
+program as “useful” or “very useful.” The majority of patients (90%) in
+the DY group chose to attend the yoga sessions in the behavioral
+intervention center. No related adverse events were observed. Partic-
+ipants rated the session as “easy” on the Borg exertion scale (patients:
+mean = 2.17 SD = 0.75, range = 1‐3; caregivers: mean = 2.57,
+SD = 0.98, range = 1‐4).
+3.3
+|
+Preliminary efficacy results
+3.3.1
+|
+Patient Physical Function
+Controlling for the above‐mentioned covariates, MLM analyses for the
+6MWT revealed a clinically significant group main effect (LSM:
+DY = 473 m, 95% CI [408, 538] vs WLC = 397 m, 95% CI [317,
+478];, d = 1.19;) so that patients in the DY group performed signifi-
+cantly better compared with those in the WLC group. Clinical
+improvements were observed at T2 (LSM: DY = 480 m, 95% CI
+[401, 560] vs WLC = 402 m, 95% CI [320, 485]; d = 1.07) and T3
+(LSM: DY = 493 m, 95% CI [370, 565] vs WLC = 374 m, 95% CI
+[315, 509]; d = .94). Patients in the DY group reported clinically signif-
+icantly lower levels of dyspnea (DY mean = 1.67, 95% CI [1.08, 2.39]
+vs WLC mean = 2.69, 95% CI [1.96, 3.46]; d = 0.83) and exertion
+(DY mean = 1.47; 95% CI [0.58, 2.36] vs WLC mean = 3.69, 95% CI
+[2.70, 4.69]; d = .80) compared with those in the WLC group during
+the 6MWT.
+3.3.2
+|
+Depressive Symptoms
+MLM analyses revealed slightly better depressive symptoms for
+patients in the DY group compared with those in the WLG group
+(LSM: DY = 7.80, 95% CI [4.25, 11.71] vs WLC = 9.84, 95% CI
+[4.22, 15.24]; d = .26). Cross‐sectional analyses found a medium effect
+size at T2 (DY mean = 7.47, 95% CI [0.94, 13.99]; vs WLC
+mean = 10.44, 95% CI [0.87, 13.31]; d = .50) and at T3 (DY
+mean = 8.29, 95% CI [3.22, 13.38] vs WLC mean = 11.29, 95% CI
+[3.21, 19.36]; d = .39). For caregivers, we found no evidence that
+the intervention reduced their depressive symptoms (LSM: DY = 6.98,
+95% CI [4.26, 9.70] vs WLC = 5.72 m, 95% CI [2.80, 8.64]; d = .12).
+3.3.3
+|
+QOL
+MLM analyses revealed a clinically significant group main effects
+for physical function (LSM: DY = 38.77, 95% CI [30.04, 47.94] vs
+WLC = 30.88, 95% CI [19.44, 42.31]; d = .66) and social function
+(LSM: DY = 45.24, 95% CI [32.42, 58.07] vs WLC = 39.09, 95%
+CI [19.72, 58,45]; d = .44) so that patients in the DY group
+reported better QOL compared with those in the WLC group.
+Cross‐sectional follow‐up analyses revealed clinically significant
+differences at T2 for role performance (LSM: DY = 40.99, 95% CI
+[31.06, 50.92] vs WLC = 35.23, 95% CI [22.23, 48.22]; d = .50)
+and mental health (LSM: DY = 56.97, 95% CI [45.64, 68.30] vs
+WLC = 50.07, 95% CI [35.29, 64.84]; d = .94) in the expected
+direction. At T3, although the DY group reported improved vitality
+(LSM: DY = 44.56, 95% CI [27.53, 61.59] vs WLC = 37.97, 95% CI
+[10.01, 65.93]; d = .60), they reported worse general health
+compared with the WLC group (LSM: DY = 44.08, 95% CI [31.35,
+56.81] vs WLC = 49.41, 95% CI [24.37, 74.46]; d = .42). According
+to the results of the MLM analyses, caregivers in the DY group did
+not show significant improvements in any of the QOL domains.
+Cross‐sectional follow‐up analyses revealed that caregivers in the
+DY group reported marginally clinically significant improvements
+in role performance (LSM: DY = 52.78, 95% CI [48.82, 56.74] vs
+WLC = 48.59, 95% CI [43.81, 53.37]; d = .51) and vitality (LSM:
+DY = 53.05, 95% CI [35.29, 64.84] vs WLC = 48.84, 95% CI
+[43.81, 53.37]; d = .39) at T2 and social function (DY LSM = 50.55,
+95% CI [45.83, 55.27] vs WLC LSM = 46.69, 95% CI [40.51,
+52.87]; d = .51) at T3 relative to those in the WLC group. See
+supplemental Table 2 for detailed results of unadjusted means for
+self‐reported measures.
+4
+|
+CONCLUSIONS
+The goal of this pilot RCT was to demonstrate the feasibility and pre-
+liminary efficacy of a DY intervention for patients undergoing TRT and
+their family caregivers, targeting patient physical function and patient
+and caregiver depressive symptoms and QOL. The results revealed
+that the trial was feasible, as it met our a priori feasibility criteria
+regarding consent, retention, and adherence rates. Of note, 80% of
+the dyads attended all 15 DY sessions, which is remarkable consider-
+ing that the majority of the patients had stage III disease and were
+undergoing aggressive chemoradiation. All of the patients and care-
+givers considered the intervention to be useful and beneficial, which
+they further demonstrated by their yoga practice outside of class.
+Based on clinically significant improvements in objective and self‐
+reported measures, the DY program may be efficacious in improving
+patients' physical function. We also observed clinically significant
+improvements in patients' social function across the 3‐month follow‐
+up period and short‐term clinically significant gains in the role perfor-
+mance and mental health domains as well depressive symptoms. The
+caregivers' treatment response was less pronounced than that of the
+patients. Although we found no role differences at baseline regarding
+depressive symptoms, unlike patients, caregivers in the DY group did
+not show improvements across the follow‐up period. Regarding
+QOL, effect sizes for caregivers ranged from small to medium, with
+marginal clinically significant improvements in vitality and role perfor-
+mance, two important aspects of QOL that are relevant to providing
+quality care and support to patients.
+Based on these findings, an efficacy RCT is warranted. Although
+the current feasibility trial has provided an essential foundation for
+evaluating the effects of a dyadic supportive care approach, remaining
+crucial issues must be addressed in future research. For example,
+whether a dyadic intervention is in fact superior to a patient‐only
+approach in general and in this particular patient population is unclear.
+Although caregivers' responsiveness to the dyadic intervention was
+modest and thus may not appear to provide a strong rationale for a
+dyadic intervention, the larger intervention context must be consid-
+ered. Enrolling patients and caregivers jointly may increase feasibility
+with regard to consent and adherence rates as demonstrated herein
+and in the behavior change literature.32,33 Without the support of a
+MILBURY ET AL.
+619
+family caregiver, a patient may be less likely to attend yoga sessions
+and practice it at home, which may compromise treatment efficacy.
+Moreover, patients indicated that they enjoyed and preferred partici-
+pating with their family members, which may account for the clinically
+significant improvements in social function we observed. Our next
+study will include qualitative interviews and pinpointed measures to
+examine the relationship constructs (ie, illness communication) as a
+potential intervention mechanism. Also, given the interdependence
+of depressive symptoms and QOL, even small treatment effects on
+caregivers may have systemic implications and, thus, optimize patients'
+responses.
+Nevertheless, several patients were ineligible for the present
+study because they lacked family caregivers who were able to partic-
+ipate, which may potentially limit external validity and feasibility of a
+larger trial. To remedy these concerns, we propose the use of video-
+conferencing delivery, which we are currently testing. As opposed to
+one primary caregiver, enrolling alternate caregivers who attend only
+a subset of sessions may also increase patient eligibility. Regarding
+the caregivers, their treatment responses may have been limited
+because their primary focus may have been supporting patients as
+opposed to practicing self‐care. Although caregivers' consent and
+retention rates tend to be much higher in dyadic intervention studies,
+they may receive greater benefit from caregiver‐only interventions,
+possibly offering respite from their caregiving. Head‐to‐head compar-
+isons of dyadic and individual‐oriented supportive care are needed to
+address these central issues in the dyadic intervention literature.34
+Future research is also needed to explore the underlying mecha-
+nisms of yoga, particularly DY, as in the present study. For patients
+undergoingTRT, breathing exercises targeting dyspnea, a common side
+effect, may be a primary mechanism by which yoga protects patients
+from physical function declines during and after TRT. In fact, patients
+in the DY group reported significantly less severe dyspnea and per-
+ceived less exertion during the 6MWT than did patients in the WLC
+group. Moreover, examining improvements in dyadic coping or illness
+communication may also be important mediators to be considered.
+4.1
+|
+Study limitations
+In addition to lacking an active control group, our study is limited by
+the sample's fairly homogenous characteristics. Patients and care-
+givers were psychologically well‐adjusted based on the rather low
+mean CES‐D scores, so how patients and caregivers with greater dis-
+tress would fare with the DY intervention is unclear. Again, an efficacy
+trial with a larger sample is needed to facilitate subgroup analyses and
+identify participant characteristics associated with differential treat-
+ment responses. Lastly, the pilot RCT was not powered to examine
+group differences and the initial evidence for efficacy presented here
+must be interpreted with caution.
+4.2
+|
+Clinical implications
+Clinical implications of the utility of this intervention in the clinical
+setting are premature at this point. However, the present pilot RCT
+provides strong evidence of the feasibility of the DY intervention for
+patients undergoing TRT and their family caregivers based on a priori
+criteria pertaining to DY consent, adherence, and retention ratings.
+Patients and caregivers rated the intervention as beneficial and useful.
+Using clinical cutoff scores, we demonstrated preliminary DY efficacy
+regarding patients' QOL and. Objectively measured physical function.
+Thus, the intervention has promise in protecting patients against
+TRT‐related toxicities. Based on these findings, a large, well‐controlled
+efficacy trial of DY is warranted.
+ACKNOWLEDGEMENT
+This research was supported by grant K01 AT007559 from the
+National Center for Complementary and Integrative Health. We
+acknowledge the MD Anderson Cancer Center's Department of
+Scientific Writing for reviewing this manuscript.
+CONFLICT OF INTEREST
+None of the authors have any actual or potential conflict of interests
+to disclose.
+ORCID
+Kathrin Milbury
+https://orcid.org/0000-0003-2605-3592
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+1036‐1048.
+SUPPORTING INFORMATION
+Additional supporting information may be found online in the
+Supporting Information section at the end of the article.
+How to cite this article: Milbury K, Liao Z, Shannon V, et al.
+Dyadic yoga program for patients undergoing thoracic radio-
+therapy and their family caregivers: Results of a pilot random-
+ized
+controlled
+trial.
+Psycho‐Oncology.
+2019;28:615–621.
+https://doi.org/10.1002/pon.4991
+MILBURY ET AL.
+621

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+                          
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+PS
+SY
+YC
+CH
+HO
+OL
+LO
+OG
+GI
+IC
+CA
+AL
+L 
+ R
+RE
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+PO
+OR
+RT
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+S 
+  
+  
+  
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+  
+  
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+  
+  
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+EP
+PT
+TU
+UA
+AL
+L 
+ A
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+ S
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+ 
+                                                                                                                                                          
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+PROOF
+Perceptual and Motor Skills, 2009, 108, 1-7.  © Perceptual and Motor Skills 2009
+DOI 10.2466/PMS.108.3.
+EFFECT OF FOUR VOLUNTARY REGULATED YOGA 
+BREATHING TECHNIQUES ON GRIP STRENGTH1
+MEESHA JOSHI AND SHIRLEY TELLES
+Swami Vivekananda Yoga Research Foundation, Bangalore, India
+Summary.—Bilateral hand-grip strength was studied in 21 male volunteers (M 
+age = 25.6 yr., SD = 5.2). All were assessed before and after five practice sessions of 
+20 min. duration: right-nostril yoga breathing, left-nostril yoga breathing, alternate-
+nostril yoga breathing, breath awareness, and a no-intervention session. Data were 
+analyzed with analyses of variance and an analysis of variance using the no-breath 
+awareness control condition as a covariate. There were no significant changes. The 
+left-hand-grip strength reduced after left-nostril yoga breathing. However, findings 
+were not considered significant, so methodological issues in yoga research which 
+could contribute to null findings and even mask actual changes were discussed.
+The basic-rest-activity cycle (BRAC) was initially described based on 
+observations made for infants and was later shown also to hold for adults 
+(Kleitman, 1963). Various physiological processes are entrained to this 
+rhythm. One of the lesser known is the nasal cycle.
+The nasal cycle is an ultradian rhythm during which both nostrils 
+are alternately patent. Originally, the periodicity was reported to range 
+between 2 and 8 hours. (Keuning, 1968). However, time analyses detect­
+ed periods for the nasal cycle and coregulated systems. These periods 
+were at 280–300, 215–275, 165–210, 145–160, 105–140, 70–100, and 40–65 
+minutes, with the greatest spectral power in longer periods during wak­
+ing (Shannahoff-Khalsa, Kennedy, Yates, & Ziegler, 1996, 1997). While 
+the nasal cycle is coupled to other rhythms such as alternating cerebral 
+hemispheric dominance and autonomic activity, it has also been sug­
+gested that right nostril dominance may correlate with the activity phase 
+of the basic-rest-activity cycle (Werntz, Bickford, Bloom, & Shannahoff-
+Khalsa, 1983; Shannahoff-Khalsa, 2008).
+A very early description by Wada, in 1922, presented a relation be­
+tween basic rhythms (i.e., hunt-eat-rest) and hand-grip strength (Shanna­
+hoff-Khalsa, 1991; Shannahoff-Khalsa, 2008). Hand-grip strength is used 
+to assess general strength, and hence, underlies work capacity, extent of 
+injury and disease, and the possibility of rehabilitation (Petersen, Petrick, 
+Connor, & Conklin, 1989). Motor activity during wakefulness showed 
+greater hand-grip strength during periods of hunger contractions than for 
+quiescent or postmeal periods. This rhythm, i.e., hunt-eat, then rest, may 
+be considered another way of viewing the basic-rest-activity cycle. Given 
+1Address correspondence to Shirley Telles, Ph.D., Patanjali Yogpeeth, Maharishi G. Dayanand 
+Gram, Bahadrabad, Haridwar, Uttarakhand 249408, India or e-mail (shirleytelles@gmail.
+com).
+PROOF
+M. JOSHI & S. TELLES
+2
+this connection between basic-rest-activity cycle and hand-grip strength 
+and the speculation that right nostril breathing corresponds to the activity 
+phase of the basic-rest-activity cycle, the effect of uninostril breathing on 
+hand-grip strength has been studied in yoga practitioners (Raghuraj, Nag­
+arathna, Nagendra, & Telles, 1997). Such a study was possible as there are 
+certain yoga breathing techniques in which practitioners learn to breathe 
+through either one of the nostrils at a time or to alternate between nostrils 
+(these are called pranayamas). These maneuvers are done by occluding one 
+nostril with the thumb and ring finger of the dominant hand in a charac­
+teristic yoga pose called nasika mudra (Swami Niranjanananda Saraswati, 
+1994). These yoga breathing practices impose uninostril or alternate nos­
+tril yoga breathing on the practitioner, hence they occur quite separate­
+ly from the spontaneously occurring nasal cycle. The 1994 study showed 
+that right-, left-, and alternate-nostril yoga breathing practiced over a 10-
+day period all brought about a bilateral increase in the hand-grip strength 
+(Raghuraj, et al., 1997).
+The present study was intended to assess the immediate effect of 
+right-, left-, and alternate-nostril breathing on bilateral hand-grip strength. 
+When each of the breathing techniques was practiced for 20 min., hand-
+grip strength was assessed before and after each of them.
+Method
+Subjects
+Twenty-one male volunteers whose ages ranged from 20 to 42 years 
+(M age = 26.0, SD = 5.5 yr.) were selected. Their range of experience of prac­
+ticing yoga breathing techniques was 3 mo. to 7 yr. (M experience = 39.4, 
+SD = 57.3 mo.). The volunteers were informed about the study, and their 
+signed consent was obtained. They were all right-hand dominant based 
+on the Edinburgh Handedness Inventory (Oldfield, 1971).
+Design
+Each subject was assessed in five sessions, which were (i) right-nostril 
+yoga breathing, (ii) left-nostril yoga breathing, (iii) alternate-nostril yoga 
+breathing, (iv) breath awareness, and (v) control (no-intervention ses­
+sion). The participants were randomly assigned to a sequence of five ses­
+sions using a random number table (Zar, 1999). Hence, each subject was 
+assessed in five sessions on five different days. Possibly, a better design 
+would have been systematically rotating the conditions so that an equal 
+number of subjects practiced the manipulation in every order, such as an 
+incomplete Latin Square whereby one-fifth of the participants would have 
+had the order 1, 2, 3, 4, 5; one-fifth of the participants the order 5, 1, 2, 3, 4; 
+and one-fifth the order 4, 5, 1, 2, 3, and so on. Since this was not done, it is 
+hard to say whether there were carry-over effects in people’s practice, es­
+PROOF
+YOGA BREATHING AND GRIP STRENGTH
+3
+pecially if the control condition was the last one. This is a methodological 
+limitation of the study.
+Assessment
+The hand-grip strength of both hands was assessed using a hand-grip 
+dynamometer (Lafayette Instruments, Co., Model No.76618, USA). Partic­
+ipants were tested in six trials, three trials for each hand alternately, with 
+an interval of 10 sec. between trials. During assessment, participants were 
+asked to keep the arm extended at shoulder level out to the side, horizon­
+tal to the ground as has been described earlier (Madan, Thombre, Bhara­
+thi, Nambinarayan, Thakur, Krishnamurthy, et al., 1992). The maximum 
+value, the average value, and the final value out of three readings were 
+used for statistical analysis.
+Intervention
+Each subject had three pranayama sessions and two control sessions. 
+The sessions were for 20 min. on five separate days at the same time of 
+the day. The five sessions are mentioned: (1) right-nostril yoga breathing 
+or suryanuloma viloma pranayama practice involves breathing exclusively 
+through the right nostril while the left nostril is occluded. (2) Left-nos­
+tril yoga breathing or chandra anuloma viloma pranayama practice involves 
+breathing through the left nostril exclusively while the right nostril is oc­
+cluded. (3) Alternate-nostril yoga breathing or nadisuddhi pranayama prac­
+tice involves breathing out from the left nostril, breathing in from the left 
+nostril, breathing out from the right nostril, breathing in from the right 
+nostril, and breathing out from the left nostril. This is one “round”. Also, 
+(4) in the breath-awareness session, participants maintained awareness 
+of the breath without manipulation of the nostrils (Nagendra, Mohan, & 
+Shriram, 1988). Throughout these practices, participants’ eyes were closed, 
+and they sat cross-legged with focus on awareness of the breath. During 
+these four practices, participants’ attention was directed to the flow of air 
+as it moved through the nostrils. (5) In the control session, participants 
+were asked to sit at ease without being aware of the breath. For expe­
+rienced yoga practitioners it could be difficult to remain without breath 
+awareness. This also limits the present findings. This session was intend­
+ed to assess whether the hand-grip strength changed when the assessment 
+was repeated after 20 min. with no intervention between the first assess­
+ment and the second one 20 min. later. In the three pranayamas involving 
+nostril manipulation, the thumb and the ring finger of the dominant hand, 
+which was the right hand for these participants, were used to manipulate 
+or occlude the nostrils. This is a characteristic yoga gesture (nasika mudra 
+in Sanskrit), prescribed during pranayama practice (Swami Niranjananan­
+da Saraswati, 1994).
+PROOF
+M. JOSHI & S. TELLES
+4
+Data Analysis
+The data obtained before and after all yoga breathing practices, i.e., 
+right-nostril yoga breathing, left-nostril yoga breathing, alternate-nostril 
+yoga breathing, breath awareness, and the control period, were compared. 
+Using SPSS, Version 10.0, a repeated-measures analysis of variance was 
+carried out with three within-subjects factors, i.e., Sessions (5 levels), As­
+sessments (2 levels, pre- and posttest), and Hands (2 levels; left and right). 
+Posttest data were compared with pretest data of the respective session 
+using post hoc analysis with a Bonferroni adjustment.
+These analyses were carried out for the average of three values, the 
+final value, and the maximum of the three. In addition, an analysis of co­
+variance was carried out using the pre- and posttest values from the no-
+breath awareness control condition as a covariate.
+Results
+The groups’ mean values for hand-grip strength for all the yoga breath­
+ing practices are given in Table 1. An analysis of covariance was done us­
+ing the control session pre- and posttest values as covariates. There was no 
+significant difference among any of the sessions for left-hand-grip strength 
+(p = .08 for the omnibus analysis of covariance). The same analysis for the 
+right hand gave a p value of .09 for the omnibus analysis of covariance.
+The three repeated-measures analyses of variance showed no signifi­
+cant difference among Sessions, Assessments, or Hands, as well as no in­
+teractions among these factors (p > .05, in all cases). This was true for the 
+average value, the final value, and the maximum of the three values.
+Since none of the above analyses showed statistical significance, there 
+was no attempt to conduct post hoc analyses. Instead, pretest and post­
+TABLE 1
+Pre- and Posttest Comparisons of Means and Standard Deviations For Final Values, 
+Maximum Values, and Average Values of Hand-grip Strength Over Five Sessions (N = 21) 
+Sessions
+Hand
+Hand-grip strength: Pre (Kg)
+Hand-grip strength: Post (Kg)
+Final
+Maximum
+Grand M
+Final
+Maximum
+Grand M
+M
+SD
+M
+SD
+M
+SD
+M
+SD
+M
+SD
+M
+SD
+Right-nostril yoga 
+breathing
+Right 43.57 6.21 44.48 6.20 43.08 5.72 42.90 4.61 44.52 4.97 43.21 4.97
+Left
+42.67 4.44 44.10 4.71 42.87 4.70 42.43 4.51 43.76 4.75 42.29 4.69
+Left-nostril yoga 
+breathing
+Right 43.86 4.94 44.90 4.67 43.51 4.55 43.14 4.03 44.81 4.55 43.28 4.47
+Left
+42.43 5.27 44.52 4.93 43.00 4.70 41.86 5.27 43.57 4.74* 42.05 4.76
+Alternate-nostril 
+yoga breathing
+Right 43.86 6.58 45.24 4.98 43.62 5.47 43.19 5.19 44.33 4.72 43.16 4.99
+Left
+43.71 4.62 44.71 4.75 43.17 5.00 42.43 4.75 44.00 4.81 42.70 4.65
+Breath awareness Right 43.52 5.13 44.57 4.96 43.29 4.52 43.95 5.30 44.71 5.43 43.51 5.58
+Left
+42.00 4.68 43.52 3.76 41.95 4.09 41.57 5.27 43.48 4.57 41.89 4.80
+Control
+Right 43.14 6.24 44.29 5.95 43.33 6.10 42.76 4.19 44.00 4.98 42.62 4.96
+Left
+41.95 5.45 44.10 4.25 42.33 4.44 42.48 4.78 43.33 4.73 42.11 4.54
+*p < .01: Posttest vs pretest (one-tailed).
+PROOF
+YOGA BREATHING AND GRIP STRENGTH
+5
+test comparisons were made at both one-tailed and two-tailed t tests for 
+paired data. The left hand-grip strength following left-nostril breathing 
+showed a decrease (p < .05, one-tailed).
+The absence of change appeared related to the small effect size. An a 
+priori analysis using the effect size showed that the sample size required to 
+produce effects would be extremely large, far exceeding the present sample 
+size of 21 persons for α value of .05. This analysis was done with G*Power 
+software, Version 3.0.10 (Faul, Erdfelder, Lang, & Buchner, 2007).
+Discussion
+The bilateral hand-grip strength was recorded for 21 male volun­
+teers before and after four yoga breathing practices, and a no-intervention 
+session, each practiced on a separate day. Despite different methods of 
+analysis, no effect of the breathing practices on hand-grip strength could 
+be seen. The sole change was a trend of decrease in the left hand-grip 
+strength following left-nostril yoga breathing which is not convincing and 
+hence is not discussed further.
+A previous study assessed effects of yoga breathing techniques, i.e., 
+right-, left-, alternate-nostril yoga breathing and one control group on bi­
+lateral hand-grip strength (Raghuraj, et al., 1997). The subjects were 130 
+children attending a 10-day residential yoga camp, and the techniques 
+were practiced as “27 rounds” four times a day. The assessments were on 
+the first day and after 10 days. There was bilateral increase in hand-grip 
+strength in all three experimental groups. In this earlier study, the effects 
+were studied over a 10-day period, whereas in the present study, assess­
+ments were made immediately before and after 20-min. practice of the in­
+terventions.
+The absence of change in hand-grip strength following the yoga 
+breathing practices could be related to certain methodological issues 
+apart from the possibility that the yoga breathing practices really did not 
+change hand-grip strength. The methodological issues are relevant to 
+yoga research and particularly to studies of this kind requiring the par­
+ticipation of volunteers who are experienced in specific yoga techniques. 
+The first issue is related to the study’s design. Early studies on medita­
+tion compared the effects of Transcendental MeditationTM with nonmedi­
+tation in age-matched volunteers (Wallace, Benson, & Wilson, 1971).
+However, given the fact that yoga practices are closely related to the 
+mental state (Lutz, Slagter, Dunne, & Davidson, 2008) and hence can be 
+expected to vary considerably among individuals, an alternative study de­
+sign was devised (Telles & Desiraju, 1993). This design is a self-as-control 
+design. In this type of design the same individual is assessed in repeated 
+sessions (e.g., meditation and nonmeditation) on separate days to reduce 
+interindividual variability. Such a design was used in the present study; 
+PROOF
+M. JOSHI & S. TELLES
+6
+however the design has a risk of a carry-over effect whereby the effect of 
+one practice influences the effects of the practice following it.
+The second methodological issue is the small sample size. It is of­
+ten difficult to get volunteers having adequate experience with the yoga 
+technique being studied, who are willing to participate in repeated as­
+sessments. However, when studying the immediate effect of a practice as 
+subtle as yoga breathing techniques (pranayamas), it appears necessary to 
+have a much larger sample size than in studies where the effects may be 
+less subtle (Telles, Naveen, Dash, Deginal, & Manjunath, 2006).
+Hence, the present study highlights the importance of certain issues 
+when designing studies of yoga. These are (i) obtaining as large a sam­
+ple size as possible when studying change with a small effect size, as was 
+seen here, and (ii) avoiding study of the same individual in too many re­
+peated sessions to prevent a carry-over effect and boredom of the volun­
+teers. To evaluate whether these yoga breathing practices actually influ­
+ence the hand-grip strength, in future, further studies should be planned 
+with a large number of volunteers and each would be assessed at the most 
+in two sessions.
+REFERENCES
+Faul, F., Erdfelder, E., Lang, A-G., & Buchner, A. (2007) G*Power 3: a flexible 
+statistical power analysis program for the social, behavioral, and biomedical sci­
+ences. Behavior Research Methods, 39, 175-191.
+Keuning, J. (1968) On the nasal cycle. International Journal of Rhinology, 6, 99-136.
+Kleitman, N. (1963) Sleep and wakefulness. Chicago, IL: Univer. of Chicago Press.
+Lutz, A., Slagter, H. A., Dunne, J. D., & Davidson, R. J. (2008) Attention regulation 
+and monitoring in meditation. Trends in Cognitive Sciences, 12, 163-169.
+Madan, M., Thombre, D. P., Bharathi, B., Nambinarayan, T. K., Thakur, S., Krishna­
+murthy, N., & Chandbrabose, A. (1992) Effects of yoga training on reaction time, 
+respiratory endurance and muscle strength. Indian Journal of Physiology and Phar­
+macology, 36, 229-233.
+Nagendra, H. R., Mohan, T., & Shriram, A. (1988) Yoga in education. Bangalore, India: 
+Vivekananda Kendra Yoga Anusandhan Samsthana.
+Oldfield, R. C. (1971) The assessment and analysis of handedness: the Edinburgh 
+inventory. Neuropsychologia, 9, 97-114.
+Petersen, P., Petrick, M., Connor, H., & Conklin, D. (1989) Grip strength and hand 
+dominance: challenging the 10% rule. American Journal of Occupational Therapy, 43, 
+444-447.
+Raghuraj, P., Nagarathna, R., Nagendra, H. R., & Telles, S. (1997) Pranayama in­
+creases grip strength without lateralized effects. Indian Journal of Physiology and 
+Pharmacology, 81, 555-561. Shannahoff-Khalsa, D. S. (1991) Lateralized rhythms 
+of the central and autonomic nervous systems. International Journal of Neuroscience, 
+11, 222-251.
+Shannahoff-Khalsa, D. S. (2008) Psychophysiological states: the ultradian dynamics of 
+mind-body interactions. Vol. 80. London: Academic Press (Elsevier Scientific Public.).
+PROOF
+YOGA BREATHING AND GRIP STRENGTH
+7
+Shannahoff-Khalsa, D. S., Kennedy, B., Yates, F. E., & Ziegler, M. G. (1996) Ult­
+radian rhythms of autonomic, cardiovascular, and neuroendocrine systems are 
+related in humans. American Journal of Physiology, 270, 873-887.
+Shannahoff-Khalsa, D. S., Kennedy, B., Yates, F. E., & Ziegler, M. G. (1997) Low-
+frequency ultradian insulin rhythms are coupled to cardiovascular, autonomic, 
+and neuroendocrine rhythms. American Journal of Physiology, 272, 962-968.
+Swami Niranjanananda Saraswati. (1994) Prana, pranayama and pranavidya. Munger, 
+India: Bihar School of Yoga.
+Telles, S., & Desiraju, T. (1993) Recording of auditory middle latency evoked po­
+tentials during the practice of meditation with the syllable ‘OM’. Indian Journal of 
+Medical Research, 98, 237-239.
+Telles, S., Naveen, K. V., Dash, M., Deginal, R., & Manjunath, N. K. (2006) Effect of 
+yoga on self-rated visual discomfort in computer users. Head & Face Medicine, 2, 
+46.
+Wallace, R. K., Benson, H., & Wilson, A. F. (1971) A wakeful hypometabolic physi­
+ologic state. American Journal of Physiology, 221, 795-799.
+Werntz, D. A., Bickford, R. G., Bloom, F. E., & Shannahoff–Khalsa, D. S. (1983) Al­
+ternating cerebral hemispheric activity and the lateralization of autonomic ner­
+vous function. Human Neurobiology, 2, 39-43.
+Zar, J. H. (1999) Biostatistical analysis. London: Prentice Hall.
+Accepted April 27, 2009.
+ 
+1 
+RUNNING HEAD: YOGA BREATHING AND GRIP STRENGTH 
+ 
+ 
+EFFECT OF FOUR VOLUNTARY REGULATED YOGA BREATHING TECHNIQUES ON 
+GRIP STRENGTH
+Swami Vivekananda Yoga Research Foundation 
+1 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Meesha Joshi and Shirley Telles  
+ 
+Bangalore, India 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+1Address correspondence to Shirley Telles, Ph.D., Patanjali Yogpeeth, Maharishi G. Dayanand 
+Gram, Bahadrabad, Haridwar, Uttarakhand 249408, India or e-mail ([email protected]). 
+ 
+ 
+ 
+2 
+Summary.—Bilateral hand-grip strength was studied in 21 male volunteers (M age=25.6 yr., 
+SD=5.2). All were assessed before and after five practice sessions of 20 min. duration: right-nostril 
+yoga breathing, left-nostril yoga breathing, alternate-nostril yoga breathing, breath awareness, and a 
+no-intervention session. Data were analyzed with analyses of variance and an analysis of variance 
+using the no-breath awareness control condition as a covariate. There were no significant changes. 
+The left-hand-grip strength reduced after left-nostril yoga breathing. However, findings were not 
+considered significant, so methodological issues in yoga research which could contribute to null 
+findings and even mask actual changes were discussed. 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+3 
+The basic-rest-activity cycle (BRAC) was initially described based on observations made 
+for infants and was later shown also to hold for adults (Kleitman, 1963). Various physiological 
+processes are entrained to this rhythm. One of the lesser known is the nasal cycle.  
+The nasal cycle is an ultradian rhythm during which both nostrils are alternately patent. 
+Originally, the periodicity was reported to range between 2 and 8 hours. (Keuning, 1868). 
+However, time analyses detected periods for the nasal cycle and coregulated systems. These periods 
+were at 280–300, 215–275, 165–210, 145–160, 105–140, 70–100, and 40–65 minutes, with the 
+greatest spectral power in longer periods during waking (Shannahoff-Khalsa, Kennedy, Yates, & 
+Ziegler, 1996, 1997). While the nasal cycle is coupled to other rhythms such as alternating cerebral 
+hemispheric dominance and autonomic activity, it has also been suggested that right nostril 
+dominance may corelate with the activity phase of the basic-rest-activity cycle (Werntz, Bickford, 
+Bloom, & Shannahoff-Khalsa, 1983; Shannahoff-Khalsa, 2008).  
+A very early description by Wada in 1922, presented a relation between basic rhythms (i.e., 
+hunt-eat-rest) and hand-grip strength (Shannahoff-Khalsa, 1991; Shannahoff-Khalsa, 2008). Hand-
+grip strength is used to assess general strength, and hence, underlies work capacity, extent of injury 
+and disease, and the possibility of rehabilitation (Petersen, Petrick, Connor, & Conklin, 1989). 
+Motor activity during wakefulness showed greater hand-grip strength during periods of hunger 
+contractions than for quiescent or postmeal periods. This rhythm, i.e., hunt-eat, then rest, may be 
+considered another way of viewing the basic-rest-activity cycle. Given this connection between 
+basic-rest-activity cycle and hand-grip strength and the speculation that right nostril breathing 
+corresponds to the activity phase of the basic-rest-activity cycle, the effect of uninostril breathing 
+on hand-grip strength has been studied in yoga practitioners (Raghuraj, Nagarathna, Nagendra, & 
+Telles, 1997). Such a study was possible as there are certain yoga breathing techniques in which 
+practitioners learn to breathe through either one of the nostrils at a time or to alternate between 
+ 
+4 
+nostrils (these are called pranayamas). These maneuvers are done by occluding one nostril with the 
+thumb and ring finger of the dominant hand in a characteristic yoga pose called nasika mudra 
+(Swami Niranjanananda Saraswati, 1994). These yoga breathing practices impose uninostril or 
+alternate nostril yoga breathing on the practitioner, hence they occur quite separately from the 
+spontaneously occurring nasal cycle. The 1994 study showed that right-, left-, and alternate-nostril 
+yoga breathing practiced over a 10-day period all brought about a bilateral increase in the hand-grip 
+strength (Raghuraj, et al., 1997).  
+The present study was intended to assess the immediate effect of right-, left-, and alternate- 
+nostril breathing on bilateral hand-grip strength. When each of the breathing techniques were 
+practiced for 20 min., hand-grip strength was assessed before and after each of them.  
+Method 
+Subjects    
+Twenty-one male volunteers whose ages ranged from 20 to 42 years (M age=26.0, SD=5.5 
+yr.) were selected. Their range of experience of practicing yoga breathing techniques was 3 mo. to 7 
+yr. (M experience=39.4, SD=57.3 mo.). The volunteers were informed about the study, and their 
+signed consent was obtained. They were all right-hand dominant based on the Edinburgh 
+Handedness Inventory (Oldfield, 1971). 
+Design  
+Each subject was assessed in five sessions, which were (i) right-nostril yoga breathing, (ii) 
+left-nostril yoga breathing, (iii) alternate-yoga nostril breathing, (iv) breath awareness, and (v) 
+control (no-intervention session). The participants were randomly assigned to a sequence of five 
+sessions using a random number table (Zar, 1999). Hence, each subject was assessed in five 
+sessions on five different days. Possibly, a better design would have been systematically rotating 
+the conditions so that an equal number of subjects practiced the manipulation in every order, such 
+ 
+5 
+as an incomplete Latin Square whereby one-fifth of the participants would have had the order 1, 2, 
+3, 4, 5; one-fifth of the participants the order 5, 1, 2, 3, 4; and one-fifth the order 4, 5, 1, 2, 3, and so 
+on. Since this was not done, it is hard to say whether there were carry-over effects in people’s 
+practice, especially if the control condition was the last one. This is a methodological limitation of 
+the study. 
+Assessment 
+The hand-grip strength of both hands was assessed using a hand-grip dynamometer 
+(Lafayette Instruments, Co., Model No.76618, USA). Participants were tested in six trials, three 
+trials for each hand alternately, with an interval of 10 sec. between trials. During assessment, 
+participants were asked to keep the arm extended at shoulder level out to the side, horizontal to the 
+ground as has been described earlier (Madan, Thombre, Bharathi, Nambinarayan, Thakur, 
+Krishnamurthy, et al., 1992). The maximum value, the average value, and the final value out of 
+three readings were used for statistical analysis. 
+Intervention 
+Each subject had three pranayama sessions and two control sessions. The sessions were for 
+20 min. on five separate days at the same time of the day. The five sessions are mentioned: (1) 
+right-nostril yoga breathing or suryanuloma viloma pranayama practice involves breathing 
+exclusively through the right nostril while the left nostril is occluded; (2) left-nostril yoga breathing 
+or chandra anuloma viloma pranayama practice involves breathing through the left nostril 
+exclusively while the right nostril is occluded; (3) alternate-nostril yoga breathing or nadisuddhi 
+pranayama practice involves breathing out from the left nostril, breathing in from the left nostril, 
+breathing out from the right nostril, breathing in from the right nostril, and breathing out from the 
+left nostril. This is one “round”. Also, (4) in the breath-awareness session, participants maintained 
+awareness of the breath without manipulation of the nostrils (Nagendra, Mohan, & Shriram, 1988). 
+ 
+6 
+Throughout these practices, participants’ eyes were closed, and they sat cross-legged with focus on 
+awareness of the breath. During these four practices, participants’ attention was directed to the flow 
+of air as it moved through the nostrils. (5) In the control session, participants were asked to sit at 
+ease without being aware of the breath. For experienced yoga practitioners it could be difficult to 
+remain without breath awareness. This also limits the present findings. This session was intended to 
+assess whether the hand-grip strength changed when the assessment was repeated after 20 min. with 
+no intervention between the first assessment and the second one 20 min. later. In the three 
+pranayamas involving nostril manipulation, the thumb and the ring finger of the dominant hand, 
+which was the right hand for these participants, was used to manipulate or occlude the nostrils. This 
+is a characteristic yoga gesture (nasika mudra in Sanskrit), prescribed during pranayama practice 
+(Swami Niranjanananda Saraswati, 1994).  
+Data Analysis 
+ 
+The data obtained before and after all yoga breathing practices, i.e., right-nostril yoga 
+breathing, left-nostril yoga breathing, alternate-nostril yoga breathing, breath awareness, and the 
+control period were compared. Using SPSS, Version 10.0, a repeated-measures analysis of variance 
+was carried out with three within-subjects factors, i.e., Sessions (5 levels), Assessments (2 levels, 
+pre- and posttest), and Hands (2 levels; left and right). Posttest data were compared with pretest 
+data of the respective session using post hoc analysis with a Bonferroni adjustment. 
+These analyses were carried out for the average of three values, the final value and the 
+maximum of the three. In addition, an analysis of covariance was carried out using the pre- and 
+posttest values from the no-breath awareness control condition as a covariate. 
+Results 
+The groups’ mean values for hand-grip strength for all the yoga breathing practices are 
+given in Table 1. An analysis of covariance was done using the control session pre- and posttest 
+ 
+7 
+values as covariates. There was no significant difference among any of the sessions for left-hand-
+grip strength (p=.08 for the omnibus analysis of covariance). The same analysis for the right hand 
+gave a p value of .09 for the omnibus analysis of covariance.  
+Insert TABLE 1 about here 
+The three repeated-measures analysis of variance showed no significant difference among 
+Sessions, Assessments, or Hands, as well as no interactions among these factors (p>.05, in all 
+cases). This was true for the average value, the final value and the maximum of the three values.  
+Since none of the above analyses showed statistical significance, there was no attempt to 
+conduct post hoc analyses. Instead, pretest and posttest comparisons were made at both one-tailed 
+and two-tailed t tests for paired data. The left hand-grip strength following left nostril breathing 
+showed a decrease (p<.05, one-tailed).  
+The absence of change appeared related to the small effect size. An a priori analysis using 
+the effect size showed that the sample size required to produce effects would be extremely large, far 
+exceeding the present sample size of 21 persons for α value of .05. This analysis was done with 
+G*Power software, Version 3.0.10 (Faul, Erdfelder, Lang, & Buchner, 2007).  
+Discussion 
+The bilateral hand-grip strength was recorded for 21 male volunteers before and after four 
+yoga breathing practices, and a no-intervention session each practiced on a separate day.  Despite 
+different methods of analysis, no effect of the breathing practices on hand-grip strength could be 
+seen. The sole change was a trend of decrease in the left hand-grip strength following left-nostril 
+yoga breathing which is not convincing and hence is not discussed further.  
+A previous study assessed effects of yoga breathing techniques i.e., right-, left-, alternate-
+nostril yoga breathing and one control group on bilateral hand-grip strength (Raghuraj, et al., 1997). 
+The subjects were 130 children attending a 10-day residential yoga camp, and the techniques were 
+ 
+8 
+practiced as “27 rounds” four times a day. The assessments were on the first day and after 10 days. 
+There was bilateral increase in hand-grip strength in all three experimental groups. In this earlier 
+study, the effects were studied over a 10-day period, whereas in the present study, assessments were 
+made immediately before and after 20-min. practice of the interventions. 
+The absence of change in hand-grip strength following the yoga breathing practices could be 
+related to certain methodological issues apart from the possibility that the yoga breathing practices 
+really did not change hand-grip strength. The methodological issues are relevant to yoga research 
+and particularly to studies of this kind requiring the participation of volunteers who are experienced 
+in specific yoga techniques. The first issue is related to the study’s design. Early studies on 
+meditation compared the effects of Transcendental MeditationTM
+The second methodological issue is the small sample size. It is often difficult to get 
+volunteers having adequate experience with the yoga technique being studied, who are willing to 
+participate in repeated assessments. However, when studying the immediate effect of a practice as 
+subtle as yoga breathing techniques (pranayamas), it appears necessary to have a much larger 
+sample size than in studies where the effects may be less subtle (Telles, Naveen, Dash, Deginal, & 
+Manjunath, 2006). 
+ with nonmeditation in age-
+matched volunteers (Wallace, Benson, & Wilson, 1971).  
+However, given the fact that yoga practices are closely related to the mental state (Lutz, 
+Salgter, Dunne, & Davidson, 2008) and hence can be expected to vary considerably among 
+individuals, an alternative study design was devised (Telles & Desiraju, 1993). This design is a self-
+as-control design. In this type of design the same individual is assessed in repeated sessions, (e.g., 
+meditation and nonmeditation) on separate days to reduce interindividual variability. Such a design 
+was used in the present study; however the design has a risk of a carry-over effect whereby the 
+effect of one practice influences the effects of the practice following it. 
+ 
+9 
+Hence, the present study highlights the importance of certain issues when designing studies 
+on yoga. These are (i) obtaining as large a sample size as possible when studying change with a 
+small effect size, as was seen here, and (ii) avoiding study of the same individual in too many 
+repeated sessions to prevent a carry-over effect and boredom of the volunteers. To evaluate whether 
+these yoga breathing practices actually influence the hand-grip strength, in future, further studies 
+should be planned with a large number of volunteers and each would be assessed at the most in two 
+sessions.     
+References 
+Faul, F., Erdfelder, E., Lang, A-G., & Buchner, A. (2007) G*Power 3: a flexible statistical power 
+analysis program for the social, behavioral, and biomedical sciences. Behavior Research 
+Methods, 39, 175-191. 
+Keuning, J. (1868) On the nasal cycle. International Journal of Rhinology, 6, 99-136.  
+Kleitman, N. (1963) Sleep and wakefulness. Chicago, IL: Univer. of Chicago Press. 
+Lutz, A., Salgter, H. A., Dunne, J. D., & Davidson, R. J. (2008) Attention regulation and 
+monitoring in meditation. Trends in Cognition Science, 12, 163-169. 
+Madan, M., Thombre, D. P., Bharathi, B., Nambinarayan, T. K., Thakur, S., Krishnamurthy, N., & 
+Chandbrabose, A. (1992) Effects of yoga training on reaction time, respiratory endurance 
+and muscle strength. Indian Journal of Physiology and Pharmacology, 36, 229-233. 
+Nagendra, H. R., Mohan, T., & Shriram, A. (1988) Yoga in education. Bangalore, India: 
+Vivekananda Kendra Yoga Anusandhan Samsthana. 
+Oldfield, R. C. (1971) The assessment and analysis of handedness: the Edinburgh inventory. 
+Neuropsycologia, 9, 97-114. 
+Petersen, P., Petrick, M., Connor, H., & Conklin, D. (1989) Grip strength and hand dominance: 
+challenging the 10% rule. American Journal of Occupational Therapy, 43, 444-447.      
+ 
+10 
+Raghuraj, P., Nagarathna, R., Nagendra, H. R., & Telles, S. (1997) Pranayama increases grip 
+strength without lateralized effects. Indian Journal of Physiology and Pharmacology, 81, 
+555-561. 
+Shannahoff-Khalsa, D. S. (1991) Lateralized rhythms of the central and autonomic nervous 
+systems. International Journal of Neuroscience, 11, 222-251.  
+Shannahoff-Khalsa, D. S. (2008) Psychophysiological states: the ultradian dynamics of mind-body 
+interactions. Vol. 80. London: Academic Press (Elsevier Scientific Public.). 
+Shannahoff-Khalsa, D. S., Kennedy, B., Yates, F. E., & Ziegler, M. G. (1996) Ultradian rhythms of 
+autonomic, cardiovascular, and neuroendocrine systems are related in humans. American 
+Journal of Physiology, 270, 873-887. 
+Shannahoff-Khalsa, D. S., Kennedy, B., Yates, F. E., & Ziegler, M. G. (1997) Low-frequency 
+ultradian insulin rhythms are coupled to cardiovascular, autonomic, and neuroendocrine 
+rhythms. American Journal of Physiology, 272, 962-968. 
+Swami Niranjanananda Saraswati (1994) Prana, pranayama and pranavidya. Munger, India: Bihar 
+School of Yoga. 
+Telles, S., & Desiraju, T. (1993) Recording of auditory middle latency evoked potentials during the 
+practice of meditation with the syllable ‘OM’. Indian Journal of Medical Research, 98, 237-
+239.  
+Telles, S., Naveen, K. V., Dash, M., Deginal, R., & Manjunath, N. K. (2006) Effect of yoga on self-
+rated visual discomfort in computer users. Head & Face Medicine, 2, 46. 
+Wallace, R. K., Benson, H., & Wilson, A. F. (1971) A wakeful hypometabolic physiologic state. 
+American Journal of Physiology, 221, 795-799. 
+ 
+11 
+Wertnz, D. A., Bickford, R. G., Bloom, F. E., & Shannahoff–Khalsa, D. S. (1983) Alternating 
+cerebral hemispheric activity and the lateralization of autonomic nervous function. Human 
+Neurobiology, 2, 39-43. 
+Zar, J. H. (1999) Biostatistical analysis. London: Prentice Hall.  
+Accepted April 27, 2009. 
+ 
+12 
+TABLE 1: Pre- and Posttest comparisons of Means and Standard Deviations for Final Values, Maximum Values, and Average Values of 
+Hand-grip Strength over Five Sessions. (N=21)  
+*p<.01: Posttest vs pretest (one-tailed) 
+Sessions 
+Hand 
+Hand-grip strength: Pre (Kg) 
+Hand-grip strength: Post (Kg) 
+Final 
+M 
+SD 
+Maximum 
+M 
+SD 
+Grand M 
+M 
+SD 
+Final 
+M 
+SD 
+Maximum 
+M 
+SD 
+Grand M 
+M 
+SD 
+Right-nostril yoga breathing 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Right 
+43.57 ± 6.21 
+44.48 ± 6.20 
+43.08 ± 5.72 
+42.90 ± 4.61 44.52 ± 4.97 
+43.21 ± 4.97 
+Left 
+42.67 ± 4.44 
+44.10 ± 4.71 
+42.87 ± 4.70 
+42.43 ± 4.51 43.76 ± 4.75 
+42.29 ± 4.69 
+Left-nostril  yoga breathing 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Right 
+43.86 ± 4.94 
+44.90 ± 4.67 
+43.51 ± 4.55 
+43.14 ± 4.03 44.81 ± 4.55 
+43.28 ± 4.47 
+Left 
+42.43 ± 5.27 
+44.52 ± 4.93 
+43.00 ± 4.70 
+41.86 ± 5.27 43.57  ± 4.74 * 
+42.05 ± 4.76 
+Alternate yoga nostril breathing  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Right 
+43.86 ± 6.58 
+45.24 ± 4.98 
+43.62 ± 5.47 
+43.19 ± 5.19 44.33 ± 4.72 
+43.16 ± 4.99 
+Left 
+43.71 ± 4.62 
+44.71 ± 4.75 
+43.17 ± 5.00 
+42.43 ± 4.75 44.00 ± 4.81 
+42.70 ± 4.65 
+Breath awareness 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Right 
+43.52 ± 5.13 
+44.57 ± 4.96 
+43.29 ± 4.52 
+43.95 ± 5.30 44.71 ± 5.43 
+43.51 ± 5.58 
+Left 
+42.00 ± 4.68 
+43.52 ± 3.76 
+41.95 ± 4.09 
+41.57 ± 5.27 43.48 ± 4.57 
+41.89 ± 4.80 
+Control 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Right 
+43.14 ± 6.24 
+44.29 ± 5.95 
+43.33 ± 6.10 
+42.76 ± 4.19 44.00 ± 4.98 
+42.62 ± 4.96 
+Left 
+41.95 ± 5.45 
+44.10 ± 4.25 
+42.33 ± 4.44 
+42.48 ± 4.78 43.33 ± 4.73 
+42.11 ± 4.54 

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+© 2021 Indian Journal of Community Medicine | Published by Wolters Kluwer - Medknow
+112
+Abstract
+Original Article
+Introduction
+Neurocognition is a sub‑discipline of neuroscience. 
+Neurocognitive abilities include learning, memory, perception, 
+attention, alertness, and problem‑solving. These abilities are 
+the brain‑mind skills needed to initiate any task from the 
+simplest to the most complex. The process of normal aging is 
+associated with substantial declines in cognitive abilities, which 
+include speed and accuracy of perception, decision‑making, 
+task‑switching, working memory, and multitasking. The 
+basic neurocognitive functions mainly attention‑alertness 
+and memory are markedly affected by age.[1,2] Last three 
+decades investigations on mind body interventions signify 
+on neurocognitive functions suggested promising effect 
+in slowing or reversing the cognitive decline associated 
+with aging process.[3,4] Further, research investigations in 
+the field of exercise science clearly indicated that regular 
+moderate exercise habit reduces the risk factor associated 
+with neurocognitive decline in healthy individuals.[1‑4] Yoga 
+is considered a mind‑body practice of Indian origin, which 
+confirms its potential benefits on the functional ability of 
+neurocognitive aspects. There are studies on the effect of 
+yoga (single or multiple interventions) and the improvement 
+of neuropsychological or psychophysiological functions.[5,6] 
+However, there is no study found on the effect of combined 
+graded yogic training on neurocognitive abilities among 
+middle‑aged population, although it is a vulnerable phase of life 
+from where every person may start the normal aging process. 
+Therefore, the present study was conducted to see the effect 
+of Six and twelve weeks of yogic training on neurocognitive 
+abilities among the middle‑aged group.
+Background: Neurocognitive abilities are the brain‑mind skills needed to initiate any task from the simplest to the most complex, decreases with 
+advancing age. Attention, alertness, and memory are the basic neurocognitive functions most affected by age. There are potential benefits of yoga 
+on neurocognitive functions because this ancient Indian technique positively nurtures the mind‑body systems. Aim of the Study: The present 
+study was aimed to evaluate the effect of 12 weeks of yogic training on neurocognitive abilities in a middle‑aged group. Methods: A total of 86 
+volunteers (46 male and 40 females, age group of 35–55 years), with no prior experience of yoga were participated in this study. Five male 
+and 4 female participants were excluded from the study. All participants divided into yoga training group (male = 21 and female = 18) and 
+control group (male = 20 and female = 18). The yoga training group underwent yoga practices, including kriya, surya namaskar, asana, 
+pranayama, and dhyana daily in the morning, for 6 days/week, for 12 weeks. Standing height, body weight, body mass index, visual reaction 
+time (RT), auditory RT (attention and alertness), and short‑term memory were assessed day 1 (pre), 6th week (mid), and 12th weeks (post) of 
+intervention. Results: Repeated‑measures analysis of variance showed that a statistically significant increased (P < 0.05) in attention‑alertness 
+and short‑term memory after 12 weeks of yogic practices. Conclusion: Integrated approach of yogic intervention may have promising effect 
+on neurocognitive abilities that concomitantly promote successful aging.
+Keywords: Healthy aging, mind‑body medicine, neurocognition
+Address for correspondence: Dr. Sridip Chatterjee, 
+Department of Physical Education, Jadavpur University, Kolkata ‑ 700 032, 
+West Bengal, India. 
+E‑mail: [email protected]
+Access this article online
+Quick Response Code:
+Website:  
+www.ijcm.org.in
+DOI:  
+10.4103/ijcm.IJCM_325_20
+ 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]
+How to cite this article: Chatterjee S, Mondal S, Singh D. Effect of 12 
+weeks of yogic training on neurocognitive variables: A quasi-experimental 
+study. Indian J Community Med 2021;46:112-6.
+Received: 07-05-20,  Accepted: 22-12-20, Published: 01-03-21
+Effect of 12 Weeks of Yogic Training on Neurocognitive 
+Variables: A Quasi-Experimental Study
+Sridip Chatterjee, Samiran Mondal1, Deepeswar Singh2
+Department of Physical Education, Jadavpur University, Kolkata, 1Department of Yogic Art and Science, Visva Bharati, Santiniketan, West Bengal, 2Division of Yoga 
+and Life Sciences, Swami Vivekananda Yoga University, Bengaluru, Karnataka, India
+Chatterjee, et al.: Effect of Yoga on neurocognitive variables
+113
+113
+Indian Journal of Community Medicine  ¦  Volume 46  ¦  Issue 1  ¦  January-March 2021
+113
+Methods
+Study location
+The present study was carried out in the city of Bolpur, West 
+Bengal, India.
+Population
+The target population was middle‑aged men and women.
+Subjects
+To meet the specific objective of the study and to find out 
+the motivated participants, a workshop on “Healthy aging 
+through Yoga” was organized in the locality of Bolpur city, 
+District–Birbhum, State–West Bengal, India. There was total 
+86 adult men (n = 46) and women (n = 40) aged between 35 
+and 55 years willingly enrolled their names to join this yoga 
+and healthy aging workshop. The sample size calculation was 
+not done before the study. However, the post hoc analysis of 
+auditory reaction time (RT) of male in the yoga group showed 
+that with the sample size 86, the calculated effect size is 0.96 
+and power is 0.99 of the study.[7] All participants were from 
+almost similar in socioeconomical background, recreationally 
+active but they have no prior experience any form of yoga 
+before the commencement of specific yoga training. Based on 
+a routine clinical examination, nine participants (5 male and 
+4 female) were excluded from the study due to major injury 
+and illness. The participants who were (n = 77; male 41 and 
+female 36) found in normal health and none of them taking any 
+medication were considered for the study. All the participants 
+were living in Bolpur city and following a similar lifestyle 
+pattern. All of them were nonvegetarian.
+Study designed
+Quasiexperimental research design and convenient sampling 
+method were considered to enroll subjects. All participants were 
+divided into two groups in respect to their serial of registration 
+for the workshop. First 39 participants were served (male 21; 
+age 39.81 ± 9.13 years; female 18, age 41.75 ± 8.70 years) 
+as the yoga training group and remaining others (n = 38) 
+were served as a nonyoga practicing group (male 20, age 
+40.17 ± 8.37 years; female 18, age 42.33 ± 8.23 years). The 
+University Research Review Board approved the study and 
+signed informed consent form was obtained from each subject. 
+All participants were tested‑three times, i.e., day 1 (pre), 
+after 6th week (mid), and after 12th week (post) assessment, 
+under similar laboratory condition. Participants were free to 
+withdraw themselves from the yoga training or assessments at 
+any point of time during the study. The final number of each 
+group completed the study is shown in the flow diagram of 
+quasi‑experimental trials [Figure 1].
+Assessments
+Demographic information, including age, gender, 
+socioeconomic status, education, and anthropometric 
+measurements, was taken on the day of enrolment. Further, 
+participants were assessed for neurocognitive abilities by 
+using visual RT (VRT), auditory RT (ART), and short‑term 
+memory. RT is an interval time between stimulus (S) and 
+response (R) in a given situation. RT was used as an index of 
+cognitive performance change, was considered as it correlates 
+with many central nervous system conditions. Digital reaction 
+timer (Lafayette Instrument Multi‑Operational Apparatus for 
+RT, Model No. 35600) was used for the collection of data. 
+Two modes were used to measure the RT, i.e., VRT using 
+“Light” stimulus; ART using “Audio” stimulus. RT was 
+recorded in term of milliseconds unit. Each subject was given 
+10 trials, and then, average of these trials was considered as 
+the RT of that subject. It was regarded as lesser the time is 
+better the cognitive ability (Manual, Lafayette Instrument, 
+3700 Sagamore Parkway North, P.O. Box 5729, Lafayette, In 
+47903 USA). The short‑term memory is holding small amount 
+of information for the short period of time. The short‑term 
+memory was measured through “serial learning” test by using 
+“Digital Memory Scope” instrument (Medicaid System, 389, 
+Ind. Area, Phase‑II, Chandigarh ‑ 160 002, India). Serial 
+Learning was recorded in terms of the right attempt made by 
+the subject out of 10 numbers accordingly.
+Intervention
+Yoga practicing group (experimental group)
+The yoga group practiced suryanamaskar (dynamic form of 
+physical posture), asanas (static type of physical posture), 
+Enrollment of Subject for 
+Workshop on Healthy Aging through Yoga
+(n = 86, male 46 and female 40)
+ Excluded (n = 9, 5 male
+and 4 Female)
+Not meeting inclusion criteria
+Assed for eligibility
+Finally included for the study
+(n = 77, male 41 and female 36)
+Allotment of 
+Yoga Practicing and Non-yoga
+Practicing Group
+Sampling Method: Convenient
+(n = 77, male 41 and female 36)
+Quasi-Experimental Design
+Yoga Practicing Group
+(male 21 and female 18)
+Non-Yoga Practicing Group
+(male 20 and female 18)
+Baseline Assessment (Pretest)
+Assessment after 6th weeks (Midtest)
+Drop Outs
+Male experimental Gr. (n = 1)
+Female experimental Gr. (n = 3)
+Male control Gr. (n = 0)
+Assessment after 12th weeks (posttest)
+Female control Gr. (n = 3)
+Participants completed and available for final data analysis
+Experimental Gr. (male 20 and female 15);
+Control Gr. (male 20 and female 15)
+Figure 1: Flow diagram of quasi‑experimental trial (n = 86)
+Chatterjee, et al.: Effect of Yoga on neurocognitive variables
+114
+Indian Journal of Community Medicine  ¦  Volume 46  ¦  Issue 1  ¦  January-March 2021
+114
+kriyas (cleansing practices), pranayamas (manipulation of 
+breathing), and dhyana (meditation) for a period of 12 weeks. 
+Training lode in the form of execution time, repetitions, and 
+degree of difficulty increased gradually from the 1st week to 
+12 weeks. Total practice time for the 1st week was 45 min and 
+reach 90 min at the end of 6 weeks. Finally, 1 h 45 min practice 
+times were fixed in the beginning of 8th week and continue 
+till 12–weeks. The detailed yogic practices were reported 
+elsewhere.[8,9] Furthermore, a general record was maintained 
+of the subjects’ activities, diet, and lifestyle during the study 
+period.
+Non‑Yoga practicing group (control group)
+The subjects of the waitlist control group following their usual 
+routine activities. They are instructed to report in the laboratory 
+once in a week. Researcher kept a detail history of their daily 
+lifestyles during these 12 weeks.
+Statistical analysis
+Data obtained through different tests and measurements were 
+processed for data analysis. Mean and standard deviation 
+as descriptive statistic, repeated measures analysis of 
+variance (RM ANOVA) as inferential statistic were used 
+for the data analysis. The RM ANOVA was utilized for two 
+factors, i.e., factor 1 within groups‑time points (pre, mid, and 
+post) measurements and factor 2 between Groups‑differences 
+between the groups (yoga practicing group and nonyoga 
+practicing group). Post hoc test was followed with within 
+and between groups’ factors. Significant level was set at 0.05 
+levels (P < 0.05).
+Results
+Baseline status
+An insignificant baseline difference was found 
+between yoga practicing group and nonyoga practicing 
+group for both male and female participants separately 
+[Table 1].
+Effect of yoga on physical characteristics
+In yoga practicing group for both male and female, body weight 
+and body mass index were fall significantly (P < 0.001) after 
+12 weeks of yogic practices compare to baseline; however, 
+in the nonyoga practicing group, no such changes were 
+found (P > 0.05).
+Effect of yoga on neurocognitive variables
+Attention and alertness
+Following 6‑week and 12‑week of combined yoga practices 
+showed a significant improvement in auditory and visual 
+reaction time compared to baseline data, in male and female 
+yoga‑practicing group [Table 2], whereas no such changes were 
+found in the non‑yoga practicing group [Figure 2]. Similarly, 
+the short‑term memory was measured through serial learning 
+test showed a significant improvement after 12‑week yogic 
+practices [Table 2 and Figure 3].
+Discussion
+It is evident that regular exercise or physical activity of 
+mild to moderate intensity, i.e., walking, freehand exercises, 
+stretching exercises, moderate strength exercises, obviously 
+reduces the risk of neurocognitive decline compared to 
+sedentary lifestyle.[2,10,11] However, this probably the first 
+quasi‑experimental study in which, 12 weeks combined yoga 
+practice regimen was applied to observe the neurocognitive 
+response in a middle‑aged group with normal health status. 
+The results of the present study showed a significant decrease 
+in ART and VRT following 6‑week and 12‑week practice 
+of yoga. This outcome clearly indicates improvement of 
+one’s attention and alertness. The outcomes are in line with 
+previous reports that yogasana can produce a significant 
+reduction in the RT of ART and VRT.[12] It was reported that 
+voluntary control on the time period of inspiratory breathing 
+positively correlated with the changes in RT.[13] Another study 
+reported that the RT was improved after the practice of Mukh 
+Bhastrika.[14] Further, 12 weeks of yoga training (asana and 
+pranayama) decrease RT[15] and also reported shortening of RT 
+after pranayama practice.[16] In a study, Borker and Pednekar[17] 
+reported that ART and VRT reduced significantly after 4 weeks 
+of pranayamic breathing exercises. In a recent study, Telles 
+et al.[15] reported that RT was decreased significantly after 
+the session of breath awareness and quite sitting, whereas no 
+change was observed immediately after 18 min of Bhastrika 
+pranayama. RT has been considered an indirect index for the 
+measurement of the processing ability of the central nervous 
+system and also a method used to determine sensory‑motor 
+Table 1: Baseline status (independent t‑test)
+Variables
+Male (n=40) 
+yoga 
+group (n=20) 
+versus non‑yoga 
+group (n=20) (P)
+Female (n=30) 
+yoga 
+group (n=15) 
+versus non‑yoga 
+group (n=15) (P)
+Body weight (kg)
+0.34
+0.54
+Body mass index (kg/mt2)
+0.47
+0.46
+Visual reaction time (ms)
+0.55
+0.38
+Auditory reaction time (ms)
+0.70
+0.24
+Short‑term memory
+0.67
+0.43
+Figure 2: Reaction time of auditory and visual tasks
+Chatterjee, et al.: Effect of Yoga on neurocognitive variables
+115
+115
+Indian Journal of Community Medicine  ¦  Volume 46  ¦  Issue 1  ¦  January-March 2021
+115
+association and performance.[18] It involves a central neural 
+mechanism and also an index of cortical arousal.[18] A decrease 
+in RT indicates improved sensory‑motor performance and 
+enhanced processing ability of the central nervous system. 
+Finally, a decrease in ART and VRT clearly expresses a 
+positive improvement in the sensory‑motor processing ability 
+that may broadly interpret as the development of central 
+nervous system functions. Therefore, from the findings of the 
+present study, it may be concluded that yogic intervention 
+for a period of 12 weeks positively improved this processing 
+ability by (i) the higher rate of information processing, 
+(ii) improving the power of concentration and the ability to 
+ignore extraneous stimuli factors, (iii) higher arousal and the 
+ability of faster information processing could be understood 
+as the alterations in afferent inputs and efferent outputs, which 
+may further control the activity of ascending and descending 
+activity of the reticular system in thalamo‑cortical levels, 
+and (iv) a decrease in sympathetic activity and increased 
+parasympathetic activity may enhance the concentration 
+ability and bring deep psychosomatic relaxation and decrease 
+in oxygen consumption. All these above possible mechanisms 
+may be attributed to the decrease of visual and ART. From the 
+above discussion, it may be concluded that a combined yoga 
+regimen in the middle‑aged group may improve attention and 
+alertness as reflected through the RT results.
+In the present study, researcher evaluates the effect of yogic 
+training on short‑term memory in a middle‑aged group. It was 
+found that short‑term memory was improved significantly in 
+the form of the serial learning score after 6th and 12th weeks 
+of yoga training. From the evidence, it could be observed that 
+aging may disrupt old memory and the processing of new 
+memory. Yoga is a type of mind‑body intervention, regular 
+practice of which helps to improve individual memory, which 
+includes perception, concentration, and attention span.[19] 
+Naveen et al. studied the impact of uninostril breathing on 
+verbal and spatial memory tests in school children. On the 
+basis of different breathing practices, all the students were 
+randomly categorized into four groups, i.e., (a) right nostril 
+breathing, (b) left nostril breathing, (c) alternate nostril 
+breathing, or (d) breath awareness without manipulation of 
+nostrils. They found a significant increase in spatial memory 
+scores in all four experimental groups after 10 days of 
+yoga breathing practice, but no such change was observed 
+in the control group.[20] Sahaj yoga practice can lead to an 
+improvement in verbal working memory[21] and breathing 
+through the left nostril able to increase the spatial cognitive 
+task.[22] In a study, Subramanya and Telles reported that 
+memory scores were improved immediately after the practice 
+of cyclic meditation.[23] The yogic education system improves 
+visual and verbal memory scores in school boys compared to 
+the modern education system.[24]
+In the present study, short‑term memory in the form of 
+serial learning scores significantly improved after yogic 
+practices in the middle‑aged group. It can be interpreted 
+as (i) Anxiety inhibit memory development, whereas yoga 
+practice reduced anxiety may improve memory scores;[25] 
+(ii) Right hemispheric (nonverbal, spatial memory) and 
+left hemispheric (verbal memory) improvement after yogic 
+training may have a positive effect on memory development;[24] 
+(iii) Yogic practices decrease psychophysiological scores of 
+arousals, and sympathetic activity may alter hypothalamic 
+functions, which is considered the highest center for autonomic 
+regulations;[22‑24]  (iv) Regular Yoga practice positively 
+improves the concentration, attention span, and visuomotor 
+speed, which may influence memory by large; and (v) some 
+practices of yogic technique modulate the function of 
+Table 2: Results (mean±standard deviation) of neurocognitive variables between yoga (experimental) and 
+nonyoga (control) training group
+Neurocognitive variables
+Yoga training group, mean±SD
+Non‑yoga training group, mean±SD
+Pretest
+Midtest (pre 
+versus mid)
+Posttest (pre 
+versus post)
+Pretest
+Midtest (pre 
+versus mid)
+Postest (pre 
+versus post)
+Auditory reaction time (ms) (male) (n=20)
+245.81±40.97
+219.80±30.76***
+196.95±16.62***
+242.50±44.07
+243.72±42.66
+237.73±39.90
+Auditory reaction time (ms) (female) (n=15)
+281.65±62.33
+249.03±56.58**
+229.18±38.88***
+283.15±73.45
+286.05±72.16
+284.71±73.35
+Visual reaction time (ms) (male) (n=20)
+281.11±59.29
+253.66±60.57***
+225.84±36.74***
+280.97±39.76
+281.65±41.20
+279.74±34.84
+Visual reaction time (ms) (female) (n=15)
+317.92±54.83
+284.28±50.82
+261.54±54.30
+321.66±84.27
+327.50±81.66
+328.97±83.22
+Short term memory (counts) (male) (n=20)
+6.93±1.75
+7.40±1.47
+8.93±0.88***
+6.67±1.14
+6.63±1.42
+6.80±1.28
+Short term memory (counts) (female) (n=15)
+7.12±1.25
+8.00±0.92
+8.62±1.06***
+7.35±1.28
+7.14±1.65
+7.50±1.14
+*P<0.01, **P<0.01 and ***P<0.001, RMANOVA, with a post hoc analysis comparing the values at baseline (pretest), 6 weeks (midtest) and 12 weeks (posttest). 
+SD: Standard deviation, RMANOVA: Repeated‑measures analysis of variance
+Figure 3: Short‑term memory
+Chatterjee, et al.: Effect of Yoga on neurocognitive variables
+116
+Indian Journal of Community Medicine  ¦  Volume 46  ¦  Issue 1  ¦  January-March 2021
+116
+hypothalamic‑hypophyseal adrenal axis, thereby may bring 
+an efficient neural effector communication, thus affecting 
+the expression of neurotrophic factors that may influence the 
+neurotransmitter like serotonin, norepinephrine and produce 
+an effective improvement in different cognitive domains like 
+memory[22]
+Limitations of the study
+i.	
+Not a randomized control trial
+ii.	 The study participants did not attend any residential camp.
+Conclusion
+On the basis of an elaborate discussion of the present 
+research findings, now it may be concluded that combined 
+yoga module (surya namaskar, kriya, asana, pranayama, 
+and dhyana) has a positive influence on the neurocognitive 
+function in middle‑aged group that concomitantly promote 
+healthy aging.
+Acknowledgment
+i.	
+CCRYN, Ministry of AYUSH, Govt. of India for financial 
+support.
+ii.	 Joynto Smriti Sangha (Community Health Club).
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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subfolder_0/Effect of Integrated Yoga as an Add-On to Physiotherapy on Walking Index, ESR, Pain, and Spasticity among Subjects with Traumatic Spinal Cord Injur.txt

@@ -0,0 +1,1011 @@
+Journal of Stem Cells 
+ISSN: 1556-8539 
+Volume 13, Number 1 
+© 2018 Nova Science Publishers, Inc. 
+ 
+ 
+ 
+ 
+Effect of Integrated Yoga as an Add-On to Physiotherapy  
+on Walking Index, ESR, Pain, and Spasticity among Subjects 
+with Traumatic Spinal Cord Injury:  
+A Randomized Control Study 
+ 
+ 
+ 
+Monali Madhusmita1,, T. M. Srinivasan1, 
+John Ebnezar1, H. R. Nagendra1,  
+and Patita Pabana Mohanty2 
+1SVYASA University, Bangalore, India 
+2Department of Physiotherapy, SVNIRTAR,  
+Odisha, India 
+ 
+                                                        
+ Corresponding Author E-mail: [email protected] 
+Abstract 
+ 
+Introduction: Traumatic Spinal Cord Injury (TSCI) is an 
+injury to the spinal cord that results in temporary or 
+permanent motor, sensory, and cognitive deficits.  
+The current conventional approach of TSCI management 
+includes surgery, pharmacology, and physical therapy, 
+which have some limitations and are associated with side 
+effects. Yoga is a form of mind-body medicine found to be 
+effective in several neurological disorders as an-add on to 
+other therapies. 
+Aim: The present study intended to see the effect of 
+Integrated Yoga (IY) intervention as an-add on to the 
+physiotherapy on walking index, ESR, pain and spasticity 
+among subjects with TSCI.  
+Methods: The study was conducted in a Rehabilitation 
+Centre at Swami Vivekananda National Institute of 
+Rehabilitation, Training and research (SVNIRTAR), 
+Odisha. A total of 125 paraplegics within age range 18-60 
+years were randomly assigned to either integrated Yoga 
+therapy + physiotherapy group (IY + PT) group (n = 62,  
+age = 33.97 ± 10.00) or Physiotherapy (PT) group (n = 63, 
+age = 32.84 ± 9.47). The participants in PT + IY group 
+received one month of integrated yoga intervention 
+consisting of yogic postures, yogic breathing techniques & 
+chanting, and yogic relaxation practices along with physical 
+therapy. Yoga session lasted for 75 mins per day and  
+6 days per week. PT group participants received only 
+physiotherapy intervention for one month. All the 
+participants were assessed for Erythrocyte Sedimentation 
+Rate (ESR), Walking Index for Spinal Cord Injury II 
+(WISCI II), Multidimensional Pain Inventory (MPI), and 
+Modified-Modified Ashworth Scale (MMAS) at the 
+baseline and after one month. 
+Results: We found statically significant changes in 4 
+variables for IY + PT group 1) Erythrocyte Sedimentation 
+Rate (P < 0.001), 2) WISCI II (P < 0.001) MPI-S1  
+(P < 0.001), MPI-S2 (P = 0.003), & MPI-S3 (P = 0.003), 
+and 4) MMAS (P < 0.001) after one month of intervention 
+compared to baseline.  
+Monali Madhusmita, T. M. Srinivasan, John Ebnezar et al. 
+58 
+Compared to PT group, IY + PT group showed 
+significantly better improvement in WISCI II (P < 0.001), 
+MPI-S3 (P = 0.003), and MMAS (P < 0.001). 
+Conclusion: The resent study suggests the usefulness of an 
+IY intervention add on to physiotherapy in the management 
+of patients with paraplegia. 
+ 
+ 
+Introduction 
+ 
+Traumatic Spinal cord injury (TSCI) is a 
+medically complex and life-disrupting condition. It is 
+an insult to the spinal cord which leads to temporary 
+or permanent, sensory, motor and autonomic deficits 
+resulting in severe disability (Alexander, Biering-
+Sorensen, Bodner, et al., 2009). Paraplegia is most 
+commonly observed condition after TSCI. Paraplegia 
+affects the activities of daily living and puts 
+socioeconomic burden on family of an individual 
+(Wyndaele & Wyndaele, 2006). Spasticity is the most 
+common complication which affects gait and 
+activities of daily living to a higher degree. It is also 
+involved in pain aggravation, deformities and 
+contractures (Burchiel, Kim, et al., 2001). Evidences 
+from 
+several 
+studies 
+suggest 
+that 
+paraplegia 
+characterized by increased systematic inflammation 
+shown by increased ESR (Hausmann, 2003). 
+Systematic inflammation in individual with paraplegia 
+is associated with increased respiratory and bladder 
+infection, further it affects the prognosis of TSCI 
+(Diana, Cardenas, Thomas, Hooton, 1995; Gris, 
+Hamilton, Weaver, 2008). 
+Available treatment for paraplegia in convention 
+medicine is surgery, pharmacological intervention  
+and physical therapies. Despite, large portion of 
+paraplegics report persistent functional disability, 
+spasticity and pain. Further, conventional therapies 
+have limited efficacy in improving systematic 
+inflammation (Bethea, John; Dietrich, Dalton, 2002).  
+In order to enhance the present management of 
+paraplegia and to get better treatment outcome 
+addition of other supportive therapies has become 
+mandatory.  
+Yoga is a form of mind body interventions. Yoga 
+is a lifestyle meant for physical, mental, social and 
+spiritual growth of an individual. In present days 
+Yoga is perceived as practice of asanas, pranayama, 
+and meditation and various kinds of yogic relaxation 
+methods (Manas, Kashinath, Nagaratna, Nagendra, 
+2017). 
+Several evidences from scientific studies suggest 
+the variety of health benefiting effects of yoga. Yoga 
+has been found useful in many chronic health 
+conditions including various neurological disorders 
+such as multiple sclerosis, stroke, Parkinson’s  
+disease etc. Studies on Yoga shows to improve  
+gait, spasticity, pain, inflammation and QoL among 
+neurologically impaired patients (Mishra, Singh, 
+Bunch, Zhang, 2012). 
+For individuals with SCI, the injury permanently 
+transforms their lives. Indeed, SCI can result in 
+diverse motor, sensory and autonomic problems  
+(Hou, Rabchevsky, 2014). Mobility impairment (e.g., 
+paraplegia and tetraplegia), bowel and bladder 
+incontinence, loss of sensation and sexual dysfunction 
+are common following SCI (Guilcher, Craven, 
+Lemieux-Charles, et al, 2013). As a result, individuals 
+with SCI have complex health needs as their 
+condition includes chronic multi-morbidity, mainly 
+associated with the development of several secondary 
+health conditions (e.g., pain and pressure ulcers) 
+(Guilcher, Craven, Lemieux, Charles, et al., 2013). In 
+addition, compared with community estimates, higher 
+rates of psychological disorders can be present in 
+17%–25% of individuals with SCI (Khazaeipour, 
+Taheri-Otaghsara, 
+Naghdi, 
+2015). 
+Particularly, 
+between 18% and 37% of individual with SCI 
+experience depression (Williams, Murray, 2015). 
+From a clinical perspective, understanding the 
+needs of individuals with SCI, knowing the person 
+and working with the family can be beneficial to 
+guide their healthcare and improve outcomes (Stiens, 
+Fawber, Yuhas, 2013). As unmet needs have a direct 
+relationship with diminished quality of life (Sweet, 
+Noreau, Leblond, et al., 2014), it is mandatory to 
+understand them and to find ways to meet them. In 
+consequence, obtaining a comprehensive picture of 
+needs by integrating the different perspectives of 
+professionals, family caregivers and individuals with 
+SCI is paramount. The challenge is in understanding 
+the evolution of these needs as they change over time. 
+The literature on SCI needs indicates that in the first-
+year post discharge, the fulfilment of critical needs 
+(e.g., housing and transportation) is below 60% 
+(Beauregard, Guindon, Noreau, et al., 2012),while the 
+long-term care needed is higher than the care received 
+Effect of Integrated Yoga as an Add-On to Physiotherapy on Walking Index, ESR, Pain … 
+59 
+for information and psychosocial care needs (van 
+Loo, Post, Bloemen, et al, 2010).Rehabilitation plays 
+a central role in maximizing function and facilitating 
+community reintegration following SCI (Anthony, 
+Ralph, Sukhvinder, et al., 2017). 
+Strategies that seek out the complementary 
+effects of combination treatments and that efficiently 
+integrate relevant technical advances in biomechanics 
+represent an untapped potential and are likely to have 
+an immediate impact. There are no published 
+randomized control trials till date available to explore 
+the efficacy of combination of complementary 
+alternative therapies with conventional main stream 
+rehabilitation treatments, in the management of SCI. 
+Hence, in present study we assessed the impact of 
+one month of yoga intervention as an add-on to 
+physiotherapy on ESR, walking Index, pain and 
+spasticity among participants with paraplegia.  
+ 
+ 
+Methodology 
+ 
+Study Participants 
+ 
+Patient admitted to the Rehabilitation Centre  
+at Swami Vivekanand National Institute of Rehabili-
+tation, Training and research (SVNIRTAR), Odisha. 
+Participants in this study were patients with post 
+traumatic paraplegia within age range 18-60 years 
+after 6 months of primary rehabilitation. Both male 
+and female individuals were considered for the study.  
+Sample size: The sample size was calculated 
+using G-power software from the previous study 
+(Sander et al., 2013), with the effect size: 0.546  
+of the Spinal Cord Independence Measure (SCIM); 
+Adjustment scale being: Alpha = 0.05, Beta = 0.85. 
+Calculated sample size was 124. 
+ 
+ 
+Inclusion and Exclusion Criteria 
+ 
+Patients 
+admitted 
+to 
+Swami 
+Vivekananda 
+National 
+Institute 
+Rehabilitation, 
+Training 
+and 
+Research (SVNIRTAR), Odisha, of both genders and 
+within age range of 18 – 60 years, those who have 
+sustained a traumatic spinal cord injury for a 
+minimum of 6 months prior to consent and have 
+completed their primary rehabilitation, and are 
+Incomplete SCI patient with American spinal injury 
+Association impairment scale (AIS)C and (AIS)D 
+with injury to the spinal cord from level anywhere 
+between T1 to L5. 
+Participants with contraindications to FES such as 
+cardiac pacemaker, epilepsy, lower limb fracture or 
+pregnancy, who are likely to experience clinically 
+significant autonomic dysreflexia and/or orthostatic 
+hypotension in response to electrical stimulation or 
+prolonged upright postures, having chronic systemic 
+diseases, e.g., hepatitis C or HIV-AIDS, having an 
+existing stage 3 or 4 pressure ulcer according to the 
+National Pressure Ulcer Advisory Panel classification, 
+have had recent major trauma or surgery within the 
+last 6 months, having degenerative myelopathy, 
+neoplasm, or congenital spinal cord anomalies and 
+concomitant medical problems that might have 
+influenced everyday function, such as malignancy, 
+brain injury or mental diseases were excluded. 
+ 
+ 
+Screening Tool 
+ 
+Standardized neurological examination protocol 
+of the American Spinal Injury Association (ASIA). 
+International Standards for Neurological Classi-
+fication of Spinal Cord Injury (ASIA Impairment 
+Scale) classifies motor and sensory impairment as 
+follows: 
+ 
+ 
+ASIA A – No motor or sensory function is 
+preserved below the level of injury (and in 
+the sacral segments S4 – S5). 
+ 
+ASIA B – Sensory but not motor function is 
+preserved below the neurological level 
+(includes the sacral segments S4 – S5). 
+ 
+ASIA C – Motor function is preserved  
+below the neurological level, but too little  
+to represent a practically usable function 
+(more than half of key muscles below the 
+neurological level have a muscle grade less 
+than 3). 
+ 
+ASIA D – Motor function is preserved below 
+the neurological level, to an extent that 
+provides practically usable function (at least 
+half of key muscles below the neurological 
+level have a muscle grade of 3 or more on a 
+scale from 0 to 5). 
+Monali Madhusmita, T. M. Srinivasan, John Ebnezar et al. 
+60 
+ 
+ASIA E – Motor and sensory functions are 
+normal. 
+ 
+ASIA A implies a complete injury, ASIA B – D 
+describe incomplete injuries. 
+ 
+ 
+Ethical Considerations 
+ 
+The study protocol was passed by S-VYASA’s 
+Institutional Ethics Committee. All procedures were 
+performed according to the Declaration of Helsinki 
+research ethics. Signed informed consent of all 
+subjects was obtained after explaining the nature  
+of study in detail and the voluntary nature of 
+participation. Confidentiality was assured as part of 
+the research process. 
+Design of the Study 
+ 
+Two group pre–post randomized wait-list control 
+(WLC) design is adopted. 
+ 
+ 
+Randomisation 
+ 
+To avoid selection biases Sequentially Numbered 
+Opaque Sealed Envelops (SNOSE) is adopted. After 
+screening, the patients are asked to select an opaque 
+envelop from the bunch which is randomly arranged 
+and the number it contains is not visible outside. The 
+envelopes are sequentially numbered but the number 
+it contains is not visible outside. The patients are  
+then allocated to the experimental or WLC group 
+according to the number they receive. Each number is 
+separately assigned to either Experimental or WLC 
+group randomly. 
+ 
+ 
+Figure 1. Trial Profile 
+Effect of Integrated Yoga as an Add-On to Physiotherapy on Walking Index, ESR, Pain … 
+61 
+Objective Assessment Tools 
+ 
+Walking Index for SCIII (WISCIII) 
+Walking Index for Spinal Cord Injury (WISCI II) 
+assesses the amount of physical assistance needed, as 
+well as devices required, for walking following 
+paralysis that results from Spinal Cord Injury  
+(SCI). Designed to be a more precise measure of 
+improvement in walking ability specific to SCI. It 
+rank orders the ability of a person to walk 10m after  
+a spinal cord injury from most to least severe 
+impairment (Ditunno & Dittuno, 2001). 
+ 
+American Spinal Injury Assessment (ASIA) 
+motor and sensory scores 
+The ASIA Impairment Scale builds on the earlier 
+Frankel scale, but includes a number of significant 
+improvements. The International Standards for 
+Neurological Classification of Spinal Cord Injury 
+(ISNCSCI) were developed by the American Spinal 
+Injury Association (ASIA) as a universal classi-
+fication tool for spinal cord injury (SCI), depending 
+upon motor and sensory impairment that results from 
+a SCI. It assesses Functional Mobility, Strength and 
+Upper Extremity Function. A tapered piece of cotton 
+and a safety pin is required to administer the test, 
+which usually takes 10-60 minutes (Furlan et al., 
+2008). 
+ 
+Modified Ashworth Scale to measure spasticity 
+Originally developed to assess the effects  
+of antispasticity drugs on spasticity in Multiple 
+Sclerosis. Modified Ashworth: measures spasticity in 
+patients with lesions of the Central Nervous System. 
+Original Ashworth Scale: Tests resistance to passive 
+movement about a joint with varying degrees of 
+velocity scores range from 0-4, with 5 choices. A 
+score of 1 indicates no resistance and 5 indicates 
+rigidity. Modified Ashworth Scale: Similar to 
+Ashworth, but adds a 1+ scoring category to indicate 
+resistance through less than half of the movement. 
+Thus scores range from 0-4, with 6 choices 
+(Bohannon & Smith, 1987). 
+ 
+Anthropometry: Body Mass Index (BMI) 
+The body mass index (BMI), or Quetelet index, is 
+a measure of relative weight based on an individual’s 
+mass and height. It is defined as the individual’s body 
+mass divided by the square of their height – with the 
+value universally being given in units of kg/m2 
+(Eknoyan and Garabed, 2007). 
+ 
+ 
+Bio-Markers 
+ 
+Erythrocyte Sedimentation Rate (ESR) 
+An erythrocyte sedimentation rate (ESR) is a type 
+of blood test that measures how quickly erythrocytes 
+(red blood cells) settle at the bottom of a test tube that 
+contains a blood sample. Normally, red blood cells 
+settle relatively slowly. A faster-than-normal rate may 
+indicate inflammation in the body. Inflammation is 
+part of your immune response system. It can be a 
+reaction to an infection or injury. ESR can be marker 
+of altered immune response seen in people with SCI 
+(Edsberg, Jennifer, Rajna, et al., 2015). 
+ 
+Assessments 
+The assessments were done on day1 and day30. 
+Fasting blood was drawn from the study participants 
+early in the morning and send to the Institute’s 
+Pathology Lab to test for ESR. The Physical 
+Examination tests like MMAS and WISCI II were 
+carried out by an Expert Physiotherapist who was 
+blinded to the study design. MPI was filled by the 
+participants with the guidance of trained staff. 
+ 
+ 
+Subjective Assessment Tools 
+ 
+Multidimensional Pain Inventory (Spinal Cord 
+Injury Version) – MPI-SCI 
+A spinal cord injury version of the MPI that 
+assesses the severity and impact of chronic pain, 
+emotional and physical adaptation to persistent  
+pain, and social support. The internal consistency  
+of the MPI-SCI sub-scales ranged from fair (.60)  
+for affective distress to substantial (.94) for pain 
+interference with activities. With the exception of the 
+support and life control sub-scales, all others showed 
+adequate test-retest reliability. The MPI-SCI measures 
+impact of pain on activities of daily living, which 
+corresponds to achievements and activities of daily 
+living, and subjective evaluations and reactions of 
+Dijker’s Model. Each item is scored on a 7-point 
+scale. Scale scores are computed by summing over all 
+Monali Madhusmita, T. M. Srinivasan, John Ebnezar et al. 
+62 
+items and then the mean is composed based on the 
+number of scale items. It is not possible to obtain a 
+total score (Turk et al., 1983). 
+ 
+ 
+Intervention 
+ 
+This study is conducted in a residential rehabili-
+tation centre at SVNIRTAR, Odisha and the inter-
+vention period is one month. 
+ 
+ 
+PT Intervention for Both Groups 
+ 
+Proprioceptive Neuro-muscular Facilitation, slow 
+and sustained stretching, prolong icing, strengthening 
+of anti-gravity muscles, functional electrical stimu-
+lation & gait training. 
+ 
+ 
+Add-On for Group YPT: for One Month,  
+IAYT with Physiotherapy 
+ 
+The specific module of ‘Integrated approach of 
+Yoga therapy (IAYT)’ for Spinal Cord injury 
+management was developed by using the concepts 
+from traditional yoga scriptures (Patanjali Yoga 
+Sutras, Upanishads and Yoga Vasishtha) that 
+highlights a holistic approach to health management 
+at physical, mental, emotional and intellectual levels. 
+The practices consisted of asana chosen specifically  
+for Spina Cord Injury (yoga postures), pranayama,  
+kriyas, relaxation techniques, Chanting of OM and 
+Mahamrytunjaya Mantra and yogic counselling for 
+stress management. The physical practices (spinal 
+cord injury special techniques) progressed from safe 
+yogic movements to yoga postures to provide traction 
+like effect and channelize the vital energy flow all 
+through the spine. 
+Table 1. Time-table for Yoga and Physiotherapy group 
+ 
+THERAPHY 
+INTERVENTION 
+TIME PERIOD 
+Active Therapy 
+1. 
+Yoga Special Technique for Spinal Cord Injury 
+2. 
+Mind Sound Resonance Technique (MSRT) 
+45 minutes 
+30 minutes 
+Passive Therapy 
+3. 
+Proprioceptive Neuro-muscular Facilitation 
+4. 
+Slow and Sustained stretching 
+5. 
+Prolong icing 
+6. 
+Strengthening of Anti-spastic muscles 
+7. 
+Functional Electrical Stimulation 
+8. 
+Gait training 
+20 minutes 
+45 minutes 
+30–45 min 
+45-60 min 
+30 min 
+15 min 
+Counseling 
+Yogic Counseling 
+40 min. twice/week 
+ 
+Table 2. Time-table for Physiotherapy group 
+ 
+THERAPHY 
+INTERVENTION 
+TIME PERIOD 
+Active Therapy 
+1. 
+Active range formation exercise (AROM) 
+2. 
+Listening to soothing music 
+45 minutes 
+30 minutes 
+Passive Therapy 
+3. 
+Proprioceptive Neuro-muscular Facilitation 
+4. 
+Slow and Sustained stretching 
+5. 
+Prolong icing 
+6. 
+Strengthening of Anti-spastic muscles 
+7. 
+Functional Electrical Stimulation 
+8. 
+Gait training 
+20 minutes 
+45 minutes 
+30–45 min 
+45-60 min 
+30 min 
+15 min 
+Counseling 
+Psychological Counseling 
+40 min. twice/week 
+Effect of Integrated Yoga as an Add-On to Physiotherapy on Walking Index, ESR, Pain … 
+63 
+Data Analysis 
+ 
+Data were analysed using the R-Studio. The 
+research team applied the Shapiro-Wilk test to assess 
+normality. The paired sample test and Wilcoxon’s 
+signed-rank test were used to find differences within a 
+group, for normal and non-normal data, respectively. 
+P < .05 was considered as statistically significant 
+change for all the variables Gender and other 
+categorical variables were analysed using χ2 test. The 
+independent sample t-test was used to check the 
+difference between groups for demographic measures. 
+ 
+ 
+Results 
+ 
+One-hundred-twenty-five 
+paraplegic 
+patients 
+participated in the study. Both groups were 
+comparable at the baseline in terms of age (p = 0.519, 
+independent t-test) and gender distribution (p = 0.636, 
+χ2 test). 
+ 
+Table 3. Comparison of the continuous variables of experimental and wait-list control group before intervention 
+(baseline), at end of therapy 
+ 
+Experimental Group 
+Control Group 
+Variables 
+Pre 
+Post 
+% Change 
+Pre 
+Post 
+P value 
+% Change 
+WISCI II  
+7.03 ± 3.87 
+11.79 ± 4.15٭٭٭@@@ 
+67.68 
+6.57 ± 2.16 
+7.87 ± 2.33٭٭٭ 
+<0.001 
+90.82 
+ESR 
+42.13 ± 26.14 
+27.63 ± 18.75٭٭٭@@@ 
+34.42 
+42.57 ± 26.58 
+41.52 ± 21.42 
+0.58 
+2.48 
+MPI-SCI_S1 
+4.36 ± 1.03 
+3.73 ± 1.22٭٭٭ 
+14.38 
+4.5 ± 1.87 
+4.13 ± 1.89٭٭٭ 
+<0.001 
+8.27 
+MPI-SCI_S2 
+3.45 ± 0.84 
+3.11 ± 0.81٭٭ 
+9.69 
+3.58 ± 0.99 
+3.55 ± 0.97 
+0.54 
+0.75 
+MPI-SCI_S3 
+2.53 ± 1.34 
+2.07 ± 1.1٭٭@@ 
+18.23 
+2.92 ± 1.2 
+2.74 ± 1.3 
+0.023 
+6.13 
+Legends: WISCI II (Walking index for SCIII), ESR (Erythrocyte Sedimentation Rate), MPI-SCI_S1 (Multidimensional Pain 
+Inventory-Section1), MPI-SCI_S2 (Multidimensional Pain Inventory-Section2), MPI-SCI_S3 (Multidimensional Pain 
+Inventory-Section3). 
+ 
+Table 4. Comparison of the categorical variables of experimental and WLC groups 
+ 
+CATEGORICAL VARIABLES 
+VARIABLE 
+PRE1(G1) 
+PRE2 (G2) 
+χ2 
+POST1 (G1) 
+POST2(G2) 
+χ2 
+MMAS 
+Grade: 1 
+4 (6.45%) 
+9 (14.3%) 
+0.505 
+36 (58.06%) 
+16 (25.4%) 
+<0.001 
+Grade: 2 
+30 (48.4%) 
+28 (44.44%) 
+26 (41.9%) 
+34 (53.97%) 
+Grade: 3 
+26 (41.9%) 
+25(39.68%) 
+0 
+13 (20.6%) 
+Grade: 4 
+2 (3.23%) 
+1(1.6%) 
+0 
+0 
+٭ P<0.05, ٭٭ P<0.01, ٭٭٭ P<0.001; Within group: pre compared with post. 
+@@@P <0.001, @@P <0.01; Comparison between group: Pre compared with Pre, and Post compared with Post. 
+ 
+The tables show the number of participants with 
+grade of spasticity before and after the study across 
+the groups.  
+ 
+ 
+Within-Group Comparisons 
+ 
+Experimental group: At the completion of  
+one-month practice of Integrated Yoga with Physio-
+therapy, the study found significant reductions in 
+Variables: (1) 34.42% for Erythrocyte Sedimentation 
+Rate (P ˂ 0.001), 67.68% for Walking index for  
+SCIII (WISCI II) (P = 0.001), 14.38% for Multi-
+dimensional Pain Inventory (MPI-S1) (P ˂ 0.001), 
+9.69% for MPI-S2 (P = 0.003), 18.23% for MPI-S3  
+(P = 0.003), and Modified-Modified Ashworth Scale 
+(MMAS) (P ˂ 0.001). 
+ 
+Control group: At the completion of one-month 
+practice of Physiotherapy only, the study found 
+significant reductions in Variables: 2.48% for 
+Erythrocyte Sedimentation Rate (P = 0.58), 19.82% 
+Monali Madhusmita, T. M. Srinivasan, John Ebnezar et al. 
+64 
+for Walking index for SCIII (WISCI II) (P ˂ 0.001), 
+8.27% for Multidimensional Pain Inventory (MPI-
+S1), P ˂ 0.001, 0.75% for MPI-S2, P = 0.54, 6.13% 
+for MPI-S3, P = 0.023, and Modified-Modified 
+Ashworth Scale (MMAS). 
+ 
+ 
+Between-Group Comparisons 
+ 
+When the groups were compared, the study found 
+the Experimental group’s results for five variables 
+were significantly different than those of the control 
+group: Erythrocyte Sedimentation Rate (ESR),  
+P ˂ 0.001, Walking index for SCIII (WISCI II),  
+P ˂ 0.000,Multidimensional Pain Inventory: MPI-S1, 
+P = 0.43,MPI-S2, P = 0.07, MPI-S3, P = 0.003  
+and Modified-Modified Ashworth Scale (MMAS),  
+P ˂ 0.000. Baseline scores were matched for other 
+variables except for MPI-S3. 
+ 
+VARIABLE 
+PRE(G1) Vs PRE(G2) 
+POST(G1) Vs 
+POST(G2) 
+WISCI II 
+0.411 
+˂0.001 
+ESR 
+0.925 
+˂0.001 
+MPI-S1 
+0.476 
+0.427 
+MPI-S2 
+0.097 
+0.067 
+MPI-S3 
+0.007 
+0.003 
+ 
+ 
+Discussion 
+ 
+This study aimed to compare the effect of add-on 
+of IY intervention to Physiotherapy, in the manage-
+ment of spinal cord injury (SCI) patients. At the end 
+of one-month the study found significant reductions in 
+Variables: Erythrocyte Sedimentation Rate, Walking 
+index for SCIII (WISCI II), Multidimensional Pain 
+Inventory: MPI-S1, (MPI-S2), MPI-S3 and Modified-
+Modified Ashworth Scale (MMAS). 
+The current study clearly shows that add-on of 
+IAYT was effective make the performance of YG was 
+better than WLC. 
+Mechanisms underlying the beneficial effects of 
+Yoga practice on spinal cord injury patients are not 
+yet well understood. Yoga represents a form of mind-
+body fitness. IAYT includes a combination of asanas, 
+pranayama, meditation and relaxation, and internally 
+directed mental focus on awareness of self, breathing, 
+and energy (Rajashree, Hankey, Nagendra, Mohanty, 
+2016). However, Muscle conditioning during yoga’s 
+intense stretching postures helps by improving 
+oxidative capacity and strength of skeletal muscles, 
+flexibility, endurance, coordination, power, static and 
+dynamic stability, decreasing glycogen utilization, in 
+turn improving physical performance and increasing 
+walking pace and stride length (Katiyar, Bihari, 
+2006). This possibly explains for the improvement in 
+scores of Walking Index for SCIII (WISCI II), and 
+shows significant difference between the groups post 
+intervention. 
+MSRT technique leads to deep relaxation, which 
+helps in downregulating the hypothalamus-pituitary-
+axis and reduces anxiety (Hewitt, 2009) and stress 
+(Robins, Hendin, Trzesniewski, 2001). By reducing 
+the activation and reactivity of the sympathoadrenal 
+system and the hypothalamic pituitary adrenal (HPA) 
+axis and promoting feelings of well-being, Yoga may 
+alleviate the effects of stress and bring up multiple 
+positive downstream effects on neuroendocrine status, 
+metabolic function and related systemic inflammatory 
+responses. These results may also explain the 
+improvements in pain in YG more than WLC 
+{Multidimensional Pain Inventory: MPI-S1, (MPI-
+S2), 
+MPI-S3}, 
+and 
+reduction 
+in 
+Erythrocyte 
+Sedimentation Rate (ESR) values which is highly 
+significant in YG. 
+Deep 
+relaxation 
+technique, 
+an 
+important 
+component of IAYT showed significant reductions in 
+the yoga group’s spasticity, possibly due to 
+modulation of cardiac autonomic function and 
+cardiorespiratory efficiency (Tomas, 2011). It may 
+also synchronize neural elements in the brain, leading 
+to 
+ANS 
+changes, 
+resulting 
+parasympathetic 
+dominance and blunted sympathetic activity leading 
+to reduced spasticity. Pranayama modifies various 
+inflatory and deflatory lung reflexes and interacts with 
+central neural elements to improve homeostatic 
+control (Tandon, Tripathi, 2012). 
+ 
+ 
+Cerebrospinal Fluid (CSF) and Traumatic 
+Spinal Cord Injury (TSCI) 
+ 
+The spinal cord injury may result in cellular 
+alterations in cerebrospinal fluid (CSF) of the TSCI 
+Effect of Integrated Yoga as an Add-On to Physiotherapy on Walking Index, ESR, Pain … 
+65 
+patients. These changes can be experimentally 
+evaluated ex vivo by isolating the CD34+ progenitor 
+stem cells from the CSF of the pre and post TSCI 
+patients. Any severe damage to CSF of these  
+TSCI patients may be reflected in the CD34+ stem 
+cells differentiation. Since the colony formation is 
+controlled by cytokines, these growth factor changes 
+may also be measured using ELISA, on the CSF of 
+the pre and post TSCI patients. Hence, whether 
+cytokine therapy could be considered for the TSCI 
+patients may be of relevance. 
+ 
+ 
+Scope and Limitations of the Study 
+ 
+This is the first randomized controlled study  
+of yoga for spinal cord injured patients with ASIA 
+score C and D (paraplegics). It used IAYT, and its 
+reasonable sample size offers good evidence for  
+the benefits of yoga-based rehabilitation. Having 
+additional subgroups stratified as motor and sensory 
+complete and incomplete would have made the  
+study more vigorous. In addition, we did not 
+investigate radiological findings, such as MRI, CT-
+scan or X-rays, which would have detailed clearly  
+the clinical outcomes, providing a fuller picture of 
+subject’s 
+anatomy 
+and 
+physiology. 
+Similarly, 
+assessments 
+of 
+neurological 
+biomarkers 
+(e.g., 
+neuroproteomics) in body fluids would throw light  
+on mechanisms. Objective measurement of bio-
+energy fields of patients with GDV or BIOWELL 
+would also explore the positive changes in energy 
+state and mood. We would recommend a multicentre 
+RCT to confirm results of the study, with a longer 
+follow-up of 6 months or more to evaluate long-term 
+efficacy. 
+ 
+ 
+Conclusions 
+ 
+Present study indicated that addition of integrated 
+yoga intervention to physiotherapy have beneficial 
+effects in terms of improving pain, inflammation, gait 
+and spasticity among patients with paraplegia. 
+Further, this study also suggest the implementation of 
+yoga intervention in the conventional rehabilitation 
+program for traumatic spinal injury patients.  
+ 
+Conflict of Interest 
+ 
+Authors declare no conflict of interest. 
+ 
+ 
+Acknowledgments 
+ 
+We are thankful to all the participants of this 
+study. We also thank you to all the staff members of 
+rehabilitation center.  
+ 
+ 
+Ethical Compliance 
+ 
+The authors have stated all possible conflicts of 
+interest within this work. The authors have stated all 
+sources of funding for this work. If this work involved 
+human participants, informed consent was received 
+from each individual. If this work involved human 
+participants, it was conducted in accordance with  
+the 1964 Declaration of Helsinki. If this work 
+involved experiments with humans or animals, it was 
+conducted in accordance with the related institutions’ 
+research ethics guidelines. 
+ 
+ 
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+Received: 1/27/18. Revised: 3/12/18. Accepted: 
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+ 
+Reproduced with permission of copyright owner. Further reproduction
+prohibited without permission.

subfolder_0/Effect of Naturopathy and Yoga Intervention on Patients with Type II Diabetes Mellitus.txt

@@ -0,0 +1,443 @@
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 320 
+Effect of Naturopathy and Yoga Intervention on Patients with Type II 
+Diabetes Mellitus 
+ 
+Shetty Prashantha, H R Nagendrab, Gangadhara VarmaB.Rc, Pailoor Subramanyad, 
+aPh.D. Scholar, Division ofYoga and Life Sciences, S-VYASA Yoga University, 
+Bengaluru, India  
+bChancellor, S-VYASA Yoga University, Bengaluru, India  
+cPost graduate (M.D Naturopathy), S.D.M College of Naturopathy and Yogic Sciences, 
+Ujire, Karnataka, India  
+dDivision of Yoga and Life Sciences, S-VYASA Yoga University, Bengaluru, India  
+Corresponding Author: GangadharaVarma B.R 
+ 
+Background and Objectives: A major part of Diabetes burden (75%) will be borne by 
+developing countries and India will be having the dubious honour of being host to the 
+maximum number of diabetics numbering about 57 millions. Complementary and 
+Alternative Medicine (CAM) modalities are found to be effective in the management of 
+Diabetes Mellitus type 2. While Naturopathy and Yoga is a part of CAM which is used in 
+the management of Diabetes Mellitus type 2, the scientific literature to support its’ 
+judicious usage is inadequate. Hence the present study evaluated the effect of 
+Naturopathy and Yoga on the Fasting blood glucose (FBG) and postprandial blood 
+glucose (PPBG) levels in patients with Type 2 Diabetes Mellitus. 
+Methods: Subjects were recruited from the Yoga and Naturopathy Hospital, 
+Shanthivana, Dharmastala, Karnataka. Two Hundred patients diagnosed for Diabetes 
+Mellitus type 2 were screened. One Hundred subjects were recruited for the single pre-
+post design study, selected based on the inclusion and exclusion criteria. Subjects were 
+assessed for FBG and PPPG levels before and after 10 days of intervention.  
+Results: The results suggested the significant changes in the levels of FBG and PPBG 
+with the p <0.001. 
+Interpretation & Conclusion: Naturopathy and Yoga is one of the major treatment 
+modality in controlling type II Diabetes Mellitus. 
+KEYWORDS: Type IIDiabetes mellitus; Complimentary &Alternative Medicine; Yoga 
+; Naturopathy 
+INTRODUCTION 
+The prevalence of Type 2 Diabetes Mellitus (T2DM) is projected to rise from 171 million 
+in 2000 to 366 million in 2030(Wild, Roglic, Green, Sicree, & King, 2004). T2DM is a 
+Abstract 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 321 
+costly, complex, chronic disease that is expected to increase in prevalence in the coming 
+decades(“Economic costs of diabetes in the U.S. in 2007.,” 2008). The estimated annual 
+cost of diabetes-related medical expenses was $132 billion in 2002, accounting for more 
+than 12 per cent of the U.S. health care budget(Hogan, Dall, & Nikolov, 2003). A major 
+part of Diabetes burden (75%) will be borne by developing countries(Arora MM, 
+Chander Y, Rai R,2000) and India has the second largest number (>61 million) of 
+individuals with T2DM in the world and this is expected to nearly double by 
+2030(Brussels, 2011).  
+The prevalence of risk factors for diabetic complications, such as hypertension, 
+obesity, and physical inactivity are also high. In 2007 67.0% of United States adults with 
+diabetes reported having hypertension, 83.5% were overweight or obese, and 38.2% 
+reported 0 being physically inactive. Cardiovascular complications are the leading cause 
+of morbidity and mortality among patients with T2DM, and cardiovascular disease 
+(CVD) risk is 2 to 8 fold higher in the diabetic population than it is in non-diabetic 
+individuals of a similar age, sex and ethnicity(Haffner, Lehto, Rönnemaa, Pyörälä, & 
+Laakso, 1998)(Brun et al., 2000). Furthermore, macro vascular complications are the 
+largest contributor to the direct and indirect costs of diabetes(“Economic costs of diabetes 
+in the U.S. In 2007.,” 2008). Micro albuminuria and retinopathy are indicators of micro 
+vascular dysfunction, and both predict a poorer outcome in patients with diabetes(Rajala, 
+Pajunpää, Koskela, & Keinänen-Kiukaanniemi, 2000)(Klein, Klein, Moss, & 
+Cruickshanks, 1999). 
+Complementary and alternative medicine (CAM) may offer novel approaches to 
+address lifestyle,behaviour change for prevention and control of chronic diseases such as 
+T2DM.   
+Naturopathic medicine is of greatest interest as it is a whole-system of CAM most 
+closely resembling conventional primary care in scope of practice, but with greater 
+delivery of healthy lifestyle counselling(Bradley et al., 2009). According to observational 
+studies, healthy lifestyle interventions are routine in naturopathic clinical care for T2DM 
+,with diet, physical activity, and stress management counselling incorporated into the 
+majority of clinical encounters (80– 100%)(Bradley & Oberg, 2006)(Bradley & Oberg, 
+2006). Care provided by Naturopathic Doctors (ND) is a particularly promising form of 
+CAM practice for diabetes, because the ND training emphasizes assessment and 
+understanding of medical risk, intensive dietary and lifestyle counselling, and the routine 
+laboratory testing necessary for on-going management(Bradley & Oberg, 2006; Bradley 
+et al., 2011; Oberg, Bradley, Allen, & McCrory, 2011).  
+In a survey conducted in United States, approximately 48% of individuals with 
+diabetes reported using CAM. Several CAM modalities like naturopathy, acupuncture, 
+therapeutic massage, reflexology, dietetics etc. are found to be effective in the 
+management of T2DM( Donald Garrow, Leonard Egede E, 2006). Retrospective 
+observational studies also suggest ND care reduces risk for T2DM and hypertension, 
+including improved glucose control and reduced blood pressure, respectively(Ellen 
+seber,2000). 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 322 
+Hence the present study is planned to find the effect of 10 days Naturopathy and 
+Yoga on Type IIDiabetes Mellitus. 
+AIM AND OBJECTIVES 
+AIM 
+• To study the effect of Naturopathy and Yoga on patients with T2DM. 
+ 
+OBJECTIVES 
+• To study the effect of Naturopathy and Yoga on Type 2 Diabetes patients with: 
+o Fasting Blood Glucose 
+o Post Prandial Blood Glucose  
+MATERIALS AND METHODS 
+Subjects: A total of two hundred patients who admitted 10 days Naturopathy and Yoga 
+Hospital, were screened to obtain hundred participants for the study. They were recruited 
+from Nature cure and Yoga therapy Hospital, Shanthivana, Dharmastala.  
+Inclusion Criteria: 
+• Diagnosed subjects of type 2 Diabetes Mellitus, who are on oral hypoglycaemic 
+drugs for the past two years. 
+• Above the age of 35 years and below the age of 85 years. 
+• Both genders were included.  
+Exclusion criteria: 
+• Uncontrolled type 2 Diabetes Mellitus. 
+• Type 2 Diabetes Mellitus who are on Insulin therapy. 
+• Diabetes associated with systemic complications. 
+The signed consent forms were obtained from all subjects for their participation.  
+Setting: 
+Study 
+conducted 
+in 
+the 
+Yoga 
+and 
+Nature 
+cure 
+Hospital, 
+Shanthivana,Dharmastala, Karnataka.The study was approved by the Institutional ethics 
+committee. 
+Study Design: The study adopts a pre-post design. The institutional ethical committee 
+approval was obtained for conducting the study. Subjects were assessed on Day 1 and 
+Day 10 during which they received Yoga practice, Naturopathic treatment and Diet 
+therapy. 
+ 
+ 
+ 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 323 
+Experimental group 
+ 
+ 
+Day 1  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Day 10 
+Assessments: The primary outcome measure was Fasting blood glucose (FBG) andPost 
+prandial blood glucose (PPBG). 
+Fasting Blood Glucose: This test requires at least eight hours of fasting, and is usually 
+done in early mornings. A suitable vein is identified, and a tourniquet applied to distend 
+the vein for puncture. The skin over the vein is antiseptically cleaned. A sterile needle 
+and syringe are used to draw about 10ml of blood from the vein, the tourniquet is 
+removed, the needle withdrawn, and the puncture site compressed for a few minutes, then 
+covered with a clean dressing. The blood sample was used for analysis. 
+Intervention 
+Yoga based physical activity: 
+INTERVENTION 
+COMPONENTS 
+Surya Namaskara 
+(sun salutations)  
+4 rounds 
+• Namaskarasana,  
+• UttithapadasanaPadahastasana,  
+• Ekapadasanchalanasana,  
+• Dwipadasanchalanasana,  
+• Shashankasana,  
+• Ashtangapanipadasana,  
+• Urdwamukashwanasana,  
+• AdhomukhaSwanasana,  
+• Ekapadasanchalanasana,  
+• Padahastasana,  
+• Uttithapadasana,  
+• Namaskarasana 
+IRT 
+ 
+Instant Relaxation Technique 
+Asanas 
+Standing Asanas 
+• Trikonasana,  
+• Padahastasana,  
+• Ardhachakrasana,  
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 324 
+• Ardhakatichakrasana 
+ 
+Supine Asanas 
+• uttitapadasana,  
+• Pavanamuktasana,  
+• Navasana,  
+• Shavasana 
+QRT 
+Quick Relaxation Technique 
+Prone Asanas 
+• Bhujangasana,  
+• Dhanurasana,  
+• Naukasana,  
+• Shalabasana 
+Sitting Asanas 
+• Vajrasana,  
+• Vakrasana,  
+• ArdhaMatsyendrasana,  
+• Yoga mudrasana 
+DRT 
+Deep Relaxation Technique 
+Yoga based stress management:  
+Pranayamas 
+Nadishodana, Surya bedhana, Kapalabhathi, Brahmari 
+Meditation 
+Omkara meditation 
+ 
+Naturopathy based diet plan: 
+7:30 am 
+Bitter gourd juice (200 ml) 
+9:00am 
+Ragigangi (250 ml) 
+12:00 noon 
+Kichadi + boiled vegetables+ buttermilk (50 ml) + papaya (200 gms) 
++ methi powder (1-2 tsp) 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 325 
+2:00pm 
+Knolkhol  juice (200 ml) 
+4:00pm 
+Barley water (200 ml) 
+7:00pm 
+2 roti + boiled vegetables + papaya (200 gms) + soup (150 ml) + 
+methi powder (1-2 tsp) 
+9:00pm 
+(If necessary) 
+Fruit (Apple) 
+ 
+Naturopathy Treatments: 
+Steam bath (10 min), Full body oil Massage(45 min), Sauna bath(10 min), under water 
+massage(20 min), Cold hip bath(20 min), Gastro Hepatic pack(20 min), neutral 
+immersion bath(20 min), cold circular jet(20 min), douche(20 min). 
+Data Analysis: 
+The present study was conducted to assess the effect of Naturopathy & Yoga in reducing 
+Fasting blood glucose level and postprandial blood glucose values. The results were 
+analysed by using SPSS (16.0).  
+RESULTS 
+The present study was conducted to assess the effect of Naturopathy & Yoga in reducing 
+Fasting blood glucose level and postprandial blood glucose values.  
+The alpha level of statistical significance was set at p<0.05. Both FBG and PPBG levels 
+showed significant reduction at the end of the intervention. 
+ 
+ 
+ 
+ 
+ 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 326 
+Fig. 1 Mean pre-post intervention of FBG 
+ 
+ 
+ 
+Fig. 2 Mean pre-post intervention of PPBG 
+ 
+DISCUSSIONS 
+The study result shows that FBG and PPBGhave significantly reduced subsequent to the 
+intervention. The Naturopathy and Yoga intervention facilitates better clinical outcomes 
+in the management of T2DM.  
+0
+50
+100
+150
+200
+250
+FBS
+Fasting Blood Sugar level 
+Pre
+Post
+0
+50
+100
+150
+200
+250
+300
+350
+PPBS
+Post Prandial Blood Sugar 
+Pre
+Post
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 327 
+Previous studies have shown decrease in the levels of FPG, PPPG and HbA1c by 
+the intervention of Yoga, Diet and Naturopathic intervention. A clinical study has shown 
+that the Naturopathic care to people with T2DMsignificantly improved glycemic control, 
+increased self-monitoring of blood glucose, improved diet, increased physical activity, 
+greater self-efficacy, improved mood and reduced problem areas in diabetes(Bradley et 
+al., 2012).Another study demonstrates the modifications in risk-factors that occur with 
+long-term naturopathic care for T2DM with notable percentages of patients achieving 
+improvements in glucose levels as measured by HbA1c and blood pressure 
+measures(Bradley et al., 2009). 
+A retrospective study suggests Naturopathic medicine is a philosophy-based, 
+complete medical system. This description of naturopathic care can serve other health 
+professionals in their referral recommendations. Naturopathic care for diabetes at this 
+representative academic facility remains mostly adjunctive, although physicians possess 
+the training and skills necessary to participate as primary care providers.  
+The naturopathic treatment approach frequently includes important dietary and 
+lifestyle recommendations included in current medical treatment guidelines for diabetes, 
+hypertension, and hyperlipidaemia, although improvements can be made on the precision 
+of recommendations(Bradley & Oberg, 2006). 
+The present study also suggested the similar results of the previous study that the 
+Naturopathy and Yoga intervention reduces both Fasting blood glucose level and Post-
+prandial glucose levels. 
+Limitation of the study: 
+• There is no control group in the study. 
+• Compared to other intervention based studies, the duration of this study is 
+considerably short. 
+• The study was limited to a fixed period of intervention. Post intervention follow 
+up was not done which is critical in evaluating a non-pharmacological therapy in 
+the management of a chronic disease like T2DM. 
+CONCLUSION 
+The present study suggested that Naturopathy and Yoga intervention has reduced 
+significantly the levels of FBG and PPBG in patients with Type II Diabetes Mellitus. The 
+Naturopathy and Yoga intervention is the main stream of management in treating Type II 
+Diabetes Mellitus. 
+Acknowledgement: 
+This study is a part of the author's Doctoral research work. The author 
+gratefullyacknowledges Dr Naveen K Visweswaraiah and Dr Manjunath NK, Joint 
+Director’s of Research, S-VYASA Yoga University, Bengaluru for their support. 
+ 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 328 
+References: 
+Bradley, R., Kozura, E., Buckle, H., Kaltunas, J., Tais, S., & Standish, L. J. (2009). 
+Description of clinical risk factor changes during naturopathic care for type 2 
+diabetes. Journal of Alternative and Complementary Medicine (New York, N.Y.), 
+15(6), 633–8. doi:10.1089/acm.2008.0249 
+Bradley, R., Kozura, E., Kaltunas, J., Oberg, E. B., Probstfield, J., & Fitzpatrick, A. L. 
+(2011). Observed Changes in Risk during Naturopathic Treatment of Hypertension. 
+Evidence-Based Complementary and Alternative Medicine : eCAM, 2011, 826751. 
+doi:10.1093/ecam/nep219 
+Bradley, R., & Oberg, E. B. (2006). Naturopathic medicine and type 2 diabetes: a 
+retrospective analysis from an academic clinic. Alternative Medicine Review : A 
+Journal 
+of 
+Clinical 
+Therapeutic, 
+11(1), 
+30–9. 
+Retrieved 
+from 
+http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2943666&tool=pmcentr
+ez&rendertype=abstract 
+Bradley, R., Sherman, K. J., Catz, S., Calabrese, C., Oberg, E. B., Jordan, L., … Cherkin, 
+D. (2012). Adjunctive naturopathic care for type 2 diabetes: patient-reported and 
+clinical outcomes after one year. BMC Complementary and Alternative Medicine, 
+12, 44. doi:10.1186/1472-6882-12-44 
+Brun, E., Nelson, R. G., Bennett, P. H., Imperatore, G., Zoppini, G., Verlato, G., & 
+Muggeo, M. (2000). Diabetes duration and cause-specific mortality in the Verona 
+Diabetes 
+Study. 
+Diabetes 
+Care, 
+23(8), 
+1119–23. 
+Retrieved 
+from 
+http://www.ncbi.nlm.nih.gov/pubmed/10937508 
+Brussels. (2011). No Title (5th editio.). Belgium: International Diabetes Federation. 
+doi:2011 
+Economic costs of diabetes in the U.S. In 2007. (2008). Diabetes Care, 31(3), 596–615. 
+doi:10.2337/dc08-9017 
+Haffner, S. M., Lehto, S., Rönnemaa, T., Pyörälä, K., & Laakso, M. (1998). Mortality 
+from coronary heart disease in subjects with type 2 diabetes and in nondiabetic 
+subjects with and without prior myocardial infarction. The New England Journal of 
+Medicine, 339(4), 229–34. doi:10.1056/NEJM199807233390404 
+Hogan, P., Dall, T., & Nikolov, P. (2003). Economic costs of diabetes in the US in 2002. 
+Diabetes 
+Care, 
+26(3), 
+917–32. 
+Retrieved 
+from 
+http://www.ncbi.nlm.nih.gov/pubmed/12610059 
+Klein, R., Klein, B. E., Moss, S. E., & Cruickshanks, K. J. (1999). Association of ocular 
+disease and mortality in a diabetic population. Archives of Ophthalmology, 117(11), 
+1487–95. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10565517 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN 2249-9598, Volume-V, Issue-I, Jan-Feb 2015 Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+ 
+Page 329 
+Malhotra, V., Singh, S., Tandon, O. P., & Sharma, S. B. (2005). The beneficial effect of 
+yoga in diabetes. Nepal Medical College Journal : NMCJ, 7(2), 145–7. Retrieved 
+from http://www.ncbi.nlm.nih.gov/pubmed/16519085 
+Oberg, E. B., Bradley, R. D., Allen, J., & McCrory, M. A. (2011). CAM: naturopathic 
+dietary interventions for patients with type 2 diabetes. Complementary Therapies in 
+Clinical Practice, 17(3), 157–61. doi:10.1016/j.ctcp.2011.02.007 
+Rajala, U., Pajunpää, H., Koskela, P., & Keinänen-Kiukaanniemi, S. (2000). High 
+cardiovascular disease mortality in subjects with visual impairment caused by 
+diabetic 
+retinopathy. 
+Diabetes 
+Care, 
+23(7), 
+957–61. 
+Retrieved 
+from 
+http://www.ncbi.nlm.nih.gov/pubmed/10895846 
+Sahay, B. K. (2007). Role of yoga in diabetes. The Journal of the Association of 
+Physicians 
+of 
+India, 
+55, 
+121–6. 
+Retrieved 
+from 
+http://www.ncbi.nlm.nih.gov/pubmed/17571741 
+Sperandei, S. (2012). Comment on: Hegde et al. effect of 3-month yoga on oxidative 
+stress in type 2 diabetes with or without complications: a controlled clinical trial. 
+Diabetes Care 2011;34: 2208-2210. Diabetes Care, 35(6), e42; author reply e43. 
+doi:10.2337/dc11-2379 
+Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004). Global prevalence of 
+diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care, 27(5), 
+1047–53. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15111519 
+ 

subfolder_0/Effect of Yoga and Physiotherapy on Pulmonary Functions in Children with Duchenne Muscular Dystrophy A Comparative Study.txt

@@ -0,0 +1,1035 @@
+© 2021 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+133
+Introduction
+Respiratory 
+failure 
+is 
+considered 
+to 
+be the major cause  (90%) of death 
+in 
+children 
+with 
+Duchenne 
+muscular 
+dystrophy  (DMD) which results from 
+weakness and degeneration of respiratory 
+muscles including diaphragm, abdominal 
+muscles, intercostal, latissimus dorsi, and 
+sternomastoid.[1] The sequence of events 
+due to respiratory muscle weakness leads 
+to reduced lung compliance, ineffective 
+cough, central and obstructive hypoxemia, 
+atelectasis, 
+repeated 
+infections, 
+and 
+imbalance in ventilation‑perfusion ratio.[2]
+The prognosis in DMD depends to a large 
+extent on the respiratory function. Patients 
+with DMD develop a restrictive respiratory 
+pattern 
+with 
+reduction 
+of 
+maximal 
+respiratory pressures and forced vital 
+Address for correspondence: 
+Dr. Pradnya Dhargave, 
+Physiotherapy Centre, 
+National Institute of Mental 
+Health and Neuro Sciences, 
+NIMHANS Hospital Campus, 
+Bengaluru ‑ 560 029, 
+Karnataka, India. 
+E‑mail: pradnya22_1999@
+yahoo.com
+Access this article online
+Website: www.ijoy.org.in
+DOI: 10.4103/ijoy.IJOY_49_20
+Quick Response Code:
+Abstract
+Context: Abnormal respiratory function is known to be detectable almost as soon as it can 
+be measured reliably. Studies have identified the effect of respiratory muscle training as well 
+as breathing exercises in improving pulmonary functions in children with Duchenne muscular 
+dystrophy (DMD). Aims: This study aims to identify the add‑on effect of yoga over physiotherapy 
+on pulmonary functions in children with DMD. Settings and Design: One hundred and twenty‑four 
+patients with DMD were randomized to two groups. Group I received home‑based physiotherapy and 
+Group II received physiotherapy along with yoga intervention. Materials and Methods: Pulmonary 
+function test  (PFT) was assessed before the intervention  (baseline data) and at regular intervals 
+of 3 months for a period of 1  year. Statistical Analysis Used: Normality was assessed using 
+Shapiro–Wilk normality test. The baseline data were analyzed using Mann–Whitney U‑test to 
+identify the homogeneity. Repeated measures analysis of variance was used to assess significant 
+changes in study parameters during the assessment of every 3 months, both within and between the 
+two groups of patients. Results: A total of 88 participants completed all the 5 assessments, with a 
+mean age of 7.9 ± 1.5 years. PFT parameters such as forced vital capacity (FVC), peak expiratory 
+flow rate, maximum voluntary ventilation  (MVV), and tidal volume during maximum voluntary 
+ventilation  (MVt) demonstrated significant improvements in Group I. In Group II, FVC and MVt 
+significantly improved from baseline up to 1  year, whereas MVV improved from baseline up to 
+9 months. Tidal volume did not show any changes in both the groups. Conclusions: The findings 
+suggest that introduction of yoga with physiotherapy intervention at an early age can be considered 
+as one of the therapeutic strategies in improving pulmonary functions in patients with DMD.
+Keywords: Duchenne muscular dystrophy, physiotherapy, pulmonary function test, respiratory 
+function, Yoga
+Effect of Yoga and Physiotherapy on Pulmonary Functions in Children 
+with Duchenne Muscular Dystrophy – A Comparative Study
+Pradnya Dhargave, 
+Atchayaram Nalini1, 
+Raghuram 
+Nagarathna2, 
+Raghupathy 
+Sendhilkumar, 
+Tittu Thomas 
+James, 
+Trichur R Raju3, 
+Talakad N 
+Sathyaprabha3
+Physiotherapy Centre, 
+National Institute of Mental 
+Health and Neuro Sciences, 
+Departments of 1Neurology and 
+3Neurophysiology, National 
+Institute of Mental Health 
+and Neuro Sciences, 2Dean, 
+Division of Yoga and Life 
+Sciences, Swami Vivekanandha 
+Yoga Research Foundation, 
+Bengaluru, Karnataka, India
+How to cite this article: Pradnya D, Nalini A, 
+Nagarathna R, Sendhilkumar R, James TT, Raju TR, 
+et al. Effect of yoga and physiotherapy on pulmonary 
+functions in children with Duchenne muscular 
+dystrophy  –  A comparative study. Int J Yoga 
+2021;14:133-40.
+Submitted: 14-May-2020     Revised: 17-Aug-2020 
+ 
+Accepted: 23-Dec-2020                 Published: 10-May-2021
+capacity  (FVC) that implicates a risk for 
+respiratory failure and death.[3] Following 
+a plateau phase, in the early years, lung 
+functions decline at a rate of 6%–8% 
+annually.[4‑6] A recent study shows a decrease 
+of vital capacity of 10.7%/year in patients 
+with DMD.[7] According to McDonald 
+et  al., the loss of walking ability and 
+spinal deformities can affect lung function, 
+but age is the most important factor.[4] 
+Consequently, measures of lung function 
+are fundamental methods to monitor the 
+outcome of patients.[6] Pulmonary function 
+test  (PFT) parameters such as FVC, peak 
+expiratory flow rate  (PEFr), tidal volume, 
+maximum voluntary ventilation (MVV), and 
+tidal volume during MVV were found to be 
+significantly lower in children with DMD 
+than in healthy individuals, which provides 
+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: WKHLRPMedknow_reprints@wolterskluwer
+.com
+Original Article
+Dhargave, et al.: Yoga with physiotherapy in DMD
+134
+134
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+an insight on the presence of subclinical pulmonary 
+dysfunction early in the course of disease that evolves later 
+into clinical dysfunction.[8] Abnormal respiratory function 
+is known to be detectable almost as soon as it can be 
+measured reliably. PFT should be performed on a regular 
+basis on patients diagnosed with DMD to understand the 
+prognosis and to initiate early interventions as required in 
+accordance with the indications identified.[8]
+Various strategies have been adopted for respiratory 
+management in patients with DMD. One study has shown 
+that steroid treatment has the potential to stabilize lung 
+function in DMD patients even in nonambulant children, 
+in those older than 10  years, and in those in whom the 
+medication was started after 7  years of age.[2] The rate of 
+decline of FVC% has been reported to reduce from 4.28% 
+to 1.36% upon initiating noninvasive ventilation.[9] Chest 
+physiotherapy and respiratory muscle training are being 
+administered in DMD patients, but their efficiency is not 
+fully established. Studies have identified the effect of 
+respiratory muscle training as well as breathing exercises 
+in improving pulmonary functions in children with DMD. 
+Yeldan et al. have showed that respiratory muscle strength 
+is enhanced in ambulatory patients with DMD with 
+training.[10]
+Yoga is a complimentary mind–body therapy which is 
+being practiced increasingly among Indian and Western 
+populations. An American survey in 2004 reported that 15 
+million adults used yoga at least once in their lifetime and 
+7.4 million during the previous year, and concluded that 
+yoga was often helpful and cost effective.[11] It has been 
+proven that yoga as an add‑on therapy in patients with 
+DMD has an effect on heart rate variability.[12] Rodrigues 
+et  al. have identified that 83% of DMD patients are able 
+to learn how to perform yoga breathing exercises and 
+could significantly demonstrate improvements in forced 
+expiratory volume in 1 s (FEV1) and FVC over a period of 
+10 months.[13] Yoga may help in improving the lifespan and 
+quality of living of DMD individuals through its influence 
+on pulmonary functions, which is least explored by 
+researchers. Although the effect of yoga and physiotherapy 
+has been studied separately, combined effect of both is not 
+known. Yoga which is a recent trend in the field of exercise 
+and fitness can be used as an adjunct with the regular 
+physical therapy program. This randomized trail aims to 
+identify the add‑on effect of yoga over physiotherapy on 
+pulmonary functions in children with DMD.
+Materials and Methods
+Participants
+Children with a confirmed diagnosis of DMD were selected 
+for the study. Boys within the age group of 5–10 years and 
+who were self‑ambulant or required minimal assistance 
+were included for the study. The exclusion criteria were as 
+follows: muscular dystrophy other than DMD, nonambulant 
+children, children with DMD who were undergoing regular 
+yoga and physiotherapy before recruitment, children with 
+DMD who were on steroids for more than 3 months, and 
+associated cardiopulmonary conditions. Written informed 
+consent was obtained from the parents or guardians of the 
+children with DMD after explaining the nature and purpose 
+of the study.
+Design
+The study was conducted for a period of 4 years. The study 
+was approved by the Institutional Review Board of the 
+institution. The consort diagram explaining the procedure 
+of the study is depicted in Figure  1. The patients were 
+randomly allocated to two groups, i.e., Group I and Group 
+II, using computer‑generated Tippet’s random number table.
+Assessments
+The demographic data and medical history of the 
+patients were documented. PFT was assessed before the 
+intervention  (baseline data) and at regular intervals of 3 
+months for a period of 1  year, using the spirometry kit 
+manufactured by Microquark Cosmed, Italy. The procedure 
+was explained to the participants, and three measurements 
+were recorded at an interval of 2  min. The best out of 
+Assessed For
+Eligibility (n = 200)
+Excluded (n = 76) 
+Not meeting criteria (n = 53)
+Declined to participate
+(n = 23)
+Included for the
+Study (n = 124)
+Allocated to Group I
+(n = 62)
+Allocated to Group II
+(n = 62)
+Lost to Follow Up
+(n = 17)
+Lost to Follow Up
+(n = 19)
+Post Test After 1
+Year (n = 45)
+Post Test after 1
+Year (n = 43)
+Figure 1: Consort diagram of the study
+Dhargave, et al.: Yoga with physiotherapy in DMD
+135
+135
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+three attempts were used for analysis. The actual values of 
+FVC, PEFr, tidal volume, MVV, and tidal volume during 
+maximum voluntary ventilation (MVt) were considered for 
+analysis.
+Intervention
+Group I received home‑based physiotherapy exercises for 
+two sessions a day: one in the morning and another in 
+the evening. Group II received one session of yoga in the 
+morning and one session of physiotherapy in the evening 
+as home program. Each session of physiotherapy and yoga 
+lasted for a maximum of 45  min. The detailed protocol 
+of physiotherapy and yoga is provided in Tables  1 and 2, 
+respectively.
+Participants were made to practice physiotherapy and yoga 
+under the supervision of physiotherapists initially for a 
+period of 1  week. Parents were also trained during these 
+supervised sessions in order to enable them to conduct 
+sessions at home. Patients were then asked to perform the 
+exercises every day at home for a period of 1 year. All the 
+parents were instructed to maintain an exercise diary which 
+was reviewed every 3 months at the time of each visit for 
+the assessment during which the home program performed 
+by the children was also reviewed.
+Data analysis
+Outcome measures for the study were assessed at 5 
+points of time during the study period  (baseline, at 3 
+months, 6 months, 9 months, and after 12 months). All 
+the variables were tested for normality using Shapiro–
+Wilk normality test. The baseline data of Group I and 
+Group II were also analyzed using Mann–Whitney U‑test 
+to identify the homogeneity between the groups. Repeated 
+measures analysis of variance  (RmANOVA) was used 
+to assess significant changes in study parameters during 
+the assessment of every 3 months, both within and 
+between the two groups of patients. Time effect  (changes 
+over the duration of treatment irrespective of type of 
+treatment), group effect  (difference between the treatment 
+groups irrespective of the time point of assessment), and 
+interaction effect (differences in the way the two treatment 
+groups differ at the five time points of assessment) were 
+also identified. Post hoc test was carried out using least 
+significant difference test. The mean difference between 
+the baseline and 1‑year follow‑up data of the individuals 
+was also analyzed according to the age groups of 5–6, 7–8, 
+and 9–10 years of age. The data were analyzed using  IBM 
+SPSS Statistics for Windows, Version 22.0, Armonk, NY: 
+IBM Corp. Released 2013  Statistics software.
+Results
+A total of 124 boys with DMD fulfilling the inclusion 
+criteria were recruited and were followed for 1  year at 
+an interval of 3 months for a total of 5 serial follow‑up 
+assessments  (including baseline). The patients were 
+randomly grouped into Group I  (physiotherapy treatment 
+regimen)  (n  =  62) and Group II  (physiotherapy and yoga 
+treatment regimen)  (n  =  62). Thirty‑six  (30%) individuals 
+dropped out from the study  (17  (57%) from Group I and 
+19  (63%) from Group II) at different time intervals and 
+88 participants  (71%) completed all the 5 assessments. 
+The mean age of individuals recruited for study was 
+7.9  ±  1.5  years. The mean height was 118.2  ±  8.4 cm 
+(ranges between 95 and 147 cm) and the mean weight was 
+20.6  ±  4.3 kg  (ranges between 11 and 32 kg). The mean 
+age of onset of the disorder was 2.8  ±  0.6  years  (ranges 
+between 1.5 and 4.0  years). The mean duration of illness 
+within the population was 5.1  ±  1.5  years  (ranges from 1 
+to 8 years).
+A comparison performed between the two groups on 
+baseline PFT parameters showed no significant changes 
+between them, thus maintaining homogeneity at the initial 
+time period of the study  [Table  3]. Serial evaluation 
+of PFT parameters was carried out at baseline and 
+after intervals of every 3 months for 1  year  [Table  4]. 
+When compared to baseline values, FVC  (P  <  0.001), 
+PEFr (P = 0.05), MVV (P < 0.001), and MVt (P < 0.001) 
+demonstrated a significant improvement in Group I. 
+In Group II, FVC  (P  <  0.001) and MVt  (P  =  0.004) 
+significantly improved from baseline up to 1 year, whereas 
+MVV (P = 0.007) improved from baseline up to 9 months. 
+Tidal volume did not demonstrate a significant difference 
+after 1 year of intervention in Groups I and II (P = 0.448 
+and 0.956, respectively). Age‑wise changes between the 
+baseline and 1‑year follow‑up assessment on the PFT 
+Table 1: Physiotherapy exercise protocol
+Exercise
+Duration 
+(min)
+Passive/active ROM exercise for all joints
+5
+Active assisted/active breathing exercises
+5
+Task‑oriented exercises: Rolling, lying to sitting, sitting to standing, standing, walking, climbing one flight of stairs, throwing 
+and kicking a ball, passing the ball from left to right and then from front to back and vice versa, hand activities
+15
+Activity‑based breathing exercises initiating with deep inspiration: Blowing pieces of paper, blowing candle placed at varying 
+distances, blowing balloons of different sizes, blowing a party whistle, blowing bubbles with a straw, picking up objects such 
+as small pieces of paper or small thermocol balls, sucking through a straw and then keeping it at a particular orientation
+10
+Stretching exercises: For trunk, chest wall, and commonly affected muscles
+10
+ROM: Range of motion
+Dhargave, et al.: Yoga with physiotherapy in DMD
+136
+136
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+parameters within the groups were also analyzed [Table 5]. 
+The age‑wise comparison in Group I showed a significant 
+improvement in FVC and MVV in all children across all 
+age groups, PEFr in 9–10 years, tidal volume in 5–6 years, 
+and MVt in 7–8  years. In Group II, FVC has shown a 
+significant improvement in children between 5 and 8 years, 
+PEFr in 7–8  years, and MVt in 5–10  years, whereas 
+MVV and tidal volume remained same. The RmANOVA 
+demonstrates no significance in group effect and interaction 
+effect for the parameters assessed in 5  timeframes. The 
+time effect shows a significance in all parameters except 
+for tidal volume.
+Discussion
+This randomized comparative study aimed at comparing 
+the effect of physiotherapy and physiotherapy with yoga 
+in children with DMD to improve pulmonary functions. 
+The mean age of onset of the study population was 
+2.8 ± 0.6 years, which is similar to other studies conducted 
+within the same population.[14,15] The results suggest that, 
+except for tidal volume, all other parameters of PFT 
+have significantly improved on the course of treatment 
+irrespective of the intervention provided. It is also 
+noteworthy that there is no significant difference between 
+the two groups based on the intervention administered at 
+any point of the timeframe of follow‑up visits.
+The skeletal muscle tissue undergoes wasting and is 
+ultimately replaced by fat and fibrotic tissue as the disease 
+progresses. In the later stage of the disease, weakness 
+of the diaphragm reduces the respiratory efficiency that 
+in turn leads to decrease in ventilation.[16‑18] Expiratory 
+lung strength begins to decline at the age of 7  years and 
+continues to worsen with age.[16] Thirty percent of children 
+with DMD had a history of respiratory complications, and 
+the frequency increased with age.[4] DMD patients may 
+develop respiratory failure due to restrictive respiratory 
+pattern. Pulmonary function increases until 10–12  years 
+of age and reaches plateau, following which it declines at 
+rate of 6%–8% annually. Vital capacity shows 10.7%/year 
+decrease in DMD children.[2]
+FVC is one of the best indicators of clinical condition of 
+the lungs.[19] Expiratory muscles are more affected than 
+inspiratory muscles in children with DMD, leading to 
+a reduced quality of cough. This can cause ineffective 
+removal of secretions and an increased chance of 
+infections.[20] Previous studies in nonambulatory patients 
+have found that FVC declines rapidly when standing 
+ceases. A percentage of FVC was found to be the parameter 
+Table 3: Comparison of baseline values of various pulmonary functions among the two study groups
+PFT
+Group I (n‑45)
+Group II (n‑43)
+Mann-Whitney U
+P
+FVC (L)
+0.9±0.2
+0.8±0.3
+768.00
+0.182
+PEFr (L/min)
+102.9±42.4
+107.3±41.3
+859.00
+0.840
+Tidal volume (L)
+0.4±0.2
+0.3±0.2
+753.00
+0.255
+MVV (L/min)
+28.7±10.1
+28.5±9.4
+838.50
+0.726
+MVt (L)
+0.3±0.1
+0.4±0.1
+781.00
+0.482
+Values are expressed as mean±SD; Mann-Whitney U‑test was performed and the level of significance kept at P<0.05. SD: Standard deviation, 
+PFT: Pulmonary function test, FVC: Forced vital capacity, PEFr: Peak expiratory flow rate, MVV: Maximum voluntary ventilation
+Table 2: Yoga protocol
+Exercise
+Duration 
+(min)
+Sukshma and Sthula Vyayama in standing position
+Manibandha Shakti Vikasaka (wrist)
+10
+Anguli Shakti Vikasaka (finger)
+Kaphoni Shakti Vikasaka (elbow)
+Bhuja Bandha Shakti Vikasaka (arm)
+Griva Shakti Vikasaka I, II, III (neck)
+Purna Bhuja Shakti Vikasaka (shoulder)
+Pada Mula Shakti Vikasaka (stand on toes)
+Pada Anguli Shakti Vikasaka (toes)
+Rekha Gati Shakti Vikasaka (walking straight line)
+Pada sanchalana (heel walking)
+Exercises in supine position
+Knee cap tightening
+Dorsal stretch
+Acute thigh flexion
+Breathing exercises
+Hand stretch breathing
+10
+Hands in and out breathing
+Tadasana breathing
+Tiger breathing and stretching
+Shalabhasana breathing
+Sethubandhana breathing
+Straight leg raising breathing
+Asanas
+Standing: Tadasana and Vrikshasana
+10
+Sitting: Vakrasana and Marjalasana
+Prone: Bhujangasana
+Supine: Pavanamuktasana, Markatasana, and 
+Sethubandasana
+Pranayama and Kriya
+7
+Yogic breathing
+Kapalabhati
+Nadishuddi
+Bhastrika and Bhramari
+Meditation
+Pranavajapa: A, U, M, and its combination “AUM"
+8
+MSRT
+MSRT: Mind sound resonance technique
+Dhargave, et al.: Yoga with physiotherapy in DMD
+137
+137
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+of pulmonary function that was most strongly correlated 
+with age and scoliosis measurements.[19] Mc Donald et  al. 
+reported 0.3% decline in FVC at ages 7–10, 8.5% decline 
+at 10–12  years, and 6.2% decline after 20  years of age.[4] 
+Annual spirometry is recommended for Duchenne children 
+older than 6  years as they can have FVC values lower 
+Table 4: Comparison of serial evaluation of values of pulmonary function tests in the two study groups
+PFT
+Group
+Baseline
+3 months
+6 months
+9 months
+12 months
+Time effect 
+F, P
+Interaction 
+effect F, P
+Group effect 
+F, P
+FVC
+I
+0.9±0.2
+0.9±0.3
+1.0±0.3
+1.1±0.3
+1.0±0.3
+14.165, 
+0.001‡
+0.393, 0.681
+0.08, 0.777
+II
+0.8±0.3
+0.9±0.3
+1.0±0.3
+1.1±0.6
+1.0±0.3
+PEFr
+I
+100.6±41.7
+114.8±46.7
+132.1±44.0
+121.6±43.5
+126 8±44.2
+4.818, 0.001†
+0.881, 0.476
+0.89, 0.347
+II
+103.4±41.2
+110±42.3
+117.0±48.4
+106.9±49.2
+116.6±48.4
+Tidal 
+volume
+I
+0.4±0.2
+0.4±0.1
+0.4±0.1
+0.4±0.2
+0.4±0.1
+1.684, 0.154
+0.424, 0.791
+1.96, 0.166
+II
+0.3±0.2
+0.3±0.1
+0.4±0.2
+0.3±0.2
+0.3±0.1
+MVV
+I
+28.1±9.7
+29.0±11.6
+33.3±11.7
+31.7±11.0
+34.6±11.0
+5.569, 
+<0.001‡
+1.119, 0.348
+0.05, 0.817
+II
+28.7±9.4
+31.8±8.6
+32.5±10.2
+33.6±9.5
+32.6±10.7
+MVt
+I
+0.3±0.1
+0.4±0.1
+0.5±0.2
+0.5±0.1
+0.5±0.2
+11.189, 
+<0.001‡
+0.659, 0.621
+0.10, 0.753
+II
+0.4±0.1
+0.4±0.3
+0.5±0.2
+0.5±0.2
+0.5±0.2
+Values are expressed as Mean±SD; RmANOVA was performed and the level of significance kept at *P<0.05, †P<0.005, ‡P<0.001. 
+SD: Standard deviation, PFT: Pulmonary function test, FVC: Forced vital capacity, PEFr: Peak expiratory flow rate, MVV: Maximum 
+voluntary ventilation, RmANOVA: Repeated measures analysis of variance
+Table 5: Age wise mean difference between baseline and 1‑year values for pulmonary functions between the two study 
+groups
+PFT values
+Group
+Age (years)
+Difference (mean±SD)
+t
+P
+FVC (L)
+I
+5-6
+−0.13±0.15
+−3.011
+0.011*
+7-8
+−0.19±0.18
+4.385
+<0.001‡
+9-10
+−0.16±0.2
+2.870
+0.014*
+II
+5-6
+−0.28±0.15
+5.859
+<0.001‡
+7-8
+−0.29±0.2
+5.332
+<0.001‡
+9-10
+−0.04±0.17
+0.817
+0.432
+PEFr (L/min)
+I
+5-6
+11.87±56.1
+0.733
+0.479
+7-8
+−9.21±0.64
+0.914
+0.376
+9-10
+−49.34±0.56
+3.385
+0.005*
+II
+5-6
+−7.16±49.25
+0.460
+0.657
+7-8
+−29.74±46.09
+2.415
+0.031*
+9-10
+−13.07±35.09
+1.290
+0.224
+Tidal volume (L)
+I
+5-6
+−0.12±0.16
+2.597
+0.023†
+7-8
+0.08±0.27
+1.228
+0.238
+9-10
+0.09±0.19
+1.823
+0.093
+II
+5-6
+−0.04±0.11
+1.102
+0.299
+7-8
+0.01±0.21
+0.211
+0.836
+9-10
+−0.01±0.34
+0.077
+0.940
+MVV (L/min)
+I
+5-6
+−7.19±7.29
+3.556
+0.004†
+7-8
+−6.65±8.24
+3.327
+0.004†
+9-10
+−7.62±11.54
+2.380
+0.035*
+II
+5-6
+−5.48±10.99
+1.495
+0.173
+7-8
+−6.12±10.95
+2.017
+0.067
+9-10
+−0.12±11.76
+0.034
+0.973
+MVt (L)
+I
+5-6
+−0.07±0.11
+1.411
+0.186
+7-8
+−0.13±0.19
+−2.867
+0.014*
+9-10
+−0.11±0.18
+1.119
+0.296
+II
+5-6
+−0.19±0.3
+3.976
+0.002†
+7-8
+−0.17±0.16
+3.632
+0.002†
+9-10
+−0.09±0.16
+2.974
+0.013*
+Values are expressed as mean±SD; Paired t‑test was performed and the level of significance level at *P<0.05, †P<0.005, 
+‡P<0.001. SD: Standard deviation, PFT: Pulmonary function test, FVC: Forced vital capacity, PEFr: Peak expiratory flow rate, MVV: Maximum 
+voluntary ventilation
+Dhargave, et al.: Yoga with physiotherapy in DMD
+138
+138
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+than 80% of predicted as early as 7  years of age.[20,21] As 
+this disease has a characteristic stage‑wise deterioration, 
+a planned and proactive approach to respiratory care is 
+advocated and appropriate surveillance, prophylaxis, and 
+intervention are needed.
+Effect of physiotherapy on pulmonary functions
+Physiotherapy improves muscle strength, reduces the 
+progression of joint contractures and spinal deformity, 
+improves respiratory functions, prolongs ambulation 
+for as long as possible, and maintains the best level of 
+health.[22,23] Topin et  al. suggested that specific training 
+improves respiratory muscle endurance in DMD and 
+the effectiveness of training appears to be dependent on 
+the quantity of training.[24] In our study when compared 
+to baseline values, with PT intervention, FVC, MVt, 
+PEFr, and MVV significantly improved from baseline 
+to 1  year. FVC and MVV are important parameters 
+of PFT which are reflective of the intercostal and 
+diaphragm muscle strength. Hence, the intervention has 
+helped in improvement/maintenance of muscle strength 
+of the respiratory muscles. PEFr also improved after 
+physiotherapy which suggests that there was an increase 
+in the flow of oxygen into the bronchioles and hence 
+increased ventilation.
+Various methods are used in the treatment of DMD to 
+improve respiratory function. This includes respiratory 
+muscle training, resisted inspiratory muscle training 
+using valves, breath stacking with resuscitation bags, 
+and glossopharyngeal breathing.[25] These methods need 
+specialists’ presence along with some equipment needed 
+all the time. Chances of development of fatigue and 
+further deterioration of respiratory muscles are another 
+complication 
+of 
+vigorous 
+respiratory 
+training.[25] 
+In 
+comparison to this, yoga which is a holistic approach is 
+relatively simple to follow at home with little training, 
+providing maintenance as well as improvements in the 
+disease course.
+Effect of yoga on pulmonary functions
+Practice of yoga in the form of low‑intensity rhythmical 
+movements with mindfulness is known to improve 
+the coping skills with physical and emotional stresses 
+effectively.[26] The yoga asanas are done with mindfulness 
+to achieve both physical and mental well‑being and 
+harmony. We have used the holistic approach suitable 
+for DMD children and included Sukshma and Sthula 
+Vyayama  (low‑exertion exercises), breathing exercises, 
+Pranayama and Kriyas with awareness and relaxation, 
+asanas, and guided meditation. Six weeks of Pranayama 
+practice in healthy volunteers have found to reduce 
+respiratory rate and increase FVC, FEV1%, MVV and 
+PEFR.[27] Similar beneficial effects were observed by 
+Makwana et  al., after 10  weeks of yoga practice, with 
+increase in inspiratory and expiratory pressures which 
+suggests that yoga training improves the strength of 
+respiratory muscles.[28]
+Overall relaxation and calming the mind through physical 
+and breathing practices is the primary goal of yogic 
+practices. Yoga in the form of Pranayama has an effect on 
+limbic system, hypothalamic medullary axis, and medullary 
+cardiovascular centers, which might have influenced 
+the cardiorespiratory system.[29] Pranayamas also help 
+in increasing respiratory capacity, whereby helping to 
+suspend respiratory cycle for a longer duration with lesser 
+effort.[30] One of the studies showed that Pranayama and 
+meditation added along with regular physiotherapy in adult 
+patients with neurological disorder showed improvement in 
+the quality of sleep.[31] Yoga has neurocardiac beneficiary 
+effect by reducing vagal tone as well as reducing the 
+catecholamine, 
+angiotensin 
+II 
+concentrations, 
+and 
+increasing bioavailability of nitric oxide.[12] Slow yoga 
+breathing decreases chemoreflex responses to hypoxia, and 
+hypercapnia in healthy practitioners with increased FVC 
+and PEFr after 3 months of practice.[32]
+The study observed significant improvements in the PFT 
+parameters on the course of treatment irrespective of the 
+intervention provided. The improvements were steady and 
+more pronounced in younger children. Yoga intervention 
+showed significant improvements in the pulmonary function 
+parameters such as FVC and MVt after 1  year, whereas 
+MVV showed a significant improvement from baseline up 
+to 9 months. There are certain advantages of using yoga 
+as a therapeutic intervention in children with DMD. Yoga 
+asanas in which the thorax and spinal movements are used, 
+there is a natural movement occurring in the costovertebral 
+joints of the thorax and the ribs.[33] This movements 
+can maintain the mobility in the thoracic cage which is 
+essential for prevention of the reduced compliance of the 
+cage in the due course. In our study, thoracic spine and 
+rib cage movement is evident by means of Vakrasana and 
+Bhujangasana.
+Comparing yoga and physiotherapy on pulmonary 
+functions
+No studies are available which have evaluated the effect 
+of yoga on serial assessment of PFT in DMD. In our 
+study, we observed that FVC, MVV, and MVt improved 
+significantly at every 3‑month follow‑up and were sustained 
+for a period of 1  year with combined therapy with yoga 
+and physiotherapy. In our study, the abnormalities in PFT 
+parameters indicated subclinical pulmonary dysfunction 
+as none of the patients demonstrated any respiratory 
+symptoms. This may evolve later in to clinical respiratory 
+dysfunction, which makes it imperative to start respiratory 
+muscle training early in the disease course to slow down its 
+progression.
+These evidences collectively show that physiotherapy 
+and 
+yoga 
+practices 
+improve 
+overall 
+respiratory 
+Dhargave, et al.: Yoga with physiotherapy in DMD
+139
+139
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+function by increasing the respiratory muscle strength, 
+maintaining the resilience of lung tissue, and improving 
+the lung capacities. Based on these objective evidences 
+of the effect of yoga on pulmonary functions, the same 
+could be extrapolated to explain the improvements 
+noted in PFT parameters in our study population. As the 
+pulmonary dysfunctions are subclinical in DMD children, 
+it is imperative to assess pulmonary functions at an early 
+age and introduce appropriate interventions which will 
+offer higher benefit in improving pulmonary functions 
+through which assisted ventilation may be delayed in 
+the disease course by which the life expectancy may be 
+expanded.
+Conclusions
+The early introduction of a pulmonary rehabilitation 
+protocol helped in maintaining and improving the 
+pulmonary functions in patients with DMD. Our findings 
+provide evidence that yoga has an add‑on effect along with 
+physiotherapy intervention at an early age, which can be 
+considered as one of the therapeutic strategies in improving 
+pulmonary functions in children with DMD.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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subfolder_0/Effect of Yoga on Immune Parameters, Cognitive Functions, and Quality of Life among HIV-Positive Children_Adolescents_ A Pilot Study.txt

@@ -0,0 +1,665 @@
+Int J Yoga. 2019 May-Aug; 12(2): 132–138.
+doi: 10.4103/ijoy.IJOY_51_18
+PMCID: PMC6521755
+PMID: 31143021
+Effect of Yoga on Immune Parameters, Cognitive Functions, and Quality
+of Life among HIV-Positive Children/Adolescents: A Pilot Study
+BP Hari Chandra, Mavathur N Ramesh, and Hogasandra R Nagendra
+Department of Life Sciences, S-VYASA Yoga University, Bengaluru, Karnataka, India
+Address for correspondence: Dr. BP Hari Chandra, No. 19, ‘Ekanatha Bhavana’, Kempegowda Nagara,
+Bengaluru - 560 019, Karnataka, India. E-mail: [email protected]
+Received 2018 Aug; Accepted 2018 Sep.
+Copyright : © 2019 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
+Context:
+HIV/AIDS individuals have problems relating to immune system, quality of life (QOL), and cognitive
+functions (CFs). Yoga is found to be useful in similar conditions. Hardly, any work is reported on yoga
+for HIV-positive adults/adolescents. Hence, this study is important.
+Aim:
+The aim of the study is to determine the effect of yoga on immune parameters, CFs, and QOL of HIV-
+positive children/adolescents.
+Settings and Design:
+Single-group, pre–post study with 4-month yoga intervention.
+Methods:
+The study had 18 children from an HIV/AIDS rehabilitation center for children/adolescents. CD4,
+CD8, CD4/CD8 ratio, and viral loads were studied. CF tests included six letter cancellation test,
+symbol digit modalities test, digit-span forward backward test, and Stroop tests. QOL was assessed
+using PedsQL-QOL and fatigue questionnaire. Depression was assessed using CDI2-SR.
+Statistical Analysis Used:
+t-test and Wilcoxon signed-rank tests, as applicable.
+Results:
+The study included 18 children/adolescents. There was improvement in general health of the
+participants. There was statistically significant increase in CD4 cells counts (p = 0.039) and significant
+decrease in viral load (p = 0.041). CD4/CD8 ratio moved to normal range. QOL significantly
+improved. CFs had mixed results with improved psychomotor performance (PP) and reduced executive
+functions.
+Conclusions:
+There was improvement in general health and immune parameters. While depression increased, QOL
+improved. CFs showed mixed results with improved PP and reduced executive functions.
+Keywords: Children/adolescents, HIV/AIDS, immune system, quality of life, yoga
+Introduction
+HIV/AIDS still remains to be one of the challenging and prevailing diseases of the modern times. The
+HIV/AIDS individuals have issues with general health owing to poor immune system leading to several
+opportunistic infections. The quality of life (QOL) is also rated to be poor among HIV/AIDS adults[1]
+and is attributed to reasons such as stigma, depression, and cultural beliefs.[2,3] Depression and
+cognitive disorders are also a prevalent comorbid mental disorders in HIV positives.[4,5,6,7]
+Depression is reported in up to 45% of HIV/AIDS patients.[8] Bhargav et al.[9] have reported that
+yoga could promote the health of HIV-infected mothers, enhance the efficacy of antiretroviral therapy
+(ART) in preventing vertical progression of HIV (mother-to-child transmission of HIV), and help
+reduce ART-related side effects. The mechanisms of action explained in the report also indicate that
+yoga would help any HIV-positive individual in general. Other reports also show that yoga helps in
+improving immune system functioning.[10] Bhargav et al.[11] describe the importance and mechanism
+of working of yoga on HIV-positive individuals and also recommend a theoretical comprehensive yoga
+module for HIV positives. However, they do not provide any empirical evidence. In spite of the clue
+that yoga can improve immune functioning, not many studies are reported on immune parameters in
+specific owing to the cost of blood tests.[12] A pilot randomized controlled trial study reports that 1-
+month yoga intervention showed improvement in CD4 count and depression among adult age group.
+[13] Yet, another single-group pre–post study has shown improvement in immunity, depression, and
+anxiety management of HIV adults.[14] Yoga has shown improvement in cognitive functions (CFs) of
+normal school children.[15] Yoga, in general, is known to also helpful in alleviating depression and
+improving QOL in several diseased conditions.[13] However, there are hardly any reports on the effect
+of yoga on children/adolescents with HIV. The current study is an attempt to determine the effect of
+yoga practice on the immune system, CFs, and QOL of HIV-positive children/adolescents.
+Methods
+This study is a part of larger study to determine the effect of yoga on the immune system, CFs, and
+QOL of HIV-positive children/adolescents. The design is a single-group pre–post study conducted on
+HIV-positive children/adolescents in an HIV/AIDS rehabilitation center (RC). The RC had 22
+children/adolescents, both males and females, at the time of the start of the study. Although all 22 were
+included in the study, for CF tests where the ability to read English was inevitable, only such of those
+having the appropriate abilities had to be considered. Further, for answering questionnaires, assistance
+was provided to the participants in the local language by research volunteers. Four participants had left
+the RC at the time of final data collection, and hence, the net number of participants were 18. The RC
+had voluntarily provided consent for the study.
+The yoga intervention largely based on a potential yoga module for HIV-positive individuals[11]
+included 1-h daily practice primarily involving loosening and breathing exercises, āsanas
+(Sūryanamaskāra - six rounds, Padmāsana, Vajrāsana, Varvāṇgāsana, Bhujangāsana, Ardhakati
+Ćakrásana, Uśtrāsana, Ardha Ćakrásana, Paśćimottanāsana, and Shavāsana) and prāṇāyāma
+(Kapālabāti (Kriya), Bhāstrika, Nāḍiśodhana, and Brāmari). Yoga was taught by a professional yoga
+teacher. Duration of intervention was 6 months. The daily routine of the participants was not disturbed,
+except for one hour yoga. Routine medical care too was not disturbed, and all the participants
+continued the standard medical care and checkups as per norms/schedules. All the participants were
+under the first-line ART routine as part of the standard medical care.
+For the study of immune parameters, health status, and related issues, the data were collected from the
+medical files proactively maintained by the RC as per norms. CD4 and CD3 counts and viral load were
+available. CD8 counts were computed using the formula CD8 = CD3 − CD4, and the CD4/CD8 ratio
+was calculated. Health-related QOL (HRQOL) was assessed with the help of PedsQL QOL
+questionnaire which has four subscales, namely, (a) health and general activities, (b) feelings, (c)
+getting along with others, and (d) about school. Fatigue-related QOL (FRQOL) was assessed through
+the PedsQL fatigue questionnaire which has three subscales (a) general fatigue (b) sleep fatigue, and
+(c) cognitive fatigue. The depression level of the candidates was assessed through self-reported child
+depression inventory, version 2 (CDI2-SR) questionnaire. The CFs were assessed through digit-span
+forward-backward (DSFB) test, symbol digit modalities test (SDMT), six letter cancellation test
+(SLCT), and Stroop test (ST). While SLCT and SDMT test for the psychomotor performance (PP),
+DSFB and ST test the executive functioning (EF) aspect of CF. Standard test procedures were used for
+the assessment in all tests. The statistical programming language R3.5.0 (with appropriate add-on
+packages) was used, and suitable codes were written for statistical computations and for graphical
+representation of data. t-test and Wilcoxon signed-rank test (WSRT) were used for determining the
+differences in the parameters for data with normal distribution and not with normal distribution,
+respectively.
+Results
+Sociodemographic data
+The participants included 18 children/adolescents of age between 8 and 18 years. The mean age was
+13.5 ± 2.46 years (mean ± standard deviation). Of 18 participants, 14 were males and 4 were female.
+General health
+At the beginning of the study, the participants had several opportunistic infections and health issues,
+namely, skin infection, eye, and ear problems, all of which were significantly reduced at the time of
+final data collection. These general health conditions are as reported by the physician during routine
+medical checkup.
+Immune parameters
+The mean CD4 cell counts significantly increased from 571.1 ± 238.0 cells/mm  before yoga to 717.4
+± 241.7 cells/mm  after yoga (p = 0.039), with typically the values at the baseline being in tune with
+that reported by an earlier study.[9] The average CD8 cell counts decreased from 1389.18 ± 572.88
+cells/mm  before yoga to 1338.82 ± 471.12 cells/mm  after yoga, which was not statistically
+significant (p = 0.477, WSRT). Mean CD4/CD8 ratio increased from 0.814 to 1.016 although the
+median difference between pre- and post-values was not statistically significant (p = 0.091; WSRT).
+The average viral load significantly reduced from 55487.5 ± 56996.4 copies/mL before yoga to 5755.4
+± 6539.3 copies/mL after yoga (p = 0.041; WSRT). Table 1 shows the summary of the immune
+parameters along with the general medical issues. Figures 1 and 2 show the distribution of CD4 and
+viral load, respectively, along with the change in the parameters case to case between pre- and post-
+yoga.
+3
+3
+3
+3
+Table 1
+General health of participants along and immune parameters
+ID
+General medical issues
+CD4
+CD4/CD8
+Viral load
+Pre
+Post
+Pre
+Post
+Pre
+Post
+Pre
+Post
+A01
+Swelling below ears
+Reduced
+346
+600↑
+0.23
+0.49↑
+77455
+310↓
+A03
+NA
+NA
+356
+952↑
+0.20
+0.57↑
+145662
+4188↓
+A04
+Skin infection
+Nil
+712
+777↑
+0.81
+0.88↑
+5676
+7029↑
+A05
+Blood from nose
+Nil
+543
+439↓
+0.29
+0.30↑
+18008
+310↓
+A06
+Liquid discharge from ear
+Reduced
+403
+397↓
+0.45
+0.39↓
+126009
+15468↓
+A12
+Skin infection, stomach pain, and tiredness
+Nil
+624
+753↑
+0.71
+0.68↑
+2567
+9153↑
+A13
+Skin infection
+Reduced
+348
+710↑
+0.12
+0.28↑
+137511
+310↓
+A14
+Tiredness due
+Nil
+829
+1081↑
+0.74
+1.01↑
+304
+7234↑
+A15
+Chest pain, mesenteric lymphadenitis, and
+skin infection
+Nil
+317
+364↑
+0.24
+0.33↑
+50461
+310↓
+A16
+Eye infection
+Reduced
+997
+911↓
+0.69
+0.54↓
+10121
+18687↑
+A22
+Skin infection and blood from nose
+Nil
+807
+907↑
+0.81
+0.83↑
+36589
+310↓
+↑=Increased compared to pre, ↓=Decreased compared to pre, NA=Not available
+Figure 1
+Change in CD4 cell counts between pre and post yoga intervention
+Figure 2
+Change in viral load between pre and post yoga intervention
+Quality-of-life parameters
+The HRQOL had an average pre score of 1439.7 ± 346.22 and an average post score of 1677.1 ±
+280.57 which was statistically significant (p = 0.013). All the four subscales indicated improvement in
+the post scores when compared to the pre scores. Of the four subscales, physical functioning subscale
+score had statistical significance (p = 0.004). Emotional, social, and school functioning scores showed
+only improvement but no statistical significance (p = 0.068, 0.123, and 0.212, respectively). The
+FRQOL of the participants showed significant improvement, with an average of 1024.3 ± 331.87
+before yoga and 1208.9 ± 344.13 after yoga (p = 0.033). All the three subscales showed an increase in
+average fatigue QOL scores, which means that the fatigue levels reduced. Of the three subscales, while
+general fatigue and cognitive fatigue scales indicated no statistical significance (p = 0.203 and 0.136,
+respectively), sleep fatigue scores indicated statistical significance (p = 0.022). Table 2 shows the
+summary of HRQOL and FRQOL results.
+Table 2
+Summary of quality-of-life results
+Pre
+Post
+P
+Count
+Mean±SD
+Count
+Mean±SD
+HRQOL
+ Physical_functioning_score
+18
+482.9±166.04
+18
+595.8↑±96.35
+0.004**
+ Emotional_functioning_score
+18
+295.1±84.36
+18
+337.5↑±79.64
+0.068
+ Social_functioning_score
+18
+363.2±87.08
+18
+406.3↑±81.6
+0.123
+ School_functioning_score
+18
+298.4±74.79
+18
+337.5↑±111.56
+0.212
+ Score_psysoc
+18
+956.8±201.23
+18
+1081.3↑±211.97
+0.04*
+ Total_HRQOL_score
+18
+1439.7±346.22
+18
+1677.1↑±280.57
+0.013*
+FRQOL
+ General fatigue
+18
+417.4±108.05
+18
+458.3↑±105.37
+0.203
+ School fatigue score
+18
+301.4±125.87
+18
+392.2↑±137.68
+0.022*
+ Cognitive fatigue
+18
+305.6±155.13
+18
+358.3↑±150.24
+0.136
+ Total_FRQOL_score
+18
+1024.3±331.87
+18
+1208.9↑±344.13
+0.033*
+*p<0.05, **p < 0.01, ↑=Increased compared to pre, ↓=Decreased compared to pre, HRQOL=Health-related
+quality of life, FRQOL=Fatigue-related quality of life, SD=Standard deviation
+The CDI2-SR-T scores were calculated as per the guidelines are given in the CDI-SR user manual.[16]
+Results revealed that the average of the total CDI-T-scores significantly increased from 55.7 ± 8.42
+before yoga to 61.1 ± 10.33 after yoga (p = 0.029). Similarly, all the subscales and the sub-subscales
+showed increase in the average T-scores. This means that the depression has increased. CDI2-SR
+classifies depression status into four categories, (1) very elevated, (2) elevated, (3) high average, and
+(4) average or lower.[16] Although there is an increase in the depression of the children, it has only
+moved from higher range of lower depression state (lower depression range = 40–59) to lower range of
+high depression range (high depression range = 60–64). Both raw scores and T-scores indicated similar
+performance. Table 3 shows the summary of the results of various CDI parameters.
+Table 3
+Results of child depression inventory subscales and sub-subscales
+CDI parameter
+Pre
+Post
+P
+Count
+Mean±SD
+Count
+Mean±SD
+Raw scores
+CDI-raw-Total
+18
+10.7±4.98
+18
+14.8↑±6.63
+0.015*
+CDI-raw-EP
+18
+5.7±2.43
+18
+7.7↑±3.74
+0.039*
+CDI-raw-NMPS
+18
+5.1±2.07
+18
+5.2↑±2.85
+0.887
+CDI-raw-NSE
+18
+0.6±1.14
+18
+2.6↑±1.62
+0***
+CDI-raw-FP
+18
+5.1±3.59
+18
+7.1↑±3.67
+0.082
+CDI-raw-INE
+18
+3.2±2.29
+18
+4.9↑±2.55
+0.032*
+CDI-raw-IP
+18
+1.8±1.73
+18
+2.1↑±1.97
+0.571
+T-scores
+CDI-T-Total
+18
+55.7±8.42
+18
+61.1↑±10.33
+0.029*
+CDI-T-EP
+18
+56.1±6.66
+18
+61.4↑±9.77
+0.041*
+CDI-T-NMPS
+18
+57.3±15.11
+18
+61.2↑±11.3
+0.203
+CDI-T-NSE
+18
+46.8±6.43
+18
+58.2↑±9.22
+0***
+CDI-T-FP
+18
+54.4±11.14
+18
+56.4↑±16.44
+0.631
+CDI-T-INE
+18
+51.3±8.78
+18
+57.3↑±10.2
+0.041*
+CDI-T-IP
+18
+57.2±14.97
+18
+59.5↑±15.97
+0.632
+Open in a separate window
+*p<0.05, **p < 0.01, ***p < 0.001, ↑=Increased compared to pre, ↓=Decreased compared to pre, CDI=Child
+depression inventory, EP=Emotional problem, FP=Functional problem, NMPS=Negative mood physical
+symptoms, NSE=Negative self-esteem, INE=Ineffectiveness, IP=Interpersonal, SD=Standard deviation
+Cognitive functions
+The results of the CF tests are summarized in Table 4. It might be noted that the number of participants
+in each of the test differs due to English reading ability, especially for ST. Another reason is that some
+children did not want to take some tests.
+Table 4
+Results of cognitive tests
+Pre
+Post
+P (t-test)
+Count
+Mean±SD
+Count
+Mean±SD
+DSF
+13
+7.2±1.77
+13
+6↓±2.27
+0.059
+DSB
+13
+1.8±1.46
+13
+4.1↑±3.2
+0.009*
+DSFB
+13
+9±2.89
+13
+10.1↑±4.35
+0.266
+Stroop_WS
+9
+40.9±23.18
+9
+55.3↑±33.42
+0.051
+Stroop_CS
+9
+33.1±7.15
+9
+37.1↑±19.17
+0.574
+Stroop_CWS
+9
+25.4±8.79
+9
+21↓±11.92
+0.458
+SDMT
+15
+20.1±10.91
+16
+43.3↑±12.21
+0***
+SLCT
+15
+23.4±11.54
+17
+27.6↑±10.81
+0.01**
+*p<0.05, **p < 0.01, ***p < 0.001, ↑=Increased compared to pre, ↓=Decreased compared to pre, DSF=Digit-
+span forward, DSB=Digit-span backward, DSFB=Digit-span forward backward, Stroop_WS=Stroop Word score,
+Stroop_CS=Stroop Color score, Stroop_CWS=Stroop Color-Word score, SDMT=Symbol Digit Modalities Test,
+SLCT=Six letter cancellation test, SD=Standard deviation
+The average DSFB total score had no statistically significant improvement (p = 0.266). A split-up of
+the score indicated that DSF score decreased with no statistical significance (p = 0.059) and the DSB
+score had a statistically significant increase (p = 0.009). There was improvement in average Stroop
+Word score and Stroop Color score although not statistically significant. The average Stroop Color-
+Word score decreased but not statistically significant (p = 0.458). There was statistically significant
+increase in the scores of SDMT (p = 0) and SLCT (p = 0.01).
+Discussion
+There has been a significant improvement in the general health condition of the participants, as
+reported by the physicians during their routine checkup. Skin infection in the participants is either
+reduced or nullified in all the participants. For want of control group in the study, the improvement
+cannot be attributed purely to yoga intervention. However, sūryanamaskāra, kapālabāti (Kriya),
+bhāstrika, and nāḍiśodhana prānāyāma in the yoga intervention are known to be excellent practices for
+participants having skin diseases.[17] Hence, yoga could have played a role in improving the status.
+The major point that was demonstrated through this study is that there was improvement in the immune
+parameters. The CD4 cells are the major marker for HIV/AIDS increased by 36.63% which is also
+statistically significant. Further, at the baseline, the counts were well matching with the ones reported
+in one of the earlier studies. The CD4/CD8 ratio improved by 42.05%. The normal CD4/CD8 ratio is
+1–4[18] and the average ratio shifted from a lower value (0.814) to normal (1.016), also indicating
+improvement in the immune system. This is further supported by the decrease in the viral load by an
+average of 178.5%. Figure 3 shows the relationship between changes in viral load against changes in
+CD4. It can be observed that in most the cases where there is a massive drop in the viral load, they are
+characterized by large increase in the CD4 cell counts.
+Figure 3
+Case-wise relation between viral load and CD4 cell counts, pre and post yoga intervention
+The case-to-case observation indicated that yoga greatly helped those participants whose viral loads
+were very high. It can be noted that participants with a viral load >18,000 cells/mm  showed a more
+significant decrease in viral load (p = 0.018, WSRT). Considering such cases, the CD4 counts and
+CD4/CD8 ratio cell count increased although not significantly (p = 0.128 and p = 0.063, WSRT).
+Overall, it can be noted that yoga has helped candidates even with high levels of viral loads. Perhaps,
+yoga seems to have an attribute of addressing the crucial problems first by prioritizing. Although in this
+study, the changes in immune parameters cannot be completely attributed to yoga program since this
+study does not have a control group; another 1-month yoga intervention study reports that there is a
+significant increase in CD4 cell counts among adults against the control group.[13] Thus, this study
+shows that yoga can help to HIV positives in increasing the CD4 cells and reducing the viral load in
+children/adolescents. However, there was no change in ART status recommended by the physicians.
+In the current study, there was mixed response to CFs. SLCT showed improvement in the result.
+Normative data for SLCT on healthy school children indicate a mean score of 24.04, for the age group
+of 9–16 years.[19] In the current study, the mean scores were 23.4 and 27.6 before and after yoga,
+respectively. Thus, at the baseline, the scores were lesser than that of normal and improved to normal
+after yoga. Similarly, SDMT also showed significant improvement (p~0). DSFB test which is a test for
+EF showed a nonsignificant improvement. Stroop tasks which also require good working memory and
+is a test of EF[20] also showed show improvement but not significant. Thus, in the current study, CFs
+pertaining PP showed significant improvement while that of EF did not. With reference to DSFB test
+while the participants showed improvement in DSB, there was difficulty with DSF test. Supporting this
+phenomenon, another study on large group of children with specific learning disabilities also showed
+similar results which are attributed to more requirement of working memory in DSF than in DSB.[20]
+It is also known that depression has a negative impact on working memory,[21] thus resulting in poor
+executive function. Incidentally, in the current study, the participants' depression level also showed an
+increase. Overall, the current study could not improve EFs of the participants owing to depression
+which also could not be improved.
+3
+There was an overall significant improvement in the QOL although not statistically significant in all the
+subscales. The physical functioning score had good significance since yoga is known to improve the
+flexibility of the body. The fatigue factors assessed through the PedsQL fatigue questionnaire also
+showed improvement. Of the three subscales, sleep/rest fatigue showed significant improvement.
+However, although not statistically significant, there was improvement in general fatigue and cognitive
+fatigue subscales. Improvement in sleep/rest fatigue state is an important aspect since HIV-positive
+individuals are known to have issues in sleep.[6]
+CDI total score had increased significantly (p < 0.05). The total score comprises emotional problem
+(EP) and the functional problem (FP). Of these, the increase in EP is statistically significant (p =
+0.039), and FP is not statistically significant (p = 0.082). EP has two components, negative mood
+physical symptoms (NMPSs) and negative self-esteem (NSE). Of these, NMPS is not statistically
+significant (p = 0.887>>0.05), whereas NSE has a high statistical significance (p~0). Thus, the
+participants have statistically significant NSE. Looking into the components of NSE in the
+questionnaire, it can be understood that there is a need to address the issues such as “things not working
+out well with” (Q.2r [question 2; r indicating reverse scoring]), “blaming themselves for the faults that
+happen” (Q.7r), and “sometimes being disgusted” (Q.8). However, for the participants, “liking
+themselves” (Q.6r) was not an issue although they had an issue about “somebody else loving them”
+(Q.24r). This means that in the current study, yoga could not address these issues but largely physical
+issues.
+Similarly, FP has two sub components ineffectiveness (INE) and interpersonal (IP). The IP has no
+statistical significance (p = 0.571). However, with INE, there is a statistically significant increase (p =
+0.032). A detailed analysis of the INE reveals through the component questionnaire that there are issues
+with “making up mind to do things” (Q.12r), “having fun at school” (Q.20r), and “feeling good relative
+to others” (Q.23). It can also be noted that the participants on an average that they do have any issues
+with “having fun” (Q.4) in general (although not at school), “to make time to do school-related things”
+(Q.14r, Q.22), and “remembering things” (Q.28). Although the EF tests indicated poor working
+memory, CDI is not sensitive to tap the difference between different types of memories. However, this
+also explains the improvement in other CFs which require memory. The component on issues related to
+going to school has been positive in spite of it being a component of INE which had overall negative
+effect. This is further supported by the improvement in the school functioning subscale of PedsQL
+QOL questionnaire. Overall, the yoga program needs to be improved to address psychosocial issues,
+which can be improved with the addition of yogic games which help children involve better with others
+and proper counseling.
+Conclusions
+In the current study, the six months yoga program could significantly improve the immune parameters
+of the HIV-positive children/adolescents. CD4 and viral load significantly improved, with CD4 cells
+increasing and viral load reducing. CD4/CD8 ratio moved to a normal range. Yoga could also improve
+the QOL of the children/adolescents. In an overall sense, yoga could not improve, in the current study,
+the depression of the children/adolescents. However, several sub components of the depression showed
+improvement or were not affected. With reference to CFs, PP improved while executive functions did
+not improve owing to depression among the participants. The major issue is with mentally preparing
+the children/adolescents to think more positively about themselves. Improvement in the yoga program
+by introducing yogic games, more of prānāyāmas, and the introduction of counseling could improve
+the situation.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgment
+The authors would like to thank research volunteers who participated in data collection.
+References
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subfolder_0/Effect of a Residential Integrated Yoga Program on Blood Glucose Levels, Physiological Variables, and Anti-Diabetic Medication Score of Patients wi.txt

@@ -0,0 +1,383 @@
+© 2018 The Author(s)
+Published by S. Karger AG, Basel
+Original Paper
+Integr Med Int 2017;4:181–186
+Effect of a Residential Integrated Yoga 
+Program on Blood Glucose Levels, 
+Physiological Variables, and Anti-Diabetic 
+Medication Score of Patients with Type 2 
+Diabetes Mellitus: A Retrospective Study
+Amit Singh a    Padmini Tekur a    Kashinath Metri a    Hemant Bhargav b    
+Nagarathna Raghuram a    Nagendra Hongasandra Ramarao a    
+a
+ Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA University), Bengaluru, India; 
+b
+ National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
+Keywords
+Type 2 diabetes · Integrated yoga · Blood sugar levels · Medication score · Lifestyle 
+Abstract
+Background: Type 2 diabetes mellitus (T2DM) is a highly prevalent disease characterized by 
+chronic hyperglycemia. Yoga is a form of mind-body intervention shown to have a positive 
+impact on several health conditions in both healthy and diseased patients. The present study 
+is intended to assess the effects of the Residential Integrated Yoga Program (RIYP) on blood 
+glucose levels in patients with T2DM. Material and Methods: Data of 598 (186 females) T2DM 
+patients from a holistic health center in Bengaluru, India, who attended a 15-day RIYP between 
+January 2013 and December 2015 was obtained retrospectively. Average age of the partici­
+pants was 56.45 ± 11.02 years. All subjects underwent a 15-day RIYP which involved yoga-
+based lifestyle changes with components of regulated sleep, balanced diet, asanas, pranaya­
+ma, relaxation techniques, meditations, yogic cleaning procedures, and tuning to the nature. 
+Fasting and post-prandial blood sugar, medication score, symptom score, systolic and diastol­
+ic blood pressure, pulse rate, and respiratory rate were assessed before and after intervention. 
+Result: There was a significant decrease in fasting (p < 0.001) and post-prandial blood sugar 
+levels (p < 0.001) along with a significant reduction in medication and symptom scores after 
+15 days of RIYP compared to baseline. Conclusion: The present study indicates that 2 weeks 
+of a yoga-based residential program improves blood glucose levels, blood pressure, and med­
+ication score in patients with T2DM. However, further randomized controlled studies need to 
+be performed in order to confirm the present findings.
+© 2018 The Author(s)
+Published by S. Karger AG, Basel
+Received: January 26, 2018
+Accepted: February 24, 2018
+Published online: April 4, 2018
+Dr. Kashinath Metri
+SVAYSA University
+# 19 Eknath Bhavan, Gavipuram circle, K G Nagar
+Bengaluru 560019 (India)
+E-Mail kgmhetre @ gmail.com
+www.karger.com/imi
+This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Interna-
+tional License (CC BY-NC-ND) (http://www.karger.com/Services/OpenAccessLicense). Usage and distribu­
+tion for commercial purposes as well as any distribution of modified material requires written permission.
+DOI: 10.1159/000487947
+182
+Integr Med Int 2017;4:181–186
+Singh et al.: Yoga for Patients with T2DM
+www.karger.com/imi
+© 2018 The Author(s). Published by S. Karger AG, Basel
+DOI: 10.1159/000487947
+Introduction
+Type 2 diabetes mellitus (T2DM) is a common metabolic disorder characterized by chronic 
+hyperglycemia. It is a leading cause of morbidity and mortality worldwide, associated with 
+severe complications such as cardiovascular disease, cerebrovascular disease, or chronic renal 
+disease. It is projected to be the 7th leading cause of death by 2030 [1]. The worldwide preva­
+lence of T2DM was estimated to be 6.4%. In Asia, 15% of the population – or 1 in 7 adults – 
+have been reported to have either elevated fasting glucose or impaired glucose tolerance [2], 
+5–12% of these persons develop type 2 diabetes every year [3]. At present, India is the country 
+with the 2nd highest number of T2DM patients, and the figure is expected to double by 2030 
+[4]. The incidence rate of T2DM cases is progressively increasing in rural parts of India, and 
+the age at onset of T2DM is also reducing gradually [5, 6] due to unhealthy lifestyles [7].
+Conventional anti-diabetic medication therapy includes oral administration of hypogly­
+cemic agents and insulin therapy. These methods have been shown to be beneficial in the 
+initial phase of T2DM; over a period of time, however, a significant number of patient reports 
+indicate a reduced efficacy of most anti-diabetic medications. Further, these medications are 
+associated with several adverse effects including weight gain [8, 9] weakness, fatigue, lactic 
+acidosis, or diarrhea, and they may increase LDL cholesterol level. Vigorous insulin treatment 
+may also carry an increased risk of atherogenesis [10, 11].
+Yoga is a form of traditional and complementary medicine. Several scientific investiga­
+tions have shown the health-benefiting effects of yoga in various chronic health conditions 
+including T2DM [12], neuromuscular diseases [13], psychiatric illnesses [14], asthma [15], 
+hypertension [16], and coronary artery disease [17].
+Material and Methods
+From a holistic health center in Bengaluru, India, data of 598 (186 females) T2DM patients, with on 
+average 8 ± 3.4 years of history of T2DM and who attended a 15-day yoga program between January 2013 
+and December 2015, was obtained retrospectively.
+Inclusion and Exclusion Criteria
+Subjects with T2DM, within the age range of 30–60 years, who meticulously followed the routine of 
+Integrated Approach of Yoga Therapy (IAYT) for 15 days during their stay at the health center, were 
+considered for the study. Subjects were excluded from the study if they were on insulin therapy, had any 
+diabetic complications, were on antipsychotic medication or steroid medication, were long-term practi­
+tioners of any kind of yoga, or had been practicing yoga within the last year.
+All subjects underwent a 15-day Residential Integrated Yoga Program (RIYP) which involved timetable-
+based, supervised, yoga-based lifestyle changes with components of regulated sleep, yogic sattvic diet, 
+asanas, pranayama, relaxation techniques, meditations, yoga-based cleansing procedures, lectures on yoga 
+philosophy, and selfless service. All subjects were assessed before and after intervention for changes in 
+fasting blood sugar, post-prandial blood sugar, medication score, and symptom scores along with systolic and 
+diastolic blood pressure, bhramari time, pulse rate, and respiratory rate.
+Ethical Considerations
+This study was approved by the institution’s Ethics Committee of SVYASA University, Bengaluru, India.
+Intervention
+The RIYP which is based on IAYT can be understood as a holistic model, which corrects imbalances at 
+the physical, mental, and emotional level through the application of multiple components such as asanas, diet, 
+loosening exercise, breathing exercises, pranayama, cyclic medication, mind sound resonance technique, 
+devotional sessions, and yogic counseling (lectures). For details on time tables followed during the 15 days 
+of RIYP, see Table 1 and 2.
+183
+Integr Med Int 2017;4:181–186
+Singh et al.: Yoga for Patients with T2DM
+www.karger.com/imi
+© 2018 The Author(s). Published by S. Karger AG, Basel
+DOI: 10.1159/000487947
+Data Analysis
+Data was analyzed using IBM SPSS software, version 10. Paired-sample t test was applied to assess 
+changes from pre- to post-RIYP in all variables. Data was presented in the form of mean and standard devi­
+ation. Statistical change with a p value < 0.05 was considered as a significant change.
+Results
+Blood Glucose Level (Table 2)
+A significant decrease in post-prandial blood sugar (from 202.79 ± 77.29 to 192.24 ± 
+79.62; p < 0.001) as well as fasting blood sugar levels (from 156.95 ± 84.82 to 134.26 ± 51.46; 
+p < 0.001) along with a significant reduction in anti-diabetic medication (from 4.76 ± 3.30 to 
+3.88 ± 3.20; p < 0.001) and symptom score (from 156.95 ± 84.82 to 134.26 ± 51.46; p < 0.001) 
+was found after 15 days of RIYP compared to baseline.
+Table 1. Details of the special yoga technique for type 2 diabetes mellitus
+Number
+Name
+Posture
+Practices
+1
+Breathing practices (5 min)
+Standing
+Hands stretch breathing
+Sitting
+Rabbit breathing
+Tiger stretch breathing
+2
+Loosening practices
+Shitihilikarana vyayamah
+(5 min)
+Standing
+Padahastasana-Ardha chakrasana vyayama
+Trikonasana vyayama
+Kati parivartana vyayama (spinal twist)
+Sitting
+Chakki chalana
+Bhunamanasana
+Supine
+Pawanmuktasana kriya
+Prone
+Dhanurasana swing
+3
+Relaxation(5 min)
+Instant relaxation technique
+4
+Surya namaskara (5 min)
+12 steps
+5
+Asanas (10 min each)
+Standing
+Ardhakati chakrasana
+Parivrtta trikonasana
+Sitting
+Vakrasana
+Ardha matsyendrasana
+Prone
+Bhujangasana
+Dhanurasana
+Supine
+Pawanmuktasana
+Matsyasana
+Relaxation (10 min)
+Deep relaxation technique
+6
+Kriyas
+Kapalabhati, vaman dhauti (once a week)
+7
+Pranayama (10 min)
+Nadi shuddhi
+Bhramari pranayama
+Om chanting
+8
+Meditation (20 min)
+Cyclic meditation
+184
+Integr Med Int 2017;4:181–186
+Singh et al.: Yoga for Patients with T2DM
+www.karger.com/imi
+© 2018 The Author(s). Published by S. Karger AG, Basel
+DOI: 10.1159/000487947
+Physiological Variables (Table 2)
+Paired-sample t test revealed a significant decrease in systolic (from 126.81 ± 18.08 to 
+108.08 ± 24.46; p < 0.001) and diastolic blood pressure (from 74.6 ± 10.45 to 63.13 ± 31.53; 
+p < 0.001), pulse rate (from 79.63 ± 9.24 to 60.93 ± 27.79; p < 0.001), and respiratory rate 
+(from 18.28 ± 3.71 to 15.66 ± 4.38; p < 0.001).
+Discussion
+The present study showed a significant improvement in blood glucose levels, physio­
+logical variables, and anti-diabetic medication score following 15 days of RIYP in patients 
+with T2DM. This suggests a potential role of RIYP in T2DM management. Yoga-based lifestyle 
+intervention is a comprehensive intervention and consists of several physical and mental 
+practices. Yoga is also cost effective and easy to maintain, requiring little in the way of 
+equipment or professional personnel, and there is evidence indicating excellent long-term 
+adherence and benefits.
+A randomized controlled trial by Nagarathna et al. [18], in 2012, showed a significant 
+reduction in oral hypoglycemic medication requirement and LDL; and increasing HDL, blood 
+glucose, HbA1c, triglyceride, total cholesterol, and VLDL following a yoga-based lifestyle 
+modification program.
+In our study, T2DM patients stayed for 15 days during which the RIYP for diabetes was 
+imparted to them. Yoga-based lifestyle takes into consideration the 5 important factors of 
+lifestyle: (1) diet, (2) physical activity, (3) sleep, (4) habits, and (5) psychological stress. The 
+designed RIYP was developed to address each of these lifestyle factors and bring balance at 
+all the levels. Medication compliance and adherence to yoga was controlled by the medical 
+doctor and yoga therapist in charge at the section; diet was controlled as standard sattvic food 
+was provided; the location of our health home – being away from city life and amidst nature 
+– could be considered as a calming factor to combat stress.
+Many previous studies have shown beneficial effects of yoga in improving overweight, 
+blood pressure, insulin levels, triglycerides [19], fasting and post-prandial blood sugar levels, 
+and pulse rate [20, 21]. Most of the above-mentioned studies where yoga therapy was bene­
+ficial in reducing blood sugar levels involved yoga intervention of discrete yoga sessions 
+(asanas, paranayama, or both) in the usual routine (mostly for 60 min per day, 1–5 days per 
+Table 2. Changes in variables after 15 days of Residential Integrated Yoga Program (RIYP) in patients with type 2 diabetes 
+mellitus
+Variables
+Pre-RIYP value,
+mean ± SD
+Post-RIYP value,
+mean ± SD
+df
+Difference (95% CI)
+p valuea
+lower
+upper
+Pulse rate, bpm
+79.63±9.24
+60.93±27.79
+597
+86.12
+55.82
+<0.001
+Respiratory rate, bpm
+18.28±3.71
+15.66±4.38
+597
+16.839
+20.556
+<0.001
+Systolic BP, mm Hg
+126.81±18.08
+108.08±24.46
+597
+–37.371
+–30.482
+<0.001
+Diastolic BP, mm Hg
+74.6±10.45
+63.13±31.53
+597
+15.37
+20.365
+<0.001
+Medication score
+4.76±3.30
+3.88±3.20
+597
+19.313
+23.623
+<0.001
+FBS, mg/dL
+156.95±84.82
+134.26±51.46
+597
+–47.055
+–35.645
+<0.001
+PPBS, mg/dL
+202.79±77.29
+192.24±79.62
+597
+–28.974
+–16.394
+<0.001
+BP, blood pressure; df, degree of freedom; FBS, fasting blood sugar level; PPBS, post-prandial blood sugar level.
+a Paired-sample t test.
+185
+Integr Med Int 2017;4:181–186
+Singh et al.: Yoga for Patients with T2DM
+www.karger.com/imi
+© 2018 The Author(s). Published by S. Karger AG, Basel
+DOI: 10.1159/000487947
+week) and the duration of intervention ranged from 6 weeks to 6 months. In our study, we 
+observed similar effects in a much shorter period of 2 weeks. This suggests that if different 
+components of yoga (viz., asanas, pranayama, meditations, relaxations, devotional sessions, 
+study of the scriptures, and yogic counseling) are integrated together on the basis of the 
+philosophy of yoga-based lifestyle then they may act synergistically and thereby provide 
+better results than those produced by any of the components of yoga alone.
+The improvement in fasting and post-prandial blood sugar levels following IAYT may be 
+attributed to an activation of the HPA axis through a reduction in stress which is associated 
+with decreased glucose levels in T2DM. Several sessions of yoga in a day may help the patients 
+to improve their glucose level.
+Though the present retrospective study was performed on a large number of T2DM 
+subjects, the lack of a control group is a major limitation of the current study. Future studies 
+should use a control group, where subjects follow a conventional lifestyle change program in 
+a residential setup and then compare the residential conventional lifestyle change program 
+with the residential yoga-based lifestyle program (RIYP).
+Conclusion
+The present study indicates that 2 weeks of yoga-based residential program improves 
+blood glucose levels, blood pressure, and medication score in T2DM patients.
+Acknowledgement
+We are thankful to all type 2 diabetes patients who participated and all the therapist and doctors 
+involved in the therapy in this study.
+Disclosure Statement
+The authors declare no conflicts of interest.
+References
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+www.karger.com/imi
+© 2018 The Author(s). Published by S. Karger AG, Basel
+DOI: 10.1159/000487947
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subfolder_0/Effect of high-frequency yoga breathing on pulmonary functions in patients with asthma..txt

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+Letter
+Effect of high-frequency yoga breathing on pulmonary functions in
+patients with asthma
+A randomized clinical trial
+Bronchial asthma is one of the most common respiratory disorders
+with significant morbidity and mortality. Patients with asthma
+experience declined lung function. Among patients with asthma,
+forced expiratory volume in 1 second (FEV1), forced vital capacity
+(FVC), and FEV1/FVC ratio were found to be lower than in age- and
+height-matched healthy individuals.1 To arrest the decline in
+ventilatory function is one of the major objectives of management
+of asthma.
+Yoga has been used to manage asthma in several clinical trials. A
+recent Cochrane review found yoga useful in alleviating symptoms
+of asthma and improving the quality of life.2 However, there is lack
+of empirical studies on the effect of specific yoga practices on lung
+functions in patients with asthma.
+Kapalabhati is a technique described in the traditional texts of
+yoga indicated for phlegm-related diseases, such as bronchial
+asthma and other respiratory disorders.3 The practice of kapa-
+labhati has been found to enhance pulmonary functions.4 It has also
+been used in combination with other yoga practices for asthma in
+most earlier clinical trials.5,6 We evaluated the immediate effects of
+kapalabhati on lung function among patients with mild and mod-
+erate asthma, comparing it with deep breathing with breath
+awareness.
+This was a single-center, randomized, prospective, controlled
+study performed at an inpatient yoga and naturopathy facility from
+South India. After screening 78 patients with clinician-diagnosed
+asthma, 60 patients were recruited for the study. A total of 35
+men and 25 women, with the mean (SD) age of 31.5 (8.23) years,
+were included in the study. We included patients from the age
+group of 20 to 50 years to restrict the study population to adults.
+Patients with severe asthma (predicted FEV1 
60%) and any other
+respiratory disorders that influence pulmonary function or a prior
+history of abdominal or thoracic surgery were excluded from the
+study. Individuals with a history of tobacco smoking were excluded
+because smoking exacerbates symptoms and restrict the lung
+functions. The demographic data of the subjects are given in Table 1.
+All the patients were trained in the practice of kapalabhati for a
+period of 10 min/d for 1 week before they were randomly assigned
+to different groups.
+The patients were randomly assigned to experimental (18 men
+and 12 women) and control (17 men and 13 women) groups
+using random numbers generated by a computer-based program
+(www.randomizer.org) with a 1:1 ratio. The protocol of the study
+was reviewed and approved by the institutional ethics committee
+of the SDM College of Naturopathy and Yogic Sciences, Ujire,
+India. Informed written consent was obtained from each patient
+before the commencement of the intervention.
+The practice of kapalabhati included breathing at 1 Hz in which
+the exhalations are kept as an intentionally active process. The
+participants were asked to sit in cross-legged position, keeping the
+back erect. On the assessment day, the experimental group practiced
+kapalabhati for10 minutes. The practicewas repeated, giving abreak
+of half a minute between 2 bouts of practice. The control group
+practiced deep breathing at 6 breaths per minute for the same
+duration, maintaining awareness on the nostrils. The assessments
+were performed before and immediately after the practice.
+On the day of assessment, the patients were asked to evacuate
+the bowels and bladder and restrain from consuming food for at
+least
+2
+hours before
+recording.
+The
+participants
+were also
+restrained from the use of all bronchodilators for at least 24 hrs
+before assessment. Spirometry was performed using the BIOPAC
+MP36 system (www.biopac.com). Three recordings were averaged
+to obtain the values of FEV1 (liters), FVC (liters), and FEV1/FEC ratio.
+The data were analyzed using SPSS statistical software, version
+16 (SPSS Inc, Chicago, Illinois). The means of preintervention and
+postintervention values in each group were analyzed using the
+paired-samples t test, and the between-group comparisons for the
+postintervention
+values
+were
+made
+using
+the
+independent-
+samples t test. The data were found to be normally distributed
+(Shapiro-Wilk
+test).
+The
+within-group
+analyses
+revealed
+a
+significant increase in FEV1 (1.91 [0.31] to 2.12 [0.35]; t ¼ 8.149; P
+< .001), FVC (2.62 [0.68] to 2.70 [0.57]; t ¼ 2.438; P < .05) and
+FEV1/FVC ratio (0.75 [0.12] to 0.80 [0.10]; t ¼ 4.232; P < .001) in
+the kapalabhati group. None of the variables had a significant
+change in the deep breathing group. The between-group analyses
+revealed a significant difference between the postintervention
+values of FEV1 (t ¼ 2.319, P < .05) and FEV1/FVC ratio (t ¼ 2.173,
+P < .05). The results are summarized in Table 2.
+Table 1
+Demographic Data of the Study Participants
+Demographic
+Experimental group
+(n ¼ 30)
+Control group
+(n ¼ 30)
+Total
+(N ¼ 60)
+Male/female
+18/12
+17/13
+35/25
+Age, mean (SD), y
+31.8 (8.47)
+31.1 (8.11)
+31.5 (8.23)
+Height, mean (SD), cm
+165.67 (9.51)
+165.83 (10.35)
+166.33 (10.66)
+Weight, mean (SD), kg
+67.53 (9.32)
+69.57 (9.27)
+68.55 (9.28)
+BMI, mean (SD)
+24.52 (1.86)
+25.21 (1.53)
+24.87 (1.73)
+Predicted FEV1 at baseline,
+mean (SD), %
+66.86 (6.74)
+66.21 (6.24)
+66.53 (6.45)
+Abbreviations: BMI, body mass index (a measure of the weight in kilograms divided
+by square of height in meters); FEV1, forced expiratory volume in 1 second.
+Disclosures: Authors have nothing to disclose.
+Contents lists available at ScienceDirect
+http://dx.doi.org/10.1016/j.anai.2016.08.009
+1081-1206/
 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
+Ann Allergy Asthma Immunol xxx (2016) 1e2
+The current study indicates a significant increase in lung func-
+tions immediately after the 10-minute practice of kapalabhati
+among the patients with bronchial asthma. There were no signifi-
+cant changes observed in the deep breathing group. In addition, a
+significant difference was observed between the 2 groups in the
+FEV1 and FEV1/FVC ratio after the intervention. A mean increase of
+approximately 200 mL in FEV1 was observed in a single session of
+kapalabhati for just 10 minutes. During the trial, none of the
+patients reported any untoward effects attributable to the practice.
+They found the practice comfortable and reported fewer episodes
+during the training phase, although we did not systematically
+record the same. Thus, this preliminary trial found the practice of
+kapalabhati
+an
+easy-to-perform
+and
+cost-effective
+means
+of
+enhancing lung function.
+Inconsistent results are reported on the effects of breathing
+practices in patients with asthma.7 To the best of our knowledge,
+this was the first systematic attempt to examine the immediate
+effects of kapalabhati in patient with asthma. The results concur
+with the earlier yoga studies reporting beneficial effects of yoga
+practices.2
+Parasympathetic dominance plays an important role in the
+pathophysiology of bronchial asthma.8,9 Earlier studies have indi-
+cated sympathetic activation after the practice of kapalabhati.10,11
+One of the postulated mechanisms of action for the observed
+effects in the study could possibly be immediate sympathetic
+activation after the practice of kapalabhati. Future trials may
+include measures of autonomic functions to understand whether
+sympathetic activation is the background mechanism.
+The practice of yoga breathing may also increase the lungs
+capacity and decrease the airway resistance. Forceful expiration, as
+practiced in kapalabhati, may lead to efficient use of the intercostal
+and diaphragmatic muscles, leading to better lung functions. The
+part of
+kapalabhati
+that involves
+isometric
+contraction
+and
+expansion of abdominal and intercostal muscles may also improve
+the strength of the intercostal muscles and thus lead to increased
+FVC and FEV1. We speculate this increase in FEV1 will lead to
+a
+transient
+increase
+in
+the
+muscle
+tone
+immediately after
+kapalabhati. The increase in FVC is suggestive of a probable role of
+kapalabhati in enhancing the oxygen-carrying capacity of the red
+blood cells and overall respiratory muscle endurance.
+Although
+this
+study
+found
+significant
+improvements
+in
+lung functions immediately after the practice of kapalabhati, the
+long-term effect of the practice in the patients remains to be esti-
+mated. There is also a need for further evaluation of the effects of the
+practice on the overall functional status in patients with asthma.
+Hence, we conclude that kapalabhati might be an effective
+intervention to improve pulmonary function among patients with
+bronchial asthma. The practice of kapalabhati, being simple and
+cost-effective, can be adapted easily by the patients. Further clinical
+trials to estimate the long-term effects and underlying mechanisms
+of effect of kapalabhati on pulmonary function are warranted.
+Puneeth Raghavendra, MD*,y
+Prashanth Shetty, PhDy
+Shivaprasad Shetty, MScy
+N.K. Manjunath, PhD*
+Apar Avinash Saoji, PhD*
+*Swami Vivekananda Yoga Anusandhana Samsthana
+Bengaluru, India
+ySri Dharmasthala Manjunatheshwara College of Naturopathy and
+Yogic Science
+Ujire, India
+[email protected]
+References
+[1] Peat JK, Woolcock AJ, Cullen K. Rate of decline of lung function in subjects
+with asthma. Eur J Respir Dis. 1987;70:171e179.
+[2] Yang Z-Y, Zhong H-B, Mao C, et al. Yoga for asthma. Cochrane Database Syst
+Rev. 2016;4:CD010346.
+[3] Muktibodhananda S. Hatha Yoga Pradipika: Light on Hatha Yoga. 2nd ed. Bihar,
+India: Yoga Publication Trust; 2002.
+[4] Dinesh T, Gaur G, Sharma V, Madanmohan T, Harichandra Kumar K,
+Bhavanani A. Comparative effect of 12 weeks of slow and fast pranayama
+training on pulmonary function in young, healthy volunteers: a randomized
+controlled trial. Int J Yoga. 2015;8:22e26.
+[5] Sabina AB, Williams A, Wall HK, Bansal S, Chupp G, Katz DL. Yoga intervention
+for adults with mild-to-moderate asthma: a pilot study. Ann Allergy Asthma
+Immunol. 2005;94:543e548.
+[6] Nagarathna R, Nagendra HR. Yoga for bronchial asthma: a controlled study. Br
+Med J (Clin Res Ed). 1985;291:1077e1079.
+[7] Freitas
+DA,
+Holloway
+EA,
+Bruno
+SS,
+Chaves
+GSS,
+Fregonezi
+GAF,
+Mendonça KPP. Breathing exercises for adults with asthma. Cochrane Data-
+base Syst Rev. 2013;1:CD001277.
+[8] Kallenbach JM, Webster T, Dowdeswell R, Reinach SG, Millar RNS, Zwi S.
+Reflex heart rate control in asthma: evidence of parasympathetic overactivity.
+Chest. 1985;87:644e648.
+[9] Morrison JF, Pearson SB, Dean HG. Parasympathetic nervous system in
+nocturnal asthma. Br Med J (Clin Res Ed). 1988;296:1427e1429.
+[10] Raghuraj P, Ramakrishnan AG, Nagendra HR, Telles S. Effect of two selected
+yogic breathing techniques on heart rate variability. Indian J Physiol Phar-
+macol. 1998;42:467e472.
+[11] Telles S, Singh N, Balkrishna A. Heart rate variability changes during high
+frequency yoga breathing and breath awareness. Biopsychosoc Med. 2011;
+13:4.
+Table 2
+Preintervention and Postintervention Effects of Kapalabhati and Deep Breathing on
+Pulmonary Functiona
+Variable
+Kapalabhati
+Deep breathing
+Pre
+Post
+t
+Pre
+Post
+t
+FEV1, Lb
+1.91 (0.31)
+2.12 (0.35)c
+8.149
+1.89 (0.31)
+1.91 (0.37)
+0.474
+FVC, L
+2.62 (0.68)
+2.70 (0.57)d
+2.438
+2.589 (0.74)
+2.59 (0.62)
+0.902
+FEV1/FVCb
+0.75 (0.12)
+0.80 (0.10)c
+4.232
+0.76 (0.14)
+0.75 (0.08)
+0.309
+aData are presented as mean (SD).
+bP < .05 (independent-samples t test).
+cP < .05 (paired-samples t test).
+dP < .001 (paired-samples t test).
+Letter / Ann Allergy Asthma Immunol xxx (2016) 1e2
+2

subfolder_0/Effect of integrated Yoga and Physical therapy on audiovisual reaction time, anxiety and depression in patients with chronic multiple sclerosis.txt

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+For Review Only
+ 
+ 
+ 
+ 
+ 
+ 
+EFFECT OF INTEGRATED YOGA AND PHYSICAL THERAPY ON 
+AUDIO-VISUAL REACTION TIME, ANXIETY AND 
+DEPRESSION IN PATIENTS WITH CHRONIC MULTIPLE 
+SCLEROSIS: A PILOT STUDY 
+ 
+ 
+Journal: Journal of Complementary and Integrative Medicine 
+Manuscript ID Draft 
+Manuscript Type: Short communication 
+Date Submitted by the Author: n/a 
+Complete List of Authors: Chobe, Shivaji ; S-VYASA Yoga University, School of Yoga and Life sciences 
+Bhargav, Hemant; S-VYASA Yoga University, School of Yoga and Life 
+Sciences 
+Nagarathna, Dr. Raghuram; Swami Vivekananda Yoga Anusandhana 
+Samsthana  
+Garner , Christoph; KWA-Klinik für Neurologische und Geriatrische 
+Rehabilitation Stift Rottal, Neurology 
+Classifications: Multiple Sclerosis, Integrated Yoga, Physical Therapy, Reaction Time, 
+Psychology 
+Keywords: Multiple Sclerosis, Integrated Yoga, Physical therapy, Reaction Time, 
+Psychology 
+  
+ 
+ 
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+For Review Only
+ 
+Title of the article: EFFECT OF INTEGRATED YOGA AND PHYSICAL THERAPY ON 
+AUDIO-VISUAL REACTION TIME, ANXIETY AND DEPRESSION IN PATIENTS 
+WITH CHRONIC MULTIPLE SCLEROSIS: A PILOT STUDY 
+1. Names of the authors (including surnames) and qualifications, institutional affiliations: 
+1. Chobe Shivaji, M.D., Lecturer, School of Yoga and Life Sciences, S-VYASA 
+Yoga University, Bangalore-560019. 
+2. Bhargav Hemant, M.D., Assistant Professor, School of Yoga and Life 
+Sciences, S-VYASA Yoga University, Bangalore-560019. 
+3. Raghuram Nagarathna, M.D, FRCP., D.Sc.,  Director, Arogyadhama Health 
+Center, S-VYASA Yoga University, Bangalore-560019. 
+4. Garner Christoph, M.D., Consultant Neurologist, KWA-Klinik für 
+Neurologische und Geriatrische Rehabilitation Stift Rottal, Bad Griesbach, 
+Germany. 
+2. The name of the department(s) and institution(s) to which the work should be attributed: 
+1. School of Yoga and Life Sciences, Arogyadhama, S-VYASA Yoga University, 
+Bangalore-560019. 
+2. KWA-Klinik für Neurologische und Geriatrische Rehabilitation Stift Rottal 
+Bad Griesbach, Germany. 
+3. The name, address, phone numbers, facsimile numbers and e-mail address of the 
+contributor responsible for correspondence about the manuscript; 
+Dr Shivaji Chobe, 
+Mob: 09483319561 
+Page 1 of 28
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+For Review Only
+Email: [email protected] 
+Address: No.19, Eknath Bhavan, Gavipuram circle, Kempegowda Nagar, 
+Bangalore-560019. 
+4. The total number of pages, total number of photographs and word counts separately for 
+abstract and for the text (excluding the references and abstract): 
+Total number of pages: 12 
+Total number of tables: 3 
+Total number of figures: 1 
+Abstract word count: 291 
+Text word count: 3,690 
+5. Information on prior or duplicate publication or submission elsewhere of any part of the 
+work/study: Not submitted anywhere else. 
+6. A statement of financial or other relationships that might lead to a conflict of interest:We 
+declare that there is no conflict of interest. 
+ 
+Page 2 of 28
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+ 
+ 
+EFFECT OF INTEGRATED YOGA AND PHYSICAL THERAPY ON AUDIO-
+VISUAL REACTION TIME, ANXIETY AND DEPRESSION IN PATIENTS WITH 
+CHRONIC MULTIPLE SCLEROSIS: A PILOT STUDY 
+ABSTRACT  
+Background: Multiple Sclerosis is characterized by a significant deterioration in auditory and 
+visual reaction times along with associated depression and anxiety. Yoga and physical 
+therapy interventions have been found to enhance recovery from these problems in various 
+neuro-psychiatric illnesses, but sufficient evidence is lacking in chronic MS population. 
+Aim: To assess the effect of Integrated Yoga and Physical therapy on audio-visual reaction 
+times, depression and anxiety in patients suffering from chronic multiple sclerosis. 
+Material and Methods: From a Neuro-rehabilitation center in Germany, eleven patients (6 
+females) suffering from multiple sclerosis for 19±7.4 years were recruited. Subjects were in 
+the age range of 55.45±10.02 years and had Extended Disability Status Scores (EDSS) below 
+7. All the subjects received mind-body intervention of Integrated Yoga and Physical therapy 
+(IYP) for three weeks. The intervention was given in a residential setup. Patients followed a 
+routine involving yogic physical postures, pranayama and meditations along with various 
+physical therapy techniques for 21 days, five days a week, 5 hours per day. They were 
+assessed before and after intervention for changes in audio-visual reaction times (using Brain 
+Fit model No OT 400), anxiety and depression (using HADS). Data was analysed using 
+paired samples  test. 
+Result: There was significant improvement in visual reaction time (p = 0.01), depression (p = 
+0.04) and anxiety (p = 0.02) scores at the end of 3 weeks as compared to the baseline. 
+Auditory reaction time showed reduction with borderline statistical significance (p = 0.058). 
+Conclusion: This pilot project suggests utility of IYP intervntion for improving audio-visual 
+reaction times and psychological health in chronic MS patients. In future, randomized 
+controlled trials with larger sample size should be performed to confirm these findings. 
+Key words: Multiple sclerosis, yoga, physical therapy, reaction time, anxiety, depression. 
+Page 3 of 28
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+ 
+ 
+INTRODUCTION 
+Multiple sclerosis (MS) is a chronic inflammatory and autoimmune neuro-degenerative disorder 
+with emotional, cognitive, and physical consequences. Patients may display a diverse array of 
+symptochronic MS including impaired mobility, sensory disturbance, chronic pain, fatigue, 
+bladder and bowel dysfunction, depression, and cognitive impairment. Patients report high levels 
+of stress, independent of physical disability [1-3]. 
+Patients with chronic MS have a defect in aspects of central auditory processing with 
+poorer hearing thresholds and increased auditory reaction times [4]. chronic MS patients have 
+been shown to have abnormalities in auditory evoked potentials indicating dysfunction of 
+different regions of the central auditory nervous system [5]. Optic pathway involvement 
+in multiple sclerosis is frequently the initial sign in the disease process [6]. Retinal nerve fiber 
+layer (RNFL) thickness is reduced in chronic MS cases and is associated with reduced visual 
+reaction times [7]. Visual impairment from axonal degeneration is increasingly recognized as 
+correlate of disability in chronic MS [8-10]. For treating chronic MS several pharmacological 
+drugs are available. Use of these drugs is limited due to their side effects a n d  benefits are 
+also not satisfactory [11]. 
+Stress is a potential trigger of disease activity in patients with relapsing-remitting 
+chronic MS. There are a few studies that point to the impact of stress on chronic MS. 
+Psychological stress has been implicated in the onset and exacerbations of several 
+autoimmune diseases including chronic MS [12]. Anecdotal accounts suggest 
+that 
+significant stressful life events frequently trigger the development of chronic MS 
+symptochronic MS. Psychological stress has been shown to precede both the onset and 
+recurrence of chronic MS symptochronic MS in 70-80% of cases, using standardized 
+assessment of life stressors measures[13]. More recently, stressful life events have been 
+shown to predict the development of new lesions and relapses in chronic MS [14]. Meta-
+analyses concerning stress and chronic MS have concluded that there was a significantly 
+increased risk of exacerbation associated with stressful life events [15, 16]. The risk of 
+developing stress-related disorders like anxiety and depression is also high in chronic MS 
+patients with lifetime prevalence of 25% and 34–50% for anxiety and depression 
+respectively[17-20].  
+Page 4 of 28
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+ 
+ 
+ 
+Yoga has gained popularity in health care systechronic MS as a mind-body intervention to 
+alleviate both mental and physical problechronic MS [21]. Yoga has already been proven to 
+incur various health benefits in chronic MS patients [22].Yoga has been found useful in 
+psychological disturbances such as anxiety and depression. It can be a viable therapeutic option 
+for reducing state anxiety [23]. Yoga could be an ancillary treatment option for patients with 
+depressive disorders and individuals with elevated levels of depression [24-25]. 
+Yoga therapy has also been found useful in improving visual and auditory functions in patients 
+suffering from various chronic stress-related disorders. Certain yoga practices (OM meditation 
+and ujjayi pränäyäma) facilitate processing of auditory information at mesencephalic and 
+diencephalic levels [26-27]. Yoga practices improve visual perception as well [28-29] There are 
+studies showing that after practicing Yoga the auditory and visual reaction time decreased 
+significantly [30-32]. Slow and fast pranayama were particularly useful in improving auditory 
+and visual reaction times [33]. Yoga based intervention is beneficial for improving several 
+domains of cognitive function including processing speed, executive function, visual memory 
+and attention of the elderly [34]. 
+ 
+Yoga therapy is superior to physical exercises because of its holistic approach.  Yoga has been  
+proven useful in treating auto-immune diseases like Rheumatoid arthritis and 
+other 
+psychosomatic ailments. Yoga techniques such as äsanäs (postures), prāṇāyāma: (voluntary, 
+regulated breathing through nostrils), yoga nidrä (guided relaxation with imagery) and 
+meditation promote physical wellbeing and mental calmness. Various studies have shown its 
+effects in stress-related disorders, respiratory allergies, depression, anxiety neurosis, diabetes, 
+coronary heart disease, and rehabilitation of disabled [35]. Also, studies have shown that yoga 
+will help in improving the quality of life, disability limitation, and rehabilitation of people with 
+chronic diseases [36]. Different kinds of Yoga techniques intervention have shown positive 
+outcomes in chronic MS population. Yoga has been found useful in decreasing pain, fatigue [37-
+38], bladder dysfunction [39], improving balance, strength, peak expiratory flow [40], cognition 
+[41], anxiety and depression [42] and quality of life [43-44] of chronic MS Patients.  
+ 
+Page 5 of 28
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+ 
+Physical therapy (PT) is another mode of treatment found effective in managing certain aspects 
+of chronic MS disease. PT intervention includes therapy using mechanical force and movement 
+which are aimed at alleviating impairments and promoting mobility, function, and quality of life 
+of patients. A course of physical therapy is associated with improved mobility, subjective 
+wellbeing, and improved mood in chronic multiple sclerosis [45]. Evidence supports that 
+exercise training is associated with improvement in walking mobility among individuals [46]. 
+Physical rehabilitation resulted in an improvement in disability and had a positive impact on 
+mental components of health-related quality of life perception at 3 and 9 weeks [47]. Neuro-
+rehabilitation has been shown to ease fatigue, bladder and bowel disturbances, sexual 
+dysfunction, cognitive and affective disorders, and spasticity symptochronic MS by improving 
+self-performance and independence [48].  
+ 
+Thus, present study was planned as an preliminary pilot attempt to assess the effect of intergrated 
+yoga and physical therapy (IYP) on auditory and visual reaction times and psychological 
+problechronic MS of anxiety and depression in chronic MS patients. 
+ 
+AIM  
+To assess the effect of IYP intervention on autonomic balance, auditory and visual functions and 
+psychological symptoms in chronic MS patients. 
+OBJECTIVES  
+1) 
+To assess the effect of IYP intervention on auditory and visual functions in patients 
+suffering from chronic MS. 
+2) 
+To assess the effect of IYP intervention on anxiety and depression in chronic MS 
+patients. 
+ 
+ 
+ 
+Page 6 of 28
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+ 
+METHODOLOGY 
+Subjects  
+From a Neuro-rehabilitation center in Germany, eleven patients (6 females) suffering from 
+multiple sclerosis for 19±7.4 years were recruited. Subjects were in the age range of 55.45±10.02 
+years and had Extended Disability Status Scores (EDSS) below 7. Inclusion criteria for the study 
+were: 1) Those who satisfied Mc Donald’s diagnostic criteria for chronic MS [49]; 2) Those 
+suffering from chronic MS (MS for more than 5 years) with EDSS<or=7; 3) Those who gave 
+written consent to participate in the study; 4) Those who had not been exposed to regular (for at 
+least a month in last 1 year) Yoga therapy practices before and 5) Those using chronic MS 
+disease modifying drugs. Whereas those who were not capable of following yoga-instructions 
+mentally and physically; those suffering from transmittable infections, advanced  dementia, 
+severe heart insuffiency (EF less than 35%) or on Artificial cardiac pace maker and COPD and 
+those with h/o substance abuse, any other organic brain illness or severe psychological morbidity 
+except anxiety and depression were excluded from the study.  
+Single group pre-post design was followed. All the subjects received mind-body intervention of 
+IYP for three weeks. They were assessed before and after intervention for changes in audio-
+visual reaction times (using Brain Fit model No OT 400), anxiety and depression (using HADS). 
+Data was analysed using paired samples  test. Signed, informed consent was obtained from the 
+subjects to participate in the study after explanations of protocol of the study. The approval from 
+the Institutional Review Board was taken. 
+INTERVENTION  
+The intervention was given in a residential setup. Patients followed a routine involving yogic 
+physical postures, pranayama and meditations along with physical therapy rehabilitation for 21 
+days, five days a week, 5 hours per day. The intervention included yoga and physical therapy 
+consisting of regular integrated yoga program (asanas, pranayama, relaxation techniques and 
+meditaions) given 5 days a week for 1 hour  daily and Physiotherapy for 5 days a week, 3 hour 
+daily. Total intervention was given for 20 days. Data was taken on day 1 and day 21.  
+ 
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+Integrated Approach of Yoga Therapy Module for chronic MS 
+Based on our 20 years of experience in dealing with chronic MS patients the following module 
+of IAYT was considered most useful (Table 1). Hence used for the study. Yoga therapy 
+techniques correct the problem from the most fundamental level. The corrections are sought 
+from the innermost causal layer of our existence (Ānandamaya kośa or the soul or the master of 
+the system). A total correction of the bodily disturbances is brought about by correcting 
+the disturbances at the emotional, psychological and the vital energy levels. The integrated 
+approach uses several techniques with a unique aim of reaching a state of silence or calmness 
+of mind or deep relaxation and rest. The special yoga module was designed by yoga 
+professionals of S-VYASA using basic principles of ancient yoga science and comprised the 
+following practices  (The daily routine included one hour of group yoga practice); see Table 
+1 [50-51]:  
+Loosening and strengthening exercises: These are Yogic loosening practices (sukshma 
+vyayamas) which help to stretch and loosen the body parts. This practice is done with 
+synchronising body movements and breathing. 
+ 
+Asanas: Yogasanas are the particular postures of the body. It includes stretching the body and 
+maininting the posture as per the capacity of  individual or for a given duration of time with 
+awareness of breath and body.  
+ 
+ 
+Kriya: 
+According 
+to 
+ancient 
+scriptures, 
+Kriyas are the 
+cleansing 
+techniques. 
+Kapalabhati, a kriya stimulates brain cells and gives it the deep rest. Kapalabhati Kriya was 
+given to the patients once a day for 5 minutes. 
+ 
+Pranayama: Pranayama is a voluntary regulated breathing while the mind is directed to the 
+flow of breath. A cycle of the slow type Pranayama  involves the phases of inhalation and 
+exhalation. There are different kinds of Pranayama which vary according to the durations of 
+the phases in the breathing cycles and the nostrils used. Yogic breathing practices were 
+included to bring about a slow rhythmic breathing pattern to reduce the breath rate with 
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+ 
+internal awareness of the touch of the flow of air through the air passages, which is an 
+effective way to get mastery over the mind (Dr. H. R. Nagendra, 2000). Practice of Pranayama 
+promotes autonomic balance through mastery over the mind. Nadishuddi is a widely 
+practiced pranayama [50-51] 
+ 
+Relaxation techniques: It begins by slowly sliding down to shavasana with the support of the 
+elbows. Legs, hands are kept apart with palms facing the roof. The whole body is allowed to 
+collapse on the ground and part by part each portion of the body is relaxed from toes to head.  
+ 
+ 
+Counseling: Yogic concepts of health and disease, role of mind in the development  of chronic 
+MS and healing property of mind are discussed.These sessions are aimed to understand the 
+need for life style change, and prevent the relapses by yogic self-management of psychosocial 
+stresses. 
+Physical Therapy for Multiple Sclerosis 
+Physical therapy intervention included therapies using mechanical force and movement aimed 
+towards remediation of impairments and promoting mobility, function, and quality of life. 
+Physical Therapies were given 5 days a week for 3 hours/day. Total intervention was given for 
+20 days.  Table 2 describes the physical therapy module. The program followed was as follows: 
+Active and passive movements using devices:  Movement trainer helps to move the arms and legs 
+slowly. As per the muscle strength, patients selected either passive, motor-assisted or active 
+resistive training. The movements are smoothly controlled, as like bicycling. Depending on the 
+model, we can train patients on  a chair, on a wheelchair or even in supine position from the bed. 
+It optimizes the motor assistance as per the individual need.  
+Galileo vibration therapy [52]:  It is based on the use of a device called “Galileo XS”. The 
+device produces a large number of vibrations, it help to improve co-ordination of movements. 
+This method has been used successful in orthopedic patients and neurological patients. It 
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+improves muscle tone. Vibration therapy utilizes stretch reflexes, directly stimulate nervous 
+system. Due to this communication between Muscles and nervous system rapidly improved.  
+Giger therapy: By lying on back Giger MD enables the patient to move his limbs in a safe and 
+painless way. Though limbs are paralyzed or have reduced function after stroke or due to chronic 
+MS. If coordination and range of movement are reduced due to spasticity or immobilization, Bu 
+using bandages and belts the therapist will be able to place the patients’ arms and legs in the 
+correct position. Giger MD helps in improving motor function and co-ordination. Also, gentle 
+rotation of the arms and legs may also affect the trunk and thus relieve pain in the joints and the 
+spine. 
+Ergometer:   It is an exercising machine which measures the work performed by exercising. It is 
+an instrument for measuring the amount of work done by body muscles and also used for to 
+increase the power of muscles. 
+Physiotherapy [53]: It builds on all traditional approaches, Using different manual therapy 
+techniques, several forms of electrotherapy, equipment-assisted therapy, therapeutic climbing, 
+massages etc. It helps to reduce balance problems, fatigue, weakness.   
+Matrix rhythm therapy[54]: It may be applied after operations and in rehabilitation. It helps to 
+decrease pain and improves symptoms of muscle and skeletal diseases. It uses oscillations to 
+produce resonance in the skeletal muscles. The oscillations are generated by a device are applied 
+to muscle fibres in specific therapeutic position. When matrix rhythm therapy is combined with 
+physiotherapy, it stimulates tight, spastic or even paralysed muscles to improve mobility of limb 
+and trunk functions and also provide targeted pain relief. 
+ASSESSMENTS  
+ 
+Audio-Visual reaction time  
+Audio-visual reaction time was measured using Device Brain-Fit Model No OT 4000 [55]. The 
+Brain-Fit is a device that can be used with children, juveniles and adults of all ages. For 
+Assessment of Temporal order threshold or as a training tool. The Temporal Order Threshold is 
+the smallest possible separation in the time between two stimuli necessary to decide which of the 
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+two stimuli (the one on the left or the one on the right) was first.  For stimuli the Brain-Fit uses 
+either auditory clicks via headphones, or visually, two red light flashes via red LEDs built into 
+the front of the device.  
+The Person response to the stimuli is by pressing either Left or Right answer button.  Each press 
+of an answer button will trigger the next stimulus pair. It is important to impress upon the Client 
+that well considered, planned responses are required – rather than immediate reactions to the 
+stimuli. They will have one minute to decide on their response before the Brain-Fit switches off 
+automatically So there is time to ‘think before pressing’. 
+ 
+Anxiety and Depression 
+Hospital Anxiety and Depression Scale (HADS)[56]: The HADS is a fourteen item scale. Seven 
+of the items relate to anxiety and seven relate to depression. It is commonly used to determine 
+the levels of anxiety and depression that a patient is experiencing. 
+DATA COLLECTION 
+Data was taken at the same time of the day in the evening on an empty stomach on the first day 
+and day 21. First day orientation and training about Brain Fit device was given to the patient and 
+then next day pre-data collection was done after satisfactory performance. Audio-visual reaction 
+time assessments using Brain fit device  and depression and anxiety assessments using Hospital 
+Anxiety and depression scale (German Version) were 1st and 21st day. One trained psychologist 
+assisted in data collection. 
+ DATA ANALYSIS 
+The Shapiro-Wilk test  used to assess the normality of all data.  Depending on the distribution of 
+data, parametric or non-parametric tests will be used to analyse the data. 
+ 
+ 
+ 
+ 
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+RESULTS  
+Figure 1 describes the study profile of the study. Table 3 shows the comparison of variables 
+before and after the intervention. It was observed that there was significant improvement in 
+visual reaction time (p = 0.01; -32.89 %), depression (p = 0.04; -41.51%) and anxiety (p = 0.02; -
+32.09%) scores at the end of 3 weeks as compared to the baseline. Auditory reaction time 
+showed reduction in scores but did not reach statistical significance (p = 0.058; -25.6%; Table 3). 
+DISCUSSION 
+Previously, in a randomised  controlled trial, 150 chronic MS paitients were randomly divided 
+into two groups : 1) Mindfulness based intervention and 2) Usual care. Intervention was given 
+for eight weeks period and follow up was done after 6 months. Depression was measured with 
+the center for epidemiologic studies depression scale (CES-D) and Anxiety with spielberger trait 
+anxiety inventory pre and post intervention. It was found that depression, fatigue, and anxiety (P 
+= .002) reduced significantly in mindfulness intervention group as compared to usual care and 
+benefit continued upto 6 months. In another study, thirty-one chronic MS patients, all female 
+with mean of age of 36.75 years and Expanded Disability Status Scale scores (EDSS) of 1.0 to 
+4.0 were recruited. Subjects were randomly assigned to one of the three groups: treadmill 
+training, yoga or control groups. Treadmill training and yoga practice consisted of 8 weeks (24 
+sessions, thrice weekly). The control group followed their own routine treatment program. 
+Balance, speed and endurance of walking, fatigue, depression and anxiety were measured by 
+Berg Balance scores, time for 10m walk and distance for a two minute walk, Fatigue Severity 
+Scale (FFS), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), 
+respectively[57].Comparison of results showed that pre- and post-interventions produced 
+significant improvements in the balance score, walking endurance, FFS score, BDI score and 
+BAI score in the treadmill training group and yoga group as compared to controls. In this study, 
+BDI scores decreased in the treadmill training group by 34.11%; whereas BAI score reduced by 
+78%. In the yoga practice group, average BDI score and BAI score decreased by 36.11% and 
+48.56%, respectively. In our study, we have found that using HADS, depression scores reduced 
+by 41.51% and anxiety scores reduced by 32.09%. This shows that a yoga and physical 
+intervention of 3 weeks may produce equivalent result of what is achieved through yoga therapy 
+or other mindfulness based intervention in 8 weeks. This is probably due to synergistic effect of 
+Page 12 of 28
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+ 
+yoga therapy with other physical therapies involved in yoga and physical therapy. These findings 
+are similar to what we have found in the present study using yoga and physical interventions. No 
+previous study has assessed the effect of alternative or complementary therapies on Audio-Visual 
+reaction times before in chronic MS patients and ours is the first attempt to explore this area.  
+After the practicing of certain yoga techniques (OM meditation and ujjayi pränäyäma)measuring 
+by the recordings of middle latency auditory evoke potentials, yoga practices facilitate the 
+processing of auditory information at mesencephalic and diencephalic levels[58-59]. Yoga 
+Practices improves visual perception as well[60-61] This may be the mechanism behind 
+enhancement of audio-visual reaction times through Yoga therapy. Also, Yoga therapy may lead 
+to increase in GABA (gamma-amino butyric acid) in the brain which may contribute towards 
+anti-anxiety and anti-depressant effects[62-63]. Similarly, another study found positive 
+therapeutic and neurotropic effects of yoga in depressive subjects. It was observed that a key 
+modulator of neoplastic changes called brain derived neurotrophic factor (BDNF) levels 
+increased after 3 months with positive correlation with fall in Hamilton Depression Rating Scale 
+(HDRS)[64]. 
+Strengths of the present study are: a) First study assessing effects of IYP intervention in chronic 
+MS patients; b) Procedures were simple and standardized modules were used; c) Study addressed 
+an important aspect of chronic MS disease; d) Both the genders were included and e) Relatively 
+longer duration of intervention was given; f)As patients followed a residential program, close 
+monitoring was possible. 
+Present study is a preliminary pilot attempt to understand and assess effect of combined yoga and 
+physical therapy and has several limitations: a) Small sample size; b) lack of control group; 
+c)Lack of robust objective variables of neuroimaging and biochemistry that would help 
+understands the mechanisms involved. 
+Future studies should be conducted by including control group, with bigger sample size and 
+longer duration of intervention using randomized controlled design. Outcome measures 
+may include other Audio-Visual testing variables to strengthen the evidence for the 
+efficacy of Integrated Mulitmodal Therapy. Objective measure of neuroimaging and 
+biochemical markers can be assessed in future studies. Effect of each therapy involved in 
+Yoga and physical therapy can be assessed separately. 
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+ 
+CONCLUSION  
+We conclude that Yoga is a feasible, easy and useful practice to improve visual reaction time and 
+psychological health in Multiple Sclerosis. However, due to the limited number of participants 
+and the lack of a control group further studies are necessary to confirm these results. 
+ACKNOWLEDGEMENT 
+We are thankful to KWA Klinik Stift Rottal Bad Griesbach, Germany for their support to conduct 
+study. We are thankful to the participants who participated in the study.  
+ 
+ 
+ 
+ 
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+ 
+ 
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+ 
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+ 
+ 
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+28. Telle S, Dash M, Manjunath NK, Deginal R, Naveen KV. Effect of Yoga on Visual 
+Perception and Visual Strain. Journal of Modern Optics 2007;54:1379-83. 
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+29. Manjunath, N.K., Shirley Telles. Improvement in Visual Perceptual Sensitivity in 
+Children Following Yoga Training. Journal of Indian Psychology 1999;17:41-5. 
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+33. Sharma VK, M R, S V, Subramanian SK, Bhavanani AB, Madanmohan, et al. Effect of 
+fast and slow pranayama practice on cognitive functions in healthy volunteers. J Clin 
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+34. Hariprasad VR, Koparde V, Sivakumar PT, Varambally S, Thirthalli J, Varghese M, et al. 
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+35. Nagarathna R, Nagendra HR, Telles S. Bangalore: Vivekananda Kendra Yoga 
+Research Foundation; [Last accessed on 30 Mar 2013]. Int J Yoga Therap 2011;21:73–6. 
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+Journal of Complementary and Integrative Medicine
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+2
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+4
+5
+6
+7
+8
+9
+10
+11
+12
+13
+14
+15
+16
+17
+18
+19
+20
+21
+22
+23
+24
+25
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+42
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+45
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+For Review Only
+ 
+ 
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+36. Nesi E. Yoga and meditation: helpful techniques to improve the life of cancer 
+patients. Giornale italiano di medicina del lavoro ed ergonomia 2011;34:2 Suppl B: B7-
+11 
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+37. Ahmadi A, Arastoo AA, Nikbakht M, ZahednejadS, Rajabpour M. Comparison of the 
+Effect of 8 weeks Aerobic and Yoga Training on Ambulatory Function, Fatigue and 
+Mood Status in chronic MS Patients. Iran Red Crescent Med J 2013;15:449-54.  
+ 
+38. Oken BS, Kishiyama S, Zajdel D, Bourdette D, Carlsen J, Haas M, et al.Randomized 
+controlled trial of yoga and exercise in multiple sclerosis. Neurology 2004;62:2058-64. 
+ 
+39. Patil NJ, Nagaratna R, Garner C, Raghuram NV, Crisan R. Effect of integrated Yoga on 
+neurogenic bladder dysfunction in patients with multiple sclerosis-A prospective 
+observational case series. Complement Ther Med 2012;20:424-30.  
+ 
+40. Salgado BC, Jones M, Ilgun S, McCord G, Loper-Powers M,  Houten P.Effects of a 4-
+month Ananda Yoga Program on Physical and Mental Health Outcomes for Persons 
+With Multiple Sclerosis. Int J Yoga Therap 2013;23:27-38. 
+ 
+41. Oken BS, Flegal K, Zajdel D, Kishiyama SS, Lovera J, Bagert B, Bourdette DN. 
+Cognition and fatigue in multiple sclerosis: Potential effects of medications with central 
+nervous system activity. J Rehabil Res Dev 2006;43:83-90. 
+ 
+42. Grossman P, Kappos L, Gensicke H, D'Souza M, Mohr DC, Penner IK, Steiner C. 
+chronic 
+MS quality of life, depression,and fatigue improve after mindfulness training: 
+a randomized trial. Neurology 2010;75:1141-9.  
+ 
+Page 19 of 28
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+Journal of Complementary and Integrative Medicine
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+8
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+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
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+47
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+58
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+For Review Only
+ 
+ 
+43. Senders A, Wahbeh H, Spain R, Shinto L.Mind-body medicine for multiple sclerosis: a 
+systematic review.Autoimmune Dis 2012;2012:567324.  
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+44. Doulatabad SN, Nooreyan K, Doulatabad AN, Noubandegani ZM.The effects of 
+pranayama, hatha and raja yoga on physical pain and the quality of life of women 
+with multiple sclerosis.Afr J Tradit Complement Altern Med 2012;10:49-52.  
+ 
+45. Wiles CM, Newcombe RG, Fuller KJ, Shaw S, Furnival-Doran J, Pickersgill TP et al. 
+Controlled randomised crossover trial of the effects of physiotherapy on mobility in 
+chronic multiple sclerosis. J Neurol Neurosurg Psychiatry 2001;70:174-9. 
+ 
+46. Snook EM,  Motl RW. Effect of exercise training on walking mobility in multiple 
+sclerosis: a meta-analysis. Neurorehabil Neural Repair 2009;23:108-16. 
+ 
+47. Solari A, Filippini G, Gasco P, Colla L, Salmaggi A, La Mantia L,et al. Physical 
+rehabilitation has a positive effect on disability in multiple sclerosis patients. Neurology 
+1999;52:57. 
+ 
+48. Kesselring J , Beer S. Symptomatic therapy and neurorehabilitation in multiple 
+sclerosis. Lancet Neurol 2005; 4: 643-52.  
+ 
+ 
+49. McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP,Lublin FD, et al. 
+Recommended diagnostic criteria for multiple sclerosis: guidelines from the International 
+Panel on the Diagnosis of Multiple Sclerosis. Ann Neurol 2001;50:121-7. 
+ 
+50. Raghuraj P, Ramakrishnan AG, Nagendra HR, Telles S. Effect of two selected yogic 
+breathing techniques on heart rate variability. Indian J Physiol Pharmacol.1998;42:467-
+72 
+ 
+Page 20 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+1
+2
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+8
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+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
+For Review Only
+ 
+ 
+51. Raghuraj P, Telles S. Immediate effect of specific nostril manipulating yoga breathing 
+practices on autonomic and respiratory variables.  Appl Psychophysiol 
+Biofeedback.2008;33:65-75. 
+ 
+52. Mason RR, Cochrane DJ, Denny GJ, Firth EC, Stannard SR. Is 8 weeks of side-
+alternating whole-body vibration a safe and acceptable modality to improve functional 
+performance in multiple sclerosis? Disabil Rehabil. 2012;34:647-54. 
+ 
+53. Rietberg  MB, Brooks D, Uitdehaag BM, Kwakkel G. Exercise therapy for multiple 
+sclerosis. Cochrane Database Syst Rev 2005;1:CD003980. 
+ 
+54. Ferruh T, Ummuhan BA, Nuran S, Ugur C. Implementation of matrix rhythm therapy 
+and conventional massage in young females and comparison of their acute effects on 
+circulation. J Altern Complement Med 2013;19:826-32. 
+ 
+55. Audio-visual reaction time was measured using Device Brain-Fit Model No OT 4000. 
+Available at: www.audiva.org/download/e_BFE_manual_lowres.pdf 
+ 
+56. Zigmond, Anthony S, Philip RS. The hospital anxiety and depression scale.  Acta 
+Psychiatr Scand.1983;  67: 361-70. 
+ 
+57. Azra Ahmadi,1 Ali Asghar Arastoo. Comparison of the Effect of 8 weeks Aerobic and 
+Yoga Training on Ambulatory Function, Fatigue and Mood Status in chronic MS 
+Patients. Iran Red Crescent Med J.2013 ;15: 449–54. 
+58. Telles S, Nagarathna S, Nagendra HR, Desiraju T. Alterations in Auditory Middle 
+Latency Evoked Potentials during Meditation on a Meaningful Symbol Om. Intern. J. 
+Neuroscience 1994;76:87-93. 
+ 
+59.  Telles S, Nagarathna S, Nagendra HR, Desiraju T. Alterations in Auditory Middle 
+Latency Evoked Potentials during Meditation on a Meaningful Symbol Om. Intern. J. 
+Neuroscience 1994 ;76:87-93.. 
+Page 21 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+1
+2
+3
+4
+5
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+7
+8
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+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
+For Review Only
+ 
+ 
+ 
+60. Telle S, Dash M, Manjunath NK, Deginal R, Naveen KV. Effect of Yoga on Visual 
+Perception and Visual Strain. J Mod Opt 2007;54:1379-83 
+ 
+61. Manjunath, N.K., Shirley Telles. Improvement in Visual Perceptual Sensitivity in 
+Children Following Yoga Training. Journal of Indian Psychology 1999;17:41-5 
+ 
+62. Streeter CC, Whitfield TH, Owen L, Rein T , Karri SK, Yakhkind  A, et al. Effects of 
+yoga versus walking on mood, anxiety, and brain GABA levels: a randomized controlled 
+MRS study. J Altern Complement Med 2010;16:1145-52. 
+ 
+ 
+63. Streeter  CC, Gerbar  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. 
+ 
+64. Naveen GH, Thirthalli J, Rao MG, Varambally S, Christopher R, Gangadhar BN. 
+Positive therapeutic and neurotropic effects of yoga in depression: A comparative study. 
+Indian J Psychiatry 2013;55:Suppl:S400-4. 
+ 
+ 
+ 
+Page 22 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+1
+2
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+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
+For Review Only
+ 
+Table 1: Integrated Yoga Module for chronic MS 
+S. 
+No. 
+Name of practice* 
+No. of 
+rounds 
+Duration 
+(Minutes) 
+Benefits for chronic MS 
+patients. 
+1 Hands in and out breathing 
+10 
+2 Increase Lung Volume & 
+Strengthening Respiratory 
+Muscles 
+2 Hand stretch breathing 
+10 
+2 
+3 
+Sukṣmavyāyāma -Loosening exercises -  
+3 repetitions each  
+Each 10 
+rounds 
+10 
+ 
+ 
+ 
+ 
+Improves Limb 
+Disabilities,Tremors 
+Ataxia 
+  
+  
+  
+i.                    Neck movements  
+ii.                  Forward & backward  bending 
+iii.                Ankle flexion & extension 
+iv.                Spinal twist 
+v.                  Shoulder rotation 
+vi.                Movements of all small joints. 
+  
+Instant Relaxation Technique (IRT) 
+1 round 
+5 minutes 
+ Relaxation 
+4 
+Asanas 
+Each 3 
+rounds 
+15 
+minutes 
+Muscle Strengthening  
+ Ardhakati Cakrasana 
+ Ardhacakrasana 
+ Padahastasana 
+Page 23 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+1
+2
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+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
+For Review Only
+ Vakrasana (chair) 
+  
+QRT 
+1 round 
+5 minutes 
+ Relaxation 
+5 Mula bandha 
+10 rounds 
+2 minutes 
+Muscle Strengthening 
+6 
+Kaphālabhāti –forced nostril breathing 
+3 rounds 
+with a gap of 
+1 minute 
+5 minutes 
+Reduces Anxiety 
+30 strokes /minute and one minute rest 
+x 3 rounds. 
+7 Nāḍiśuddhi prāṇāyāma 
+9 rounds 
+5 minutes 
+Reduce Stress Level 
+8 Deep Relaxation Technique (DRT). 
+1 round 
+10 
+minutes 
+Reduce Spasticity 
+*Above module was performed 60 minutes once  a day – 5 days a week 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Page 24 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+1
+2
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+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
+For Review Only
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Page 25 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+1
+2
+3
+4
+5
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+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
+For Review Only
+Table 2:  Physical Therapy Module for Chronic MS 
+Sr. No 
+Physical therapies 
+Duration per day 
+Duration per week 
+1 
+GIGER MD Therapy 
+30 min 
+ 
+ 
+5 days per Week 
+ 
+2 
+Galileo Training 
+30 min 
+3 
+Active/passive Movements 
+30 min 
+4 
+Ergometer 
+30 min 
+5. 
+Matrix Therapy 
+30 min 
+1 day per week 
+6. 
+Physiotherapy 
+90 min 
+3 days per week 
+ 
+ 
+ 
+Page 26 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+1
+2
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+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
+For Review Only
+Table  3: Table showing comparisons before and after 3 weeks of Integrated Yoga &  Physical 
+Therapy Intervention 
+Sr. 
+No 
+Variables 
+Mean ±SD 
+Confidence 
+interval of the 
+difference 
+Pa 
+value 
+Percentage 
+change 
+Pre 
+Post 
+Lower 
+Upper 
+2 
+VRT 
+244.64   ±156.38 
+164.18  ±124.26 
+16.77 
+144.14 
+0.018* 
+-32.89 
+3 
+ART 
+273.09   ±248.29 
+203.18  ±157.22 
+142.82 
+2.13 
+0.058 
+-25.6 
+4 
+HADS-A 
+4.55        ±3.91 
+3.09       ±3.67 
+0.28 
+2.63 
+0.020* 
+-32.09 
+5 
+HADS-D 
+4.36        ±3.11 
+2.55       ±2.07 
+0.71 
+3.56 
+0.43* 
+-41.51 
+ 
+a paired sample t test 
+*P≤ 0.05 
+Abbreviations: VRT: Visual reaction time; ART: Auditory reaction time; HADS-A: Hospital 
+anxiety and Depression scale for anxiety; HADS-D: : Hospital anxiety and Depression scale for 
+depression. 
+ 
+ 
+Page 27 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
+1
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+8
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+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
+For Review Only
+Figure 1:  Study Profile 
+ 
+ 
+ 
+ 
+ 
+  
+  
+ 
+ 
+ 
+ 
+  
+ 
+ 
+ 
+ 
+Number of subjects 
+Screened (n= 25)  
+No of Subjects who 
+satisfied Inclusion 
+Criteria (n=15) 
+Pre Data collection 
+(n=15) 
+Post Data collection 
+(n=11) 
+Reason for dropout 
+3= patients left the rehab center early 
+before completion of study.                     
+1= refused to participate for post data 
+collection 
+Page 28 of 28
+Journal of Complementary and Integrative Medicine
+Journal of Complementary and Integrative Medicine
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+11
+12
+13
+14
+15
+16
+17
+18
+19
+20
+21
+22
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+24
+25
+26
+27
+28
+29
+30
+31
+32
+33
+34
+35
+36
+37
+38
+39
+40
+41
+42
+43
+44
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subfolder_0/Effect of integrated yoga on anxiety, depression & well being in normal pregnancy..txt

@@ -0,0 +1,1051 @@
+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/authorsrights
+Author's personal copy
+Effect of integrated yoga on anxiety, depression & well being in
+normal pregnancy
+M. Satyapriya, R. Nagarathna*, V. Padmalatha, H.R. Nagendra
+Division of Yoga and Life Sciences, SVYASA, 19, Eknath Bhavan, Gavipuram Circle, K.G. Nagar, Bengaluru 560019, India
+Keywords:
+Integrated yoga
+Normal pregnancy
+Stress
+Anxiety
+Depression
+a b s t r a c t
+Objective: To study the effect of integrated yoga on Pregnancy experience, anxiety, and depression in
+normal pregnancy.
+Methods: This Prospective Randomized control study recruited 96 women in 20th week of normal
+pregnancy. Yoga group (n ¼ 51) practiced integrated yoga and control group (n ¼ 45) did standard
+antenatal exercises, one hour daily, from 20th to 36th week of gestation. ManneWhitney and Wilcoxon’s
+tests were used for statistical analysis.
+Results: There was significant difference between groups (ManneWhitney p < 0.001) in all variables.
+There were significant changes within groups (Wilcoxon’s p < 0.001) in both groups. Pregnancy related
+experience (PEQ) reduced in yoga by 26.86%, State (STAI I) anxiety (decreased 15.65% in yoga, increased
+13.76% in control), Trait (STAI II) anxiety (decreased 8.97% in yoga, increased 5.02% in control) and
+Depression (HADS) (decreased 30.67% in yoga, increased 3.57% in control).
+Conclusion: Yoga reduces anxiety, depression and pregnancy related uncomfortable experiences.
+
 2013 Elsevier Ltd. All rights reserved.
+1. Introduction
+Pregnancy is a unique state of physiological stress, which ne-
+cessitates physical, mental and social adaptation. Animal experi-
+ments and human studies have shown that prenatal maternal
+stress is associated with increased risk for spontaneous abortion,
+preterm labor, fetal malformations, and asymmetric growth retar-
+dation [1]. Evidence of long-term functional disorders in the
+offspring after prenatal exposure to stress is limited. But retro-
+spective studies [2] and two prospective studies support such ef-
+fects [3] on the behavioral development with attentional deficits,
+hyper anxiety and disturbed social behavior [4].
+Pregnant women respond differently to identical stressful
+stimuli, depending on genetic factors, personality traits, previous
+experience and social support. Anxiety and depression are two
+common responses to stressfully demanding situations that may
+affect healthy progression of pregnancy as observed by many re-
+searchers. Bennett et al. reported Prevalence rates of clinical
+depression at 7.4%, 12.8%, and 12.0% for the first, second, and third
+trimesters, respectively [5]. There are studies that have shown that
+high scores of Anxiety results in increased incidence of preterm
+labor [6], reduced birth weight and small fetal head size [7].
+A review of preclinical and clinical studies on the deleterious effects
+of maternal depression showed that it affects not only the mother
+but also has short and long term effects on the offspring [8].
+Depressed women had higher symptom frequency, more discom-
+fort, flatulence and fatigue [9]. Postpartum weight retention in
+obese mothers was associated with psychological distress during
+early pregnancy [10]. Depression that continues in the Postpartum
+period is associated with negative childbirth experience [11] and
+when untreated, impairs the mother-infant attachments and re-
+sults in cognitive, emotional and behavioral consequences in
+childhood [12]. Ventegodt et al. showed that the global quality of
+life of the mother during pregnancy is important for the quality of
+life of the child and their attitudes toward life and philosophy of life
+[13]. Studies on adolescent quality of life (HR-QOL) point to
+adversity in the neural pathways that are determined in their fetal
+developmental stage [14]. It is alarming to note that review articles
+say that there are no controlled studies on the safety of antide-
+pressant use in pregnancy and lactation [8]. This points to an urgent
+need for non-pharmacological interventions.
+Very simple
+interventions
+such as
+educating
+women
+by
+providing information about benefits and risks of prenatal physical
+activity motivates them to practice better health behaviors [15].
+Cognitive-behavioral intervention led to improvement in the bio-
+logical stress response of pregnant women with sub clinically
+elevated stress, anxiety, or depressive symptoms [16]. A controlled
+clinical trial on outpatient ante-partum women who met DSM-IV
+* Corresponding author. Tel.: þ91 9845088086; fax: þ91 (0)80 26608645.
+E-mail address: [email protected] (R. Nagarathna).
+Contents lists available at SciVerse ScienceDirect
+Complementary Therapies in Clinical Practice
+journal homepage: www.elsevier.com/locate/ctcp
+1744-3881/$ e see front matter 
 2013 Elsevier Ltd. All rights reserved.
+http://dx.doi.org/10.1016/j.ctcp.2013.06.003
+Complementary Therapies in Clinical Practice 19 (2013) 230e236
+Author's personal copy
+criteria for major depressive disorder, found significant improve-
+ment in mood after 16 weeks of Interpersonal psychotherapy [17].
+Massage therapy showed reduced anxiety, improved mood and
+better sleep with fewer complications during labor and postnatal
+period [18] with lesser incidence of prematurity and low birth
+weight [19]. Exercise in the third trimester was associated with
+lesser state-anxiety [20]. Applied relaxation training showed sig-
+nificant reductions in state/trait anxiety and perceived stress [21].
+‘Attending nurse-led relaxation education’ reduced the need for
+cesarean section, and/or instrumental extraction and also the
+number of infants with low birth weight [22].
+Yoga, with its holistic approach, has been used to promote
+positive health for centuries in India [23]. Several clinical trials
+point to the beneficial effects of yoga in Asthma [24,25], Hyper-
+tension [26,27], Pain Managament [28,29], Diabetes [30], Cancer
+[31], and Mood Changes [32]. Yoga improves the Quality of life [33]
+and reduces stress as evidenced by reduced anxiety levels [34,35],
+serum cortisol levels [36,37] with lower metabolic rate in yoga
+practitioners [38].
+To date there are a few publications on the effect of integrated
+approach of yoga (IAYT) on pregnancy outcome [39]. In a case
+control study Narendran et al. showed the positive effects of IAYT
+on mode of delivery, birth weight of the infant and pregnancy
+complications. Again, in those pregnancies with abnormal flow in
+umbilical and uterine arteries (observed in ultrasound Doppler
+scanning), there was improvement in birth weight, decrease in
+preterm labor and intrauterine growth restriction [40].
+Sun et al. [41]. observed that 12e14 week yoga program pro-
+duced lesser scores on Discomforts of Pregnancy (DoPQ) in 38e
+40th week of gestation with higher self-efficacy and outcome
+expectancy in both the active and second stages of labor. It is
+known that Physiological stress reactivity is dampened during
+pregnancy [42]. We demonstrated improved autonomic adapt-
+ability (in heart rate variability) with reduced perceived stress
+levels [43] that resulted in better quality of life (WHOQoL 100) and
+interpersonal relationships (FIRO-B) after integrated yoga in
+pregnant women [44]. We hypothesized that these observations
+could be due to reduced anxiety and depressive responses to
+perceived stress and planned to document these variables in the
+same cohort in which we observed the above changes which is
+reported here.
+2. Methods
+2.1. Participants
+2.1.1. Sample size
+A sample size of 88 was obtained by using the ‘G power’ soft-
+ware, (alpha ¼ 0.05, power ¼ 0.8 and effect size ¼ 0.54). The effect
+size was calculated from the mean and SD values of an earlier
+interventional study [45]. We recruited 122 women to provide for
+any dropouts.
+Ninety six women (20e35 years) between 18th to 20th weeks
+of gestation who satisfied the selection criteria were randomized
+to yoga (51) and control groups (45). They were recruited from a
+pool of 200 subjects who had registered for antenatal care at
+Maiya multispecialty hospital in south Bengaluru, India. The
+following criteria were followed to ensure inclusion of only
+normal pregnancies and avoid those who may have high stress
+levels: (a) gestational age between 18 and 20 weeks, (b) prime
+gravidae and (c) multi gravidae with at least one live child. The
+exclusion criteria were: (a) associated medical problems, (diabetes,
+hypertension, etc), (b) multiple pregnancy, (c) IVF pregnancy, (d)
+previous history of IUGR, (e) maternal physical abnormalities, (f)
+fetal abnormality on ultrasound scanning and (h) previous expo-
+sure to yoga.
+2.2. Consent
+Institutional ethical committee of the yoga university (S-VYASA)
+had cleared the project. Signed informed consent was obtained
+from all subjects before randomization.
+2.3. Design
+This was a prospective randomized two-armed control design
+with supervised practices for both groups from the time of
+recruitment till delivery.
+2.4. Procedure
+After obtaining the signed informed consent, the subjects were
+allocated to two groups (yoga and control) using a computer
+generated random number (www.Randomizer.com) table. Pre and
+post assessments were done at the time of recruitment (between 18
+and 20 weeks of pregnancy) and at 36th week. Yoga group prac-
+ticed specific set of integrated yoga. The control group practiced
+standard antenatal exercises. Both groups learnt the practices (in
+batches of 4e10) from trained instructors in sessions of 2 h/day (3
+days/week) for one month. Subsequently, they continued the
+practices at home using a pre recorded instruction cassette for one
+hour each day. Both groups had refresher classes of 2 h each time
+they came for their antenatal obstetric assessment. (Once in 3
+weeks up to 28 weeks and every two weeks up to 36 weeks).
+Compliance was ensured by phone calls and maintenance of an
+activity diary.
+2.5. Masking
+As this was an interventional study, the participants or the
+trainer could not be blinded. Attempts were made to mask
+wherever feasible to reduce the bias. The team who did the as-
+sessments was not involved in administering the intervention.
+The statistician 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.
+2.6. Intervention
+The yoga module used for the experimental intervention called
+Integrated approach of yoga therapy (IAYT) during pregnancy
+which was developed specifically for the purpose culled out from
+original scriptures (Patanjali Yoga Sutras, and Mandukaya Karika)
+that highlight the concepts of a holistic approach to health man-
+agement at physical, mental, emotional and intellectual levels with
+techniques to improve mental equilibrium. Table 1 shows the list of
+yoga practices used in three trimesters. The number of asanas
+(physical postures) performed in standing, sitting or lying prone or
+supine postures went on reducing with increasing gestational age.
+These asanas done with internal awareness (eyes closed) promotes
+full range of motion of the body part by graded gradually increasing
+stretches followed by relaxation, that results in flexibility of the
+joints and strengthening of the muscles. The breathing techniques
+(Pranayama) focus on conscious prolongation of all three compo-
+nents of breathing cycle (inhalation, effortless retention, and
+exhalation) that results in better vital capacity and balance of vital
+energy. Meditation included techniques such as listening to one’s
+M. Satyapriya et al. / Complementary Therapies in Clinical Practice 19 (2013) 230e236
+231
+Author's personal copy
+own breath or repeating a mantra to bring about a state of self-
+awareness and inner calm [39].
+The control group practiced the standard antenatal practices
+which included simple stretching exercises (Table 1) approved by
+the Executive Council of the society of Obstetrician and Gynecolo-
+gists of Canada, and by the board of directors of the Canadian so-
+ciety for exercise physiology [46].
+2.7. Assessments
+1. PEQ: Pregnancy experiences Questionnaire
+The Pregnancy experiences Questionnaire addresses Pregnancy-
+specific stressors and concerns experienced during pregnancy [47]
+PEQ has 41 questions related to somatic symptoms, Pregnancy,
+fetus/infant and parenting concerns, baby-image, and attitudes to
+sex. Women are asked to rate how severe each item has been for
+them in the past month on a three-point scale (1e3) with the total
+scores ranging from 41 to 123 with higher scores indicating higher
+stress levels. PEQ has good internal consistency (a ¼ 0.87e0.91)
+[48] with Test-retest reliability coefficients varying from 0.64e0.84
+depending on the time period sampled (one to six months).
+2. STAI: state trait anxiety inventory
+The STAI [49] comprises two-self report scales for measuring
+two distinct anxiety concepts, the State anxiety and Trait anxi-
+ety. Both scales contain 20 statements that asks the respondent
+to describe how she feels at a particular moment (state anxiety)
+or how she generally feels (trait anxiety). State anxiety is
+conceptualized as a transitory emotional state, where as trait
+anxiety refers to relatively stable individual differences in
+proneness to anxiety. The respondents were required to rate
+themselves on a four point Lickhert scale ‘not at all’ to ‘very much
+so’ on various anxiety related symptoms which they experience
+in the past weeks for the state scale or how they generally feel
+Table 1
+Yoga and exercise intervention group practice details (60 min daily).
+Yoga group
+2nd Trimester
+3rd Trimester
+Control group
+2nd Trimester
+3rd Trimester
+A. Lectures
+15 min
+10 min
+A. Lectures
+15 min
+10 min
+B. Breathing exercises
+10 min
+5 min
+B. Loosening exercises
+10 min
+5 min
+1. Hasta 
+ay
+ama 
+svasanam
+(Hands in and out breathing)
+Yes
+Yes
+1. Twisting
+Yes
+Yes
+2. Hasta vist
+ara 
+svasanam
+(Hands stretch breathing)
+Yes
+Yes
+2. Forward & backward bend
+Yes
+No
+3. Gulpha vist
+ara 
+svasanam
+(Ankle stretch breathing)
+Yes
+Yes
+3. Side bending
+Yes
+Yes
+4. Vy
+aghra 
+svasanam
+(Tiger breathing)
+Yes
+No
+4. Calf-raise
+Yes
+Yes
+5. Setu bandha 
+svasanam
+(Bridge posture breathing)
+Yes
+No
+5. Hamstring stretch
+Yes
+Yes
+6. Lateral Pulls- up & down
+Yes
+No
+7. Calf extension
+Yes
+No
+8. Hip Abduction
+No
+Yes
+C. Asana Postures
+15 min
+10 min
+C. Antenatal Exercises
+15 min
+10 min
+Standing Asanas
+Standing exercises
+1. Tadasana (tree pose)
+Yes
+Yes
+1. Thigh stretch
+Yes
+Yes
+2. Ardhakati-chakrasana
+(Lateral Arc Pose)
+Yes
+Yes
+2. Push-up & Down
+Yes
+Yes
+3. Trikonasana .(triangle pose)
+Yes
+Yes
+3. Pulls Downs
+Yes
+No
+4. Low-Back lift
+Yes
+No
+Sitting Asanas
+Sitting exercises
+4. Vajrasana (Ankle Pose)
+Yes
+Yes
+5. Inner thigh Stretch
+Yes
+Yes
+5. Vakrasana (spine twist pose)
+Yes
+No
+6. Calf stretch
+Yes
+Yes
+6. Siddhasana (sage pose)
+No
+Yes
+7. Dips
+Yes
+No
+7. BaddhaKonasana (Bound
+Ankle Pose)
+No
+Yes
+8. Squatting
+No
+Yes
+8. UpavistaKonasana (spread
+legs pose)
+No
+Yes
+9. Hip abduction
+Yes
+Yes
+9. Squatting (Garland pose)
+No
+Yes
+10. Shoulder-chest stretch
+Yes
+Yes
+11 Neck and upper back stretch
+Yes
+Yes
+Supine Asanas
+12. Seated Rowing
+Yes
+Yes
+10. Viparita karani
+(half shoulder stand)
+Yes
+No
+13. Oblique curis
+Yes
+Yes
+11. Ardha- pavanamuktasana
+(folded leg lumbar stretch)
+Yes
+Yes
+14. Kick backs
+Yes
+Yes
+15. Pelvic floor exercise
+Yes
+Yes
+Supine exercise
+16. Pelvic Tilt
+Yes
+Yes
+D. Pranayama and Meditation
+10 min
+20 min
+D. Slow Walking
+10 min
+20 min
+1. Sectional breathing
+Yes
+Yes
+2. Naadisuddhi
+Yes
+Yes
+3. Sheetali
+Yes
+Yes
+4. bharamari
+Yes
+Yes
+5. Nadanusandhana
+Yes
+Yes
+6. Om Meditation
+E. Deep relaxation technique
+10 min
+15 min
+E. Supine Rest (10 min)
+10 min
+15 min
+M. Satyapriya et al. / Complementary Therapies in Clinical Practice 19 (2013) 230e236
+232
+Author's personal copy
+for the trait scale [49]. STAI is widely used and has been shown to
+have high reliability and validity [49] with a Cronbach’s alpha of
+0.88 and 0.83 for state (STAI-I) and trait anxiety (STAI-II) respec-
+tively [50].
+3. HADS: Hospital Anxiety Depression Scale
+HADS is a self-assessment scale developed by Zigmond and
+Snaith [51]. It is a widely used self-report instrument designed to
+assess the dimensions of anxiety and depression in non-psychiatric
+population [52,53]. It has 14 items that consist of two subscales of
+seven items each, to measure the levels of anxiety and depression.
+Each item is rated on a scale from 0 (not at all) to 3 (very much).
+This is a widely used reliable scale with Cronbach’s alpha of 0.89
+[54].
+3. Data analysis
+Statistical analysis was done using SPSS Version 10.0. Chi
+squared test and independent samples ‘t’ test were used for base-
+line comparisons and mean differences within groups. As the data
+were not normally distributed, ManneWhitney test (between
+groups) and Wilcoxon’s test (within groups) were used for statis-
+tical analysis.
+4. Results
+Fig. 1 shows the trial profile. 200 women who registered at the
+antenatal clinic of the institute were screened; 122 women who
+satisfied the selection criteria, 105 consented and the final data was
+available on 96 women (yoga 51 and control 45). There were 2 drop
+outs in yoga and 7 in control. The reasons for drop out included: (i)
+Irregular attendance (ii) shifts from control to yoga group because
+of increasing popularity of yoga through the media, and (iii) social
+reasons: moved out of Bangalore for delivery and post partum care
+to mother’s house as a sentimental social custom of south India.
+The two groups were matched on maternal characteristics
+(Table 2) and baseline scores were not normally distributed.
+Table 3 shows the results after the intervention. State (STAI I)
+anxiety reduced in yoga (15.65%, p < 0.001) with significant dif-
+ference between groups (P < 0.001); it increased in the control
+group (13.76 %, p < 0.007); Trait (STAI II) anxiety also reduced in
+yoga (8.97%, p < 0.001) and increased in the control group (5.02%,
+p < 0.09) with significant difference between groups (p < 0.001).
+Anxiety as measured by HADS also reduced in yoga (29.12%,
+p < 0.001) with significant difference between groups (p < 0.001).
+Depression (HADS) reduced in yoga (30.67%, p < 0.001) with sig-
+nificant difference between groups (p < 0.001). Pregnancy related
+experience questionnaire showed significant changes in the yoga
+(26.86%, p < 0.001) group with significant difference between
+groups (p < 0.001).
+5. Discussion
+This prospective randomized control study compared the effect
+of daily practice of integrated yoga program with standard ante-
+natal exercises in normal pregnant women from 20th to 36th
+weeks. Anxiety and Depression reduced with improvement in
+pregnancy experience after yoga with significant difference be-
+tween groups (P < 0.001). There were no adverse effects in any of
+the cases.
+Although the women in control group were doing the practices
+of physical activity as planned and were reporting the regularity of
+practices, there was significant increase in state (13.76%) and trait
+(5%) anxiety as pregnancy advanced. The reason for this increase
+could be: although it is well known that physical activity reduces
+Fig. 1. Antenatal RCT profile.
+M. Satyapriya et al. / Complementary Therapies in Clinical Practice 19 (2013) 230e236
+233
+Author's personal copy
+stress and improves health, it appears that, this may not be suffi-
+cient to prepare the woman to manage the psychological response
+(anxiety) to demanding situations of life, i.e. anticipation of com-
+plications and pain of delivery. Yoga, by definition is mastery over
+the modifications of mind (Patanjali e chitta vrtti nirodhah) and
+offers techniques that invoke the inbuilt capability to manage the
+psychological and physiological challenges. Regular practice of in-
+tegrated yoga leads to a balanced state of mind (samatvam yoga as
+stated in bhagavadgita) that does not get perturbed by these
+challenges [55] by improving neural plasticity [56].
+5.1. Comparisons
+There are very few studies that have looked at the effect of yoga
+on stress, anxiety or depression during pregnancy. Two studies
+have reported reduction in trait anxiety (p < 0.05) in third trimester
+in
+healthy
+pregnant
+nulliparous
+women
+who
+practiced
+mindfulness-based yoga between 12 to 32 weeks [57,58]. We have
+earlier reported reduction in perceived stress and better autonomic
+adaptability [43]. There are several studies that have looked at the
+effect of different types of yoga practices on anxiety, depression,
+wellness and quality of life in clinical conditions and normal
+healthy volunteers. To our knowledge this is the first study that has
+reported the effect of yoga on pregnancy experience, anxiety and
+depression.
+Nidhi et al. reported significant reductions in both state [12.27%]
+and trait [14.97%] anxiety in adolescent girls with polycystic
+ovarian disease [59]. Subramanya et al. [60] observed a reduction in
+state anxiety (22.4%) immediately after Cyclic Meditation in normal
+volunteers. Rao et al. in their randomized control study on early
+breast cancer patients observed reduction in both state and trait
+anxiety by add-on yoga [61]. Twelve weeks of Iyengar yoga reduced
+the state and trait anxieties in normal volunteers [62] and in
+women with mental distress [63]. Our present study observed
+a15.65% reduction in state anxiety and 9% reduction in trait anxiety
+in yoga group of pregnant women.
+There was a 48.2% reduction in anxiety levels (HADS) after 6
+weeks of add-on yoga in breast cancer patients undergoing radia-
+tion therapy [64]. Sudarshan Kriya and related practices reduced
+the scores on depression from 4.11  2.99 to 2.73  2.19 and Anxiety
+scores from 7.60  3.71 to 5.87  3.18 after yoga practice in adult
+volunteers [65]. In the present study, there was better reduction in
+anxiety score (HADS) in the yoga (29.12%) group compared to the
+control group (1.69%); reduction in Depression score was also
+higher in yoga (30.67%) than the control group (3.57%).
+Looking at effect of yoga on the discomforts of pregnancy, we
+observed higher degree of improvement in the yoga (26.86%) group
+as compared to control group (13.55%) in their Pregnancy experi-
+ence .Sun et al. [41]. studied the effects of a 12e14 week yoga
+program and showed significantly less discomfort in the 38e40th
+week
+of
+gestation with
+higher
+self-efficacy expectancy and
+outcome expectancy in both the active and second stages of labour
+than the women in the control group.
+5.2. Mechanism: stress reduction
+Anxiety and depression are the experiences that a person
+actually feels in response to perceived stress. Studies using ultra-
+sound Doppler flow velocimetry have shown high resistance of the
+uterine arteries in women with high anxiety scores in the third
+trimester [66]. It has been reported that high scores on perceived
+stress and anxiety are related to increase in HPA-Axis-activity [67].
+Based on our results we may hypothesize that yoga’s benefits
+Table 3
+Changes after intervention in both groups N ¼ 51 (Y) and 45 ¼ (C).
+Variable
+Group
+20th Weeks
+36th Weeks
+Effect size
+% Differ
+Confidence intervals
+Sig-P valuesa
+20th Week
+36th Week
+Within Gps
+pre/post
+Between Gps
+post/post
+LB
+UB
+LB
+UB
+STAI-I
+Y
+35.71  7.10
+30.12  5.72
+0.993
+15.65Y
+33.89
+37.74
+28.75
+32.04
+0.001
+0.001
+C
+36.44  5.99
+39.71  6.8
+0.683
+13.76[
+34.18
+37.74
+36.76
+41.04
+0.007
+STAI-II
+Y
+36.18  6.81
+31.20  6.16
+0.43
+8.97Y
+34.47
+38.17
+29.66
+33.02
+0.001
+0.001
+C
+37.64  5.93
+39.53  7.20
+0.26
+5.02[
+35.36
+38.85
+36.40
+40.83
+0.090
+HADS anxiety
+Y
+7.35  2.45
+5.22  1.36
+0.910
+29.12Y
+6.66
+8.04
+4.83
+5.60
+0.001
+0.001
+C
+7.69  2.84
+7.82  3.43
+0.048
+1.69[
+6.84
+8.54
+6.79
+8.85
+0.731
+HADS depression
+Y
+6.39  2.55
+4.43  1.39
+0.796
+30.67Y
+5.67
+7.11
+4.04
+4.82
+0.001
+0.001
+C
+6.73  2.22
+6.98  2.91
+0.091
+3.57[
+6.07
+7.40
+6.10
+7.85
+0.592
+PES
+Y
+68.02  5.47
+49.75  5.99
+2.55
+26.86Y
+66.48
+69.56
+48.06
+51.43
+0.001
+0.001
+C
+68.20  5.84
+58.96  8.81
+1.37
+13.55Y
+66.45
+69.95
+56.31
+61.60
+0.001
+Abbreviations: LB: Lower Bound, UB: Upper Bound.
+Note: There is significant difference between groups with better improvement in yoga group on all three variables.
+a Wilcoxon’s signed ranks test (within groups); ManneWhitney U test (between groups).
+Table 2
+Showing demographic characteristics of the subjects.
+Variables
+Yoga (N ¼ 51)
+Control (N ¼ 45)
+Mean  S.D
+Mean  S.D
+Age
+26.41  3.01
+24.96  2.58
+Height (inches)
+63.67  1.81
+62.84  1.98
+Gravida
+G1
+45 (88%)
+40 (87%)
+G2
+5 (12%)
+6 (13%)
+Occupation
+Working
+33 (65%)
+21 (49%)
+Not working
+house wives
+18 (35%)
+24 (51%)
+Weight (kg)
+Pre
+63.69  9.67
+61.56  8.56
+Post
+71.82  9.90
+69.91  8.84
+BMI
+Pre
+24.97  3.52
+25.05  3.80
+Post
+28.54  3.60
+28.55  3.86
+BP (systolic)
+Pre
+114.71  14.74
+115.07  8.13
+Post
+117.25  9.61
+118.00  8.15
+BP (diastolic)
+Pre
+73.12  5.43
+72.40  6.56
+Post
+75.06  5.33
+75.84  6.24
+Abbreviations: G1, Prima; G2, Secunda 2; W, Working; HW, Housewife; Wt, Weight;
+BMI, Body mass index; BP, Blood pressure.
+Group means and SE’s of all participant variables; all 20th week (¼ Pre) except
+where stated Post (¼ 36th week). No difference between groups was statistically
+significant on any Pre or Post variable (Gravidae and Work Chi square test; others
+independent samples ‘t’ test).
+M. Satyapriya et al. / Complementary Therapies in Clinical Practice 19 (2013) 230e236
+234
+Author's personal copy
+would be mediated through reduction in the abnormal activity of
+the maternal sympatheticeadrenalemedullary system (SAM) and
+hypothalamicepituitaryeadrenocortical axis (HPA-axis) [42]. Bet-
+ter autonomic stability with reduced sympathetic arousal and
+increased parasympathetic tone has been demonstrated in normal
+adults [68] after yoga. Also, we have shown reduced perceived
+stress and better autonomic adaptability during normal pregnancy
+after integrated yoga [43] pointing to better plasticity of ANS and its
+ability to restore the basal state of relaxation quickly after a stress
+response.
+Better psychological health resulting from stress reduction may
+have contributed to the improvement observed on PEQ in this
+study. We have published earlier that these women had much
+better quality of life and interpersonal relationships [44] that points
+to the positive psychological state that yoga can induce. Thus, these
+psychological changes may explain the physiological changes
+observed as better outcomes seen in our earlier studies on inte-
+grated yoga in both normal [39,43] and high risk pregnancies
+[44,69]. This may also promote a healthier ANS programming in the
+fetus [42,70] which may help in preventing diseases related to
+autonomic nervous system hyperactivity in the offspring.
+The Word yoga comes from a Sanskrit root ‘Yuj’ that means ‘to
+yoke’, ‘to join’, to unite the mind, body and the spirit; and to direct
+and concentrate one’s attention by calming down the restless mind
+[55]. 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 aspects that could explain the observed benefits.
+6. Conclusion
+Regular practice of integrated yoga in second and third trimester
+is more effective than antenatal exercises in reducing anxiety,
+Depression and improving the pregnancy experience.
+6.1. Limitations
+a. Possible interaction between the groups could not be avoided.
+b. Requests for shift from control to yoga group due to popularity
+of yoga through the media led to unexpected number of drop
+outs.
+6.2. Generalizability
+As yoga is widely accepted even in the west today and there are
+good number of centers round the globe which have been teaching
+yoga for pregnancy, this study offers the scientific evidence for the
+safety and benefits of this module of integrated yoga. Thus, we
+recommend that obstetricians incorporate these practices in all
+antenatal clinics in all sections of the society.
+6.3. Suggestions for future research
+More studies in different ethnic groups, in abnormal preg-
+nancies and by use of different types of Yoga may throw more
+light on ANS modulations in pregnancy. Multi centric trials
+including a more comprehensive battery of variables to measure
+ANS functions and changes in hormonal levels may unravel the
+hidden mechanisms of yoga, since the exact nature of the auto-
+nomic changes involved in stress adaptation are poorly under-
+stood [70].
+Conflict of interest
+We hereby declare that authors do not have any conflict of in-
+terest while carrying out this research.
+Source of funding
+This project was funded by the mother institution SVYASA.
+Acknowledgment
+We thank the management and the staff of the hospital where
+the study was conducted, and also the SVYASA University who
+helped us throughout the study. We thank Mr. Pradhan B for his
+help in statistical analysis.
+References
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+236

subfolder_0/Effect of juice fasting on urine pH_a controllrd study.txt

@@ -0,0 +1,436 @@
+Naturopathic Fasting Therapy is the cornerstone of most Naturopathic therapy protocols. It has been claimed to 
+reduce the acidity of the body, but this has not been conclusively proven. The present study was designed to assess 
+the effect of Naturopathic Fasting Therapy on Urine pH young healthy volunteers. Seventy participants with ages 
+ranging from 19-21 years (group mean age ±SD; 20 ±0.8 years) were assigned to either a fasting group (n=35) or a 
+vegetarian diet group (n=35).  The two groups were matched for age, education and routines. Fasting was conducted 
+for a period of five days under supervision by project coordinators. We executed a matched controlled design with 
+urine pH assessed by testing first void midstream urine using pH meter at baseline and every day subsequently until 
+the period of fasting ended. Data were analyzed using IBM SPSS 20. The data were checked for normality. The data 
+was checked for normality and then a Paired samples t-test was performed to investigate statistically significant 
+difference within-group in urine pH of fasting group and control group. Urine pH increased by 0.24 ±0.49 pH units 
+(p <0.05) after five days'Naturopathic Fasting Therapy Naturopathic Fasting Therapy significantly increases Urine 
+pH. This signifies that acidity of the plasma is reduced, which can be linked to many health benefits.
+Keywords: naturopathic fasting therapy, urine ph, acidity
+thicker juice (in this case, pineapple juice), to mono fruit diet, to 
+Naturopathy is a drugless system of medicine, which comprises of non-
+natural diet, to a vegetarian diet on successive days.
+invasive treatment modalities drawn from natural elements viz., earth, 
+water, fire, air and space. It is based on the principles that the body can 
+However, there has been very limited research conducted on 
+heal itself of any disease, if provided with the right opportunity. 
+fasting therapy to establish the metabolic changes in the body 
+Naturopathic theories state that when a wrong lifestyle is followed, the 
+affected by it. The physiological changes that occur during fasting 
+different functions of the body are compromised, causing disease, and 
+are not completely understood, regardless of the cause for fasting 
+therefore, following the right lifestyle may cure any disease.
+(for example, medical, lifestyle, religious, political or famine).[1]
+Yoga in addition to being a preventive health practice is also a 
+The pH of plasma is determined by the concentration and 
+therapeutic science, which works on the intricate mechanisms of 
+chemical properties of the acids and bases dissolved in it. Three 
+mind and body. It is a science of living that prescribes certain rules 
+classes of acids and bases can be identified:
+and regulations to be followed on a moral basis, control of body, 
+●Carbonic Acid, formed by intermediary metabolism and disposed 
+breath and mind, withdrawal of the senses inwards, and mental 
+off principally by pulmonary ventilation - variation in the rate of 
+training of concentration to reach meditative states and absolution.
+pulmonary ventilation controls the plasma concentration of 
+Among the therapeutic modalities utilized in Naturopathic 
+Carbonic Acid.
+medicine, fasting therapy is the foremost and most important 
+●Metabolizable acids are either absorbed from diet or arise in the 
+modality. Abstaining from food altogether or a specific type of food 
+process of intermediary metabolism and are mainly disposed off 
+for a specific period of time is said to be associated with myriad 
+by intermediary metabolism
+health benefits and is said to be effective in treating any disease. 
+●Non-metabolizable acids are disposed off by renal mechanisms, 
+Calorie restriction, a therapy similar to fasting therapy, has been 
+which also control their concentration in plasma [2]. All acids 
+found to have numerous health benefits and has been associated with 
+except those formed by CO2 are termed non-volatile acids, as 
+a number of biochemical changes in the body's metabolic markers. A 
+they cannot be disposed off by respiratory mechanisms, lactic 
+type of fasting therapy is juice fasting, where the patient remains on 
+acid and uric acid for example.
+liquids for a certain period of time.
+There are four main factors that influence the pH of the ECF, and 
+Naturopathic Fasting Therapy involves a gradual shift from 
+therefore, urine: Protein, Phosphorous, Potassium and Magnesium. 
+regular food habits to a natural (raw fruits and vegetables) diet, then 
+The intake of these four factors is directly proportional to the acid 
+to a mono fruit diet, following which the patient is given different 
+load on the kidneys, and they have been used to formulate an index 
+fruit and/or vegetable juices, which are generally citrus fruit juices. 
+called PRAL (Potential Renal Acid Load).
+For our study, case group subjects were provided lemon juice with 
+Urine pH is determined primarily by a combination of body 
+honey four times during the complete fasting days. Breaking the fast 
+surface and dietary intake, where fruits and vegetables contribute to 
+was done the same way, in reverse order: from lemon juice to a 
+alkalinizing urine pH, whereas meat, fish and dairy products 
+contribute to lowering urine pH.[3]
+There has been considerable change from the hunter gatherer 
+civilization to the present in the type of food consumed and thereby 
+pH and net acid load in the human diet.[4]
+Effect of juice fasting on urine ph: A controlled study
+Indian Journal of Health and Wellbeing 
+2014, 6(1), 41-44
+http://www.iahrw.com/index.php/home/journal_detail/19#list
+© 2015 Indian Association of Health, 
+Research and Welfare
+ISSN-p-2229-5356,e-2321-3698
+Correspondence should be sent to Achyuthan Eswar
+Sri Dharmasthala Manjunatheswara College of Naturopathy 
+and Yogic Sciences, Ujire Swami Vivekananda Yoga 
+Anusandhana Samsthana (S-VYASA), Bengaluru
+Prashanth Shetty, Achyuthan Eswar, Rajkumari 
+Roshni Raj Lakshmi,Balakrishna Shetty and Nithin
+Sri Dharmasthala Manjunatheswara College of 
+Naturopathy and Yogic Sciences, Ujire
+H.R.Nagendra and Suhas Vinchurkar
+Swami Vivekananda Yoga Anusandhana 
+Samsthana (S-VYASA), Bengaluru
+With the agricultural revolution (last 10,000 years) and even more 
+Calorie Restriction (CR) and Naturopathic Fasting Therapy (NF) 
+recently with industrialization (last 200 years), there has been a 
+have been shown to be effective in improving outcomes in a number 
+decrease in potassium (K) compared to sodium (Na) and an increase 
+of disease pathologies. There are also a number of molecular 
+in chloride compared to bicarbonate found in the diet. It is generally 
+mechanisms that have been identified to explain the reason behind 
+accepted that agricultural humans today have a diet poor in 
+the same.
+magnesium and potassium as well as fiber and rich in saturated fat, 
+●Fasting therapy may be a potential therapeutic intervention for 
+simple sugars, sodium, and chloride as compared to the 
+cancer, due to its ability to influence a wide a range of cellular 
+preagricultural period.[5]
+mechanisms that promote healing.[16]
+The ratio of potassium to sodium has reversed, K/Na previously 
+●NF reduces pain in RA patients and increases SCFA production in 
+was 10 to 1 whereas the modern diet has a ratio of 1 to 3.[6] This 
+the gut.[17]
+results in a diet that may induce metabolic acidosis which is 
+●NF enhances immunity, as measured by increased levels of 
+mismatched to the genetically determined nutritional 
+secretory Immunoglobulin. [18]
+requirements.[7] With aging, there is a gradual loss of renal acid-base 
+With this background, we aimed at finding if a five-day 
+regulatory function and a resultant increase in diet-induced 
+Naturopathic Fasting Therapy protocol would influence the body's 
+metabolic acidosis while on the modern diet [8]
+acidity. Therefore, the current study was designed to evaluate the 
+A low-carbohydrate high-protein diet with its increased acid load 
+effect of Naturopathic Fasting Therapy on Urine pH.
+results in many changes in urinary chemistry. Urinary magnesium 
+levels, urinary citrate and pH are decreased, urinary calcium, un-
+Method
+dissociated uric acid, and phosphates are increased. All of these 
+Participants
+result in an increased risk for kidney stones.[9]
+Urine pH relates to dietary acid-base load. Higher fruit and 
+We identified a congruent group of 60 healthy volunteers of both 
+vegetable intake, and lower meat intake are related to more alkaline 
+genders from a college in south India. Students who have had a 
+urine.[10] An index to predict the effect of a particular food on the 
+history of anxiety or depression or any other psychiatric problem or 
+acid-base balance in the body is PRAL (Potential Renal Acid Load), 
+were under any psychiatric or psychedelic drugs or who have 
+which is an indicator of the amount of diet-derived acid the kidneys 
+indulged in substance abuse were excluded from the study. Also, 
+have to dispose off. An estimate of PRAL based on consumption of 4 
+students who have a history of kidney disease were excluded. The 
+nutrients - proteins, phosphorous, potassium and magnesium - gives 
+participants' ages ranged from 19-21 years (group mean age ±SD; 20 
+a good estimate of Net Acid Excretion.[11]
+±0.8 years) and were assigned to fasting group (n=30; 20 ±0.4 years) 
+and a control group with normal vegetarian diet (n = 30; 23±4.6 
+Acidic urine, and thus acidic plasma, has been found to have many 
+years). This was a group of students belonging to the same class and 
+detrimental effects on health:
+therefore were matched for age, education and routines. The 
+●Acidic Urine has been found to have a significantly increased 
+Institutional ethics committee approved this study and a signed 
+bladder cancer risk.[12]
+informed consent was obtained from all the subjects following 
+●Extracellular (Interstitial) pH (pHe) of solid tumors is 
+explanation of the study. 
+significantly more acidic, compared to normal tissues.[13] The 
+The Naturopathic Fasting Therapy Group subjects were provided 
+more acidic the extracellular fluid, the more efficiently a cancer 
+with vegetarian diet on the first day, raw diet on the second day, fruit 
+can generate ATP [14]
+mono diet on the third day, lemon honey juice on the fourth, fifth, 
+●Children who have a higher Potential Renal Acid Load are prone 
+sixth and seventh days, grape juice on the eighth day, fruit mono diet 
+to have a higher systolic blood pressure.[15]
+on the ninth day, raw diet on the tenth day and vegetarian diet on 
+Increasing fruit/vegetable servings has been found to increase 
+eleventh day. The quantity of lemon honey juice provided was 250 
+urine pH and significantly decrease estimated dietary Net 
+ml. Following is the diet schedule followed for the fasting therapy 
+Endogenous Acid Production, thus reducing the risk of osteoporosis 
+group:
+in midlife women.
+Day
+Breakfast
+Lunch
+Evening snack
+Dinner
+Day 1
+Normal Vegetarian Breakfast
+Normal Vegetarian Lunch
+-
+Normal Vegetarian Dinner
+Day 2
+Lemon Juice with Honey
+Pineapple, Watermelon, 
+Lemon Juice with Honey
+Pineapple, Watermelon, Papaya, 
+Papaya, Banana, Tomato, 
+Banana, Tomato, Cucumber, Carrot, 
+Cucumber, Carrot, Onion
+Onion
+Day 3
+Lemon Juice with Honey
+Watermelon
+Lemon Juice with Honey
+Watermelon
+Day 4
+Lemon Juice with Honey
+Lemon Juice with Honey
+Lemon Juice with Honey
+Lemon Juice with Honey
+Day 5
+Lemon Juice with Honey
+Lemon Juice with Honey
+Lemon Juice with Honey
+Lemon Juice with Honey
+Day 6
+Lemon Juice with Honey
+Lemon Juice with Honey
+Lemon Juice with Honey
+Lemon Juice with Honey
+Day 7
+Lemon Juice with Honey
+Lemon Juice with Honey
+Lemon Juice with Honey
+Lemon Juice with Honey
+Day 8
+Lemon Juice with Honey
+Grape Juice
+Lemon Juice with Honey
+Grape Juice
+Day 9
+Lemon Juice with Honey
+Watermelon
+Lemon Juice with Honey
+Watermelon
+Day 10
+Lemon Juice with Honey
+Pineapple, Watermelon, 
+Lemon Juice with Honey
+Pineapple, Watermelon, 
+Table 1: Diet given to the Naturopathic Fasting Therapy group
+SHETTY ET AL./ EFFECT OF JUICE FASTING ON URINE PH: A CONTROLLED 
+42
+Apart from these juices, the subjects were asked to drink a minimum 
+investigate statistically significant difference within group in urine 
+of 2 liters of water daily, to ensure that they remain hydrated.
+pH of fasting group and control group. 
+The subjects' daily schedule included:
+For all the analysis, we present 95% confidence intervals and 
+considered p < 0.05 as significant.
+●Enema with 300-500 ml pure water twice a day, every morning 
+and evening.
+Results
+●Yoga practice for an hour in the morning and an hour in the 
+evening, consisting of light physical exercises and asana, 
+Urine pH was significantly higher in the fasting group following the 
+breathing practices and pranayamas, meditation and relaxation.
+administration of Naturopathic Fasting Therapy (paired samples t-
+test, t =-3.91, p < 0.05).  The control group (Normal Vegetarian Diet) 
+●Prayer session every early evening, with a half hour of Bhajans 
+showed no significant changes ring the study period (paired samples 
+and chants.
+t-test, t =-0.62).
+Research design
+Group mean values ±S. D. and are given in Table 2.
+We executed a matched controlled design comprising two groups 
+Table 2: Means and standard deviations for Urine pH for fasting and 
+pre-post assessments using the pH meter to test urine pH daily during 
+control groups
+Naturopathy Fasting Therapy (NF) for the fasting group and 
+similarly, daily for Control group. A schematic presentation of the 
+Groups
+Pre
+Post
+t-value
+P-value
+design is presented in Figure 1.
+Fasting group
+5.24 ±0.36
+5.48* ±0.22
+-3.91
+0.01
+Figure 1: Schematic presentation of the study design
+(n=30)
+Control group
+5.32 ±0.35
+5.31 ±0.27
+-0.62
+0.73
+(n=30)
+* p<0.05, Paired Samples t-test
+Discussion
+In the present study, we investigated whether Naturopathic Fasting 
+Therapy is associated with any change in urine pH. We found that the 
+fasting group demonstrated higher urine pH against those eating a 
+normal vegetarian diet for 5 days.
+An acidic Urine and ECF are associated with negative outcomes 
+in a number of diseases, such as bladder cancer, solid tumors and 
+high systolic blood pressure.[12, 13, 14] One of the most important 
+indicators of Urine pH is diet. Diet-derived acid causes a shift in pH 
+towards an acidic one, and higher fruit and vegetable intake as well 
+as lower meat are associated with a more alkaline urine pH.[10]
+An index to predict the effect of a particular food on the acid-base 
+Assessments
+balance in the body is PRAL (Potential Renal Acid Load), which is 
+We assessed urine pH using pH meter. Subjects were provided with 
+an indicator of the amount of diet-derived acid the kidneys have to 
+20 ml urine sample bottles, in which they collected, first void 
+dispose off.[11] An estimate of PRAL based on consumption of 4 
+midstream urine every morning and handed them over. The samples 
+nutrients - proteins, phosphorous, potassium and magnesium - gives 
+were then taken to the Biochemistry lab for analysis.
+a good estimate of Net Acid Excretion.[11]
+A pH meter that was calibrated to pH 5 was used. The electrode was 
+Potential Renal Acid Load during one day of Lemon Juice Fasting, 
+completely dipped in each sample and the meter was switched on, the 
+inclusive of four glasses of lemon juice:
+reading displayed being taken as accurate to 1 significant figure. 
+●PRAL (mEq/d) = 0.49 ×protein (g/d) + 0.037 ×P (mg/d) −0.021 
+After analysis of each sample, the meter was switched off and the 
+×K (mg/d) −0.026 ×Mg (mg/d) −0.013 ×Ca (mg/d)
+electrode thoroughly washed and wiped before analysis of the next 
+●PRAL (mEq/d) =0.49 ×0.46 + 0.037 ×6.89 −0.021 ×116.6 −0.026 
+sample.
+×5.21 −0.013 ×9.16
+Data analysis
+●PRAL (mEq/d) = 0.23 + 0.25 −2.45 −0.14 −0.12 = -2.28 mEq/day
+A PRAL of -2.28 mEq/day indicates that the amount of the acid 
+Data were analyzed using IBM SPSS 20. The data was checked for 
+that the kidneys have to dispose off will reduce, thereby reducing the 
+normality and then a Paired samples t-test was performed to 
+Pomegranate, Papaya, Mango, 
+Pomegranate, Papaya, Mango, 
+Sapodilla, Banana, Tomato, 
+Sapodilla, Banana, Tomato, 
+Cucumber, Carrot, Onion
+Cucumber, Carrot, Onion
+Day 11
+Khichdi [rice and moong dal 
+Banana, Tomato, boiled ashgourd 
+Banana, Tomato, boiled ridge gourd 
+porridge with minimal salt]
+and spinach seasoned with a little 
+seasoned with a little salt, fennel seed 
+salt, fennel seed powder, coriander 
+powder, coriander seed powder and 
+seed powder and grated coconut.
+grated coconut
+Indian Journal of Health and Wellbeing 2014, 6(1), 41-44
+43
+acidity of, and increasing the pH of the urine and the blood. On the 
+other hand, there is one factor that would indicate a shift in urine pH 
+towards acidity. During prolonged periods of starvation, there is an 
+shift from glycolysis to lipolysis and  other metabolic adaptations to 
+low calorie intake, causing a shift in blood pH towards an acidic one. 
+However, there are juices provided during NF Therapy that might 
+prevent this from occurring, by providing a source of energy from 
+simple sugars such as those present in fruits and honey.[19] In order 
+to understand the overall effect of this complex mechanism of acid-
+base balance, we looked at urine pH readings during the first eight 
+days of the study, till the last day of NF Therapy. 
+First Void Urine pH increased by 0.24 ±0.49 pH units, (p<0.05), 
+showing a trend towards alkalinity, in conformation with the PRAL 
+of -2.28 mEq/day of the diet provided to the Naturopathic Fasting 
+Therapy group. Net Acid Excretion, thus, reduced during an 
+intervention of NF Therapy, showing that the acidosis associated 
+with a shift in metabolism to lipolysis and protein utilisation is 
+countered effectively and overcome by Naturopathic Fasting 
+Therapy.
+These findings suggest that a five-day Naturopathic Fasting 
+Therapy regimen can lead to a reduction in acidity of the ECF in 
+healthy individuals. Thus, fasting can have important uses in the 
+background of modern day diets, in which net acid load is 
+considerably high compared to hunter-gatherer civilizations[4], due 
+to higher sodium:potassium and chloride:bicarbonate consumption 
+ratio,[6] reduced magnesium, potassium and fiber, and increased fat 
+and simple sugars.[5] Also, fasting may be a potentially effective tool 
+to use in geriatric care, as renal acid-base regulatory function reduces 
+with age, resulting in an increased diet-induced metabolic 
+acidosis.[8]
+Further studies are warranted in all age groups and conditions to 
+ascertain this effect of Naturopathic Fasting Therapy.
+References
+pH.Journal of the American Dietetic Association95, 791797 (1995).
+Ströhle, A., Hahn, A. & Sebastian, A. Estimation of the diet-dependent net acid load in 
+229 worldwide historically studied hunter-gatherer societies. American Journal of 
+Clinical Nutrition91, 406412 (2010).
+Sebastian, A., Frassetto, L. A., Sellmeyer, D. E., Merriam, R. L. & Morris, R. C. 
+Estimation of the net acid load of the diet of ancestral preagricultural Homo sapiens 
+and their hominid ancestors. American Journal of Clinical Nutrition76, 13081316 
+(2002).
+Frassetto, L., Morris, Jr., R. C., Sellmeyer, D. E., Todd, K. & Sebastian, A. Diet, 
+evolution and aging. European Journal of Nutrition40, 200213 (2001).
+Konner, M. & Eaton, S.B. Paleolithic nutrition: twenty-five years later.Nutrition in 
+clinical practice : official publication of the American Society for Parenteral and 
+Enteral Nutrition 25, 594-602 (2010).
+Lindeman, R.D. & Goldman, R. Anatomic and physiologic age changes in the kidney. 
+Experimental Gerontology21, 379-406 (1986).
+Reddy, S.T., Wang, C.Y., Sakhaee, K., Brinkley, L. & Pak, C.Y.C. Effect of low-
+carbohydrate high-protein diets on acid-base balance, stone-forming propensity, and 
+calcium metabolism. American Journal of Kidney Diseases40, 265-274 (2002).
+Welch, A.A., Mulligan, A., Binghan, S.A., Khaw, K.T. Urine pH is an indicator of 
+dietary acid-base load, fruit and vegetables and meat intakes: results from the 
+European Prospective Investigation into Cancer and Nutrition (EPIC)-Norfolk 
+population study. British Journal of Nutrition99, 1335-1343 (2007)
+Remer, T., Dimitriou, T. &Manz, F. Dietary potential renal acid load and renal net acid 
+excretion in healthy, free-living children and adolescents.American Journal of 
+Clinical Nutrition 77, 1255-1260 (2003).
+Alguacil, J., Kogevinas, M., Silverman, D.T., Malats, N., Real, F.X., García-Closas, M., 
+Tardón, A., Rivas, M., Torà, M., García-Closas, R., Serra, C., Carrato, A., Pfeiffer, 
+R.M., Fortuny, J., Samanic, C., Rothman, N. Urinary pH, cigarette smoking and 
+bladder cancer risk.Carcinogenesis32, 843-847 (2011).
+Raghunand, N., He, X.,vanSluis, R., Mahoney, B., Baggett, B., Taylor, C.W., Paine-
+Murrieta, G., Roe, D., Bhujwalla, Z.M., Gillies, R.J. Enhancement of chemotherapy 
+by manipulation of tumourpH.British Journal of Cancer80, 1005-1011 (1999).
+Damaghi, M., Wojtkowiak, J.W. &Gillies, R.J. pH sensing and regulation in cancer. 
+Frontiers in Physiology4 DEC, (2013).
+Krupp, D., Shi, L. & Remer, T. Longitudinal relationships between diet-dependent renal 
+acid load and blood pressure development in healthy children. Kidney 
+international85, 204-10 (2014).
+Lee, C. & Longo, V.D. Fasting vs dietary restriction in cellular protection and cancer 
+treatment: from model organisms to patients. Oncogene 30, 3305-3316 (2011).
+Abendroth, A. Michalsen, A., Lüdtke, R., Rüffer, A., Musial, F., Dobos, G.J. Changes of 
+Intestinal Microflora in Patients with Rheumatoid Arthritis during Fasting or a 
+Mediterranean Diet. ForschendeKomplementarmedizin (2006)17, 307-313 (2010).
+Beer, A.M., Rüffer, A., Balles, J. &Ostermann, T. Progression of intestinal secretory 
+Mazurak, N. Günther, A., Grau, F.S., Muth, E.R., Pustovoyt, M., Bischoff, S.C, Zipfel, 
+immunoglobulin A and the condition of the patients during naturopathic therapy and 
+S., Enck, P. Effects of a 48-h fast on heart rate variability and cortisol levels in healthy 
+fasting therapy. ForschendeKomplementarmedizin und klassischeNaturheilkunde = 
+female subjects. European Journal of Clinical Nutrition67, 4016 (2013).
+Research in Complementary and Natural Classical Medicine8, 346-353 (2001).
+Shaw, J. C. Nonmetabolizable base balance: effect of diet composition on plasma 
+Manninen, A.H. Metabolic effects of the very-low-carbohydrate diets: misunderstood 
+pH.The Journal of Nutrition119, 17891798 (1989).
+“villains”of human metabolism. Journal of the International Society of Sports 
+Remer, T. &Manz, F. Potential renal acid load of foods and its influence on urine 
+Nutrition 1, 7-11 (2004).
+SHETTY ET AL./ EFFECT OF JUICE FASTING ON URINE PH: A CONTROLLED 
+44

subfolder_0/Effect of mud pack to eyes on psychological variables in healthy volunteers a pilot randomized controlled trial.txt

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+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Journal of Complementary and Integrative Medicine. 2018; 20160085
+Short Communication
+Reshma Jogdand1 / A. Mooventhan2 / NK Manjunath3
+Effect of mud packto eyes on psychological
+variablesin healthyvolunteers: a pilot
+randomizedcontrolled trial
+1 Department of Yoga and Naturopathy, S-VYASA University, Bengaluru, Karnataka, India
+2 Center for Integrative Medicine and Research (CIMR), All India Institute of Medical Sciences (AIIMS), New Delhi, India, E-mail:
+[email protected]
+3 Division of Yoga and Life Sciences, and Head, Department of Research and Development, S-VYASA University, Bengaluru,
+Karnataka, India
+Abstract:
+Background: Mud pack is one of the fundamental therapeutic procedures used in naturopathy to treat various
+diseases. There is a lack of scientific evidence for the use of mud-pack application in psychological variables. The
+present study aims at evaluating the effect of mud pack to eyes on psychological variables in healthy volunteers.
+Materials and methods: Sixty healthy individuals with the age varied from 18 to 21 years were recruited and
+randomly divided into either mud-pack group (n=30) or wet-pack group (n=30). Mud-pack group received
+mud pack to eyes and wet-pack group received wet pack to eyes for a duration of 30 min/session (a total of 15
+sessions). Psychological assessments like Mindful Attention Awareness Scale (MAAS), Perservative Thinking
+Questionnaire (PTQ) and Positive and Negative Affect Scale (PANAS) were taken before and after the interven-
+tion. Statistical analysis was performed using statistical package for the social sciences, version 16.
+Results: Result of this study showed a significant reduction in PTQ score and PANAS negative score in both
+mud-pack and wet-pack groups. But, a significant increase in MAAS score was observed only in the mud-pack
+group, unlike wet-pack group. However, there was no significant difference found in between group analysis.
+Conclusions: Result suggests that though both mud pack and wet pack to eyes reduced the scores of PTQ and
+negative affects, only mud pack to eyes increased the state of mindfulness in healthy individuals.
+Keywords: hydrotherapy, mindfulness, mud therapy, naturopathy, water
+DOI: 10.1515/jcim-2016-0085
+Received: August 22, 2016; Accepted: May 28, 2018
+Background
+Mud is a mixture of inorganic and organic matter with water, which has undergone geological and biological
+processes under the influence of various physico-chemical factors [1]. Mud-pack therapy is a therapeutic ap-
+plication of natural products containing a mix of mineral or mineral-medicinal water (including seawater or
+salt water from lakes) with organic or inorganic compounds resulting from geological, biological or evens both
+processes, used in the form of a wrap or a bath [2].
+In India, mud pack to eyes is one of the treatment procedures commonly employed by the naturopathy
+physicians in patient with psychological and psychosomatic disorders. In previous studies, mud therapy was
+shown to be an effective treatment modality in various psychosomatic diseases like rheumatoid arthritis [3],
+psoriatic arthritis [4], fibromyalgia syndrome [5], spondylitis associated with inflammatory bowel disease [6]
+and also in osteoarthritis of knee [7]. Though mud therapy is used in various psychological and psychosomatic
+diseases, there is lack of evidence in its precised psychological effects. To the best of our knowledge, there is no
+known study reported the effect of mud pack to eyes on psychological variables. Hence, this present study was
+performed to evaluate the effect of mud pack to eyes on psychological variables in healthy volunteers.
+A. Mooventhan is the corresponding author.
+© 2018 Walter de Gruyter GmbH, Berlin/Boston.
+This content is free.
+1
+Unauthenticated
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+Jogdand et al.
+DE GRUYTER
+Materials and methods
+Subjects
+Sixty healthy individuals with the age varied from 18 to 21 years were recruited from a residential college
+(located in South India, India.). Both male and female genders aged 18 years and above who were willing to
+participate in the study were included. Subjects with the history of any systemic and mental illness, regular use
+of medication for any diseases, addiction to smoking and alcoholism were excluded from the study. The study
+protocol was approved and a written informed consent was obtained from each subject.
+Study design
+This is a pilot randomized controlled trial, in which subjects were randomly divided into either mud-pack group
+(n=30) or wet-pack group (n=30). Mud-pack group received mud pack to eyes and wet-pack group received
+wet pack to eyes. Baseline and post-test assessments were taken before and after the intervention. Trail profile
+has been given in Figure 1.
+Figure 1: Trial profile.
+Randomization
+All the recruited subjects were randomly divided into either mud-pack group (n=30) or wet-pack group (n=30)
+using computerized randomization. Randomization was performed by one of the authors who did not involve
+in either intervention or any part of the investigation.
+2
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+DE GRUYTER
+Jogdand et al.
+Blinding/masking
+Since the intervention was given with the closed eyes, all the subjects were blinded to the mud-pack and wet-
+pack interventions. Investigator was kept blind to the mud-pack and wet-pack groups.
+Assessment
+Mindful Attention Awareness Scale (MAAS): It is a 15-item single-dimension measure of trait mindfulness
+designed to assess a core characteristic of mindfulness, namely, a receptive state of mind in which attention,
+informed by a sensitive awareness of what is occurring in the present, simply observes what is taking place.
+Here, the subject was asked to indicate how frequently or infrequently they currently have each experience and
+answer according to what really reflects their experience rather than what they think as their experience should
+be. Response options ranged from 1 to 6, where 1=almost always; 2=very frequently; 3=somewhat frequently;
+4=somewhat infrequently; 5=very infrequently; 6=almost never. Internal consistency levels (Cronbach’s alphas)
+generally range from 0.80 to 0.90. The MAAS has demonstrated high test–retest reliability, discriminant and
+convergent validity, known-groups validity and criterion validity [8].
+Perseverative Thinking Questionnaire (PTQ): It is a 15-item questionnaire in which the subjects were asked to
+describe how he/she typically thinks about his/her negative experiences or problems. They were instructed to
+read and rate all the 15-item the extent to which they apply to them when they think about negative experiences
+or problems. Response options ranged from 0 to 4, where 0=never; 1=rarely; 2=sometimes; 3=often; 4=almost
+always. Internal consistencies (Cronbach’s alphas) were found for the total scale is 0.95 [9].
+Positive and Negative Affect Schedule (PANAS): It consists of two ten-item scales that describe different
+feelings and emotions for positive affects (PAs) and negative affects (NAs) respectively. The ten items for PA
+are attentive, interested, alert, excited, enthusiastic, inspired, proud, determined, strong and active, and the
+ten items for NA are distressed, upset, hostile, irritable, scared, afraid, ashamed, guilty, nervous and jittery.
+Subjects were instructed to read each item and then mark the appropriate answer in the space next to that word
+to indicate to what extent they have felt like this in the past few hours. Response options ranged from 1 to 5,
+where 1=very slightly or not at all; 2=a little; 3=moderately; 4=quite a bit; 5=extremely. The scores generated
+used to vary along the scale of 10–50, with lower scores indicating low (positive or negative) affect and higher
+scores indicating high (positive or negative) affect. The validity and the reliability of the PANAS have been
+tested [10].
+Intervention
+Mud-pack group: All the subjects received mud pack to eyes. Mud pack was prepared using clay obtained from
+about 6 ft below the surface of the earth. Clay was exposed in sunlight, crushed very well, and pebbles and
+stones were removed. The clay was then made into a smooth paste with pure water 1 h before the intervention.
+Mud was kept on a strip of cotton cloth to prepare eye pack (9 cm × 6 cm × 1 cm). The mud pack was prepared
+using water at 20–21oC. All the subjects were asked to lay down on the back with closed eyes, followed by mud
+pack was kept on the subject’s closed eyelids for the duration of 30 min/session for 15 sessions.
+Wet-pack group: All the subjects received wet pack to eyes. Wet pack (9 cm × 6 cm × 1 cm) was prepared
+using cotton cloth wetted in water at the temperature of 20–21oC. All the subjects were asked to lay down on
+the back with closed eyes, followed by mud pack was kept on the subject’s closed eyelids for the duration of 30
+min/session for 15 sessions.
+Statistical analysis
+All the data were checked for the normality test using Kolmogorov–Smirnov and Shapiro–Wilk. Statistical
+analysis was performed using paired sample t-test for within group and independent sample t-test for between
+groups analysis. p-Value <0.05 was considered as significant.
+Results
+Of 83 subjects, 23 subjects did not fulfil the criteria and hence did not include in the study. Recruited 60 sub-
+jects were randomized into either mud-pack group (n=30) or wet-pack group (n=30). Five subjects in each
+3
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+Jogdand et al.
+DE GRUYTER
+group were irregular and did not complete the study. Hence, their data were not included for the analysis.
+Demographic (Table 1) and the baseline assessments were comparable and no significant difference exists in
+between groups except PANAS positive score (Table 2).
+Table 1: Demographic variables of mud-pack group (n=25) and wet-pack group (n=25).
+Variables
+Mud-pack group (n=25)
+Wet-pack group (n=25)
+Age, years
+17.96 ± 0.89
+18.04 ± 0.20
+Gender
+7 Males/18 females
+9 Males/16 females
+Height, cm
+160.64 ± 10.70
+166.28 ± 11.29
+Weight, kg
+45.80 ± 4.24
+45.68 ± 4.59
+Body mass
+index, kg/m2
+28.54 ± 2.28
+27.48 ± 2.07
+Table 2: Baseline and post-test assessments of mud-pack (n=25) and wet-pack (n=25) groups.
+Variables
+Assessment
+Mud-pack group
+(with paired t-test
+values)
+Wet-pack group
+(with paired t-test
+values)
+Independent
+samples t-test
+t-Value
+p-Value
+MAAS
+Baseline
+53.20 ± 12.819
+59.68 ± 15.510
+1.610
+>0.05
+Post
+68.96 ± 13.843
+60.60 ± 15.984
+1.977
+>0.05
+t=4.412
+p<0.001
+t=0.326
+p>0.05
+PTQ
+Baseline
+29.36 ± 11.284
+27.36 ± 10.336
+0.654
+>0.05
+Post
+20.32 ± 14.642
+19.04 ± 13.284
+0.324
+>0.05
+t=2.392
+p<0.05
+t=3.410
+p<0.01
+PANAS
+Positive score
+Baseline
+37.88 ± 6.240
+33.72 ± 5.374
+2.526
+<0.05
+Post
+38.44 ± 6.844
+36.56 ± 7.528
+0.924
+>0.05
+t=0.416
+p>0.05
+t=1.741
+p>0.05
+Negative score
+Baseline
+22.84 ± 7.809
+20.16 ± 6.606
+1.310
+>0.05
+Post
+18.76 ± 5.995
+16.56 ± 5.165
+1.390
+>0.05
+t=2.548
+p<0.05
+t=2.616
+p<0.05
+All values are in mean ± standard deviation. MAAS: Mindful Attention Awareness Scale; PANAS: Positive and Negative Affect Scale;
+PTQ: Perservative Thinking Questionnaire.
+Result of this study showed a significant reduction in PTQ and PANAS negative scores in both mud-pack
+and wet-pack groups. But, a significant increase in MAAS score was observed only in mud-pack group unlike
+wet-pack group. However, there was no significant difference found in between groups (Table 2).
+Discussion
+Result of this study showed a significant reduction in PTQ score and PANAS NA score along with a significant
+increase in MAAS score in subjects those who underwent mud pack to eyes. It suggests that mud pack to eyes
+is an effective modality in reducing the repeated negative thinking (RNT) and NAs while increasing the state
+of mindfulness in healthy individuals.
+A number of different emotional problems have been found to be related to heightened levels of repetitive
+negative thinking in the form of worry and/or rumination. For example, individuals with depressive disor-
+ders have shown to ruminate excessively about the symptoms, causes and consequences of the depression. The
+heightened levels of rumination and/or worry are present in various disorders including post-traumatic stress
+disorder, social phobia, obsessive–compulsive disorder, insomnia, eating disorders, panic disorder, hypochon-
+driasis, alcohol use disorder, psychosis and bipolar disorder. The PTQ is regarded as a valid measure of RNT
+[9]. Result of this study showed a significant reduction in the PTQ score followed by the 15 sessions of mud pack
+to eyes in healthy individuals. It suggests that mud pack to eyes might be useful in reducing RNT. However,
+since this study is conducted in healthy individuals, further studies in clinical population are required to find
+its effect in the prevention and management of various psychological disorders related with RNT.
+In PANAS, the PA represents the extent to which an individual experiences pleasurable engagement while
+the NA represents the extent to which an individual experiences unpleasurable engagement with the envi-
+ronment [10]. The high NA scores reflect ‘subjective distress’ and low NA scores reflect ‘a state of calmness
+4
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+DE GRUYTER
+Jogdand et al.
+and serenity’ [11]. Hence, in this study, a significant reduction in NA score after 15 sessions of mud pack to
+eyes suggests that mud-pack therapy might be useful in increasing a state of calmness and serenity in healthy
+individuals.
+Mindfulness is defined as paying attention in a particular way: on purpose, in the present moment, and
+non-judgmentally. The MAAS positively correlated with various measures of well-being like life satisfaction,
+optimism, and self-esteem and negatively correlated with neuroticism [8] (a stable temperament that is one of
+the vulnerable factors for depression) [12], depression, anxiety and unpleasant affect [8]. Hence, increase in the
+MAAS score followed by the 15 sessions of mud pack to eyes might be useful in increasing attention, optimism
+and self-esteem in healthy individuals.
+Likewise, wet pack to eyes has also showed a significant reduction in PTQ and PANAS NA scores. However,
+there was no significant change in MAAS score compared to its respective baseline. It suggests that though wet
+pack to eyes is effective in reducing RNT and NAs, it was not effective in increasing the state of mindfulness in
+healthy individuals. Hence, even though both mud pack to eyes and wet pack to eyes are effective in reducing
+RNT and NAs, mud pack to eyes was effective in increasing the state of mindfulness too in healthy individuals.
+In various studies, cold application has shown to be effective in improving cardiovascular functions includ-
+ing workload of the heart [13, 14] and autonomic functions towards either sympathetic withdrawal or parasym-
+pathetic activation [15]. Reduction in sympathetic withdrawal is known to activate a state of relaxation and
+activate relaxation response [16]. And thus, a significant reduction in RNT and NA both in mud-pack group
+and wet-pack group might be possibly through either sympathetic withdrawal or parasympathetic activation
+due to the cooling and relaxing effect followed by the application of wet pack to eyes or mud pack to eyes.
+Though water application produces effect that are similar to mud application and can be applied more easily
+and cleanly than mud application, the moisture and coolness retaining property of a mud application (mud
+pack or direct application) is much longer than a water application (pack or compress) [17]. It suggests that
+mud pack to eyes might have produced a better relaxation through its longer cooling effect that is needed to
+increase the state of mindfulness than wet pack to eyes.
+Stress is one of the risk factors associated with sympathetic activation that increases muscle rigidity, blood
+pressure, cortisol and restless mood [16] that are known to affect the mindfulness. Whereas, mud application
+has shown to be effective in reducing muscle rigidity [17], blood pressure and salivary cortisol (indicative of
+reduction in stress) and in improving mood [18] that helps in increasing mindfulness. Since mud is a mixture
+of inorganic and organic matter with water, which has undergone geological and biological processes under
+the influence of various physico-chemical factors [1], the beneficial effects of or mechanism of action of mud
+application were reported to be as a result of combination of its chemical and thermal effects [19]. Whereas,
+the beneficial effect of water application is believed to be mainly as a result of thermal effects. Hence, mud
+application has reported to produce a better therapeutic effect than water application [17]. This explains the
+possible mechanism for the increase in the state of mindfulness in mud-pack group unlike wet-pack group.
+However, further studies are required to warrant the effect of mud therapy on autonomic functions and the
+mechanism behind its effect.
+Strengths of the study: To the best of our knowledge, this is the first study reporting the effect of mud pack
+to eyes on various psychological variables in healthy individuals. Subjects and the investigator were blind to
+the mud-pack and wet-pack groups. Both the applications were feasible, acceptable and none of the subject
+reported any adverse reaction throughout the study period. Hence, this study reports a simple, low-cost inter-
+vention that can be given by anyone.
+Limitations of the study: Sample size was small and it was not calculated based on the previous study. Study
+was conducted in healthy volunteers and thus, application of its results in the pathological condition is limiting
+the scope of the study. Assessments were based on the subjective methods and not on any objective measures.
+Hence, further study is required with larger sample size and objective variables in healthy as well as in clinical
+conditions for the better understanding.
+Conclusions
+Result suggests that though both mud pack and wet pack to eyes reduced the scores of PTQ and NAs, only
+mud pack to eyes increased the state of mindfulness in healthy individuals.
+Author contributions: All the authors have accepted responsibility for the entire content of this submitted
+manuscript and approved submission.
+Research funding: None declared.
+5
+Unauthenticated
+Download Date | 7/26/18 3:11 AM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+Jogdand et al.
+DE GRUYTER
+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] Chadzopulu A, Adraniotis J, Theodosopoulou E. The therapeutic effects of mud. Prog Health Sci. 2011;1:132–6.
+[2] Espejo L, Cardero MA, Garrido EM, Caro B, Torres S. Effects of mud pack therapy on patients with knee osteoarthritis. A randomized con-
+trolled clinical trial. Anales De Hidrología Médica. 2012;5:109–21.
+[3] Codish S, Abu-Shakra M, Flusser D, Friger M, Sukenik S. Mud compress therapy for the hands of patients with rheumatoid arthritis.
+Rheumatol Int. 2005;25:49–54.
+[4] Elkayam O, Ophir J, Brener S, Paran D, Wigler I, Efron D, et al. Immediate and delayed effects of treatment at the Dead Sea in patients with
+psoriatic arthritis. Rheumatol Int. 2000;19:77–82.
+[5] Bellometti S, Galzigna L. Function of the hypothalamic adrenal axis in patients with fibromyalgia syndrome undergoing mud-pack treat-
+ment. Int J Clin Pharmacol Res. 1999;19:27–33.
+[6] Cozzi F, Podswiadek M, Cardinale G, Oliviero F, Dani L, Sfriso P
+, et al. Mud-bath treatment in spondylitis associated with inflammatory
+bowel disease–a pilot randomised clinical trial. Joint Bone Spine. 2007;74:436–9.
+[7] Bostan B, Sen U, Güneş T, Sahin SA, Sen C, Erdem M, et al. Comparison of intra-articular hyaluronic acid and mud pack therapy in the
+treatment of knee osteoarthritis. Acta Orthop Traumatol Turc. 2010;44:42–7.
+[8] De Bruin EI, Zijlstra BJ, van de Weijer-Bergsma E, Bögels SM. The mindful attention awareness scale for adolescents (MAAS-A): psycho-
+metric properties in a Dutch sample. Mindfulness (NY). 2011;2:201–11.
+[9] Ehring T, Zetsche U, Weidacker K, Wahl K, Schönfeld S, Ehlers A. The Perseverative Thinking Questionnaire (PTQ): validation of a content-
+independent measure of repetitive negative thinking. J Behav Ther Exp Psychiat. 2011;42:225–32.
+[10] Crawford JR, Henry JD. The Positive and Negative Affect Schedule (PANAS): construct validity, measurement properties and normative
+data in a large non-clinical sample. Br J Clin Psychol. 2004;43:245–65.
+[11] Merz EL, Malcarne VL, Roesch SC, Ko CM, Emerson M, Roma VG, et al. Psychometric properties of Positive and Negative Affect Schedule
+(PANAS) original and short forms in an African American community sample. J Affect Disord. 2013;151:942–9.
+[12] Barnhofer T, Duggan DS, Griffith JW. Dispositional mindfulness moderates the relation between neuroticism and depressive symptoms.
+Pers Individ Dif. 2011;51:958–62.
+[13] 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.
+[14] Das SV, Mooventhan A, Manjunath NK. A study on immediate effect of cold abdominal pack on blood glucose level and cardiovascular
+functions in patients with type 2 diabetes mellitus. J Clin Diagn Res. 2018;12:KC01–KC04
+[15] 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.
+[16] Dusek JA, Benson H. Mind-body medicine: a model of the comparative clinical impact of the acute stress and relaxation responses. Minn
+Med. 2009;92:47–50.
+[17] Rastogi R. Therapeutic uses of mud therapy in naturopathy. Indian J Trad Knowl. 2012;11:556–9.
+[18] Stier-Jarmer M, Frisch D, Oberhauser C, Immich G, Kirschneck M, Schuh A. Effects of single moor baths on physiological stress response
+and psychological state: a pilot study. Int J Biometeorol. 2017;61:1957–64.
+[19] Odabaş E, Turan M, Erdem H, Pay S, Güleç M, Karagülle MZ. The effect of mud pack treatment in knee osteoarthritis. Turk J Rheumatol.
+2009;24:72–6.
+6
+Unauthenticated
+Download Date | 7/26/18 3:11 AM

subfolder_0/Effect of trataka (Yogic Visual Concentration) on the performance in the corsi-block tapping task A repeated measures study.txt

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+ORIGINAL RESEARCH
+published: 17 December 2021
+doi: 10.3389/fpsyg.2021.773049
+Edited by:
+Pietro Spataro,
+Mercatorum University, Italy
+Reviewed by:
+Karin Matko,
+Technische Universität Chemnitz,
+Germany
+Srikanth N. Jois,
+World Pranic Healing Foundation
+India, India
+*Correspondence:
+Apar Avinash Saoji
+[email protected]
+Specialty section:
+This article was submitted to
+Cognition,
+a section of the journal
+Frontiers in Psychology
+Received: 09 September 2021
+Accepted: 22 November 2021
+Published: 17 December 2021
+Citation:
+Swathi PS, Bhat R and Saoji AA
+(2021) Effect of Trataka (Yogic Visual
+Concentration) on the Performance in
+the Corsi-Block Tapping Task: A
+Repeated Measures Study.
+Front. Psychol. 12:773049.
+doi: 10.3389/fpsyg.2021.773049
+Effect of Trataka (Yogic Visual
+Concentration) on the Performance
+in the Corsi-Block Tapping Task: A
+Repeated Measures Study
+P. S. Swathi, Raghavendra Bhat and Apar Avinash Saoji*
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India
+Background and Objective: Attention and memory are essential aspects of cognitive
+health. Yogasanas, pranayama, and meditation have shown to improve cognitive
+functions. There has been no assessment of Trataka (yogic visual concentration) on
+working or on spatial memory. The present study was planned to assess the immediate
+effects of Trataka and of eye exercise sessions on the Corsi-block tapping task (CBTT).
+Methods: A total of 41 healthy volunteers of both genders with age 23.21 ± 2.81 years
+were recruited. All participants underwent baseline assessment, followed by 2 weeks of
+training in Trataka (including eye exercise). Each training session lasted for 20 min/day
+for 6 days a week. After completion of the training period, a 1-week washout period
+was given. Each participant then was assessed in two sessions in Trataka and in eye
+exercise on two separate days, maintaining the same time of the day. Repeated measure
+analysis of variance with Holm’s adjustment was performed to check the difference
+between the sessions.
+Results: Significant within-subjects effects were observed for forward Corsi span
+andforward total score (p < 0.001), and also for backward Corsi span (p < 0.05) and
+backward total score (p < 0.05). Post hoc analyses revealed Trataka session to be better
+than eye exercises and baseline. The eye exercise session did not show any significant
+changes in the CBTT.
+Conclusion: The result suggests that Trataka session improves working memory,
+spatial memory, and spatial attention.
+Keywords: Trataka, yoga, shatkriya, kriya, Corsi-block tapping task, eye exercise, cognition, spatial memory
+INTRODUCTION
+Yoga, an ancient Indian tradition, is aimed at all-round personality development (Taimni, 2010).
+The practices in the discipline of yoga include yama and niyama (moral and ethical conduct),
+asana (physical postures), pranayama (regulated breathing), dharana, dhyana (meditation), and
+shuddhikriya (cleansing practices). Scientific research in recent times has explored the positive
+impact of yoga practices on various domains of physiology and psychology in healthy and
+therapeutic settings (Field, 2016). One major area of interest in yoga research has been the effects of
+yoga practices on cognition and performance. Yoga practices appear to prevent neurodegeneration
+and enhance neuroplasticity by influencing specific brain areas involved with domains of cognition
+Frontiers in Psychology | www.frontiersin.org
+1
+December 2021 | Volume 12 | Article 773049
+Swathi et al.
+Trataka and Cognition
+such as hippocampus, amygdala, prefrontal cortex, insula, and
+default mode network (Marciniak et al., 2014; Gothe et al.,
+2019). A meta-analysis, which included fifteen RCTs and
+eight acute exposure studies, indicated the beneficial effect of
+yoga on cognition, attention, processing speed, and memory
+(Gothe and McAuley, 2015).
+Various aspects of cognition, such as spatial and visual
+memory scores (Joshi and Telles, 2008; Garg et al., 2016; Gupta
+et al., 2019), verbal memory (Naveen et al., 1997), executive
+functions, attention, and concentration (Chattha et al., 2008),
+working memory (Subramanya and Telles, 2009), response
+inhibition (Rajesh et al., 2014), visual attention (Jarraya et al.,
+2019), and task-switching (Anusuya et al., 2021), were found to be
+positively influenced through yoga practices such as yogasanas,
+pranayama, and meditation techniques. Yoga practice was found
+to be better than physical exercises in improving cognitive
+functions in school children (Vhavle et al., 2019).
+The classical texts of Hathayoga described the profound
+impact of the six cleansing techniques on various aspects of
+one’s personality, which are also validated through empirical
+studies (Muktibodhananda, 1999; Swathi et al., 2020). Trataka
+(Yogic Visual concentration) is one of the cleansing techniques
+considered to enhance vision and positively influence cognitive
+processes. Since the process of Trataka involves focused attention
+on a candle flame, the practice leads to the mind becoming
+one-pointed and arouses inner vision (Muktibodhananda, 1999).
+Earlier studies on Trataka and cognition have demonstrated
+enhanced performance in Stroop Task (Raghavendra and Singh,
+2016; Sherlee and David, 2020), Six Letter Cancelation, Trail
+Making tasks (Talwadkar et al., 2014), and Critical Flicker Fusion
+(Mallick and Kulkarni, 2010). Considering the earlier studies
+on Trataka and cognition, we hypothesize that Trataka may
+positively influence the domains of cognition, such as spatial
+and working memory. Corsi-block tapping task (CBTT) is a
+neuropsychological test that measures visuospatial short-term
+and working memory. The task can be performed using a
+computer to collect the data with precision (Kessels et al.,
+2000; Siddi et al., 2020). Considering the wide use and ease
+of administration of CBTT, the current study was designed to
+evaluate the effect of Trataka on the performance in the CBTT.
+MATERIALS AND METHODS
+Participants
+A total of 90 volunteers from a University in South India were
+briefed about the study protocol. Out of which, 60 consented to
+participate in the study. The inclusion criteria were normal vision
+(6/6) on Snellen’s chart and regular physical and psychological
+health as assessed by a physician who, otherwise, had no role
+in the study. We included participants with prior experience of
+yoga practices other than Trataka. We excluded volunteers who
+had any known eye disorders, including refractive errors, color
+blindness, glaucoma, cataract, any ophthalmological surgeries, or
+presence of cognitive or neurological disorders, respiratory or
+cardiac, and sensory abnormalities. We also excluded participants
+who had a history of smoking or alcoholism. Finally, 41
+subjects (8 male and 33 female) with their mean (± SD) age
+23.21 ± 2.81 years were recruited to the study. Out of the 41
+subjects, 31 were pursuing their undergraduate education, 4 were
+graduates, and 6 had completed postgraduation. Their experience
+in yoga ranged between 1 and 7 years (mean ± SD = 3.98 ± 1.44).
+Sample Size Calculation
+The sample size was calculated using G∗power where alpha was
+0.05 and power was 0.8. The effect size was found to be 0.50
+(Gupta et al., 2019). The recommended sample size resulted in
+being 33 participants for each session. Considering dropouts to
+be at about 25% during the training, we decided to have 41
+participants for each session.
+Ethical Consideration and Trial
+Registration
+The Institutional Ethics committee approved the study of the
+university (Ref. No: RES/IEC-SVYASA/182-C/2021). Written
+informed consent was obtained from individual participants
+before their recruitment to the study. The study was registered
+with the Clinical Trial Registry of India (CTRI/2021/03/031872).
+Trial Design
+We executed a within-subject repeated measures design. All
+participants underwent baseline assessment, followed by 2 weeks
+of training in Trataka (including eye exercise). Each training
+session lasted for 20 min/day for 6 days a week. This orientation
+was administered to avoid individual variations in the practice.
+After completion of the training period, a 1-week washout period
+was given. Each participant then was assessed in two sessions in
+Trataka and in eye exercise on two separate days, maintaining
+the same time of the day (between 4 pm and 6 pm). The order
+of allotment of Trataka and eye exercise sessions was block
+randomized using a web-based random number generator1. Half
+the participants practiced Trataka on day 1, eye exercise on day 2
+and vice versa. The CBTT was recorded following both the trial
+conditions (Trataka and eye exercise).
+Intervention
+Baseline
+The participants were asked to give their baseline assessment
+without any intervention. On the day of baseline assessment, the
+participants were seated comfortably in a cross-legged position
+for 5 min prior to the commencement of the CBTT performance.
+Trataka Session
+Each Trataka session consisted of 20 min practice. Throughout
+the practice, the participants were seated comfortably on the floor
+in a cross-legged position. The practice consists of 2 distinct
+stages. Each Trataka session involved a preparatory stage of eye
+exercises for 10 min. These were performed with eyes open in a
+well-lit, soundproofed recording room in the laboratory. During
+this stage, the participants were asked to move the eyeballs in
+horizontal, vertical, diagonal, and circular directions. The second
+1www.randomizer.org
+Frontiers in Psychology | www.frontiersin.org
+2
+December 2021 | Volume 12 | Article 773049
+Swathi et al.
+Trataka and Cognition
+stage is the practice of gazing at the candle flame in a dark room,
+where the candle was placed at the participant’s eye level at a
+distance of 2 m. The participants were asked to fix their gaze
+on the candle flame for about 2 to 3 min without blinking their
+eyes. Then they were asked to visualize the candle flame between
+the eyebrows with closed eyes. This process was repeated for
+three rounds. Later, subjects were asked to defocus, and practice
+concluded in silence with a prayer. This stage lasted for a total
+duration of 10 min. A pre-recorded audio was used to maintain
+uniformity of the practice among participants.
+Eye Exercise Session
+The eye exercise session included eyeball movements in the
+horizontal, vertical, diagonal, and circular directions for 10 min
+followed by 10 min of quiet sitting with closed eyes. The eyes open
+part was performed in well-lit room, while the eyes closed part
+was performed by switching offthe lights to maintain similarity
+of interventions.
+Assessments
+Corsi-Block Tapping Task
+Corsi-block tapping task is a popular neuro-psychological task
+used to assess working and spatial memory. Nine blue squares
+appear on the screen. For each trial, the squares "light up" as
+yellow one by one in a varying sequence. After the presentation,
+the participants had to click each of the boxes in a similar order
+in which they have to "lit up" the first part of the task, i.e.,
+forward tapping. In the second part of the task, they maintained
+the reverse order, i.e., backward tapping (Kessels et al., 2008).
+The task begins with a two-box sequence to a maximum of nine.
+The test gets terminated when the participant cannot remember
+the sequence for two consecutive trials at any one level. Hence,
+the test assesses the following four variables: (i) forward Corsi
+span, (ii) forward total score, (iii) backward Corsi span, and
+(iv) the backward total score. Figure 1 illustrates the forward
+and backward CBTT.
+Presentation of Corsi-Block Tapping Task
+We assessed the participants at baseline, following Trataka and
+eye exercise sessions. The participants were asked to avoid
+caffeine consumption on all the assessment days as it may
+alter their cognitive abilities. The CBTT (Kessels et al., 2000,
+2008) was presented using the INQUISIT software package 4.0
+(Millisecond Software, LLC, Seattle, WA, United States) on a
+Dell desktop computer with a 21.5 color monitor. Uniform
+configuration was maintained for the computers on which the
+CBTT was presented to maintain the uniform processing speed.
+All participants received a practice session prior to the actual
+assessment session to familiarize themselves with the CBTT. The
+experiment was conducted individually in a room under standard
+fluorescent lighting in the research laboratory.
+Data Analysis
+The data were tabulated and data analyses were performed using
+JASP statistical package version 0.14.12. The data were tested
+2https://jasp-stats.org
+for normality and repeated measures (RM) ANOVA for within-
+subjects effects. Post hoc corrections were done using Holm’s
+method for checking the differences between sessions.
+RESULTS
+All 41 participants (eight male) completed all three sessions.
+RM ANOVA demonstrated significant within-subjects effect in
+Forward Corsi Span F(2,80) = 8.757, p < 0.001; Forward total
+scores F(2,80) = 11.377, p < 0.001; Backward Corsi Span
+F(2,80) = 3.629, p = 0.031; Backward total scores F(2,80) = 3.950,
+p = 0.023. The within-subjects effects obtained through RM
+ANOVA are presented in Table 1.
+Pairwise
+comparisons
+between
+the
+sessions
+performed
+through RM ANOVA with Holm’s corrections demonstrated
+significantly higher scores following Trataka sessions when
+compared with baseline for Forward Corsi Span, t = −4.11,
+p < 0.001; Forward Total Score, t = −4.76, p < 0.001; and
+Backward Total Score, t = −2.74, p < 0.05. Scores following
+the Trataka session were significantly higher than following Eye
+exercises for Forward Corsi Span, t = 2.74, p < 0.05; Forward
+Total Score, t = 2.65, p < 0.05. The scores increased from
+baseline, following Eye exercise only for Forward Total Scores,
+t = −2.10, p < 0.05. The effect sizes and t-values for between
+sessions using RM ANOVA with Holm’s correction along with
+the group mean and SD are reported in Table 2.
+DISCUSSION
+The current study was designed to elicit if the practice of
+Trataka affects the working and the spatial memory through the
+performances in the CBTT. All the four measures, viz., forward
+and backward Corsi spans, and total scores, demonstrated
+significance within the subject’s effect. The Corsi span and total
+scores were higher following Trataka while comparing with
+baseline and Eye exercises. Scores following eye exercises and
+baseline sessions were insignificant except in Forward total score.
+The forward span and total score of CBTT measure material-
+specific slave systems. The backward test measures primarily
+tax central executive resources (Monaco et al., 2013). Thus,
+improvements in both forward and backward span and total
+scores indicated a positive effect of Trataka on working, spatial
+memory, and executive functions while comparing with baseline
+and eye exercises.
+Earlier studies on Trataka and cognition have shown
+improvements in the domains of selective attention, cognitive
+flexibility, and response inhibition through the Stroop task
+(Raghavendra and Singh, 2016; Sherlee and David, 2020).
+Another study shown improvement in the performance of critical
+flicker fusion after the immediate practice of Trataka in 35
+volunteers (Mallick and Kulkarni, 2010). After the practice of
+Trataka for 26 days, the performances of the digit span test, the
+six-letter cancelation test, and the trail making test significantly
+improved in thirty elderly subjects compared to the waitlist
+control group (Talwadkar et al., 2014). Thus, improvements
+Frontiers in Psychology | www.frontiersin.org
+3
+December 2021 | Volume 12 | Article 773049
+Swathi et al.
+Trataka and Cognition
+FIGURE 1 | Corsi-block tapping task (CBTT): Forward and backward.
+TABLE 1 | Results of repeated measures analysis of variance for
+within-subjects effects.
+Variable
+F
+df
+P
+Partial η2
+Forward Corsi span
+8.757
+2, 80
+<0.001
+0.180
+Forward total score
+11.377
+2, 80
+<0.001
+0.221
+Backward Corsi span
+3.629
+2, 80
+=0.031
+0.083
+Backward total score
+3.950
+2, 80
+=0.023
+0.090
+noted in our study in the cognitive abilities following Trataka are
+similar to the earlier studies.
+Trataka practice is indicated to positively influence cognition
+from both classical texts of yoga (Muktibodhananda, 1999)
+and
+empirical
+studies
+(Swathi
+et
+al.,
+2020).
+Although
+classified as a cleansing procedure, the practice of Trataka
+is similar to focused meditation techniques. Earlier studies
+on
+meditation
+for
+a
+total
+duration
+of
+8
+weeks
+shown
+decreased negative mood and enhanced attention, working
+memory, and decreased state anxiety on the trier social
+stress test (TSST) in population naive to meditation practice
+(Basso et al., 2019). Another focused attention meditation
+showed significant improvement in working memory in the
+reading span test and in activation of bilateral dorsolateral
+prefrontal cortex (DLPFC) during the intervention in the
+experimental group (Yamaya et al., 2021). Similarly, other
+Yoga interventions showed improved cognitive communicative
+abilities (Namratha et al., 2017).
+The improvement in the performance of CBTT may
+have been mediated through relaxation, attained through the
+Frontiers in Psychology | www.frontiersin.org
+4
+December 2021 | Volume 12 | Article 773049
+Swathi et al.
+Trataka and Cognition
+TABLE 2 | Pairwise comparisons between sessions for the performance in Corsi-block tapping task (CBTT) using repeated measures ANOVA with Holm’s Corrections.
+Variables
+Baseline
+Trataka
+Eye exercise
+Baseline vs. Trataka
+Baseline vs. Eye exercise
+Trataka vs. Eye exercise
+t value
+p value
+Cohen’s d
+t value
+p value
+Cohen’s d
+t value
+p value
+Cohen’s d
+Forward Corsi span
+5.5 ± 0.8
+6.1 ± 0.9
+5.7 ± 1.0
+−4.11
+<0.001
+0.642
+−1.37
+=0.17
+0.214
+2.74
+<0.05
+0.428
+Forward total score
+44.26±15.59
+56.95 ± 17.77
+49.87 ± 18.60
+−4.76
+<0.001
+0.743
+−2.10
+<0.05
+0.329
+2.65
+<0.05
+0.415
+Backward Corsi span
+5.9 ± 0.4
+6.1 ± 0.4
+5.8 ± 0.7
+−2.22
+=0.06
+0.348
+0.20
+=0.84
+0.032
+2.43
+=0.052
+0.379
+Backward total score
+51.41 ± 10.67
+56.68 ± 10.91
+52.97 ± 11.67
+−2.74
+<0.05
+0.427
+−0.81
+=0.42
+0.127
+1.92
+=0.115
+0.301
+practice of Trataka (Raghavendra and Ramamurthy, 2014). The
+possible mechanisms for improving working and spatial memory
+following the Trataka session could be the process of Trataka
+itself, involving focused attention. This focused attention is
+also elaborated in the Yoga Sutras (aphorisms) of Patanjali
+(Taimni, 2010). A recent study has also demonstrated enhanced
+mindfulness, attention, and reduced mind-wandering with the
+practice of Trataka (Swathi et al., 2021). Thus, improved working
+memory found in our study could be due to a reduction in
+mind-wandering and enhanced focusing. The prefrontal cortex
+is associated with memory, attention, executive functions, and
+various other complex cognitive functions (Miller, 2000). Thus,
+the results following the Trataka session could be due to
+activation of the prefrontal cortex. However, further studies
+with neuroimaging techniques may be required to confirm this
+mechanism of action.
+Another possible mechanism could be a surge in melatonin
+release due to practice in the dim light. It is known that bright
+light tunes the suprachiasmatic nucleus (SCN) that regulates the
+circadian rhythm. Exposure to bright light impedes the melatonin
+synthesis, whereas the dim light initiates the surge in melatonin
+release (Zisapel, 2018). Melatonin has been found to positively
+influence learning and memory (Zakaria et al., 2016). Thus,
+further studies on Trataka may assess the serum melatonin levels
+as one of the variables.
+Our
+study
+indicated
+a
+beneficial
+role
+of
+Trataka
+in
+enhancing the CBTT performance in healthy volunteers.
+CBTT performance is commonly altered in neurodegenerative
+disorders such as early-stage Parkinson’s (Stoffers et al., 2003)
+and Alzheimer’s disease (Guariglia, 2007). Thus, future studies
+may be planned in a clinical population, where the CBTT
+performance is compromised.
+Using a repeated measures design for immediate effect is
+one of the strengths of the study. We also used a computer-
+based program to execute CBTT, which enabled robust results
+(Brunetti et al., 2014). The limitation of the study includes not
+incorporating a neuro-imaging technique, which has limited
+our ability to predict the exact mechanism of action. Thus,
+future studies on Trataka and cognitive performance should
+include neuroimaging techniques. Another major limitation of
+the study is control condition which had eye exercise for
+10 min followed by 10 min of quiet sitting in which they
+were told not to meditate. However, we are not sure if during
+quiet sitting, if they focused on breathing or let their mind
+wandered freely. We could not get an equal number of male
+and female participants and were also unable to study the
+impact of long-term practice of tataka. Lastly, the effect of
+Trataka in a population with mild cognitive decline could be
+studied in future.
+CONCLUSION
+The results of this study indicated a positive impact of the
+Trataka session on the CBTT, indicating enhanced working
+memory, spatial memory, and spatial attention among the
+subjects compared to the baseline and eye exercise sessions.
+Frontiers in Psychology | www.frontiersin.org
+5
+December 2021 | Volume 12 | Article 773049
+Swathi et al.
+Trataka and Cognition
+Thus, Trataka could be used to improve memory and attention
+in young adults.
+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. The patients/participants provided their written
+informed consent to participate in this study.
+AUTHOR CONTRIBUTIONS
+PS was involved in conceptualization, execution, data collection,
+and writing and editing of the manuscript. RB was involved
+in conceptualization, data analysis and interpretation, and
+writing and editing of the manuscript. AS was involved in
+conceptualization, data collection, analysis and interpretation,
+and writing and editing of the manuscript. All authors
+contributed to the article and approved the submitted version.
+FUNDING
+The authors gratefully acknowledge Swami Vivekananda Yoga
+Anusandhana Samsthana (Deemed to be University), Bengaluru,
+for the funding.
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+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 © 2021 Swathi, Bhat and Saoji. 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 Psychology | www.frontiersin.org
+7
+December 2021 | Volume 12 | Article 773049

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+Work 33 (2009) 297–306
+297
+DOI 10.3233/WOR-2009-0877
+IOS Press
+Effect of yoga on musculoskeletal discomfort
+and motor functions in professional computer
+users
+Shirley Telles∗, Manoj Dash and K.V. Naveen
+Swami Vivekananda Yoga Research Foundation [a Yoga University], Bangalore, India
+Received 6 October 2007
+Accepted 18 February 2008
+Abstract. The self-rated musculoskeletal discomfort, hand grip strength, tapping speed, and low back and hamstring flexibility
+(based on a sit and reach task) were assessed in 291 professional computer users. They were then randomized as Yoga (YG;
+n = 146) and Wait-list control (WL; n = 145) groups. Follow-up assessments for both groups were after 60 days during which
+the YG group practiced yoga for 60 minutes daily, for 5 days in a week. The WL group spent the same time in their usual
+recreational activities. At the end of 60 days, the YG group (n = 62) showed a significant decrease in the frequency, intensity
+and degree of interference due to musculoskeletal discomfort, an increase in bilateral hand grip strength, the right hand tapping
+speed, and low back and hamstring flexibility (repeated measures ANOVA and post hoc analysis with Bonferroni adjustment).
+In contrast, the WL group (n = 56) showed an increase in musculoskeletal discomfort and a decrease in left hand tapping speed.
+The results suggest that yoga practice is a useful addition to the routine of professional computer users.
+1. Background of the study
+There is extensive evidence that working with com-
+puter terminals and keyboards is associated with the
+development and exacerbation of a variety of work-
+related disorders involving the back, neck, and upper
+limbs [2]. These conditions are known as cumulative
+trauma disorder (CTD). The National Institute for Oc-
+cupational Safety and Health (NIOSH) estimated that
+15–20 percent of the workforce in the United States is
+at risk of developingCTD [20]. In India a survey of 500
+professional computer users showed that over 50 per-
+cent of them had symptoms of established CTD [25].
+Many investigators have identified the risk factors
+that are closely related with CTD of the upper extrem-
+ities. These include repetitive motion, excessive force,
+∗Address for correspondence:
+Shirley Telles, Ph.D., Patanjali
+Yogpeeth, Maharishi Dayanand Gram, New Delhi-Haridwar High-
+way, Bahadrabad, Haridwar 249 402, India. Tel.: +91 1334 240008;
+Fax: +91 1334 244805; E-mail: [email protected].
+and maintenance of awkward or constrained postures
+for prolonged periods [1,16,27].
+Various solutions to CTD include modifying work-
+stations, using alternative keyboards and pointing de-
+vices, and adopting software solutions to minimize the
+key presses required to execute elaborate routines [33].
+However these are only partial solutions to CTD. It
+is essential to keep professional computer users aware
+about injurious keyboard techniques, as well as pos-
+tures and working styles which place them at risk [14,
+22].
+Apart from this there have been studies to evaluate
+the impact of lifestyle on the prevention of CTD while
+complementary treatments have been used in the man-
+agement of this condition. A cross-sectional survey
+of 134,072 respondents in Canada, showed that being
+physically active during leisure time was associated
+with a lower prevalence of work-related upper body
+CTD compared to the general prevalence of 5.9 percent
+in the Canadian population [24].
+In the management of CTD various combinations
+of exercise and health awareness strategies have been
+1051-9815/09/$17.00 2009 – IOS Press and the authors. All rights reserved
+298
+S. Telles et al. / Yoga and motor functions in computer professionals
+tried. For example, daily exercises which emphasize
+posturalawarenesstocorrectpoorpostureandprovidea
+basic physiological understanding of the disorder have
+been found effective in reducing stiffness and pain of
+the upper back and neck in CTD [23]. There is also
+some evidence to indicate that splinting, laser acupunc-
+ture, yoga and therapeutic ultrasound may be effec-
+tive in the short to medium term (i.e., up to 6 months)
+management of carpal tunnel syndrome [10]. This was
+based on an assessment of two systematic reviews, six-
+teen randomized controlled trials (RCTs) and a single
+before-and-after study using historical controls.
+An
+earlier RCT did indicate the benefits of yoga over splint-
+ing for carpal tunnel syndrome [9]. In this trial the ben-
+efit was derived from practicing eleven yoga postures
+intended to strengthen, stretch, and balance each joint
+in the upper body, practiced along with relaxation given
+twice weekly, for eight weeks. Following yoga the par-
+ticipants showed a significant decrease in pain and an
+increase in grip strength whereas a control group (who
+were given a wrist splint to supplement their treatment)
+showed no change.
+The hand grip strength measures muscle strength and
+endurance in the hand and forearm muscles.
+Expe-
+rienced computer users with symptoms of discomfort
+in the hand-wrist and forearm-elbow had lower pinch
+grip strength than those who were asymptomatic [15].
+In a separate study on normal volunteers and patients
+with rheumatoidarthritis, the hand grip strength of both
+hands measured with a grip dynamometer increased
+in normal adults, children and in rheumatoid arthritis
+patients following yoga practice which included yoga
+postures (asanas), voluntarily regulated yoga breathing
+(pranayamas), and meditation (dhyana) [5]. An equal
+number of normal adults, children, and patients with
+rheumatoid arthritis who did not practice yoga showed
+no increase in hand grip strength, suggesting that there
+was no re-test effect. Given the fact that symptomatic
+computer users did have a lower pinch grip strength
+and that hand grip strength has been shown to improve
+with yoga practice [5,28] in the present study hand grip
+strength was assessed in professional computer users
+following yoga.
+In an earlier study another aspect of motor func-
+tion, viz., motor speed, was also found to improve fol-
+lowing thirty days of practicing a combination of yo-
+ga postures, breathing techniques and meditation ev-
+ery day [4]. The number of successive, rapid alternat-
+ing movements in a given time, as in a tapping speed
+task, is a standard measure to clinically evaluate motor
+speed [26]. Following thirty days of yoga the tapping
+speed increased in the first ten seconds of the thirty-
+second tapping speed task. This showed that motor
+speed for repetitive finger movements increased fol-
+lowing yoga, but since the increase was not sustained
+for thirty seconds, it suggested that endurance was not
+improved. In the present study it was considered rele-
+vant to study the tapping speed based on a report that in
+contrast to earlier biomechanicaltheories, the key press
+force and key press speed were negatively associated
+with musculoskeletal discomfort [18]. In particular,
+slower key press speeds were associated with higher
+levels of right shoulder discomfort and fatigue.
+The effect of yoga practice on the hand grip strength
+and tapping speed have not been studied in professional
+computer users who are potentiallyat risk of developing
+CTD
+2. Methods
+2.1. Purpose of the study
+The present randomized controlled trial was con-
+ducted to assess the effect of sixty days of yoga practice
+on musculoskeletal discomfort, motor functions (viz.,
+strength and motor speed) and hip and lower back flex-
+ibility in professional computer users. This research
+may help to develop a yoga module attending to the
+specific requirements of professional computer users.
+2.2. Sampling
+Two hundred and ninety one persons working in a
+software company in Bangalore, India were recruited
+for the study. All the participants in the study used
+a computer for at least 6 hours each day, for 5 days
+in a week. Persons of both sexes with ages ranging
+between 21 and 49 years participated in the trial. The
+following conditions were the basis for excluding par-
+ticipants from the trial: (i) those who reported symp-
+toms of musculoskeletaldiscomfort(neck/shoulderand
+hand/arm) during a clinical examination, requiring the
+use of analgesics and (ii) subjects who were left hand
+dominant. Hand dominancewas assessed using the Ed-
+inburgh handedness inventory [21]. All subjects were
+right hand dominant. None of the participants had to
+be excluded based on the criteria mentioned above.
+Both groups had comparable job assignments and
+responsibilities based on rating by the human resource
+personnel from the software company.
+All of them
+were involved in software development and had com-
+S. Telles et al. / Yoga and motor functions in computer professionals
+299
+Total number selected & randomly assigned to two groups=291 
+Yoga 
+Group
+Control 
+Group
+Pre 
+(n=146)
+Pre 
+(n=145)
+Post
+(n= 62)
+Post
+(n= 56)
+Drop outs, unable to 
+regularly attend: 
+1. Intervention (n=57) 
+2. Assessments (n=27) 
+Drop outs, unable to 
+regularly attend: 
+1. Recreational 
+activities (n=58) 
+2. Assessments (n=31)
+Fig. 1. The trial profile of the randomized controlled study.
+parable experience in it, having spent comparable time
+working in software development and also having tasks
+of comparable complexity assigned to them.
+The details of the study were explained to the partic-
+ipants and their consent to participate in the study was
+obtained. The project was approved by the ethics com-
+mittee of the research foundation and had the approval
+of the human resource department of the software com-
+pany.
+2.3. Design
+The 291 participants were randomizedas two groups
+using a standard random number table prior to their as-
+sessment. The two groups were then designated as (i)
+intervention (i.e., yoga, n = 146) and (ii) wait list con-
+trol (n = 145), by a person from the software company
+who had no other part in the study. The yoga (YG) and
+wait list control (WL) groups were comparable with
+respect to their age [group average (± S.D.) 32.8 (±
+8.6) years and 31.9 (± 10.2) years, respectively], gen-
+der distribution [11 females in YG group and 13 in WL
+group], the type of work they did, their workstations
+and the number of hours they used a computer each
+day.
+Both groups were assessed at baseline and after
+60 days. During the 60 days the YG group had an
+hour of yoga practice each day, for five days in a week.
+While the YG group practiced yoga the WL group spent
+the time in the recreation center of the software com-
+pany where 60 percent of them talked to their friends,
+12 percent spent time playing indoor games, 12 percent
+exercised 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 rou-
+tine. Hence the wait-list control group served mainly to
+assess the changes related to repeated-testing after 60
+days. During the 60 days there were 84 drop outs from
+the trial in the YG group and 89 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 YG and WL
+groups). Most of the participants who were consid-
+ered as ‘drop-outs’ had been posted to other companies
+elsewhere during the two month study period. To be
+considered as regular in their participation they had to
+have a minimum of 38 days of attendance during the
+60 day period. The trial profile is given in Fig. 1.
+These details as well as the trial profile have been
+provided in an earlier report of the effects of this yoga
+programon symptoms of visual discomfort(i.e., of ‘dry
+eye’) [29].
+2.4. Assessments
+2.4.1. Musculoskeletal and hand discomfort
+The Cornell Musculoskeletal Discomfort Question-
+naire (CMDQ) The Cornell Musculoskeletal Discom-
+fort Questionnaire (CMDQ) is a questionnaire which
+combines a body map diagram with questions about
+the seven day prevalence of musculoskeletal pain,
+its’ severity, and if it interfered with performing
+job duties.
+This questionnaire was used in a 1999
+study of musculoskeletal discomfort among keyboard
+users [12]. Since this survey was based on another in-
+strument called the Nordic Musculoskeletal Question-
+naire (NMQ), it was concluded that the CMDQ had
+300
+S. Telles et al. / Yoga and motor functions in computer professionals
+the same validity [12] The CMDQ has face validity
+and test-retest reliability, though this was studied over
+a three week period [12]. The main limitations of this
+instrument are the lack of clinical validity testing for it
+specifically and the fact that it is primarily developed
+for use in upper body disorders. The tool does not as-
+sess if the musculoskeletal discomfort is work-related.
+The CMDQ was used to assess: (i) frequencyof pain
+episodes during the last work week at: neck; shoulder;
+elbow; arm; wrist; hands and fingers, (ii) the inten-
+sity of pain expressed as level of discomfort and (iii)
+the interference with the ability to work. The symp-
+toms were considered during the week before assess-
+ment. The scores were analyzed by weighting the rat-
+ing scores to more easily identifythe most serious prob-
+lems and summing the rating values for each person
+for the whole body, right hand and left hand separately
+as follows. For frequency the rating was: Never = 0,
+1–2 times/week = 1.5, 3–4 times/week = 3.5, Every
+day = 5, and Several times every day = 10. The level
+of discomfort scores were analyzed as: Slightly = 1,
+Moderately uncomfortable = 2, and Very uncomfort-
+able = 3. The Interference scores were rated as: Not
+at all = 1, Slightly interfered = 2, and Substantially
+interfered = 3.
+The person who administered the questionnaire and
+scored the response sheets was not aware to which
+group the subjects belonged.
+2.4.2. Hand grip strength
+Hand grip strength of both hands was assessed us-
+ing a hand grip dynamometer (Lafayette Instruments,
+Model No. 76618, Indiana, USA). Subjects were tested
+in 6 trials, 3 for each hand alternately, with a gap of
+10 seconds between trials. During the assessment sub-
+jects were asked to keep their arm extended at shoul-
+der level, horizontal to the ground, with extension at
+the elbow as has been described earlier [5]. The max-
+imum value obtained during the three trials was used
+for statistical analysis.
+2.4.3. Tapping speed
+Tapping speed was measured using an apparatus con-
+sisting of an 18 inch fiber-resin board with two rect-
+angular metal plates on either end, 11 inches apart
+(Lafayette Instruments, Model No. 32012, Indiana,
+USA) The apparatus has a metal stylus connected to
+it and contacts between the stylus and the two metal
+plates are registered on an impulse counter. Subjects
+were instructed to use their right hand to hold the stylus
+and tap on the steel plate which is on the right side
+of the board, and to use their left hand for the board
+on the left side. They were asked to tap as rapidly as
+possible. The apparatus was kept on a table at the level
+which the keyboard was kept and tapping was carried
+out with the wrist supported and the stylus held as a
+pen is held. Assessments were made for both hands,
+and the order of testing a particular hand was alternated
+for different subjects. Tapping speed was assessed in
+three contiguous periods of 10 seconds. This was done
+separately for each hand.
+2.4.4. Low back and hamstring flexibility
+Low back and hamstring flexibility were assessed
+using a standard sit-and-reach apparatus (Lafayette In-
+struments, Model No. 01285, Indiana, USA) and fol-
+lowing a standard method [7]. The test involves sitting
+on the floor with legs out straight ahead. Bare feet
+are placed with the soles flat against the box, shoulder-
+width apart. Both knees are held flat against the floor
+by the tester.
+With hands on top of each other and
+palms facing down, the subject reaches forward along
+the measuring line as far as possible, sliding a plate
+with a marker, along the scale as far forward as possi-
+ble. After one practice reach, the second reach is held
+for at least two seconds while the distance is record-
+ed. It is made sure that there are no jerky movements,
+and that the fingertips remain level and the legs flat.
+The distance to which the plate and indicator are slid
+forward are recorded to the nearest cm.
+2.5. Intervention
+The yoga sessions were taught by an instructor who
+had completed a one year diploma in yoga at an uni-
+versity recognized by the Indian government. He had
+taken up the diploma after graduation. After this he had
+been teaching yoga to people with normal health for
+ten years at the time the project commenced. The yoga
+sessions were conducted in a room set aside for the em-
+ployees’ recreational use which was located within the
+company premises. The yoga sessions were conducted
+during a 1 hour period set aside for recreation between
+17.30 and 18.30 hours each day. The participants’ yoga
+practice and attendance of the sessions were monitored
+by the yoga instructor.
+The 60 minute yoga program included yoga postures
+(asanas, 15 minutes), exercises for the joints and back
+(sithilikarana vyayama, 10 minutes), regulated breath-
+ing (pranayamas, 10 minutes), visual cleansing exer-
+cises (trataka, 10 minutes), and guided relaxation (15
+minutes). These techniques were selected based on pre-
+S. Telles et al. / Yoga and motor functions in computer professionals
+301
+(i) Yoga posture (asana)
+(ii) Regulated yoga breathing 
+(iii) Back stretch exercise 
+(iv) Visual cleansing  exercise 
+(v) Guided relaxation
+Fig. 2. This shows a single individual practicing (i) a yoga posture or asana, (ii) voluntarily regulated yoga breathing (pranayama), (iii) a back
+stretch exercise (sithilikarana vyayama), (iv) a visual cleansing exercise (trataka), and (v) guided relaxation.
+vious research which has shown that practicing them re-
+duced musculoskeletal discomfort [11], increased grip
+strength [5] and tapping speed [4]. Figure 2 shows a
+single individual practicing (i) a yoga posture or asana,
+(ii) voluntarily regulated yoga breathing (pranayama),
+(iii) a back stretch exercise (sithilikarana vyayama),
+(iv) a visual cleansing exercise(trataka), and (v) guided
+relaxation.
+2.6. Data analysis
+The data were analyzed using SPSS Version 10.0.
+2.6.1. Musculoskeletal and hand discomfort
+Three repeated measures analyses ofvariance (ANO-
+VA) were carried out separately for the frequency, dis-
+comfort and level of interference, with one Between-
+subjects factor, viz., Groups (with two levels, i.e., YG
+and WL groups) and two Within-subjects factors, viz.,
+Assessments (with two levels, i.e., day 1 and day 60)
+and Sites (with three levels, i.e., whole body, right hand
+and left hand).
+Post-hoc analyses using pair wise comparisons be-
+tween day 1 and day 60, for the whole body, right hand
+and left hand were done separately, with Bonferroni
+adjustment.
+302
+S. Telles et al. / Yoga and motor functions in computer professionals
+2.6.2. Hand grip strength and tapping speed
+The hand grip strength data were analyzed with re-
+peated measures analyses of variance (ANOVA) with
+one Between-subjects factor, viz., Groups (with two
+levels, i.e., YG and WL groups) and two Within-
+subjects factors, viz., Assessments (with two levels,
+i.e., day 1 and day 60) and Hands (with two levels, i.e.,
+right hand and left hand).
+For the tapping speed the numberof contacts made in
+specified time intervals were analyzed with an ANOVA
+which had one Between-subjects factor, viz., Groups
+(with two levels, i.e., YG and WL groups) and three
+Within-subjects factors, viz., Assessments (with two
+levels, i.e., day 1 and day 60), Hands (with two levels,
+i.e., right hand and left hand) and Time (with three
+levels, i.e., 10 sec., 20 sec. and 30 sec.).
+Post-hoc analyses for pair wise comparisons between
+mean values were done with Bonferroni adjustment.
+2.6.3. Low back and hamstring flexibility
+The data were analyzed with an ANOVA for repeat-
+ed measures 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., day 1 and day 60).
+Post-hoc analyses for pair wise comparisons between
+mean values were done with Bonferroni adjustment.
+3. Results
+3.1. The repeated measures ANOVA
+3.1.1. Musculoskeletal discomfort
+The repeated measures ANOVA showed a significant
+difference between the two groups i.e., YG and WL
+groups (F = 7.448, DF = 1.116, p < 0.01). There
+was also a significant difference between the three sites
+i.e., body as a whole, right hand and left hand (F =
+146.799, DF = 1.125, 130.460, p < 0.001; Huynh-
+Feldtε = 0.562) and the three indicators of discomfort
+i.e., frequency, severity and interference (F = 67.107,
+DF = 1.200, 139.929, p < 0.001; Huynh-Feldt ε =
+0.603). There was a significant interaction between
+assessments [day 1 and day 60] and sites (F = 6.928,
+DF = 1.376, 153.806, p < 0.01]; Huynh-Feldtε =
+0.663); and between sites and indicators of discom-
+fort (F = 36.617, DF = 1.283, 148.779 p < 0.001;
+Huynh-Feldtε = 0.321). This suggests that these fac-
+tors were not independent of each other [34].
+3.1.2. Hand grip strength and tapping speed
+The repeated measures ANOVA showed a signifi-
+cant difference in hand grip strength between Assess-
+ments (F = 9.658, DF = 1,116, p < 0.01) and Hands
+(F = 11.524, DF = 1,116, p < 0.01). There was no
+difference between the YG and WL group.
+The tapping speed showed a significant difference
+between Hands (F = 27.854, DF = 1,116, p < 0.001)
+and Time, that is 10, 20 and 30 seconds (F = 21.451,
+DF = 2, 232, p < 0.001). The interaction between
+Assessments and Hands (F = 5.755, DF = 1,116, p <
+0.05) was also significantly different. This suggests
+that the effect of one factor was not independent of a
+particular level of the other factor(s) [34]. There was
+no difference between the YG and WL group.
+3.1.3. Low back and hamstring flexibility
+The repeated measures ANOVA showeda significant
+difference between the two groups i.e., YG and WL
+groups (F = 4.934, DF = 1,116, p < 0.05). There
+was a significant difference in sit and reach scores be-
+tween assessments (F = 58.556, DF = 1,116, p <
+0.001).
+3.2. Post-hoc analyses
+3.2.1. Musculoskeletal discomfort
+Post-hoc analyses by pair wise comparisons with
+Bonferroni adjustment for the YG group showed a sig-
+nificant decrease following two months of yoga com-
+pared to before, in the frequency of discomfort for the
+whole body (p < 0.001), right hand (p < 0.001) and
+the left hand (p < 0.01). The level of discomfort also
+decreased at the three sites mentioned above (p < 0.01
+in all cases). There was also a decrease in the extent to
+which discomfort interfered with their routine work in
+the three sites mentioned above (p < 0.01 for the whole
+body and the right hand; p < 0.05 for the left hand).
+In contrast, the WL group showed a significant in-
+crease in frequency of discomfort for the whole body
+(p < 0.001), the right hand (p < 0.001) and the left
+hand (p < 0.001). The level of discomfort also in-
+creased at the three sites mentioned above (p < 0.001
+in all cases) respectively. There was also an increase
+in the extent to which discomfort interfered with their
+routine work at the same three sites (p < 0.001 in all
+cases).
+The groups mean values and standard deviations are
+given in Table 1.
+S. Telles et al. / Yoga and motor functions in computer professionals
+303
+Table 1
+Scores in the Cornell musculoskeletal and hand discomfort questionnaire in yoga [YG] and wait list control [WL] groups
+Sites
+Day
+Yoga
+Wait list control
+Frequency
+Level
+Interference
+Frequency
+Level
+Interference
+Whole Body
+1
+18.53 ± 18.19
+11.56 ± 9.32
+11.74 ± 9.35
+16.95 ± 17.34
+10.25 ± 8.31
+10.54 ± 9.06
+60
+8.37 ± 11.02∗∗∗
+5.40 ± 6.55∗∗∗
+5.60 ± 6.88∗∗∗
+24.2 ± 18.79∗∗∗
+15.16 ± 9.46∗∗∗
+13.77 ± 9.20∗∗∗
+Right hand
+1
+4.96 ± 5.95
+3.06 ± 3.65
+3.37 ± 3.84
+3.31 ± 3.73
+2.16 ± 2.17
+2.48 ± 2.67
+60
+2.10 ± 3.38∗∗∗
+1.44 ± 2.23∗∗∗
+1.73 ± 2.74∗∗∗
+7.62 ± 7.16∗∗∗
+4.68 ± 4.03∗∗∗
+4.30 ± 3.62∗∗∗
+Left hand
+1
+3.88 ± 5.59
+2.61 ± 3.63
+2.77 ± 3.92
+1.41 ± 2.11
+0.96 ± 1.48
+1.23 ± 2.05
+60
+1.85 ± 3.28∗∗
+1.16 ± 2.04∗∗
+1.44 ± 2.55∗
+6.14 ± 6.55∗∗∗
+4.12 ± 3.95∗∗∗
+3.29 ± 3.17∗∗∗
+Values are Mean ± S.D.
+∗p < 0.05, ∗∗p < 0.01 and ∗∗∗p < 0.001, Post-hoc analyses with Bonferroni adjustment comparing Day 60 with Day 1.
+3.2.2. Hand grip strength and tapping speed
+Post-hoc analyses with Bonferroni adjustment by
+pair wise comparisons of values after yoga compared
+with before showed a significant increase in hand grip
+strength scores for the YG group on day 60 compared
+to day 1 for the right hand (p < 0.05) and for the left
+hand (p < 0.01). In contrast, there was no significant
+change in the WL group.
+The groups mean values with standard deviations are
+given in Table 2.
+Tapping speed of the YG group showed a significant
+increase for the right hand speed at 10 seconds (p <
+0.05) and 30 seconds (p < 0.05). In the WL group
+tapping speed significantly decreased for the left hand
+at 10 seconds (p < 0.001) on day 60 compared to day
+1. The groups mean values with standard deviations
+are given in Table 2.
+3.2.3. Low back and hamstring flexibility
+Post-hoc analyses by pair wise comparisons with
+Bonferroni adjustment showed a significant increase in
+the values obtained in the Sit and Reach Task for the
+YG group on day 60 compared to day 1 (p < 0.001).
+In contrast, there was no significant change in the WL
+group.
+The groups mean values with standard deviations are
+given in Table 2.
+4. Discussion
+In the present study eight weeks of yoga practice sig-
+nificantly decreased self–reported musculoskeletal dis-
+comfort in 62 professional computer users. Also, they
+showed an increase in the bilateral hand grip strength,
+the tapping speed of the right hand, and an increase
+in low back and hamstring flexibility based on a stan-
+dard sit and reach task. In contrast, after sixty days
+of no-intervention and carrying on with their routine
+recreational activities 55 professional computer users
+who formed the WL group showed an increase in mus-
+culoskeletal discomfort and a decrease in left hand tap-
+ping speed.
+Earlier, musculoskeletal discomfort and pain of the
+hands, neck and back were shown to be associated
+with different psychosocial factors [8]. For example,
+increased physical workload, such as an increase in
+work pressure and greater time spent at a computer was
+related to symptoms in the neck, shoulder, hand and
+wrist [3]. Conversely neck and low back discomfort
+were associated with mental distress related to either
+of two extremes viz., monotonous work [13] or a high
+mental work demand [30]. This suggests that greater
+mental workload has a bigger impact on discomfort of
+the neck and back, whereas upper limb discomfort may
+be more closely related to a physical work load.
+The decrease in discomfortfollowing yoga was com-
+parable for the whole body, the right hand and the left
+hand. In contrast, the WL group showed an increase in
+the level of discomfort after eight weeks. The level of
+discomfort was high for the left hand (277.4 percent)
+and for the right hand (106.7 percent) compared to the
+body as a whole (40.4 percent). Hence while the mus-
+culoskeletal discomfort increased to a greater extent
+in both hands than in the rest of the body, in the WL
+group, the improvement in the YG group was compa-
+rable at all three sites. Here, musculoskeletal discom-
+fort was assessed using a subjective rating scale, not
+some more objective method. Given the fact that it was
+more likely that the WL (control group) felt deprived
+of the additional care in the form of interaction with
+the yoga teacher, which the yoga group had, this could
+possibly have made the control group more likely to
+experience and express subjectively rated discomfort.
+This is specially possible since additional care (in this
+case interaction with the yoga therapist), is known to
+have psychological benefits [6].
+In another study, experienced computer users with
+symptoms of discomfort in the hand-wrist and forearm-
+elbow had no difference in their hand grip strength
+304
+S. Telles et al. / Yoga and motor functions in computer professionals
+Table 2
+Tapping speed in subjects during 0–10 seconds, 10-20 seconds, 20–30 seconds, Average of 30 seconds, grip
+strength and scores for the sit and reach task in YG and WL groups
+Variables
+Hand
+Yoga
+Wait-list control
+Day 1
+Day 60
+Day 1
+Day 60
+Tapping speed at 10 Sec.
+RIGHT
+32.6 ± 8.2
+34.5 ± 7.5∗
+33.2 ± 7.9
+32.0 ± 7.2
+LEFT
+35.8 ± 7.3
+36.7 ± 6.8
+36.1 ± 6.5
+33.1 ± 6.3∗∗∗
+Tapping speed at 20 Sec.
+RIGHT
+32.8 ± 9.3
+34.1 ± 7.8
+32.7 ± 7.9
+32.6 ± 8.2
+LEFT
+35.7 ± 7.2
+36.5 ± 6.2
+35.8 ± 6.3
+34.4 ± 5.8
+Tapping speed at 30 Sec.
+RIGHT
+31.5 ± 7.6
+33.4 ± 7.0∗
+30.4 ± 7.7
+31.2 ± 6.8
+LEFT
+33.9 ± 5.7
+34.1 ± 6.5
+34.0 ± 6.7
+33.3 ± 5.8
+Grip strength
+RIGHT
+31.3 ± 8.8
+32.8 ± 8.9∗
+32.0 ± 8.3
+33.0 ± 8.0
+LEFT
+30.2 ± 9.1
+32.0 ± 9.0∗∗
+31.2 ± 8.4
+32.2 ± 7.2
+Scores for the sit and reach task
+–
+25.0 ± 7.1
+35.0 ± 8.7
+∗∗∗
+27.2 ± 9.4
+26.8 ± 7.4
+Values are group means ± S.D.
+∗p < 0.05, ∗∗p < 0.01 and ∗∗∗p < 0.001, Post-hoc analyses with Bonferroni adjustment comparing Day 60
+with Day 1.
+but had lower pinch grip strength than those who were
+asymptomatic [15]. These observations are comparable
+to those of the WL group in the present study that
+showed no change in hand grip strength after eight
+weeks with no specific intervention.
+In an earlier study a combination of yoga practices
+which included postures, breathing techniques, and
+meditation, increased the hand grip strength in physical
+activity instructors, over a three month period [28]. In
+another study the hand grip strength also increased in
+children after 10 days of practice and adults after 30
+days of practice [5]. In the same report, patients with
+rheumatoid arthritis showed an increase in hand grip
+strength after a 15 day period of yoga practice. In-
+creased hand grip strength following varying durations
+of yoga practice may be related to the availability of
+energy and oxidation of glucose, as these factors are
+known to influence grip strength [19].
+While increased hand grip strength after yoga sug-
+gests an increase in muscle strength and endurance,
+similar results were not seen in another study which ex-
+amined the impact of yoga on a thirty seconds tapping
+speed task [4], In this earlier study, following a month
+of yoga practice the tapping speed, which is correlated
+with motor speed for repetitive movements increased
+within the first ten seconds of the task. However when
+the participants continued the task for three contiguous
+10 second periods, the tapping speed was significantly
+lower in the last 10 seconds for both yoga and con-
+trol groups at both pre and post assessments. Hence
+for this repetitive and continuous task yoga practice
+did not reduce fatigue. Here, the increase in tapping
+speed could have been an initial spurt of speed which
+was not sustained. In contrast, in the present study,
+the increase in tapping speed in the YG group was
+seen after 10 and 30 seconds, with a non-significant
+trend of increase at 20 seconds. Hence these results
+suggest that the increase in motor speed was sustained
+over 30 seconds. Motor speed is determined by muscle
+strength, endurance, and co-ordination. An increase in
+some, or all, of these factors may have contributed to
+the increase in tapping speed. However the increase in
+right hand tapping speed, with no increase for the left
+hand is difficult to explain. This is especially difficult
+to explain as frequent use of a computer keyboard was
+shown to increase left hand performance scores on a
+dexterity task [30].
+In contrast to the YG group the WL group showed a
+decrease in left hand tapping speed during the first ten
+seconds, at the end of eight weeks. This may have been
+related to work fatigue during the eight week period.
+However, the decrease in the initial speed could also be
+related to psychological factors [31,32] and poor moti-
+vation for the task in the absence of an intervention [6].
+The latter point is related to the fact that in the absence
+of being given an intervention the WL group may not
+have felt that their performance was likely to change
+and hence may not have been enthusiastic at re-test.
+The increased scores in the sit and reach task fol-
+lowing yoga are suggestive of an increase in hamstring
+and low back flexibility. Improved flexibility is asso-
+ciated with a lower risk of developing muscle tension
+and pain [17]. This may have also contributed to the
+decreased musculoskeletal discomfort following yoga.
+There were two main limitations to the study. One
+limitation was the large numbers of drop-outs from both
+groups. The main reason why participants dropped out
+of the study was because they had job assignments for
+which they were posted elsewhere in or outside India.
+Out of 57 drop-outs from the YG group, who were
+not able to regularly attend the intervention, 6 of them
+dropped out as they preferred to use the 60 minute peri-
+S. Telles et al. / Yoga and motor functions in computer professionals
+305
+od kept aside for recreation for some activity other than
+yoga. The majority dropped out as they were posted
+elsewhere. A second limitation is that the intervention
+was for 60 minutes, for 5 days each week. This would
+require special commitment for the participants to set
+aside this amount of time on all working days. The
+yoga program was designed to address at least three
+problems which are known to arise in computer users.
+These are musculoskeletal discomfort, symptoms of
+visual discomfort, and mental stress. However future
+research needs to be carried out to determine whether
+the duration of the program could be shortened and still
+get the same benefits.
+5. Conclusion
+In summary the present trial showed that yoga prac-
+ticed for an hour a day, 5 days in a week, for sixty
+days decreases self rated musculoskeletal discomfort,
+improves muscle strength and speed and low back and
+hamstring flexibility. These results suggest that yoga is
+a useful addition to the routine of professional comput-
+er users. Based on this, employees of software com-
+panies would need to commit 5 hours a week for yoga
+practice and their employers would need to facilitate
+this in terms of providinga place to practice yoga, time,
+and arranging for informed instruction on yoga.
+6. Recommendations for future studies
+In the present study theyoga program was for 60min-
+utes, 5 days in a week. Future research could be planned
+to determine the usefulness of a shorter duration yoga
+program. Also, it would be useful to determine whether
+practicing yoga for some days as part of a group and for
+the remaining days at home using pre-recordedinstruc-
+tions and maintaining a diary, would also be effective.
+These options could make it easy for more participants
+to comply with the program.
+The present randomized controlled trial was limited
+to a sixty day follow-up period. Further studies could
+be planned with a longer duration follow-up period. It
+would also be desirable to study whether yoga prac-
+tice prevents the development of CTD in professional
+computer users.
+Acknowledgements
+The research was funded by the Central Council
+for Research in Yoga and Naturopathy, Department of
+AYUSH, Ministry of Health and Family Welfare, Gov-
+ernment of India, New Delhi, India, which is gratefully
+acknowledged.
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subfolder_0/Effect of yoga on symptom management in breast cancer patient A randomized controled trial.txt

@@ -0,0 +1,1064 @@
+73
+International Journal of Yoga y Vol. 2 y Jul-Dec-2009
+of care they receive. Primary care providers, specialists, 
+other health care providers, patients, and families all have 
+an important role in symptom management throughout the 
+course of cancer. Therefore, using interventions that help 
+alleviate distressful symptoms and improve quality of life as 
+an add-on to conventional treatments are recommended as a 
+cohesive strategy to mitigate this problem.[6] 
+Symptoms are perceived indicators of a change in 
+healthy functioning as experienced by patients.[7] They 
+are multidimensional, having subjective, perceptional, 
+and experiential characteristics.[8,9] These characteristics 
+include both the physiologic sensations that signal 
+patients that some internal condition is different and the 
+interpretive processes that motivate patients to construct 
+INTRODUCTION
+The diagnosis and treatment of breast cancer can pose 
+a considerable amount of physical, psychological, and 
+emotional distress,[1-3] and affects about 80% of the 
+patients during initial stages of their treatment.[3] Though 
+advancements in the treatment of cancer have improved 
+survival rates in cancer patients, they have to endure 
+distressing symptoms for a longer time than ever before. 
+Patients with breast cancer normally receive multimodal 
+treatment over a long period of time[4,5] and experience 
+a multitude of symptoms that grossly affect their overall 
+quality of life and survival. As patients live longer with 
+cancer, concern is growing about both the health-related 
+quality of life of those diagnosed with cancer and the quality 
+Objectives: This study compares the effects of an integrated yoga program with brief supportive therapy on distressful 
+symptoms in breast cancer outpatients undergoing adjuvant radiotherapy.
+Materials and 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 during the course of their 
+adjuvant radiotherapy. Assessments included Rotterdam Symptom Check List and European Organization for Research in 
+the Treatment of Cancer—Quality of Life (EORTC QoL C30) symptom scale. Assessments were done at baseline and after 
+6 weeks of radiotherapy treatment. 
+Results: A GLM repeated-measures ANOVA showed a signifi
+ cant decrease in psychological distress (P = 0.01), fatigue 
+(P = 0.007), insomnia (P = 0.001), and appetite loss (P = 0.002) over time in the yoga group as compared to controls. There 
+was signifi
+ cant improvement in the activity level (P = 0.02) in the yoga group as compared to controls. There was a signifi
+ cant 
+positive correlation between physical and psychological distress and fatigue, nausea and vomiting, pain, dyspnea, insomnia, 
+appetite loss, and constipation. There was a signifi
+ cant negative correlation between the activity level and fatigue, nausea 
+and vomiting, pain, dyspnea, insomnia, and appetite loss.
+Conclusion: The results suggest benefi
+ cial effects with yoga intervention in managing cancer- and treatment-related symptoms 
+in breast cancer patients.
+Key words: Breast cancer; meditation; stress; symptom distress; yoga.
+ABSTRACT
+Effects of yoga on symptom management in breast cancer 
+patients: A randomized controlled trial
+S Hosakote Vadiraja, M Raghavendra Rao1, R Hongasandra Nagendra, Raghuram Nagarathna, Mohan Rekha, 
+Nanjundiah Vanitha2, S Kodaganuru Gopinath1, BS Srinath2, MS Vishweshwara2, YS Madhavi2, Basavalingaiah S Ajaikumar2, 
+S Bilimagga Ramesh1, Nalini Rao1
+Departments of Yoga Research, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, 1Surgical and Radiation Oncology, 
+Bangalore Institute of Oncology, 2Radiation Oncology, Bharath Hospital and Institute of Oncology, Mysore, India
+Address for correspondence: Dr. Nagarathna Raghuram,
+No. 19, Eknath Bhavan, Gavipuram Circle, 
+K.G. Nagar, Bangalore - 560 019, India.
+E-mail: [email protected]
+DOI: 10.4103/0973-6131.60048
+Original Article
+[Downloaded free from http://www.ijoy.org.in on Friday, March 12, 2010]
+International Journal of Yoga y Vol. 2 y Jul-Dec-2009
+74
+Vadiraja, et al. 
+meanings for the symptoms and decide how to respond to 
+them.[10] The perceived discomfort experienced in relation 
+to the symptom can lead to anxiety and depression if 
+patients are unable to cope with this distress. This can 
+significantly impact patient outcomes in terms of quality 
+of life, functional and emotional status, compliance to 
+treatment, self-care and management, mortality, and 
+morbidity.[11-13] Therefore adopting symptom management 
+strategies that reduce symptom experience can significantly 
+benefit the patient’s activity, functioning, and health 
+outcomes. Although research is producing new insights 
+into the causes of and cures for cancer, efforts to manage 
+the symptoms of the disease and its treatment have not 
+kept pace. Evidence suggests that pain is frequently 
+undertreated. Patients and health care providers have 
+reported depression and a persistent lack of energy as 
+the aggressiveness of therapy has been increased and/or the 
+underlying malignancy has worsened. The challenge is to 
+increase awareness of the importance of recognizing and 
+actively addressing cancer-related symptoms when they 
+occur. Specifically, we need to be able to identify who is 
+at risk for cancer-related pain, depression, and/or fatigue; 
+what treatments work best to address these symptoms when 
+they occur; and how best to deliver interventions across 
+the continuum of care.[6]
+Various psychosocial interventions and behavioral 
+approaches have been used over the decades to alleviate 
+distress and reduce distressing side effects or symptoms 
+in these populations.[14-19] Preliminary findings suggest 
+beneficial effects for yoga in improving mood, coping, 
+adjustment, and decrease in distressful symptoms such as 
+loss of appetite and fatigue in cancer patients. However, 
+subjects in these studies were a heterogeneous mix of 
+cancer patients in varying stages of disease and treatment. 
+Since cancer patients experience a multitude of symptoms 
+of varying clusters at various stages of their disease and 
+conventional treatment, it is difficult to ascertain if yoga 
+intervention is beneficial in reducing a group of symptoms 
+that are specific to the treatment and stage of their disease. 
+It has also been shown that most of these symptoms 
+may persist even after completion of treatment thereby 
+impacting their quality of life. Managing these symptoms 
+effectively during the early course of treatment has been 
+shown to improve patient outcomes during later stages of 
+their disease. 
+In this study, we compare the effects of “integrated yoga 
+program” with “brief supportive therapy” on symptom 
+control in early operable breast cancer patients undergoing 
+adjuvant radiotherapy. 
+MATERIALS AND METHODS
+Though the primary objective in our study was to evaluate 
+effects of yoga on quality of life, the secondary objective 
+was to evaluate its effects on symptom control. In this 
+paper, we focus on effects of yoga in managing distressful 
+symptoms in early breast cancer patients receiving 
+adjuvant radiotherapy.
+Subjects
+Eighty-five recently diagnosed women with stage II and III 
+breast cancer from two different urban cancer centers were 
+recruited for this study over a 2-year period from January 2004 
+to June 2006. All subjects had undergone primary treatment 
+as surgery and were receiving adjuvant radiotherapy. Patients 
+were eligible to participate in this study if they met the 
+following selection criteria at the start of the study: (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) written consent to participate in the study. Subjects were 
+excluded if they had (i) any concurrent medical condition 
+that was likely to interfere with the treatment, (ii) major 
+psychiatric, neurological 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 fractionations 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 random 
+numbers. Randomization was performed using concealed 
+allocation protocol into two study arms. Personnel who had 
+no part in the trial performed randomization. 
+Sample size 
+The primary hypothesis of the study was to evaluate the 
+effects of yoga intervention on the improvement in quality-
+of-life measures. Earlier study with Mindfulness-Based 
+Stress Reduction Program (MBSR) had shown a modest effect 
+size (ES = 0.38) on EORTC QoL C30 global quality-of-life 
+measure. We used G power to calculate the sample size with 
+α = 0.05 and β = 0.2, and the above-mentioned 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 [Figure 1]. The reasons for dropouts 
+were migration to other hospitals (n = 4), use of other 
+complementary therapies (e.g., homeopathy or ayurveda) 
+(n = 2), refusal to continue the study (n = 2), time 
+[Downloaded free from http://www.ijoy.org.in on Friday, March 12, 2010]
+75
+International Journal of Yoga y Vol. 2 y Jul-Dec-2009
+Yoga and cancer symptom management
+constraints (n = 4), and other concurrent illnesses such as 
+infections delaying radiotherapy and intervention (n = 1). 
+Measures
+Before randomization demographic information, medical 
+history, and clinical data were ascertained from all 
+consenting participants. 
+Rotterdam symptom check list 
+Participants completed the Rotterdam Symptom Check 
+List (RSCL) that measures symptoms that cause physical 
+distress, psychological distress, and impairment in the 
+activities of daily living. The RSCL is a 39-item scale 
+which has been widely used as a brief measure of quality 
+of life in cancer patients. It covers important domains 
+of psychological distress, physical status (disease and 
+treatment items), functional status, and global quality 
+of life. Evidence of its reliability and validity has been 
+found in a number of research settings. It comprises three 
+subscales and includes one global question: How would 
+you describe your quality of life during the past week? 
+Responses range from “extremely poor” to “excellent” 
+on a seven-point scale. The psychological symptom 
+subscale contains eight symptoms. Respondents are 
+asked to indicate the frequency with which they have 
+experienced each symptom in the past week on a four-
+point scale, ranging from “not at all” (0) to “very much” 
+(3). Possible scores on this scale therefore range from 0 to 
+24. The physical symptom subscale contains 22 symptoms; 
+scores on this scale range from 0 to 66. The third subscale 
+assesses whether respondents are able to perform eight 
+activities, given their condition in the past week. Responses 
+range from “unable” (0) to “without help” (3), and the 
+possible range of scores on this subscale is from 0 to 24 
+with lower scores representing better levels of functioning. 
+The reliability of this scale has been reported to range from 
+0.68 to 0.90 for physical and psychological distress and 
+from 0.42 to 0.89 for the activity subscale.[20]
+Treatment-related symptoms were assessed using the 
+European Organization for the Research and Treatment of 
+Cancer—Quality of Life (EORTC QoL C30 questionnaire, 
+version 1).[21] Though this 30-item questionnaire provides 
+a measure on the dimensions of global health status, 
+physical role, emotional, cognitive, social functioning, and 
+cancer-related symptomatology, we report results of only 
+cancer-related symptomatology. Assessments were carried 
+out before and after radiotherapy treatment. 
+Interventions
+The intervention group received the integrated yoga program 
+and the control group received brief supportive therapy 
+intervention, each imparted as a one-to-one session with 
+the therapist. The yoga intervention consisted of a set of 
+asanas (postures done with awareness), breathing exercises, 
+pranayama (voluntarily regulated nostril breathing), 
+meditation, and yogic relaxation techniques with imagery 
+(mind–sound resonance technique and cyclic meditation). 
+These practices were based on principles of attention 
+diversion, mindful awareness, and relaxation to cope with 
+day-to-day stressful experiences. Participants were required 
+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 
+radiotherapy. These sessions started with a few easy yoga 
+postures, breathing exercises, and pranayama (voluntarily 
+regulated nostril breathing), and yogic relaxation. After this 
+preparatory 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,[22] or breath awareness and 
+impulses of touch emanating from palms and fingers while 
+practicing 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” 
+practices.[23] 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 
+center. We chose to have this as a control intervention mainly 
+to control for the nonspecific effects of the yoga program that 
+may be associated with factors such as attention, support, 
+and a sense of control as described in our earlier study.[24] 
+Subjects and their caretakers underwent counseling by a 
+trained social worker (once in 10 days, 15-min sessions) 
+during their hospital visits for adjuvant radiotherapy. The 
+control group received 3-4 such counseling sessions during 
+a 6-week period, where as the intervention group received 
+Figure 1: Trial profi
+ le
+Number of patients screened (N = 165)
+Eligible patients (N = 103)
+Random assignment (n = 88)
+Supportive counseling (n = 44)
+Yoga intervention (n = 44)
+Post assessment (n = 42)
+Post assessment (n = 33)
+2           Study dropout                  11
+Reasons for drop out
+0      Migration to other hospital     4 
+0      Used other CAM                    2
+1      Refusal to continue study      1
+1      Time constraint                      3
+0      Concurrent illness                  1
+[Downloaded free from http://www.ijoy.org.in on Friday, March 12, 2010]
+International Journal of Yoga y Vol. 2 y Jul-Dec-2009
+76
+anywhere between 18 and 24 yoga sessions. 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 factor being 
+groups at two levels (yoga vs. supportive therapy). Both 
+group-by-time interaction effects and between-subjects 
+and within-subjects effects were assessed. Post-hoc tests 
+were done using Bonferroni’s correction for changes at 
+different time points between groups. Intention–to-treat 
+analysis was also done on the initially randomized sample 
+(n = 88) with the baseline measure and postradiotherapy 
+measure (post-RT) for all participants. Baseline value was 
+carried forward for participants who did not have a post-RT 
+measure (study dropouts). Pearson’s correlation analyses 
+were used to study the bivariate relationships between 
+quality-of-life domains and treatment related symptoms. 
+RESULTS
+A total of 74 participants (yoga, n = 40; control, n = 34) 
+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 57 subjects 
+received radiotherapy following mastectomy and three 
+cycles of chemotherapy. Participants in both groups were 
+comparable with respect to sociodemographic and medical 
+characteristics [Table 1].
+Psychological distress
+A repeated-measures analysis of variance was done on 
+psychological distress scores. Results showed significant 
+group-by-time interaction effects [F (1, 72) = 7.64, 
+P = 0.01] and between-subject effects [F (1, 72) = 7.91, 
+P = 0.01]. Post-hoc tests using Bonferroni’s correction 
+showed significant differences between yoga and control 
+groups in post-RT measures alone (mean difference ± SE, 
+3.72±1.07; P = 0.001). There was a significant within-
+subjects difference (post- and pre-RT measure) in the yoga 
+group alone (mean difference ± SE, 2.95±0.66; P < 0.001; 
+95% CI 1.6-4.3) but not in the control group (0.26±0.71; 
+P = 0.71; 95% CI−1.1 to 1.6) [Table 2]. Intention-to-treat 
+analysis on the initially randomized sample showed 
+significant improvement in psychological distress between 
+groups following intervention (−3.47±0.73, P < 0.001, 
+−4.91 to −2.03) [Table 3].
+Table 1: Demographic and medical characteristics of 
+the initially randomized sample
+All
+subjects
+Yoga
+group
+Control group
+n = 88 (%) n = 44 (%) n = 44 (%)
+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
+51.1
+10
+22.7
+III
+54
+61.4
+22
+47.7
+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
+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
+Table 2: Comparison of scores for distress, activity, and 
+symptom scale of European organization for research 
+in the treatment of cancer QoLC30 scores using GLM 
+repeated-measures ANOVA between yoga and control 
+groups
+Outcome 
+variables
+Yoga (y)
+(n = 42)
+Control (c) 
+(n = 33)
+Adjusted 
+mean (y-c) 
+(95% CI)
+Effect 
+size
+Pre
+Post
+Pre
+Post
+Psychological 
+distress
+6.90
+(3.36)
+4.15
+(3.28)**
+7.83
+(3.55)
+7.37
+(3.65)
+−3.22
+(−4.81 to 
+−1.63)
+0.39
+Physical 
+distress
+13.52
+(6.16)
+9.98
+(7.04)**
+14.23
+(7.70)
+14.89
+(8.36)
+−4.91
+(−8.45 to 
+−1.37)
+0.33
+Activity level
+20.20
+(5.78)
+20.35
+(5.35)*
+18.23
+(6.19)
+17.11
+(6.47)
+3.24
+(0.52-5.95)
+0.14
+Fatigue
+44.76
+(22.89)
+31.37
+(21.79)**
+50.46
+(22.41)
+52.09
+(24.24)
+−20.72
+(−31.40 to 
+−10.04)
+0.33
+Pain
+33.74
+(26.74)
+23.17
+(27.10)*
+42.47
+(28.49)
+41.52
+(32.57)
+−18.36
+(−32.39 to 
+−4.32)
+0.14
+Dyspnea
+8.13
+(17.92)
+5.69
+(12.69)
+12.12
+(18.29)
+10.13
+(17.63)
+−4.44
+(−11.47 to 
+2.59)
+0.01
+Insomnia
+47.15
+(34.14)
+21.14
+(26.62)*
+34.34
+(25.66)
+35.44
+(32.11)
+−14.31
+(−27.91 to 
+−0.69)
+0.47
+Nausea and 
+vomiting
+13.41
+(21.48)
+6.91
+(13.93)
+11.11
+(14.23)
+6.69
+(13.09)
+0.22
+(−6.10 to 
+6.55)
+0.05
+Appetite loss 21.95
+(24.28)
+15.45
+(19.86)**
+20.20
+(26.27)
+33.39
+(28.79)
+−17.95
+(−29.25 to 
+−6.65)
+0.38
+Diarrhea
+3.25
+(12.48)
+0.81
+(5.21)
+3.03
+(12.81)
+4.07
+(13.83)
+−3.26
+(−7.92 to 
+1.41)
+0.01
+Constipation
+6.50
+(20.03)
+6.50
+(20.03)
+7.07
+(21.66)
+8.11
+(22.08)
+−1.61
+(−11.38 to 
+8.17)
+0.14
+*P values < 0.05 and **P values < 0.01, for post-hoc tests comparing 
+groups at pre- and postradiotherapy using Bonferroni’s correction.
+Vadiraja, et al. 
+[Downloaded free from http://www.ijoy.org.in on Friday, March 12, 2010]
+77
+International Journal of Yoga y Vol. 2 y Jul-Dec-2009
+Physical distress
+A repeated-measures analysis of variance was done 
+on physical distress scores. There was no significant 
+group- by- time interaction effect [F (1, 72) = 3.86, P = 0.05] 
+or between-subjects effect [F (1, 72) = 1.49, P = 0.23]. Post-
+hoc tests using Bonferroni’s corrections also did not show 
+significant differences between yoga and control groups in 
+post-RT measures (mean difference ± SE, −3.31 ± 1 .77; 
+P = 0.07). But there was a significant within-subjects 
+difference (post- and pre-RT measure) in the yoga group alone 
+(mean difference ± SE, 3.20 ± 1.04; P < 0.01, 95% CI 1.1-
+5.2) but not in the control group (0.18 ± 1.13, P = 0.88, -2.0 
+to 2.4) [Table 2]. Intention-to-treat analysis on the initially 
+randomized sample showed significant improvement in 
+physical distress between groups following intervention 
+(−4.18 ± 1.74, P = 0.02, −7.65 to −0.72) [Table 3].
+Activity level
+A repeated-measures analysis of variance was done on 
+activity level scores. There was no significant group-by-
+time interaction effect [F (1, 72) = 1.82, P = 0.18] but 
+a significant between-subjects effect [F (1, 72) = 5.31, 
+P = 0.02]. Post-hoc tests using Bonferroni’s corrections 
+showed significant differences between yoga and control 
+groups in post-RT measures alone (mean difference ± 
+SE, 3.65 ± 1.37; P = 0.01). There was no significant 
+within-subjects effect in yoga or control groups following 
+intervention [Table 2]. Intention-to-treat analysis did 
+not show any significant changes between groups in the 
+activity level [Table 3].
+European organization for research in the treatment of 
+cancer QoL C30 symptom scale
+A repeated-measures analysis of variance was done on 
+symptom scores. Results showed significant group-by-time 
+interaction effects for fatigue [F (1, 72) = 7.74, P = 0.007], 
+insomnia [F (1, 72) = 16.24, P = 0.001] and appetite loss 
+[F (1, 72) = 10.41, P = 0.002] and significant between-
+subjects effects for fatigue [F (1, 72) = 8.26, P = 0.01] but 
+not for insomnia [F (1, 72) = 0.02, P = 0.90] and appetite 
+loss [F (1, 72) = 2.72, P = 0.10]. Post-hoc tests using 
+Bonferroni’s correction showed significant differences 
+between yoga and control groups in post-RT measures 
+alone for fatigue (mean difference ± SE, −20.72±5.36; 
+P = 0.001), insomnia (−14.31 ± 6.83, P = 0.04), and 
+appetite loss (−17.95 ± 5.67, P = 0.002). There was a 
+significant decrease in fatigue (mean difference ± SE, 13.39 
+± 3.61; P < 0.001; 95% CI 6.2-20.5) and insomnia (26.02 
+± 4.49; P < 0.001; 17.0-34.9) in the yoga group alone; 
+there was a significant increase in loss of appetite in the 
+control group (−13.19 ± 4.54, P = 0.005, −22.2 to −4.1) 
+[Table 2]. Intention-to-treat analysis on the initially 
+randomized sample showed significant improvement in 
+fatigue (−17.26 ± 4.89, P = 0.001, −26.99 to −7.53), pain 
+(16-.93 ± 6.09, P = 0.007, −29.05 to −4.82), insomnia 
+(−13.49 ± 6.60, P = 0.04, -26.60 to −0.38), and appetite 
+loss (−14.07 ± 5.46, P = 0.01, −24.93 to −3.22) between 
+groups following intervention [Table 3]. Other symptoms 
+such as pain, dyspnea, nausea and vomiting, diarrhea, and 
+constipation did not change significantly with time in both 
+groups, and only pain showed significant between-subjects 
+effects [F (1, 72) = 5.20, P = 0.03]. Post-hoc tests using 
+Bonferroni’s correction showed significant differences 
+between yoga and control groups in pain scores in the 
+post-RT measure (mean difference ± SE, −18.36 ± 7.04; 
+P = 0.01). There was a significant decrease in pain (mean 
+difference ± SE, 10.57±4.34; P = 0.02, 95% CI 1.9-19.2) 
+and nausea and vomiting (6.50 ± 2.77, P = 0.02, 0.9-12.0) 
+in the yoga group alone following intervention [Table 2]. 
+Intention-to-treat analysis did not show any significant 
+changes between groups in nausea and vomiting, dyspnea, 
+constipation, and diarrhea [Table 3]. 
+Bivariate relationships 
+Bivariate relationships were determined between the outcome 
+measures. There was a significant positive correlation 
+between physical and psychological distress and fatigue, 
+nausea and vomiting, pain, dyspnea, insomnia, appetite loss, 
+and constipation. There was a significant negative correlation 
+of activity levels with fatigue, nausea and vomiting, pain, 
+dyspnea, insomnia, and appetite loss [Table 4]. 
+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 = 88)
+Outcome 
+variables
+Yoga (44)
+Control (44)
+Pre
+Post
+Pre
+Post
+Psychological 
+distress
+6.75 
+(3.43)
+4.25 
+(3.34)**
+8.09 
+(3.32)
+7.72 
+(3.43)
+Physical 
+distress
+14.05 
+(7.22)
+10.82 
+(8.19)*
+14.47 
+(7.52)
+15.00 
+(8.06)
+Activity level
+20.11 
+(6.05)
+20.25 
+(5.69)
+18.70 
+(5.91)
+17.79 
+(6.23)
+Fatigue
+45.48 
+(24.08)
+33.26 
+(23.82)**
+49.32 
+(20.72)
+50.52 
+(22.31)
+Pain
+34.07 
+(27.96)
+24.44 
+(28.56)**
+42.04 
+(25.79)
+41.38 
+(28.96)
+Dyspnea
+8.89 
+(19.33)
+6.67 
+(15.24)
+11.36 
+(17.52)
+9.86 
+(16.96)
+Insomnia
+48.15 
+(35.22)
+24.44 
+(30.48)*
+37.12 
+(27.10)
+37.93 
+(31.74)
+Nausea and 
+vomiting
+15.55 
+(24.46)
+9.64 
+(19.62)
+13.26 
+(17.45)
+9.97 
+(17.35)
+Appetite loss
+22.96 
+(26.42)
+17.03 
+(23.16)*
+21.21 
+(26.01)
+31.10 
+(28.16)
+Diarrhea
+2.96 
+(11.94)
+0.74 
+(4.97)
+3.03 
+(12.07)
+3.80 
+(12.87)
+Constipation
+8.15 
+(23.74)
+8.15 
+(23.74)
+8.33 
+(21.71)
+9.11 
+(21.98)
+*P < 0.05 and **P < 0.01 for post-hoc tests comparing groups at 
+different time points using Bonferroni’s correction
+Yoga and cancer symptom management
+[Downloaded free from http://www.ijoy.org.in on Friday, March 12, 2010]
+International Journal of Yoga y Vol. 2 y Jul-Dec-2009
+78
+Adherence to intervention
+Adherence to intervention was good with 29.7% attending 
+10-20 supervised sessions, 56.7% attending 20-25 
+supervised sessions, and 13.7% attending > 25 supervised 
+sessions over a 6-week period. The level of adherence did 
+not seem to affect symptom scores (results not shown).
+DISCUSSION
+This study evaluated the effects of integrated approach of yoga 
+therapy on symptom distress among early-stage breast cancer 
+patients undergoing adjuvant radiotherapy. A significant 
+reduction was observed in psychological distress, physical 
+distress, a significant increase in the activity level on the 
+RSCL and a significant reduction in fatigue, pain, insomnia, 
+nausea and vomiting on the EORTC QoL symptom subscale 
+following yoga intervention as compared to controls. 
+These results offer further support for preliminary findings 
+that have shown beneficial effects of yoga intervention in 
+reducing distressful symptoms such as fatigue, pain, loss of 
+appetite, and insomnia and improving mood and quality-
+of-life concerns in cancer patients. Though beneficial 
+effects are seen with yoga on symptom management, it 
+should be noted that subjects in these studies were in 
+various stages of treatment and disease and had varied 
+diagnosis contributing to generalizability of findings.[25] In 
+our study, the cohort sample were patients with stage II 
+and III breast cancer receiving adjuvant therapy and our 
+results support benefits of yoga in modulating distressful 
+symptoms related to adjuvant radiotherapy. 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 measures. The effect size was high (Cohen’s f >3) 
+for fatigue, insomnia, psychological distress, and physical 
+distress and moderate for pain and activity. 
+There was a significant positive correlation between 
+symptoms and physical and psychological distress and 
+negative correlation between these and activity. The results 
+indicate that yoga intervention was helpful in reducing 
+these distressing symptoms and that reduction in these 
+could have reduced physical and psychological distress and 
+improved activity. Patients with cancer often have multiple 
+symptoms and symptoms can often cluster together in a 
+systematic way whereby treatment of one can influence the 
+treatment of other symptoms as well.[26] Though studying 
+the effects of intervention on symptom clusters is not 
+the main aim of this study, its effects on a multitude of 
+symptoms such as pain, fatigue, nausea, insomnia, and 
+loss of appetite could have nevertheless contributed to 
+improvement in health outcomes. Moreover, most of these 
+symptoms persist throughout the course of disease, and 
+the effective treatment of these in initial stages is known 
+to affect health outcomes later even after the completion of 
+treatment.[27] It may be hypothesized that yoga could serve 
+to be a prophylactic intervention in the initial stages of 
+treatment affecting quality-of-life outcomes in future. This 
+is more so important in today’s scenario where efforts are 
+being directed at producing new insights into the causes of 
+and cures for cancer, rather than managing the symptoms 
+due to the disease and their treatment.
+Evidence suggests that pain, fatigue, and depression are 
+frequently undertreated. Patients and health care providers 
+have reported depression and a persistent lack of energy as 
+the aggressiveness of therapy has been increased and/or the 
+underlying malignancy has worsened.[6] Cancer symptom 
+management would benefit if an integrated intervention 
+plan existed for a cluster of symptoms based on a clear 
+understanding of which symptoms are likely to cluster, 
+when clustering is likely to occur, and how a symptom 
+cluster affects patient outcomes at different stages of 
+treatment. Most of these symptom clusters are influenced 
+by patient’s perception, awareness, education, and mood 
+states, and can be explained through various biologic, 
+psychological, behavioral, and sociocultural mechanisms 
+that constitute a symptom interaction network and symptom 
+experience.[28] The experience of multiple simultaneous 
+symptoms has a synergistic effect on symptom distress.[29] 
+Management of symptoms therefore requires a holistic 
+approach that integrates behavioral and mind–body 
+strategies; this is more so emphasized in earlier studies 
+that have shown several stress reduction and mind–body 
+approaches to reduce distressful symptoms and manage 
+mood states in cancer patients. The results of our study 
+reinforce findings of our earlier study that has shown 
+beneficial effects of yoga intervention in managing 
+chemotherapy-related nausea and vomiting.[24] This simple 
+intervention can be imparted to nurses and cancer care 
+givers especially in developing countries where access 
+and resources for supportive care rarely exist. 
+There are several limitations to our study; one among 
+them could be inequality in contact time for interventions. 
+Table 4: Pearson correlation (r-values) between symptoms 
+on European Organization for Research in the treatment 
+of Cancer QoL C30 and distress subscales on the RSCL
+Physical 
+distress
+Psychological 
+distress
+Activity
+Fatigue
+0.68**
+0.62**
+–0.40**
+Nausea and vomiting
+0.48**
+0.27*
+–0.39**
+Pain
+0.34**
+0.42**
+–0.06
+Dyspnea
+0.09
+0.16
+–0.16
+Insomnia
+0.35**
+0.36**
+–0.20
+Appetite loss
+0.23*
+0.40**
+–0.03
+Constipation
+0.38**
+0.27*
+–0.37**
+Diarrhea
+0.19
+-0.05
+–0.38**
+*P values < 0.05 and **P values < 0.01 for Pearson’s correlation
+Vadiraja, et al. 
+[Downloaded free from http://www.ijoy.org.in on Friday, March 12, 2010]
+79
+International Journal of Yoga y Vol. 2 y Jul-Dec-2009
+However, it should be noted that supportive therapy[30] 
+interaction was only used to negate the confounding 
+variables such as instructor–patient interaction, education, 
+and attention that could have significantly reduced distress 
+in these patients.[31] 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.
+In conclusion, our yoga intervention shows beneficial 
+findings in managing cancer-related symptoms in early 
+breast cancer patients taking recourse to adjuvant 
+radiotherapy. More robust measures to assess individual 
+symptoms must be attempted in future studies. Future 
+studies should unravel putative mechanisms of action of 
+our intervention for each of these symptoms. 
+ACKNOWLEDGMENTS
+This research was supported by a grant from Central Council 
+for Research in Yoga and Naturopathy, Ministry of Health and 
+Family Welfare, Govt. of India. We are thankful to Dr. Jayashree 
+and Ms. Jayalakshmi for imparting the yoga intervention. 
+REFERENCES
+1. 
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+Thomas BC, Pandey M, Ramdas K, Nair MK. Psychological distress in cancer 
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+3. 
+Hughes J. Emotional reactions to diagnosis and treatment of early breast 
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+4. 
+Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F, et al. 
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+Ragaz J, Jackson SM, Le N, Plenderleith IH, Spinelli JJ, Basco VE, et al 
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+6. 
+Patrick DL, Ferketich SL, Frame PS, Harris JJ, Hendricks CB, Levin B, et al 
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+Monogr 2004;32:9-16.
+7. 
+Hegyvary ST. Patient care outcomes related to management of symptoms. 
+Ann Rev Nursing Res 1993;11:145-68.
+8. 
+Dodd M, Janson S, Facione N, Faucett J, Froelicher ES, Humphreys J, et al 
+Advancing the science of symptom management. J Adv Nurs 2001;33:668-76.
+9. 
+Teel CS, Meek P, McNamara AM, Watson L. Perspectives unifying symptom 
+interpretation. Image J Nurs Sch 1997;29:175-81.
+10. de Vito Dabbs A, Hoffman LA, Swigart V, Happ MB, Iacono AT, Dauber JH. 
+Using conceptual triangulation to develop an integrated model of the symptom 
+experience of acute rejection after lung transplantation. ANS Adv Nurs Sci 
+2004;27:138-49.
+11. 
+Kurtz ME, Kurtz JC, Stommel M, Given CW, Given B. The infl
+ uence of 
+symptoms, age, comorbidity and cancer site on physical functioning and mental 
+health of geriatric women patients. Women Health Psychol 1999;29:1-12.
+12. Degner LF, Sloan JA. Symptom distress in newly diagnosed ambulatory 
+cancer patients and as a predictor of survival in lung cancer. J Pain Symp 
+Manage 1995;10:423-31.
+13. Fu MR, LeMone P, McDaniel RW. An integrated approach to an analysis 
+of symptom management in patients with cancer. Oncol Nursing Forum 
+2004;31:65-70.
+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. Andersen BL. Psychological interventions for cancer patients to enhance the 
+quality of life. J Consult Clin Psychol 1992;60:552-68.
+16. Cunningham AJ. Adjuvant psychological therapy for cancer patients: Putting 
+it on the same footing as adjunctive medical therapies. Psychooncology 
+2000;9:367-71.
+17. Meyer TJ, Mark MM. Effects of psychosocial interventions with adult 
+cancer patients: A meta-analysis of randomized experiments. Health Psychol 
+1995;14:101-8.
+18. Owen JE, Klapow JC, Hicken B, Tucker DC. Psychosocial interventions 
+for cancer: Review and analysis using a three-tiered outcomes model. 
+Psychooncology 2001;10:218-30.
+19. Targ EF, Levine EG. The effi
+ cacy of a mind -body-spirit group for women 
+with breast cancer: A randomized controlled trial. Gen Hosp Psychiatry 
+2002;24:238-48.
+20. de Haes JC, Olschewski M. Quality of life assessment in a cross-cultural 
+context: Use of the Rotterdam Symptom Checklist in a multinational 
+randomised trial comparing CMF and Zoladex (Goserlin) treatment in early 
+breast cancer. Ann Oncol 1998;9:745-750.
+21. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al 
+The European Organization for Research and Treatment 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.
+22. 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.
+23. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration 
+following two yoga relaxation techniques. Appl Psychophysiol Biofeedback 
+2000;25:221-7.
+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 emesis in breast cancer patients. Eur J Cancer Care 
+2007;16:462-74.
+25. Bower JE, Woolery A, Sternlieb B, Garet D. Yoga for cancer patients and 
+survivors. Cancer Control 2005;12:165-71.
+26. Barsevick AM. The elusive concept of the symptom cluster. Oncol Nurs 
+Forum 2007;34:971-80.
+27. Shimozuma K, Ganz PA, Petersen L, Hirji K. Quality of life in the fi
+ rst year 
+after breast cancer surgery: Rehabilitation needs and patterns of recovery. 
+Breast Cancer Res Treat 1999;56:45-57.
+28. Parker KP, Kimble LP, Dunbar SB, Clark PC. Symptom interactions as 
+mechanisms underlying symptom pairs and clusters. J Nurs Scholarsh 
+2005;37:209-15.
+29. Lenz ER, Pugh LC, Milligan RA, Gift A, Suppe F. The middle-range theory 
+of unpleasant symptoms: An update. ANS Adv Nurs Sci 1997;19:14-27.
+30. Telch CF, Telch MJ. Group coping skills instruction and supportive group 
+therapy for cancer patients: A comparison of strategies. J Consult Clin Psychol 
+1986;54:802-8.
+31. Greer S, Moorey S, Baruch JD, Watson M, Robertson BM, Mason A, et al 
+Adjuvant psychological therapy for patients with cancer: A prospective 
+randomised trial. BMJ 1992;304:675-80. 
+Yoga and cancer symptom management
+[Downloaded free from http://www.ijoy.org.in on Friday, March 12, 2010]

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+July 2016, Vol 14, No.4
+306
+Journal of Integrative Medicine
+Journal homepage: 
+www.jcimjournal.com/jim
+www.elsevier.com/locate/issn/20954964
+Available also online at www.sciencedirect.com. 
+Copyright © 2015, Journal of Integrative Medicine Editorial Office. 
+E-edition published by Elsevier (Singapore) Pte Ltd. All rights reserved.
+http://dx.doi.org/10.1016/S2095-4964(16)60266-2
+Received April 21, 2016; accepted May 29, 2016.
+Correspondence: A. Mooventhan, MD; E-mail: [email protected]
+●  Short Report
+Effects of ice massage of the head and spine on 
+heart rate variability in healthy volunteers
+A. Mooventhan
+1, L. Nivethitha
+2
+1.	Sri Dharmasthala Manjunatheshwara College of Naturopathy and Yogic Sciences and Hospital, 
+Ujire-574240, Karnataka, India
+2.	Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru-560019, Karnataka, India
+ABSTRACT
+OBJECTIVE: Ice massage (IM) is one of the treatment procedures used in hydrotherapy. Though its 
+various physiological/therapeutic effects have been reported, effects of IM of the head and spine on heart 
+rate variability (HRV) have not been studied. Thus, this study evaluated the effects of IM of the head and 
+spine on HRV in healthy volunteers.
+METHODS: Thirty subjects were randomly divided into 3 sessions: (1) IM, (2) tap water massage (TWM) and 
+(3) prone rest (PR). Heart rate (HR) and HRV were assessed before and after each intervention session.
+RESULTS: A significant increase in the mean of the intervals between adjacent QRS complexes or the 
+instantaneous HR (RRI), square root of mean of sum of squares of differences between adjacent normal 
+to normal (NN) intervals (RMSSD), number of interval differences of successive NN intervals greater 
+than 50 milliseconds (NN50), proportion derived by dividing NN50 by total number of NN intervals 
+along with significant reduction in HR after IM session; significant increase in RRI along with significant 
+reduction in HR after TWM, and a significant increase only in RMSSD after PR were observed. However, 
+there was no significant difference between the sessions. 
+CONCLUSION: Results of this study suggest that 20 min of IM of the head and spine is effective in 
+reducing HR and improving HRV through vagal dominance in healthy volunteers. 
+Keywords: heart rate variability; hydrotherapy; massage therapy
+Citation: 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(4): 306–310. 
+1  Introduction
+Naturopathy is a drugless system that aims to bring 
+harmony in the physical, mental, moral and spiritual planes 
+of living
+[1]. It is a distinct type of primary care medicine that 
+blends age-old healing traditions with scientific advances and 
+current research
+[2]. It consists of hydrotherapy, diet therapy, 
+fasting therapy, mud therapy, helio therapy and air therapy
+[1]. 
+Hydrotherapy is the external/internal use of water in any 
+of its forms (ice, water and steam) at various temperatures, 
+pressures, durations and locations on the body for the 
+promotion of health or the treatment of various diseases. It 
+was used widely in ancient cultures including India, Egypt 
+and China
+[3].
+Cardiovascular functions are controlled by neural 
+factors, hormones and temperature
+[4]. Ice is a therapeutic 
+agent used in medicine as an integral part of injury 
+treatment and rehabilitation
+[5]. The application of ice has 
+been shown to produce physiologic changes
+[6], such as 
+reduction in pain, edema, nerve conduction velocities, 
+July 2016, Vol 14, No.4
+307
+Journal of Integrative Medicine
+www.jcimjournal.com/jim
+cellular metabolism and local blood flow. It also has 
+been shown to induce local anesthesia around treatment 
+area
+[5,7,8], attenuate ischemic tissue damage and reduce 
+microcirculatory impairment
+[8].
+Ice massage (IM) of the head and spine is one of the 
+naturopathic treatments used to reduce blood pressure
+[9]. 
+Though it is widely used, the precise physiological 
+responses have not been fully explored and, to the best of 
+our knowledge, no study has reported the effect of IM of 
+the head and spine on heart rate variability (HRV). Thus, 
+the present study evaluates the effect of IM of the head 
+and spine on HRV in healthy volunteers.
+2  Materials and methods
+2.1  Subjects
+A total of 30 healthy male volunteers between 18 and 
+25 years of age were recruited from a residential college 
+in south India based on the inclusion criteria.
+2.1.1  Inclusion criteria
+The criteria for inclusion of patients in the present 
+study were: aged 18 years and above, male, and willing to 
+participate in the study.
+2.1.2  Exclusion criteria
+Subjects were excluded if they had a history of any 
+systemic and/or mental illness, regular use of any 
+medications, regular smoking and/or regular alcohol 
+consumption. 
+The study protocol was approved by the institutional 
+ethics committee of Sri Dharmasthala Manjunatheshwara 
+College of Naturopathy and Yogic Sciences and a written 
+informed consent was obtained from each subject.
+2.2  Study design
+A cross over design was used, in which
+ each 
+participant was assessed in three different intervention 
+sessions: (1) IM, (2) tap water massage (TWM) and 
+(3) prone rest (PR). Subjects were assigned to treatment 
+order randomly by drawing from an envelope with the 
+description of the three different orders (n=10)
+[10]. The 
+sessions were performed on days 1, 2 and 3 respectively 
+in orders: IM, TWM, PR (the first order); TWM, PR, IM 
+(the second order); or PR, IM, TWM (the third order). 
+Assessments of heart rate (HR) and HRV were measured 
+before or after 20 min of each intervention session. The 
+trial profile is shown in Figure 1.
+2.3  Intervention
+Each subject received 3 intervention sessions in any 
+one of the 3 different orders as described in the above. 
+The duration of each intervention session was about 
+20 min
+[5,11–13]. Duration of the intervention was chosen 
+based on a previous study
+[14].
+2.3.1  IM session 
+Subjects were asked to lie prone on the massage table. 
+Then, IM was given to the head and spine by continuous 
+longitudinal displacements
+[7] by means of a rubber bag 
+filled with ice
+[15] (1–2 
+oC) for the duration of 20 min
+[5,11–13]. 
+The use of an ice bag was mainly to avoid overuse injuries 
+among the patients
+[6].
+2.3.2  TWM session 
+TWM was given as an active control for IM. Subjects 
+were asked to lie prone on a massage table. Then 
+TWM was given to the head and spine by continuous 
+longitudinal displacements by means of a rubber bag filled 
+with tap water (24–25 
+oC) for the duration of 20 min.
+2.3.3  PR session 
+PR was given as a passive control, in which subjects did 
+not receive any hydrotherapic intervention, but similar to 
+IM and TWM, all subjects were asked to lie in the prone 
+position for 20 min. The prone rest was given to avoid 
+postural variation.
+2.4  Assessments
+2.4.1  Anthropometrics
+Height (cm) was measured using a standard measuring 
+tape
+[4]. Weight (kg) and body mass index (BMI, kg/m
+2) were 
+measured using Body Composition Analyzer (TANITA 
+SC-330, Japan), which calculates body composition from 
+bio-electric impedance, and measured by the unit
+[16]. The 
+measurement was done by asking the subjects to stand erect 
+with bare feet on the footplate of the analyzer.
+2.4.2  HR and HRV
+HR and HRV were assessed using a four-channel 
+polygraph
+ (MP 36, Biopac Student Lab, BIOPAC System 
+Inc, USA). The Ag/AgCl pre-gelled electrodes were 
+placed according to the standard limb lead II configuration 
+for recording electrocardiogram. Data were acquired at 
+the sampling rate of 1 024 Hz.
+2.4.3  Data extraction
+Frequency domain and time domain analysis of 
+the HRV data were carried out for baseline and post-
+intervention (5 min recordings for each) for each of 
+the three intervention sessions. The data recorded were 
+visually inspected off-line and only noise-free data 
+were included for the analysis
+[17].
+The data were analyzed with an HRV analysis program 
+developed by the Biomedical Signal Analysis Group 
+(University of Kuopio, Finland)
+[18]. The energy in the 
+HRV series in the following specific frequency bands 
+was studied: low frequency (LF) band (0.05–0.15 Hz), 
+and high frequency (HF) band (0.15–0.5 Hz). LF/HF 
+ratio was also calculated. The LF and HF band values 
+were expressed as normalized units. The following 
+components of the time domain HRV were analyzed: 
+(1) the mean of the intervals between adjacent QRS 
+complexes or the instantaneous HR (RRI), (2) HR, 
+(3) the square root of the mean of the sum of the 
+squares of differences between adjacent normal to 
+www.jcimjournal.com/jim
+July 2016, Vol 14, No.4
+308
+Journal of Integrative Medicine
+normal (NN) intervals (RMSSD), (4) the number of 
+interval differences of successive NN intervals greater 
+than 50 milliseconds (NN50) and (5) the proportion 
+derived by dividing NN50 by the total number of NN 
+intervals (pNN50)
+[17].
+2.5  Statistical analysis
+Statistical analysis was performed using Statistical 
+Package for the Social Sciences (SPSS for Windows, 
+Version 16.0, SPSS Inc., Chicago, IL). Analysis of variance 
+for repeated measures, followed by post-hoc analysis with 
+Bonferroni adjustment for multiple comparisons, was 
+performed for testing patients’ responses. A P value < 0.05 
+was considered to be significant.
+3  Results
+3.1  Demographic variables
+Thirty subjects were assigned into 3 intervention 
+sessions on 3 different days. Baseline and post-ntervention 
+assessments of each session were made before and after 
+the respective intervention session. Of 30 subjects’ 
+data, there were movement artefacts in the data of 5 
+subjects [IM session (n=2), TWM session (n=1), PR 
+session (n=2)]; thus these data were not included in the 
+statistical analysis. Demographic variables of the study 
+subjects were shown in Table 1. There was no significant 
+difference among the sessions in baseline assessment in 
+any of the variables (Table 2).
+Figure 1  Trial profile
+IM: ice massage; TWM: tap water massage; PR: prone rest.
+Table 1  Demographic variables of the study group (n=25)
+Variable
+Data
+Age (Year)
+ 20.88±2.39
+Height (cm)
+168.72±6.88
+Weight (kg)
+ 63.08±8.41
+Body mass index (kg/m
+2)
+ 22.08±1.97
+3.2  Effects of IM on HR and HRV
+Result of this present study showed significant increases 
+in RRI, RMSSD, NN50, pNN50 along with significant 
+reduction in HR after IM. Significant increase in RRI 
+along with significant reduction in HR after TWM; and a 
+significant increase only in RMSSD after PR. However, there 
+were no significant differences among the sessions (Table 2).
+4  Discussion 
+Though the results of this present study showed no 
+change in the frequency domains such as LF, HF, and 
+LF/HF values after all the three intervention sessions, 
+significant increases in RRI, RMSSD, NN50 and pNN50, 
+along with significant reduction in HR, were observed 
+after IM session. This showed that 20 min of IM of the 
+head and spine reduced HR and improved HRV towards 
+parasympathetic dominance or sympathetic withdrawal. 
+July 2016, Vol 14, No.4
+309
+Journal of Integrative Medicine
+www.jcimjournal.com/jim
+Table 2  Baseline and post-intervention assessments of IM, TWM and control sessions
+Session
+n
+RRI
+(ms)
+HR
+(b/min)
+RMSSD
+(ms)
+NN50
+(count)
+pNN50
+(%)
+LF 
+HF
+LF/HF
+(ms
+2)
+IM
+25
+Baseline
+843.19±105.39
+72.53±8.44
+54.32±23.17
+91.12±55.06
+28.38±18.13
+48.46±14.59
+51.54±14.59
+1.18±1.02
+Post
+896.18±117.26
+68.51±8.64
+67.99±33.02
+115.68±57.80 37.96±19.91
+47.53±18.87
+52.47±18.87
+1.38±1.72
+P value
+0.001
+0.001
+0.013
+0.017
+0.010
+0.800
+0.800
+0.603
+TWM
+25
+Baseline
+839.04±92.00
+72.82±8.16
+64.64±44.97
+88.44±56.44
+29.64±21.13
+52.27±16.98
+47.73±16.98
+1.47±1.22
+Post
+873.19±115.73
+70.39±9.45
+66.67±36.23
+93.96±53.70
+32.73±21.12
+54.39±16.22
+45.61±16.22
+1.57±1.33
+P value
+0.004
+0.008
+0.775
+0.523
+0.310
+0.567
+0.567
+0.752
+Control
+25
+Baseline
+857.62±102.09
+71.27±7.94
+58.17±30.89
+111.40±68.52 33.59±22.74
+48.03±15.19
+51.97±15.19
+1.16±0.99
+Post
+863.80±104.19
+70.99±8.45
+66.67±38.23
+110.20±69.89 33.39±22.97
+50.12±18.05
+47.56±20.34
+1.77±2.60
+P value
+0.639
+0.805
+0.027
+*
+0.864
+0.930
+0.468
+0.203
+0.117
+All values are presented as mean ± standard deviation and analyzed using repeated measures of analysis of variance and post-hoc 
+analysis with Bonferroni correction. P values are results of within-session analysis. IM: ice massage; TWM: tap water massage; 
+RRI: the intervals between adjacent QRS complexes or the instantaneous HR; HR: heart rate; RMSSD: the square root of the mean 
+of the sum of the squares of differences between adjacent NN intervals; NN50: the number of interval differences of successive NN 
+intervals greater than 50 milliseconds; pNN50: proportion derived by dividing NN50 by the total number of NN intervals; LF: low 
+frequency; HF: high frequency.
+The time domain measures of the HRV, i.e., mean RRI, 
+RMSSD and NN50 have been recognized as stronger 
+predictors of vagal modulation than frequency domain 
+measures
+[18]. Thus, the increases in RRI, RMSSD, NN50, 
+pNN50 following IM are suggestive of vagal dominance.
+Generally, it is thought that the LF power of the 
+HRV corresponds to the cardiac sympathetic activity; 
+conversely, HF power corresponds to the cardiac 
+parasympathetic activity. However, there is still some 
+debate over this matter. It has been reported that neither 
+the LF power band nor the HF power band is exclusive 
+indices of cardiac sympathetic and parasympathetic 
+tone, respectively. The LF power was reduced after 
+selective cardiac parasympathectomy, but did not totally 
+disappear after a β-adrenoceptor blockage, resulting from 
+denervation. Further, the sympathetic activity can also 
+influence the HF power but to a lesser extent than the 
+effect of parasympathetic activity on the LF power
+[17,18].
+A previous study that focused on three types of cold 
+stimulation treatments included: (1) immersing the hand/
+foot in ice water, (2) ice application to forehead and (3) ice 
+application to face. This study found that HR and blood 
+pressure increased only in the case of hand immersion. 
+However, ice application to the forehead or face produced 
+an insignificant reduction in HR, as well as insignificant 
+changes in blood pressure. This finding indicated that the 
+application of ice to the forehead and face might have 
+an effect on reducing HR, while to hand/foot had the 
+opposite effect
+[19]. Another study on ice bag application to 
+the head and spine showed a significant reduction in pulse 
+rate and blood pressure, which supports the results of our 
+study
+[9].
+A significant increase in RRI coupled with a significant 
+reduction in HR, following TWM, indicated that 20 min 
+of TWM to the head and spine affected HR and HRV. 
+Since within-session analysis of IM of the head and spine 
+showed improvement in all the time-domain variables 
+of HRV spectra and a significant reduction in HR, it 
+may be considered as influencing the HRV towards 
+vagal dominance, which is unlike TWM and PR. This 
+effect might be used for the prevention and treatment of 
+cardiovascular diseases, including hypertension and its 
+related problems.
+5  Strength of the study
+To the best of our knowledge this is the first study 
+evaluating the effect of IM of the head and spine on HRV 
+in healthy volunteers. A previous study reported that ice 
+used in IM treatment should weigh at least 0.6 kg for 
+www.jcimjournal.com/jim
+July 2016, Vol 14, No.4
+310
+Journal of Integrative Medicine
+cold treatment
+[11]. In this study, we used approximately 
+0.6–0.8 kg for IM, resulting in no adverse side effect, 
+such as the cold-induced burn or discomfort. Hence, this 
+study reports a simple, low-cost intervention that can be 
+given by anyone.
+6  Limitations of the study
+This study was conducted in the healthy male 
+volunteers, limiting the application of our findings 
+to females and pathological conditions. Investigators 
+were not blinded for the intervention sessions. 
+Although clinicians were aware of the treatments they 
+delivered, all assessments were performed with standard 
+equipment. Additional assessments, such as continuous 
+blood pressure monitoring, baroreceptor sensitivity, 
+photo plethysmography and galvanic skin resistance 
+would have given better understanding of the state of the 
+autonomic nervous system. The present study assessed 
+only the immediate effects of IM, PR and TWM of the 
+head and spine on HRV, but did not assess its long-
+term effects or its underlying mechanisms. Hence, 
+further studies are required (i.e., randomized control 
+trials) engaging a larger sample size, using advanced 
+techniques and taking place over a greater period of 
+time, in order to evaluate its precise physiological effects 
+and underlying mechanisms. 
+7  Conclusion
+Results of this study suggest that 20 min of IM of 
+the head and spine is effective at reducing HR and in 
+improving HRV towards vagal dominance in healthy 
+volunteers.
+8  Conflict of interest
+None declared.
+REFERENCES
+1	
+Rastogi R. Current approaches of research in naturopathy: 
+how far is its evidence base? J Tradit Med Clin Naturop. 
+2012; 1(2): 107–112. 
+2	
+Fleming SA, Gutknecht NC. Naturopathy and the primary 
+care practice. Prim Care. 2010; 37(1): 119–136. 
+3	
+Mooventhan A, Nivethitha L. Scientific evidence-based 
+effects of hydrotherapy on various systems of the body. N 
+Am J Med Sci. 2014; 6(5): 199–209. 
+4	
+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(2): 91–96. 
+5	
+Dykstra JH, Hill HM, Miller MG, Cheatham CC, Michael 
+TJ, Baker RJ. Comparisons of cubed ice, crushed ice, 
+and wetted ice on intramuscular and surface temperature 
+changes. J Athl Train. 2009; 44(2): 136–141. 
+6	
+Bender AL, Kramer EE, Brucker JB, Demchak TJ, Cordova 
+ML, Stone MB. Local ice-bag application and triceps surae 
+muscle temperature during treadmill walking. J Athl Train. 
+2005; 40(4): 271–275. 
+7	
+Herrera E, Sandoval MC, Camargo DM, Salvini TF. Motor 
+and sensory nerve conduction are affected differently by ice 
+pack, ice massage, and cold water immersion. Phys Ther. 
+2010; 90(4): 581–591. 
+8	
+Holwerda SW, Trowbridge CA, Womochel KS, Keller 
+DM. Effects of cold modality application with static and 
+intermittent pneumatic compression on tissue temperature 
+and systemic cardiovascular responses. Sports Health. 
+2013; 5(1): 27–33. 
+9	
+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(1): 53–56. 
+10	 Mooventhan A, Khode V. Effect of Bhramari pranayama 
+and OM chanting on pulmonary function in healthy 
+individuals: a prospective randomized control trial. Int J 
+Yoga. 2014; 7(2): 104–110. 
+11	 Janwantanakul P. The effect of quantity of ice and size 
+of contact area on ice pack/skin interface temperature. 
+Physiotherapy. 2009; 95(2): 120–125. 
+12	 Richendollar ML, Darby LA, Brown TM. Ice bag 
+application, active warm-up, and 3 measures of maximal 
+functional performance. J Athl Train. 2006; 41(4): 364–370. 
+13	 Leite M, Ribeiro F. Liquid ice fails to cool the skin surface 
+as effectively as crushed ice in a wet towel. Physiother 
+Theory Pract. 2010; 26(6): 393–398. 
+14	 Gorji HM, Nesami BM, Ayyasi M, Ghafari R, Yazdani J. 
+Comparison of ice packs application and relaxation therapy 
+in pain reduction during chest tube removal following 
+cardiac surgery. N Am J Med Sci. 2014; 6(1): 19–24. 
+15	 Kellogg JH. Rational hydrotherapy. 2nd ed. Pune: National 
+Institute of Naturopathy. 2005: 856.
+16	 Wouters EJ, Van Nunen AM, Geenen R, Kolotkin RL, 
+Vingerhoets AJ. Effects of aquajogging in obese adults: a 
+pilot study. J Obes. 2010: 231074. 
+17	 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(1): 35–42. 
+18	 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: 184–193. 
+19	 Allen MT, Shelley KS, Boquet AJ Jr. A comparison of 
+cardiovascular and autonomic adjustments to three types 
+of cold stimulation tasks. Int J Psychophysiol. 1992; 13(1): 
+59–69. 

subfolder_0/Effects of yoga on natural killer cell counts in early breast cancer patients undergoing conventional treatment.txt

@@ -0,0 +1,175 @@
+PERSONAL USE
+ONLY
+Effects of yoga on natural killer cell counts in early breast 
+cancer patients undergoing conventional treatment
+Comment to:
+Recreational music-making modulates natural killer cell activity, 
+cytokines, and mood states in corporate employees
+Masatada Wachi, Masahiro Koyama, Masanori Utsuyama, 
+Barry B. Bittman, Masanobu Kitagawa, Katsuiku Hirokawa
+Med Sci Monit, 2007; 13(2): CR57-70
+Dear Editor,
+Recreational music-making (RMM) was evaluated as a stress-
+alleviating strategy in Japanese corporate male employ-
+ees and was compared to leisure reading as a control [1]. 
+Following a single session of RMM, the volunteers showed 
+enhanced mood, lower gene expression levels of the stress-
+induced cytokine interleukin-10, and higher natural killer 
+(NK) cell activity. The increase in NK cell activity was espe-
+cially seen in individuals who had low levels prior to inte-
+rvention. These changes were attributed to the stress-alle-
+viating effects of RMM.
+It was interesting to note that the benefi
+ ts were noted after 
+a single session of RMM. Similarly, practicing yoga has also 
+been shown to reduce subjectively rated occupational stress 
+levels as well as psychophysiological signs of stress following 
+a short, two-day training program [2].
+A randomized controlled trial assessed the effect of a yoga 
+program on NK cell counts in breast cancer patients un-
+dergoing conventional cancer treatment (i.e., surgery fol-
+lowed by radiotherapy and chemotherapy). The study had 
+the approval of the institutional review board and the pa-
+tients gave their consent to participate in the trial. Thirty-
+seven women with recently diagnosed stage II and III 
+operable breast cancer were randomized to receive yoga 
+(n=16; mean age ±S.D, 47.0±7.6 years) or supportive thera-
+py (n=21; mean age ±S.D, 49.8±12.9 years) before primary 
+surgery. None of them had any secondary malignancy, re-
+cent infections, or other medical conditions which would 
+have infl
+ uenced the outcome of the interventions or the as-
+sessments. The age (±1 year), stage of disease, grade, and 
+lymph node status were similar in the yoga and supportive 
+therapy (control) groups.
+Blood samples were collected between 8 a.m. and 12 p.m. 
+to reduce diurnal variation. A baseline assessment was done 
+prior to surgery. Follow-up assessments were done at 4 we-
+eks following the baseline assessment (i.e., after surgery), 
+10 weeks from baseline (i.e., after radiotherapy), and 32 
+weeks from baseline (i.e., after 6 cycles of chemothera-
+py). Peripheral blood lymphocytes were characterized for 
+NK cell subsets using immunohistochemistry (Alkaline 
+Phosphatase Anti-Alkaline Phosphatase technique). The 
+cells were counted per two hundred fi
+ elds and the mean 
+percentage of CD56 positive cells per hundred fi
+ elds was 
+extrapolated.
+The yoga group received a program which included dif-
+ferent yoga techniques while the control group received 
+supportive counseling sessions. The yoga program consi-
+sted of postures practiced with awareness (asanas, for 15 
+minutes), voluntarily regulated yoga breathing (pranayama, 
+for 15 minutes), and relaxation while supine (shavasana or 
+the corpse posture) combined with imagery (30 minutes). 
+The supportive counseling sessions increased the patients’ 
+knowledge about the disease and treatment options, there-
+by reducing their apprehensions and anxiety. The patients 
+had four yoga sessions in the period before and after surge-
+ry and had three yoga sessions per week during their adju-
+vant radiotherapy treatment with self-practice at home on 
+the remaining days. During chemotherapy, patients had 
+a yoga session on the same day as chemotherapy, which 
+was once in twenty-one days and had an additional yoga 
+session once in ten days. The instructor monitored their 
+practice at home everyday by telephone calls and house 
+visits. Participants were also requested to maintain a da-
+ily diary listing the yoga practices done, duration of prac-
+tice, experience of distressful symptoms, intake of medi-
+cation and their diet. The control intervention consisted 
+of brief supportive therapy with education that is routine-
+ly offered to patients as a part of their care in the center. 
+This control intervention was chosen to control for fac-
+tors such as attention and support from contact with the 
+instructor. Patients and their relatives underwent counse-
+ling by a trained social worker once in 10 days, as 15 mi-
+nute sessions during their hospital visits for adjuvant ra-
+diotherapy and chemotherapy. Patients in the supportive 
+therapy group also completed daily diaries on treatment 
+related symptoms, medication and their diet during che-
+motherapy. Data were analyzed using a repeated measures 
+LE3
+Letter to Editor
+WWW.MEDSCIMONIT.COM
+LE
+Current Contents/Clinical Medicine • IF(2006)=1.595 • Index Medicus/MEDLINE • EMBASE/Excerpta Medica • Chemical Abstracts • Index Copernicus
+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
+analysis of variance and post-hoc analyses with Bonferroni 
+adjustment.
+There was a signifi
+ cant decrease in the NK cell percentage 
+in the control group from baseline/pre-surgery (22.0±4.2) 
+to post-surgery (16.8±3.7; p<0.05) and from pre-surge-
+ry (22.0±4.2) to post-chemotherapy (13.8±3.2; p<0.001). 
+In contrast, the NK cell percentage did not signifi
+ can-
+tly decrease in the yoga group, at corresponding time po-
+ints [i.e., baseline/pre-surgery (20.1±6.5) to post-surgery 
+(19.8±5.8); and from pre-surgery (20.1±6.5) to post-chemo-
+therapy (16.9±3.2)]. The NK cell percentage was higher in 
+the yoga group (16.9±3.2) post-chemotherapy compared to 
+the control group (13.8±3.2; p<0.05). However, there were 
+no signifi
+ cant differences between groups following surge-
+ry and radiotherapy.
+These fi
+ ndings are consistent with those of other, non-yoga 
+stress reduction interventions [3]. Also, an earlier study sho-
+wed an increase in NK cell counts after 24 weeks of yoga 
+voluntarily regulated rhythmic breathing (sudarashan kriya 
+yoga and pranayama) in patients with cancer [4].
+Decrements in NK cell counts have been found to be an 
+important predictor for survival in advanced breast cancer 
+patients. The present results suggest that practicing yoga 
+helped to reduce immune suppression associated with che-
+motherapy in early breast cancer patients. Catecholamines 
+and glucocorticoids have been shown to rapidly and marke-
+dly affect the dynamics and distribution of NK cells in the 
+spleen. liver, lungs, circulating blood, and marginating pool 
+of blood [5,6]. It may be hypothesized that changes in these 
+hormone levels following yoga [7], could be one of the ways 
+in which yoga practice infl
+ uences NK cell levels.
+Sincerely,
+Raghavendra M. Rao1, Shirley Telles2,
+Hongasandra R. Nagendra1, Raghuram Nagarathna1,
+Kodaganur S. Gopinath3, Shastry Srinath3,
+Chandrashekara Srikantaiah4
+1 Swami Vivekananda Yoga Research Foundation, 
+Bangalore, India;
+2 Patanjali Yogpeeth, Haridwar, Uttarakhand, India;
+3 Bangalore Institute of Oncology, Bangalore, India;
+4 Department of Clinical Immunology, MS Ramaiah 
+Medical Teaching Hospital, Bangalore, India;
+e-mail: [email protected]
+REFERENCES:
+ 1. Wachi M, Koyama M, Utsuyama M et al: Recreational music-making mo-
+dulates natural killer cell activity, cytokines, and mood states in corpo-
+rate employees. Med Sci Monit, 2007; 13(2): CR57–70
+ 2. 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
+ 3. Carlson LE, Speca M, Patel KD et al: Mindfulness-based stress reduc-
+tion in relation to quality of life, mood, symptoms of stress, and immu-
+ne parameters in breast and prostate cancer outpatients. Psychosom 
+Med, 2003; 65: 571–81
+ 4. Kochupillai V, Kumar P, Singh D et al: Effect of rhythmic breathing 
+(Sudarshan Kriya and Pranayam) on immune functions and tobacco 
+addiction. Ann NY Acad Sci, 2005; 1056: 242–52
+ 5. Dhabhar FS, Miller AH, McEwen BS et al: Effects of stress on immu-
+ne cell distribution. Dynamics and hormonal mechanisms. J Immunol, 
+1995; 154: 5511–27
+ 6. Brosschot JF, Benschop RJ, Godaert GL et al: Effects of experimental 
+psychological stress on distribution and function of peripheral blood 
+cells. Psychosom Med, 1992; 54: 394–406
+ 7. Granath J, Ingvarsson S, von Thiele U et al: Stress management: a ran-
+domized study of cognitive behavioural therapy and yoga. Cogn Behav 
+Ther, 2006; 35(1): 3–10
+Received: 2008.01.22
+LE4
+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/Efficacy of Naturopathy And Yoga In Bronchial Asthma..txt

@@ -0,0 +1,979 @@
+232
+Rao, Kadam, Jagannathan, Babina, Rao and Nagendra
+Indian J Physiol Pharmacol 2014; 58(3)
+Original Article
+Efficacy of naturopathy and yoga in bronchial asthma
+Y Chitharanjan Rao1, Avinash Kadam2, Aarti Jagannathan3*,
+N. Babina4, Raghavendra Rao5 and
+Hongasandra Ramarao Nagendra6
+1 PhD Scholar, SVYASA, Bangalore, India
+2 M.Sc. (Pharmaceutical Medicine), Research Associate, INYS-Medical Research Society, Jindal Nature
+Cure Institute, Bangalore
+3 PhD, Asst Prof, Division of Yoga and Life Sciences, SVYASA, Bangalore, India
+4 BNYS, Jt. Project officer – INYS-Medical Research Society, Jindal Nature Cure Institute, Bangalore
+5 PhD, Research consultant – INYS-Medical Research Society, Jindal Nature cure Institute, Bangalore
+6 PhD, Vice Chancellor, SVYASA, Bangalore, India
+Abstract
+The aim of the study was to test the efficacy of a one month in-patient naturopathy and yoga programme
+for patients with asthma. Retrospective data of 159 bronchial asthma patients, undergoing the naturopathy
+and yoga programme, was analyzed for Forced Vital Capacity, Forced Expiratory Volume at the end of 1
+second, Maximum Voluntary Ventilation and Peak Expiratory Flow Rate on admission, 11th day, on discharge
+and once in three months for three years. The paired sample t test results showed significant increase in
+the Forced Vital Capacity and Forced Expiratory Volume from the date of admission up to 6th month
+(P<0.0035) post Bonferroni correction. Maximum Voluntary Ventilation significantly increased from admission
+till the date of discharge (P<0.0035) and Peak Expiratory Flow Rate significantly increased from admission
+till the 36th month of follow-up (P<0.0035), post Bonferroni correction. This validated the beneficial effect of
+combining naturopathy and yoga for the management of bronchial asthma.
+Indian J Physiol Pharmacol 2014; 58(3) : 232–238
+Introduction
+Research has shown that different types of alternative
+and complementary treatments like acupuncture,
+yoga, tai chi, chuan and hypnosis have been used
+by asthma patients in alleviating their symptoms (1).
+A meta-analytical review of seven databases including
+three RCTs and one NRCT suggested that yoga lead
+to significant greater reduction in airway hyper-
+response, PC20 (needed to provoke a 20% reduction
+in forced expiratory volume in the first-second weekly
+number of asthma attacks), and the need for drug
+treatment (2). Other reviews have also reported that
+yoga leads to a significant greater reduction in airway
+hyper-response, weekly number of asthma attacks
+and drug treatment (3-7).
+In the last decade, there have been only 12
+experimental studies in the field of yoga and asthma
+(8-17). As yoga is a long-term treatment - with its
+efficacy most pronounced after 4-8 weeks, it is very
+*Corresponding author :
+Dr. Aarti Jagannathan, Assistant Professor, Swami
+Vivekananda Yoga Anusandhana Samsthana, #19,
+Ekanath Bhavan, Gavipuram Circle, K.G. Nagar, Bangalore –
+560 019, India, Fax: 26608645; Tel: +91-9448150690;
+E-mail: [email protected]
+(Received on September 5, 2012)
+Indian J Physiol Pharmacol 2014; 58(3)
+Naturopathy and Yoga for Asthma
+233
+assess reversibility after inhalation of short acting
+bronchodialators) (4) reversibility (determined by an
+increase in FEV1 of ≥12 percent from baseline).
+These patients were not controlled satisfactorily by
+conventional medicines prior to their enrollment into
+the study. Patients with other major health problems
+(medical/neurological/psychiatric) were excluded from
+the study. Before enrolling in the study all the
+patients were using conventional medicines as
+prescribed by their physician. As these patients were
+treated by different physicians who were not a part
+of the current study, the researchers had no control
+on the method of treatment used prior to their
+enrollment in the study. Hence at the start of study
+each patient was examined by the investigator/
+naturopath physician. Based on the patient’s disease
+condition the investigator prescribed the minimum
+pharmacological intervention/medication dosage to
+help control the symptoms.
+The combined intervention of Naturopathy and Yoga
+was provided as a residential treatment for a period
+of one month at Jindal Nature Cure Hospital. The
+Yoga session included physical activity, relaxation,
+regulated breathing and philosophical aspects of
+yoga. The Integrated yoga module was selected from
+the integrated set of yoga practices used in earlier
+studies on yoga for positive health (18). The yoga
+sessions were conducted three times in a day.
+Morning sessions of asanas were conducted for about
+one hour. It consisted of ‘suryanamaskar’ of 4 rounds
+and other asanas such as Ardha cakräsana,
+Pädahastäsana, Vajräsana, Supta vajräsana, Ardha
+matsendrsana, Paschimottasana, Ustrasana,
+Naukasana, Shashanasana, Halàsana or Mayüräsana,
+Dhanuräsana, Sarvängäsana, Matyäsana, Ardha
+sirsasana or sirsasana, Vipareetakarani (one round
+of each asana). Beside this ‘yogic kriyas’ such as
+Jalaneti, Gargling, Ghee drop in nose, Vamana
+dhuti (once in three days), Rubber neti, Trataka,
+Kapälabhäti, Laughing Exercises – were practiced
+for half an hour. The afternoon session consisted of
+half an hour of yoga asanas (as listed above) which
+included one round of each asana. The evening
+session consisted of half an hour of ‘yoga nidra’. All
+sessions were done under supervision – in the
+presence of a qualified yoga instructor, specially
+trained for the study protocol.
+essential to have extended follow-up studies to test
+the efficacy of yoga for treatment of asthma. In the
+last few decades, only one long-term follow-up study
+(3-54 months follow-up) has been conducted to
+assess the effect of a 2 week integrated yoga therapy
+programme on patients suffering from asthma (18).
+This study showed that there was a significant
+improvement in the yoga group in the weekly number
+of attacks of asthma, scores for drug treatment, and
+peak flow rate (18).
+Along with the mind-body therapy of yoga that
+integrates physical postures, breathing exercises,
+and meditation, the researchers of the current study
+believe that the intake of naturopathic medicine
+[natural substances to treat the patient (19)] can
+create a lasting effect in the patient‘s mental,
+emotional, and physical states. Till date only one
+self controlled matched study has looked at the
+efficacy of a 21 day naturopathy and yoga intervention
+in bronchial asthma and has shown significant
+improvement in PEFR, VC, FVC, FEV1, FEV/FEC%,
+MVV, ESR and absolute Eosinophil count (11). We
+have thus attempted to analyze retrospective data of
+a study which was designed to test the efficacy of
+a combined treatment of naturopathy and yoga
+treatment in patients with asthma, using a
+longitudinal follow-up design (36 month follow-up
+design).
+Methods
+The current study was a retrospective study and
+hence all cases available of bronchial asthma in the
+INYS Medical Research Society – Jindal Nature Cure
+database and meeting the eligibility criteria were
+selected [n=159 patients (74 males and 85 females)].
+The average age of these patients ranged from 18 to
+70 years [mean age (SD): 39.8 (13.0) years] and
+their average education was tenth standard. The
+average (SD) duration of untreated illness (asthma)
+was 10(8.01) months. 71% of patients had a family
+history of asthma.
+In the original study, diagnosis of asthma was arrived
+at based on the: (1) detailed medical history, (2)
+physical examination including auscultation, (3)
+spirometry measures (to demonstrate obstruction and
+234
+Rao, Kadam, Jagannathan, Babina, Rao and Nagendra
+Indian J Physiol Pharmacol 2014; 58(3)
+Naturopathy therapies were selected as per the
+standard practice/treatment prescribed for patients
+with asthma. The treatment included various
+combinations of naturopathic treatments such as diet,
+mud pack, enema, steam bath, steam inhalation,
+hot-hip bath, contrast foot bath, oxygen bath, hot-
+foot arm bath, drainage massage, oil massage,
+neutral immersion bath, vibro-drainage massage, hot
+check pack, sauna, half bath, neutral spinal bath
+and asthma bath.
+Both men and women were provided the same
+intervention programme. Menopausal patients were
+not excluded from the study. If a woman patient was
+observed to be menstruating during the study period,
+she was barred from practicing therapies which were
+considered contraindicative during the period (like
+abdominal packs and hydrotherapy treatments
+involving abdomen and pelvis and yogic exercises
+contraindicative during menstruation). The remaining
+therapies were continued with these women
+participants.
+The subjects were assessed at baseline, 11th day
+and after 21 days (post naturopathy-yoga
+intervention). The subjects were followed up once in
+every three months for three years. During each
+follow-up visit, the patients were examined by a
+physician and based on the patient’s condition the
+anti asthmatic drugs were first documented and then
+either reduced or stopped. In case of aggravation of
+symptoms after stopping/reduction of pharmacological
+medications inhaled bronchodilators were used as
+rescue medications to manage acute bronchospasm;
+and/or naturopathy therapies (like hot chest pack,
+hot foot immersion) were provided for symptomatic
+relief. In an eventuality of these therapies failing to
+relieve the symptoms, there was a provision in
+protocol to provide symptomatic relief medication (â
+agonist) based on the assessment of a general
+physician.
+The outcome variables assessed were Forced Vital
+Capacity (FVC), Forced Expiratory Volume (FEV1),
+Maximum Voluntary Ventilation (MVV) and Peak
+Expiratory Flow Rate. FVC was the total volume of
+air breathed out by the person after a full inspiration
+(inhalation) into a spirometer. FEV1 was the volume
+of air expired into a spirometer in the first second
+(FEV1). MVV was measured based on how quickly
+one can exhale (MVV) and PEFR was measured as
+the greatest amount of air one can breathe in and
+out during one minute. FVC, MVV were assessed
+using a ‘spirometry’, whereas PEFR was assessed
+using ‘Peal flow meter’.
+The above primary study data was retrospectively
+analyzed in the year 2008-2011, from the medical
+record files of the Jindal Nature Cure Hospital using
+the Statistical Software of Social Sciences (SPSS)
+version 10. The baseline data of the patients was
+assessed using Kolmogorov-Smirnov test for
+normality. As the data normally distributed (P>0.200)
+and the study design did not have a control group,
+paired t test was used to analyze the pre/post data.
+Due to multiple comparisons with baseline, Bonferroni
+correction was also conducted using the formula
+0.05/n (where n=14, as there were 14 pair wise
+comparisons only with baseline). Though Bonferroni
+correction is usually used with ANOVA, statistical
+experts have opined that in case of multiple baseline
+comparisons with t test, this method could be used
+to increase the power of the test used and to
+determine the significant results (20). The Holm–
+Bonferroni method, a uniformly more powerful test
+procedure (i.e. more powerful regardless of the values
+of the unobservable parameters) was also considered
+as an effective alternative power test. However, as
+current methods for obtaining confidence intervals
+for the Holm-Bonferroni method do not guarantee
+confidence intervals that are contained within those
+obtained using the Bonferroni correction (21), the
+authors of this paper have analyzed the data using
+only Bonferroni correction.
+Results
+Records detailed that as all the patients were under
+direct observation and care of investigator there was
+very good compliance to the interventions during their
+stay in the hospital. Though the patients were advised
+to continue the interventions at home post discharge,
+their compliance to these treatments during the 3
+years of study period was checked but not
+documented. Out of the 159 recruited patients,
+Indian J Physiol Pharmacol 2014; 58(3)
+Naturopathy and Yoga for Asthma
+235
+medical records showed that only 134 underwent the
+intervention and assessments and only 34 patients
+(FVC, FEV1, MVV; 78.6% attrition) -78 patients
+(PEFRM; 50.9% attrition) completed the 36 month
+follow-up visit.
+Table I shows the mean (SD) values for Forced Vital
+Capacity (FVC), Forced Expiratory Volume (FEV1),
+Maximum Voluntary Ventilation (MVV) and Peck
+Expiratory Flow Rate Morning (PEFR) and Table II
+shows the differential mean and SD values along
+with the t test values and significance computed
+using the paired sample t test. There was a significant
+increase in FVC, FEV1 mean values from admission
+to 6th month (P<0.0035, Table II) post Bonferroni
+correction. There was also significant increase in
+the MVV mean values; however only from admission
+till the date of discharge (P<0.0035, Table II).
+Significant increase in the PEFR mean values was
+observed from admission till the 36th month of follow-
+up (P<0.0035, Table II) except for the 9th month,
+post Bonferroni correction.
+TABLE I : Mean (SD) of Forced Vital Capacity (FVC), Forced Expiratory Volume at 1 second (FEV1), Maximum
+Voluntary Ventilation (MVV) and Peck Expiratory Flow Rate (PEFR) over the 36 month study period.
+FVC (Liters)
+FEV1 (Liters)
+MVV (Liters/Min)
+PERF (Liters/Min)
+Time
+n
+Mean±SD
+n
+Mean±SD
+n
+Mean±SD
+n
+Mean±SD
+OA
+133
+2.00 (0.77)
+133
+1.54 (0.64)
+133
+53.58 (25.59)
+25
+228.00 (101.78)
+11D
+134
+2.15 (0.83)
+134
+1.67 (0.68)
+134
+57.34 (27.53)
+29
+324.14 (150.06)
+OD
+129
+2.15 (0.86)
+130
+1.67 (0.71)
+130
+58.74 (29.67)
+33
+339.09 (131.21)
+3M
+55
+2.34 (0.74)
+55
+1.78 (0.61)
+55
+65.17 (31.03)
+117
+340.85 (119.16)
+6M
+67
+2.23 (0.77)
+67
+1.68 (0.60)
+67
+60.60 (26.54)
+106
+335.94 (111.81)
+9M
+53
+2.10 (0.83)
+53
+1.55 (0.63)
+52
+55.60 (24.95)
+100
+322.36 (123.53)
+12M
+49
+2.11 (0.64)
+51
+1.66 (0.58)
+51
+59.67 (25.60)
+96
+326.15 (120.82)
+15M
+43
+2.22 (0.79)
+42
+1.70 (0.63)
+42
+58.07 (26.53)
+96
+330.88 (123.66)
+18M
+49
+2.05 (0.77)
+50
+1.57 (0.64)
+50
+54.07 (24.69)
+90
+322.33 (120.81)
+21M
+48
+2.06 (0.82)
+47
+1.57 (0.63)
+46
+56.51 (25.36)
+90
+324.33 (118.15)
+24M
+44
+1.94 (0.78)
+45
+1.53 (0.63)
+45
+54.33 (26.20)
+85
+327.29 (120.55)
+27M
+40
+2.03 (0.68)
+40
+1.62 (0.53)
+40
+56.92 (23.75)
+82
+335.98 (112.99)
+30M
+42
+2.06 (0.76)
+42
+1.63 (0.65)
+42
+53.49 (27.04)
+80
+337.50 (111.04)
+33M
+47
+2.02 (0.75)
+47
+1.57 (0.62)
+46
+53.36 (24.96)
+72
+333.17 (117.25)
+36M
+34
+1.76 (0.71)
+34
+1.39 (0.60)
+34
+51.97 (26.06)
+78
+325.13 (117.06)
+#OA: On admission; OD: On discharge; 11D: On 11th day; 3M/6M…: On 3 month/6 month…
+TABLE II :
+Paired Samples t Test for Forced Vital Capacity (FVC), Forced Expiratory Volume at 1 second (FEV1), Maximum
+Voluntary Ventilation (MVV) and Peck Expiratory Flow Rate (PEFR) over the 36 month study period.
+FVC (Liters)
+FEV1 (Liters)
+MVV (Liters/Min)
+PERF (Liters/Min)
+Time
+n
+Mean (SD)
+t
+Sig.
+n
+Mean (SD)
+t
+Sig.
+n
+Mean (SD)
+t
+Sig.
+n
+Mean (SD)
+t
+Sig.
+OA-11D
+129 –0.17 (0.39)
+–5.06
+.00*
+129
+–0.14 (0.31)
+–5.15
+.00*
+129
+–4.44 (12.83)
+–3.93
+.00* 20
+–84.50 (90.29)
+–4.19 .00*
+OA-OD
+124 –0.19 (0.51)
+–4.08
+.00*
+125
+–0.16 (0.44)
+–3.95
+.00*
+124
+–6.82 (16.24)
+–4.68
+.00* 23
+–87.39 (84.22)
+–4.98 .00*
+OA-3M
+51
+–0.22 (0.49)
+–3.23
+.00*
+51
+–0.16 (0.36)
+–5.15
+.00*
+52
+–4.16 (17.60)
+–1.70
+.09
+21
+–88.57 (86.04)
+–4.72 .00*
+OA-6M
+53
+–0.20 (0.42)
+–3.36
+.00*
+53
+–0.17 (0.35)
+–3.61
+.00*
+53
+–4.51 (17.56)
+–1.87
+.07
+17
+–92.94 (100.48) –3.81 .00*
+OA-9M
+44
+–0.10 (0.44)
+–1.47 0.15
+44
+–0.08 (0.43)
+–1.27 0.21
+43
+–0.22 (16.39)
+–0.09
+.93
+16
+–73.13 (103.26) –2.83 .01
+OA-12M
+38
+–0.17 (0.38)
+–2.73 0.01
+39
+–0.12 (0.31)
+–2.44 0.02
+40
+–2.81 (15.75)
+–1.13
+.27
+22
+–84.09 (87.98)
+–4.48 .00*
+OA-15M
+35
+–0.18 (0.35)
+–2.95 0.01
+35
+–0.18 (0.34)
+–3.08 .004
+36
+–4.04 (16.47)
+–1.47
+.15
+17
+–88.82 (89.50)
+–4.09 .00*
+OA-18M
+38
+–0.07 (0.46)
+–0.99 0.33
+38
+–0.07 (0.44)
+–1.00 0.32
+39
+–1.81 (22.52)
+0.50
+.62
+19
+–78.95 (88.88)
+–3.87 .00*
+OA-21M
+41
+–0.13 (0.45)
+–1.84 0.07
+41
+–0.12 (0.38)
+–1.96 0.06
+40
+–2.18 (17.79)
+–0.78
+.44
+19
+–76.84 (92.80)
+–3.61 .00*
+OA-24M
+37
+0.03 (0.36)
+0.53
+0.60
+37
+–0.05 (0.39)
+–0.82 0.42
+38
+–1.84 (17.90)
+–0.63
+.53
+16
+–76.88 (84.99)
+–3.62 .00*
+OA-27M
+36
+–0.11 (0.39)
+–1.68 0.10
+36
+–0.11 (0.35)
+–1.80 0.08
+36
+–0.37 (14.87)
+–0.15
+.88
+15
+–98.00 (76.74)
+–4.95 .00*
+OA-30M
+38
+–0.05 (0.42)
+–0.78 0.44
+38
+–0.07 (0.33)
+–1.27 0.21
+39
+4.37 (16.34)
+1.67
+.10
+15
+–94.67 (95.38)
+–3.84 .00*
+OA-33M
+42
+0.01 (0.51)
+0.06
+0.95
+42
+–0.05 (0.41)
+–.735 0.47
+41
+–0.52 (18.11)
+–0.18
+.86
+14
+–104.29 (70.13) –5.56 .00*
+OA-36M
+32
+0.19 (0.45)
+2.33
+0.03
+32
+0.11 (0.35)
+1.72
+1.0
+32
+2.69 (11.92)
+1.28
+.21
+16
+–100.63 (86.45) –4.66 .00*
+*Bonferroni Correction p<0.0035, alpha = 0.05
+#OA: On admission; OD: On discharge; 11D: On 11th day; 3M/6M…: On 3 month/ 6 month…
+236
+Rao, Kadam, Jagannathan, Babina, Rao and Nagendra
+Indian J Physiol Pharmacol 2014; 58(3)
+To understand the gender differences, independent
+sample t test analysis was conducted. The results
+depicted that FVC, FEV1, MVV and PEFR were
+significantly lower in men as compared to females
+at the time of discharge (P<0.05, Table III). However
+the same variables were significantly higher in males
+as compared to females at the last follow-up (36th
+month; P<0.05, Table IV).
+on FVC, FEV1, MVV and PEFR, as long as the
+intervention is practiced regularly by the patients. A
+look at Table I shows that all the outcome variables
+have significant results from admission till date of
+discharge (the time period during which the patients
+practiced yoga and naturopathy as in-patients) Due
+to the positive results during admission, it could be
+assumed that the patients continued to practice both
+the interventions at home for the next few months
+(positive results observed in all outcome variables
+till the 6th month). However, even though the patients
+were followed up every three months for two years
+post discharge, the possible lack of motivation to
+continue the interventions at home could be one of
+the reasons for lack of significance in most outcome
+variables post 6 months.
+In case of yoga and naturopathy, it is well known
+that regular practice of the interventions can only
+bring about desired results. However this aspect is
+also true vice-versa, where it is often observed that
+positive results of an intervention are a strong
+indicator for continuation of the treatment. It could
+be reasoned that the lack of motivation to continue
+practice post 6 months could have resulted in
+stagnation in symptoms, which in turn could have
+acted as a disillusionment to continue with the
+treatment itself. This could possibly explain the large
+attrition or drop-out rates in the study.
+In such a scenario, it would be best to discuss the
+results and the effectiveness of the intervention when
+it is practiced regularly. A number of studies have
+shown varied results with respect to FEV and FVC
+as output variables in testing the efficacy of
+interventions for asthma. One such study showed
+that there was no significant difference in pre- and
+post-FEV1 and pre- and post-FVC and in their
+percentage predicted. Thus it was concluded that
+reversibility in FEV1 levels or percentage change in
+FEV1 are promising lab parameter to assess the
+efficacy of intervention in asthma patients (22). In
+another study PEFR and FEV1 improved significantly
+following inhalation of bronchodilator in each of the
+five spacers. Similarly delta FEV1 and percentage
+improvement were comparable in the five groups. This
+study corroborates the results of our study where
+both the Forced Expiratory Volume (FEV) and (Peak
+TABLE III : Gender differences in efficacy of yoga and
+naturopathy across variables on discharge.
+Mean±Std.
+95% confidence
+Sig.
+Variables
+deviation
+interval of the
+(2-tailed)
+difference lower
+BMI0D
+Male
+21.1±4.5
+–4.674
+.000*
+Female
+24.1±5.7
+FVC_0D
+Male
+2.5±1.1
+.2802
+.000*
+Female
+1.9±0.5
+FEV1_0D
+Male
+1.8±0.9
+5.950E-02
+.015**
+Female
+1.5±0.5
+FE1FVCOD
+Male
+71.4±14.6
+–12.152
+.002*
+Female
+78.9±12.4
+MVV_OD
+Male
+68.0±38.3
+6.772
+.001*
+Female
+51.3±17.1
+PEFRM_OD
+Male
+396.7±143.6
+18.73
+.019**
+Female
+291.1±100.3
+ESR_OD
+Male
+7.3±8.5
+–10.71
+.010**
+Female
+13.4±18.3
+   *P<0.01; **P<0.05.
+TABLE IV : Gender differences in efficacy of yoga and
+naturopathy across variables on 36th month follow-up.
+Mean±Std.
+95% confidence
+Sig.
+Variables
+Deviation
+interval of the
+(2-tailed)
+difference lower
+BMI_36M
+Male
+21.9±3.8
+–5.67
+.001*
+Female
+25.5±5.2
+FVC_36M
+Male
+2.0±0.9
+9.822E-02
+.019**
+Female
+1.5±0.4
+MVV_36M
+Male
+61.5±32.3
+1.873
+.031**
+Female
+42.5±12.9
+PEFRM_36M
+Male
+367.2±126.2
+37.11
+.001*
+Female
+280.8±88.3
+*P<0.01; **P<0.05.
+Discussion
+The above results depict that the combined yoga
+and naturopathy intervention has a significant effect
+Indian J Physiol Pharmacol 2014; 58(3)
+Naturopathy and Yoga for Asthma
+237
+Expiratory Flow Rate) PEFR values have seen
+an increase (improvement) from admission to
+discharge. Only one study till date has looked at
+the Maximal minute ventilation during exercise
+and pulmonary function of 78 elite winter athletes
+(25 males, 53 females; 25 EIB positive, 53 normal)
+retrospectively (23). In such a scenario, our study
+is the first to show the positive relation between
+MVV and improvement in symptoms of asthma
+patients through the use of yoga and naturopathy
+treatment.
+The results of gender comparison depict that though
+males improved better than females at discharge,
+females improved better than males at the end of
+36th month of the study. According to the treating
+team at INYS-Medical Research Society, Jindal
+Nature cure Institute, Bangalore, the patients were
+banned from using addictive substances (i.e. nicotine)
+during their stay at the hospital, as nicotine had an
+adverse reaction to the asthma symptoms. Though
+not documented, a number of males in the current
+study were addicted to nicotine and the team
+felt that, it was difficult to control the additive/drug
+habits of the patients once they were discharged
+from the hospital. This could be one of the causes
+for the gender differences at different timelines of
+the study.
+This study has some inherent limitations: (1) As a
+retrospective study, it is difficult to interpret the result
+based on the current cultural milieu and patient
+characteristics of the hospital, (2) Due to lack of
+control group, the result could be interpreted as an
+outcome of extraneous factors or time factor (patient
+improving over time) instead of the effectiveness of
+the treatment introduced, (3) As the interventions of
+yoga and naturopathy were provided together, it was
+difficult to tease out the individual effects of each of
+the interventions for asthma. A cross-over design
+could have helped in this purpose. Further, to
+strengthen the overall study methodology, future
+research could focus on conducting a prospective
+randomized control clinical trial based on the GINA
+guidelines (for diagnosis and management of bronchial
+asthma), with a large sample size.
+In spite of the limitations explained above, the current
+study is a classic longitudinal study with a 36 month
+follow-up of patients who have undergone a combined
+naturopathy and yoga intervention. As all patients
+were on conventional care at baseline, practicing the
+combined naturopathy and yoga treatment, clearly
+demonstrated positive and significant changes in lung
+function even after tapering of the antiasthamatic
+medications. The naturopathy treatment helped create
+a lasting effect in the patient‘s mental, emotional,
+and physical states and yoga helped reduce the
+frequency of infections (by enhancing the immunity)
+and mental stress. In this context, the present
+study can have significant clinical implications
+as a new and modern solution for bronchial
+asthma patients who suffer from the other adverse
+effects of consuming oral pharmacological medicines.
+Further propagating naturopathy and yoga as a
+way of life (long term practice of intervention), could
+help not just control symptom exacerbation but
+also improve the overall health and immunity of the
+patient.
+Conclusion
+The current study provides evidence that if practiced
+regularly, a combined intervention of naturopathy and
+yoga is an effective alternative treatment for bronchial
+asthma. A rigorous prospective randomized control
+clinical trial based on the GINA guidelines for
+diagnosis and management of bronchial asthma, with
+a large sample size would help further validate these
+results and also tease out the effects of the individual
+and/or combined treatments.
+Acknowledgements
+The authors would like to thank Soumya S, staff of
+Swami Vivekananda Yoga Anusandhana Samasthana
+(SVYASA), Bangalore for helping in the preparation
+of the manuscript. The authors would also like to
+thank INYS-Medical Research Society, Jindal Nature
+Cure Institute, Bangalore for funding and conducting
+the project.
+238
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subfolder_0/Efficacy of Yoga as an add-on to Physiotherapy in the management of Patients with Paraplegia Randomized Controlled Trial.txt

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+See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/331733548
+Efficacy of Yoga as an Add-on to Physiotherapy in the Management of
+Patients with Paraplegia: Randomised Controlled Trial
+Article  in  JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH · March 2019
+DOI: 10.7860/JCDR/2019/40429.12724
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+Journal of Clinical and Diagnostic Research. 2019 Mar, Vol-13(3): KC01-KC06
+1
+DOI: 10.7860/JCDR/2019/40429.12724
+Complementary/Alternative 
+Medicine Section
+Efficacy of Yoga as an Add-on to Physiotherapy 
+in the Management of Patients with Paraplegia: 
+Randomised Controlled Trial
+Original Article
+INTRODUCTION
+Spinal Cord Injury (SCI) is a catastrophic event which is sudden 
+and unexpected that can affect the patient’s normal sensory, motor 
+and autonomic function, leading to dependency, morbidity and 
+deterioration in mental health and QOF [1,2]. SCI leads to immense 
+economic burden on the country’s health care system [3,4]. The 
+true impact of SCI can be reflected through the average prevalence 
+rate of 1:1000, and the mean incidence estimated to be between 
+4-9 cases per 100,000 populations per year, worldwide [5]. It was 
+also reported that the gender ratio in traumatic SCI is 3:1 (men: 
+women), whereas gender is equally distributed in non-traumatic SCI 
+[4]. Management of acute TSCI often involves surgery followed by 
+long term rehabilitation to improve functional abilities and QoL [6]. 
+Patients with SCI often experience post-traumatic stress disorder 
+and distress which are associated with decrease compliance with 
+rehabilitation. Prevalence of other co-morbidities such as emotional 
+distress, psychological issues and Post-Traumatic Stress Disorders 
+(PTSD) is very high which makes an adjustment to Activities of Daily 
+Living (ADL) very poor [7].
+Evidence shows raised CRP in chronic SCI patients even without 
+the evidence of any concurrent infections, which is an indicator of 
+systemic inflammation and is associated with poor rehabilitation 
+outcome [8]. Increased Body Mass Index (BMI) in SCI is associated 
+with increased risk of Cardio-Vascular Disease (CVD). BMI has 
+been used in earlier studies as a stand-in predictor of risk of 
+obesity in individuals with SCI [9,10]. The therapeutic benefit of 
+medications is often inadequate in the management of neurological 
+and psychiatric disorders [11]. Various other studies have proved 
+that yoga, a form of mindbody intervention and Physical Therapy 
+(PT) have enhanced recovery in various neuropsychiatric illnesses 
+[12]. Yoga enhances motor and sensory function, ADL, gait, mental 
+flexibility, psychological well-being and relaxation in individuals with 
+SCI [13-15].
+Different yogic techniques incorporated into the rehabilitation 
+protocol of individuals with SCI, with proper guided assistance, is 
+believed to stimulate neural pathways and neurotransmitters [16]. 
+This, in turn, can be valuable instrument in the regeneration of nerve 
+fibres in SCI patients [17]. However, a large number of studies 
+recommended RCTs to assess the impact of yoga in SCI [13,15,18]. 
+Therefore, authors hypothesised to see the add-on effect of Yoga 
+therapy along with Physiotherapy may improve motor and sensory 
+scores on ASIA scale, QoL, inflammatory markers, distress and 
+functional independence in patients with Spinal Cord Injury, rather 
+than Physiotherapy rehabilitation alone in paraplegic patients.
+MATERIALS AND METHODS
+Design
+This was a single-blind pre-post randomised controlled trial where 
+all participants were randomly divided into two groups: (i) add-
+on yoga and physiotherapy group (IYP); and (ii) Physiotherapy 
+Group (PT). Prior to randomisation each participant was assessed 
+at the baseline.
+Participants
+A total of 157 SCI patients who were admitted to the Swami 
+Vivekananda National Institute of Rehabilitation, Training and 
+Research (SVNIRTAR), Odisha, India, were screened using ASIA 
+scale during the period between April 2018 to October 2018. The 
+sample size was calculated using G-power software by fixing the 
+alpha at 0.05 powered at 0.8 and the effect size of 0.55 based on the 
+Monali Madhusmita1, John Ebnezar2, Thaiyar Madabusi Srinivasan3, Patita Pabana Mohanty4, 
+Singh Deepeshwar5, Balaram Pradhan6
+Keywords:	c-Reactive protein, Neurotrophins, Quality of life, Spinal cord injury, Spinal cord injury independence measure
+ABSTRACT
+Introduction: Traumatic Spinal Cord Injury (SCI) is a leading 
+cause of disability. Varying injury level and severity generate a 
+spectrum of neurological dysfunction and a reduction in long-
+term Quality of Life (QOL) with a decrease in mobility.
+Aim: To evaluate the add-on effect of a Yoga program along 
+with physiotherapy on individuals with paraplegia.
+Materials and Methods: A total of 124 SCI patients of both 
+genders with age range 18-60 years, having incomplete SCI 
+(AIS)-C and (AIS)-D, and admitted to the rehabilitation centre, 
+India, were randomly allocated into two groups i.e.,: (i) Study 
+group-Integrated Yoga and Physiotherapy (IYP) (n=62; age 
+means and SD: 33.97±10.0 years); and (ii) control group-
+Physiotherapy (PT) (n=62; age mean and SD:32.84±9.5 years). 
+These participants were assessed on primary outcome 
+measures: (i) American Spinal Injury Association Impairment 
+(ASIA) scale; (ii)  c-Reactive Protein (CRP); (iii) Spinal Cord 
+Injury Independence Measure (SCIM); and (iv) Medically Based 
+Emotional Distress Scale (MEDS). The secondary outcome 
+measures were: (i) Body Mass Index (BMI); and (ii) Quality of 
+Life Index Spinal Cord Injury - Version III (SCI-QOL index), were 
+measured before and after one-month interventions.
+Results: The IYP group showed a significant reduction in 
+scores of CRP (p<0.001), SCIM (p<0.001), MEDS (p<0.001), 
+and improvement in SCI-QoL Index (p<0.001) compared to the 
+control group. There was no significant change observed in the 
+ASIA scale between the two groups.
+Conclusion: One-month Integrated Yoga and Physiotherapy 
+program is more effective than physiotherapy intervention 
+alone, in the management of paraplegia patients.
+Monali Madhusmita et al., Comparison of Add-on of Integrated Yoga Therapy on Spinal Cord Injury Patients/(Paraplegics)	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2019 Mar, Vol-13(3): KC01-KC06
+2
+were done on Day 1 and Day 30. All practices included in the yoga 
+practice protocol were safe, feasible and have been adapted for the 
+intervention with consent from authors of the previous study [19]. 
+An attendance register was maintained to monitor the attendance of 
+the participants. A cut-off of 70% attendance was kept to consider 
+for analysis of data.
+Yoga therapy for IYP group: The specific module of yoga therapy 
+for SCI management was developed by using the concepts from 
+traditional yoga scriptures (Patanjali Yoga Sutras, Upanishads 
+and Yoga Vashishtha) that highlight a holistic approach to health 
+management at physical, mental, emotional and intellectual levels. 
+The practices consisted of yogic postures (asanas), breathing 
+practices (pranayama), cleansing techniques (kriya), relaxation 
+techniques, meditation and yogic counselling, chosen specifically for 
+SCI. SCI special techniques progressed from safe yogic movements 
+to yoga postures that provide traction like effect and channelise the 
+vital energy flow all through the spine. The details of yoga therapy 
+practices are given in [Table/Fig-2].
+mean and standard deviation of the SCIM from the previous study 
+[15]. The optimal sample size was 62 participants in each group.
+Inclusion Criteria included; being 18-60 years, having incomplete 
+SCI (AIS)-C {motor grade <3 below the neurologic level of injury} 
+and (AIS)-D{a motor grade of at least 3 below the neurologic level of 
+injury} patients of both genders, having sustained a traumatic spinal 
+cord injury for a minimum of six months prior to consent and having 
+completed their primary rehabilitation. Patients were excluded from 
+the study if they: (a) have any contraindications to Faradic Electrical 
+Stimulation (FES) such as a cardiac pacemaker, epilepsy, lower limb 
+fracture or pregnancy; (b) are likely to experience clinically significant 
+autonomic dysreflexia and/or orthostatic hypotension in response to 
+electrical stimulation or prolonged upright postures; (c) have chronic 
+systemic diseases, e.g., Hepatitis-C or HIV-AIDS or have an existing 
+Stage 3 or 4 pressure ulcer; (d) have degenerative myelopathy, 
+neoplasm, congenital spinal cord anomalies or concomitant 
+medical problems that might influence everyday function, such 
+as malignancy, brain injury or mental diseases; and (e) have had 
+recent major trauma or surgery within the last six months. Based 
+on the inclusion/exclusion criteria, 33 participants were excluded. 
+Remaining 124 participants were randomly allocated to the 
+experimental and control group [Table/Fig-1]. Assessments for the 
+male and female participants were done separately.
+[Table/Fig-1]:	 Consort flow chart.
+Type of practice
+Practice name (Sanskrit and English)
+Duration of 
+practice
+Loosening practices/
+Sukshma Vyayama of 
+Upper limb
+Finger movements
+Five Minutes. 
+(five rounds 
+each movement)
+Wrist movements
+Elbow movements
+Shoulder movements
+Loosening practices/
+Sukshma Vyayama of 
+Lower limb (With or 
+without support)
+Toes movements
+Five Minutes 
+(five rounds 
+each movement)
+Ankle movements
+Knee movements
+Hip movements
+Asanas (with support 
+or props)
+Padahastasana (hand under foot pose)
+Two Minutes 
+(two repetitions)
+Ardhachakrasana (half-moon pose)
+Two Min (two 
+repetitions)
+Ardhakati Chakrasana (half waist 
+rotation pose)
+Two Minutes 
+(two repetitions)
+Vakrasana (half spinal twist pose)
+Two Minutes 
+(two repetitions)
+Kriya
+Kapalbhati (high frequency yoga 
+breathing)
+Two Minutes 
+(15 rounds)
+Pranayama
+Vibhagiya Pranayama (sectional 
+breathing)
+Three Minutes 
+(six rounds)
+Nadishuddhi (alternate nostril breathing)
+Five Minutes 
+(nine rounds)
+Bhramari (humming sound breathing)
+Five Minutes 
+(nine rounds)
+Bhastrika (rapid ventilation breathing 
+practice)
+Two Minutes 
+(six rounds)
+Relaxation Practice
+Deep relaxation technique
+10 Minutes
+Mind sound resonance technique
+30 Minutes
+[Table/Fig-2]:	 Integrated yoga therapy module for spinal cord injury.
+For both groups, the Physiotherapy intervention was common and 
+consisted of: (i) Proprioceptive Neuromuscular Facilitation (PNF); 
+(ii) slow and sustained stretching; (iii) prolong icing; (iv) strengthening 
+of anti-gravity muscles; (v) functional electrical stimulation; and 
+(vi) gait training.
+Physiotherapy session for both the groups lasted for 60 minutes/day 
+and six days/week for one month.
+ASSESSMENTS
+Primary Outcomes
+American Spinal Injury Association (ASIA) impairment scale: 
+The ASIA Impairment Scale is an improvisation of the earlier Frankel 
+scale and includes a number of important improvements. The 
+International Standards for Neurological Classification of Spinal 
+Cord Injury (ISNCSCI) was developed by the ASIA as a universal 
+Ethical Clearance
+The study was approved by the Institutional Ethics Committee of 
+University (RES/IEC-SVYASA/93/2016). Signed informed consent 
+was obtained from the head of the institution and each participant, 
+upon explaining the study details. CTRI Registration Number: 
+CTRI/2018/07/014779.
+Randomisation
+A Total of 124 participants were assigned in two groups, 62 in each, 
+using computer-based random number generator. One hundred 
+and twenty-four envelopes were prepared, and each participant 
+was asked to pick an envelope. Depending on the number in the 
+envelope, participants were considered either in IYP group or in PT 
+group {known as Sequentially Numbered Opaque Sealed Envelopes 
+(SNOSE) randomisation technique}.
+Intervention
+Participants in the IYP group received 75 minutes (six days/week) 
+of an integrated yoga intervention for one month. Data collections 
+www.jcdr.net	
+Monali Madhusmita et al., Comparison of Add-on of Integrated Yoga Therapy on Spinal Cord Injury Patients/(Paraplegics)
+Journal of Clinical and Diagnostic Research. 2019 Mar, Vol-13(3): KC01-KC06
+3
+classification tool for SCI, depending upon motor and sensory 
+impairment that results from an SCI. In sensory examination, two 
+aspects of sensation are examined: light touch and pinprick. A 
+grade of 0 denotes absent sensation, 1 denotes impaired or altered 
+sensation and 2 denotes normal sensation. The motor examination 
+consists of testing key muscle functions. Motor strength is recorded 
+for each muscle group bilaterally and is graded using a universal 
+six-point scale (graded as 0-5) where 0 denotes total paralysis and 
+5 is normal [20].
+Bio-marker: c-Reactive Protein (CRP) is a blood test marker for 
+inflammation in the body [21]. Blood samples from the patients 
+were collected early in the morning at 8.00 a.m. for the sake of 
+convenience without any other prior instructions of fasting. The 
+CRP levels <1.0 mg/dL was denoted as negative and CRP levels 
+>1.0 mg/dL was denoted as positive [22].
+Spinal Cord Independence Measure (SCIM): Functional recovery 
+may or may not follow/translate into neurologic recovery. SCIM 
+III is a sensitive outcome measure designed to assess functional 
+status relevant to SCI. It can be used as a scale in traumatic and 
+non-traumatic, acute and chronic SCI. There is a total of 19 items 
+on the SCIM III, which are divided into three subscales (self-care, 
+respiration and sphincter management, and mobility). A total score 
+out of 100 is achieved, with the subscales weighted as follows: self-
+care: scored 0-20; respiration and sphincter management: scored 
+0-40; and mobility: scored 0-40. Scores are higher in patients that 
+require less assistance or fewer aids to complete basic activities of 
+daily living and life support activities. SCIM III has been validated 
+with excellent internal consistency (Cronbach’s alpha=0.91), 
+excellent inter-rater reliability (r=0.99), and excellent correlation with 
+the Functional Independence Measure (FIM) (r=0.85, p<0.01) [23].
+Medical-Based Emotional Distress Scale (MEDS): The MEDS 
+is a 60-item (7 subscales) clinician-administered questionnaire that 
+is completed following a structured interview to assess emotional 
+reactions to severe physical illness or disability that are not the direct 
+result of a physical condition or problem. This instrument measures 
+distress along seven subscales: Dysphoria (8 items), Irritability 
+(9 items), Anhedonia (11 items), Social Withdrawal (9 items), 
+Ruminations over past events (6 items), Cognitive Perspective in 
+the Present (8 items), and Expectations for the future (9 items). Each 
+item provides a question and is followed by a range of responses 
+that are on a 5-point scale for either intensity (how much?) or 
+frequency (how often?). The questions are organised by subscale 
+and the interview is structured such that a denial of problems in a 
+certain area allows the interviewer to skip to the next subscale [24].
+Secondary Outcomes
+Quality of Life Index Spinal Cord Injury-Version III: The ferrans 
+and powers quality of life index spinal cord injury-version III is an index 
+of 74 items divided into two parts: satisfaction and importance. The 
+Ferrans and Powers Quality of Life (QLI) emerged its specific version 
+for spinal cord injury, known as QLI Spinal Cord Injury - Version III. 
+It was developed by Carol Estwing Ferrans and Powers Marjorie in 
+1984 [25]. The QLI-SCI was developed to measure quality of life 
+specifically in people with spinal cord injury. It can be administered 
+by interview or by self-report and contains 37 items and each item is 
+rated on a scale of 1 (least satisfied/important) to 6 (most satisfied/
+important). Five scores of 0-30 (0=less satisfied, 30=most satisfied) 
+are calculated for the following subscales:
+• 
+Total quality of life score
+• 
+Health and functioning subscale
+• 
+Social and economic subscale
+• 
+Psychological/spiritual subscale
+• 
+Family Subscale
+Calculation of score weighs satisfaction scores according to the 
+level of importance assigned to each item.
+Anthropometry: Body Mass Index (BMI), The BMI, or Quetelet 
+index, is a measure of relative weight based on an individual’s mass 
+and height [26]. For measuring the height, the recumbent length of 
+the study participants was measured by making them lies supine on 
+a raised mat table. With the participant’s head in the Frankfort plane, 
+authors placed one metal plate against the top of the participant’s 
+head and the ruler along the right side of the participant’s body. 
+With the right leg aligned with their hip, the other end of the ruler 
+was placed on the distal end of the calcaneus of their right foot. 
+If the participant had spasticity, contractures, or could not lay flat 
+or dorsiflex the ankle to 90°, authors manually assisted them in 
+extending the leg as far as possible or dorsiflexing the ankle. Height 
+was then recorded to the nearest 1/16 of an inch [27]. Total weight 
+was measured using a Wheelchair (WC) platform scale and the 
+participant’s weight was recorded with his/her WC. The participant 
+then transferred out of his/her WC and the WC was weighed alone. 
+Body weight was calculated by subtracting WC weight from the 
+total weight.
+Statistical ANALYSIS
+Data were analysed using the R-Studio. Shapiro-Francia test was 
+used to check the normality of data distribution. Gender and other 
+categorical variables were analysed using chi-square test. Mc-Nemar 
+test was used to analyse within the group differences in categorical 
+variables. The independent sample t-test was used for between-
+group analysis and paired samples-test was used for within-group 
+change from pre- to post- at Day 1 and Day 30. Pearson’s correlation 
+was done between age and outcome measured variables. The level 
+of significance considered for the present study was p<0.05.
+RESULTS
+One-hundred-twenty-four paraplegic patients participated in the 
+study. The mean age of the participants was 33±10.0 years and 
+32.84±9.5 years in IYP and PT group respectively. The number 
+of males and females were almost similar in both the groups. 
+The characteristics and socio-demographic information of study 
+participants are presented in [Table/Fig-3].
+Within-group Comparisons
+At the completion of one month, the difference between BMI, 
+SCI-QOL, SCIM, MEDS, CRP and ASIA score was statistically 
+significant in both the groups however the percentage difference 
+and the change in the number of participants were more in IYP 
+group [Table/Fig-4,5].
+The male participants in IYP (n=54) and in PT (n=53) showed that 
+there was a significant change in BMI (p<0.001; p<0.05), SCI-
+QOL Index (p<0.001; p<0.001), SCIM (p<0.001; p<0.001), and 
+MEDS (p<0.001; p<0.005) when compared with baseline. Similarly, 
+female participants in IYP (n=8) and in PT (n=9) also demonstrated 
+significant improvement in BMI (p=0.477; p=0.429), SCI-QOL 
+Index (p<0.001; p=0.339), SCIM (p<0.005; p<0.001), and MEDS 
+(p<0.001; p<0.005) when compared with baseline [Table/Fig-6a,b].
+Between-group Comparisons
+Between groups comparison showed that there was a significant 
+difference in post scores of both the groups in the following 
+assessments: CRP (p<0.001), SCI-QoL Index (p<0.05), MEDS 
+(p<0.001). However, ASIA (p=0.241), SCIM (p=0.069), and BMI 
+(p=0.475) scores were not significantly different [Table/Fig-7]. The 
+male participants in IYP (n=54) and PT (n=53) showed that there was 
+no significant difference in BMI (p=0.729), SCI-QOL Index (p=0.12), 
+SCIM (p=0.109), but a significant difference in MEDS (p<0.001) in 
+post scores of both groups. Similarly, female participants in IYP (n=8) 
+and in PT (n=9) also demonstrated significant difference in SCI-QOL 
+Index (p=0.012), and MEDS (p=0.019), but no significant difference in 
+BMI (p=0.280) and SCIM (p=0.452) when post compared with post.
+Monali Madhusmita et al., Comparison of Add-on of Integrated Yoga Therapy on Spinal Cord Injury Patients/(Paraplegics)	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2019 Mar, Vol-13(3): KC01-KC06
+4
+Measurements
+Categories
+IYP
+PT
+Age (Mean±SD)
+33.97±10.002
+32.84±9.465
+Gender
+Male
+54
+53
+Female
+08
+09
+Languages 
+known
+Hindi
+49 (79.03%)
+55 (88.88%)
+English
+28 (45.16%)
+35 (56.45%)
+Odiya
+50 (80.64%)
+52 (83.87%)
+Others
+31 (50%)
+24 (39.36%)
+Mechanism of 
+injury
+Fall from height
+30 (48.19%)
+24 (39.15%)
+Fall of weight
+06 (9.67%)
+10 (15.52%)
+Motor vehicle accident
+19 (30.64%)
+24 (38.33%)
+Miscellaneous
+07 (11.5%)
+04 (07.2%)
+Educational 
+level
+0-9 years
+09 (14.52%)
+04 (6.45%)
+10-12 Years
+48 (77.42%)
+51 (82.26%)
+>12 Years
+05 (8.06%)
+07 (11.29%)
+Occupational 
+activity
+Employed
+25 (40.32%)
+17 (27.42%)
+Light physical activity
+18 (29.03%)
+22 (35.48%)
+Moderate/heavy physical activity
+15 (24.19%)
+21 (33.87%)
+Unemployed
+4 (6.45%)
+2 (3.23%)
+Marital status
+Married
+35 (56.45%)
+42 (67.74%)
+Unmarried
+23 (37.09%)
+14 (22.58%)
+Divorcee
+04 (6.45%)
+06 (9.68%)
+Neurological 
+level of injury
+T2 – T5
+23 (37.097%)
+25 (40.32%)
+T6 – T9
+22 (35.48%)
+20 (32.26%)
+T10 – L1
+17 (27.42%)
+17 (27.42%)
+ASIA scale
+C
+45 (72.58%)
+42 (67.74%)
+D
+17 (27.42%)
+20 (32.26%)
+[Table/Fig-3]:	 Characteristics of the study participants.
+Variables
+IYP
+PT
+Pre
+Post
+Total
+p-value
+Pre
+Post
+Total
+p-value
+CRP
+Negative
+14 (100%)
+0 (0.0%)
+62 (100%)
+<0.001*
+11 (64.7%)
+06 (35.3%)
+62 (100%)
+=0.035*
+Positive
+34 (70.8%)
+14 (29.2%)
+=0.027@
+17 (37.8%)
+28 (62.2%)
+=0.086@
+ASIA
+C
+24 (53.3%)
+21 (46.7%)
+62 (100%)
+<0.001*
+30 (71.4%)
+12 (28.6%)
+62 (100%)
+<0.001*
+D
+0 (0.0%)
+17 (100%)
+<0.001@
+0 (0.0%)
+20 (100%)
+<0.001@
+[Table/Fig-5]:	 Within and between group comparison of categorical variables of IYP and PT groups.
+CRP: c-Reactive protein; ASIA: American spinal injury association; *Mc-Nemar chi-square test was used to analyse within the group differences in Categorical Variables; @chi-square test was used to analyse 
+between the group differences in Categorical Variables
+Variables
+IYP Vs PT
+IYP Vs PT
+Pre (p-value)
+Post (p-value)
+BMI
+0.359
+0.475
+SCI-QoL
+0.319
+0.015
+SCIM
+0.432
+0.069
+MEDS
+0.847
+<0.001
+[Table/Fig-7]:	 Between group comparison of continuous variables of IYP and PT 
+groups.
+Independent Sample t-Test was used to analyse between the group differences in Continuous 
+Variables
+The outcome measures that were positively correlated with age in 
+males of PT group are SCI-QoL Index (r=0.513, p<0.001), MEDS 
+(r=0.244, p=0.078) and SCIM (r=0.604, p<0.001). However, ASIA 
+(r=-0.233, p=0.093), BMI (r=-0.159, p=0.255), CRP (r=-0.034, 
+p=0.809), and BMI (r=-0.159, p=0.255) were found to be negatively 
+correlated with age, using Pearson’s correlation.
+The outcome measures that were positively correlated with age in 
+females of PT group are CRP (r=-0.059, p=0.871), SCI-QoL Index 
+(r=0.811, p=0.004), MEDS (r=0.626, p=0.053), and SCIM (r=0.845, 
+p=0.002). However, BMI (r=-0.304, p=0.464), ASIA (r=-0.326, 
+p=-0.358), were found to be negatively correlated with age, using 
+Pearson’s correlation.
+(a) Gender difference of IYP Group
+IYP group
+Males (n=54)
+Females (n=08)
+Variables
+Pre
+Post
+Pre
+Post
+BMI
+24.72±3.6
+23.89±3.3***
+25.71±3.67
+25.35±3.09***
+SCI-Qol Index
+6.75±2.8
+9.41±2.8 (NS)
+8.05±2.07
+11.58±1.94***
+SCIM
+48.11±10.57
+56.11±11.46**
+44.88±8.53
+55.0±11.92***
+MEDS
+14.95±5.43
+11.43±4.60 (NS)
+16.74±4.49
+9.94±3.39 (NS)
+(b) Gender difference of PT Group
+PT group
+Males (n=53)
+Females (n=09)
+Variables
+Pre
+Post
+Pre
+Post
+BMI
+24.29±3.69
+23.63±4.38*
+23.93±4.64
+23.36±4.20 (NS)
+SCI-Qol Index
+7.31±2.69
+8.5±3.19**
+7.65±2.99
+8.07±3.05***
+SCIM
+49.87±11.33
+52.43±12.05***
+46.10±15.18
+50.00±14.89**
+MEDS
+15.17±5.26
+15.88±5.46***
+14.08±4.91
+15.23±4.88**
+[Table/Fig-6a,b]:	 Gender difference of continuous variables within the two groups.
+The significance is presented as *p<0.05, **p<0.01, ***p<0.001, and NS=Not significant; Within 
+group: pre with post.
+The outcome measures that were positively correlated with age 
+in males of IYP group are BMI (r=.63, p<0.05), CRP (p<0.001), 
+SCI-QoL Index (r=.087, p=0.532) ASIA (r=1, p<0.05), and SCIM 
+(r=0.458, p<0.001). However, MEDS (r=-0.046, p=0.744) and 
+BMI (r=-0.074, p=0.596) were found to be negatively correlated 
+with age, using Pearson’s correlation.  The outcome measures 
+that were positively correlated with age in females of IYP 
+group  are CRP (r=0.385, p=-0.347), SCI-QoL Index (r=.096, 
+p=0.821), MEDS (r=0.113, p=0.789). However, ASIA (r=-0.342, 
+p=-0.406), BMI (r=-0.304, p=0.464), SCIM (r=-0.312, p=0.452), 
+were found to be negatively correlated with age, using Pearson’s 
+correlation.
+Variables
+IYP
+PT
+Pre
+Post
+% Change
+Pre
+Post
+% Change
+BMI
+24.85±3.61
+24.08±3.26***
+3.09
+24.24±3.82
+23.59±4.32*
+2.67
+SCI-QOL
+6.87±2.77
+9.74±2.75***@
+41.82
+7.36±2.72
+8.43±3.15***
+14.56
+SCIM
+47.69±10.32
+55.97±11.42***
+17.35
+49.27±11.96
+52.05±12.44***
+5.64
+MEDS
+15.18±5.32
+11.24±4.47***@@@
+25.96
+15.0±5.18
+15.78±5.34***
+5.18
+[Table/Fig-4]:	 Within group comparison of continuous variables of IYP and PT groups.
+Paired Sample t-Test was used to analyse within the group differences in Continuous Variables; BMI: Body mass index; SCI-QoL: Spinal cord injury-quality of life index; SCIM: Spinal cord injury independence 
+measure; MEDS: Medically based emotional distress scale; The significance is presented as *p<0.05; *p<0.01, *p<0.001; Within group: pre compared with post; @@@p<0.001; @ p<0.05; Comparison between 
+group: Pre-compared with Pre, and Post compared with Post.
+www.jcdr.net	
+Monali Madhusmita et al., Comparison of Add-on of Integrated Yoga Therapy on Spinal Cord Injury Patients/(Paraplegics)
+Journal of Clinical and Diagnostic Research. 2019 Mar, Vol-13(3): KC01-KC06
+5
+DISCUSSION
+This is the first randomised control trial of yoga in SCI which was 
+done to compare the effect of IYP to PT in the management of 
+SCI patients on ASIA score, functional independence, distress, an 
+inflammatory marker, quality of life and BMI. The strength of the 
+study is its study design and the large sample size. The percentage 
+change in the post scores of ASIA, BMI, SCI-Qol, SCIM, MEDS 
+and CRP is higher in IYP than the PT group, when compared with 
+pre-scores. Similarly, between groups comparison showed IYP 
+group had significantly better improvement in SCI-QoL, MEDS and 
+CRP
+, than PT group which suggest that yoga therapy could be a 
+feasible, cost-effective, easy-to-accomplish, non-pharmacological 
+intervention aiding rehabilitation of paraplegics.
+The non-pharmacological approach of yoga therapy [28,29] which 
+encompass a combination of physical postures, voluntary breathing 
+practices, cleansing techniques, concentration and relaxation 
+techniques [30]. As observed in the outcomes, the positive changes 
+in the IYP group compared to PT group may be due to psychological 
+benefits; calming effect, increasing awareness, attention span, 
+acceptance, adaptability and a sense of security resulting from the 
+practice of yoga therapy [31]. The process adopted during the yoga 
+program included stimulation and successively followed by relaxation 
+might have helped in breaking the loop of the uncontrolled speed of 
+thoughts (stress) [32] and better psychological health resulting from 
+stress reduction [33] through slowly gaining mastery over the mind 
+[34]. Increase in thalamic GABA levels, improvement in mood and 
+anxiety levels, and a decrease in depressive symptoms has been 
+demonstrated by 12 weeks of yoga practice, in two recent studies 
+[35,36]. A possible mechanism is explored hereunder.
+There is strong evidence showing an association of raised CRP 
+with chronic SCI which is mainly due to prevailing systemic 
+inflammation and not due to any infection condition [8,37,38]. 
+As per the study protocol, authors wanted to observe whether 
+the add-on of yoga therapy does improve chronic systemic 
+inflammation in patients who have already undergone their primary 
+rehabilitation. The reduction in CRP scores indicates a significant 
+reduction in systemic inflammation in IYP group in comparison to 
+the PT group. Reduction in inflammation can be directly attributed 
+to a significant decrease in stress in the IYP group. Yoga has a 
+beneficial impact on reducing stress than simple exercises, as 
+shown in previous studies [39]. Relaxation and calming effect is 
+unique to yoga which in turn helps to modulates Hypothalamus-
+Pituitary-Adrenal-Axis (HPA-axis) and resulted in reducing 
+inflammation [40]. It is likely that yoga practice improves immune 
+function [41] and this could add to bring a significant change in 
+the parameters measured.
+The present study reported the functional improvement (in areas 
+such as self-care, respiration, sphincter management and mobility) 
+is better in IYP group (% change=17.35%) as indicated by SCIM 
+scores as compared to PT group (% change=5.64%), though no 
+significant differences were observed in between the two groups. 
+This finding aligns with the results of another clinical trial on 
+paraplegics where there was a highly significant improvement in 
+spasticity and gait after receiving yoga therapy [42].
+Emotional distress is well managed by yoga which is reflected 
+in the reduction of symptoms score of MEDS. Improvement in 
+emotional distress results in decreased sympathetic activity and 
+may be attributed to better autonomic modulation. The function 
+of the Autonomic Nervous System (ANS) becomes more specific 
+resulting in a tilt in balance in favour of the Parasympathetic 
+Nervous System (PNS), in turn resulting in emotional stability and 
+distress reduction [11]. Previous studies have shown that yogic 
+practices handle anxiety and depression well, resulting in enhanced 
+self-esteem and betterment in performances of Activities of Daily 
+Living (ADL) [43]. A six-week specialised yoga program has shown 
+similar results where there have been significant improvements in 
+depressive symptoms, mindfulness and self-compassion in yoga 
+group compared to control [13]. Thus, improvement in SCI-QoL 
+Index can be attributed to improvement in psychological states 
+due to yogic practices.
+Yoga postures (asanas) are targeted to extend the spine in controlled 
+measure and also to twist the spine gently. These asanas could 
+increase blood flow in the spinal arteries and thus bring improved 
+oxygen with increased healing possibilities, as demonstrated by a 
+previous study [15]. Neural tissue plasticity can be promoted by 
+several factors including neurotrophic factors, neurotransmitters, 
+endocrines, cytoskeleton proteins and neuronal electrical activity 
+to name a few [16]. The practice of yoga can enhance the above 
+mentioned factors and could have possibly increased the production 
+of neurotrophic factors (e.g., -BDNF, VEGF, IGF-1 etc.,) that would 
+have mediated neurogenesis and neuroplasticity [44,45]. This, in 
+turn, is likely to improve sensory, motor and autonomic function in 
+SCI patients. Hence, the current study clearly showed that because 
+of add-on of yoga therapy, improvements in IYP group was better 
+than the PT group [Table/Fig-8].
+[Table/Fig-8]:	 Summarises possible mechanism for add-on yoga module in 
+improving patient outcomes in SCI.
+Though both groups (IYP and PT) showed improvements in the 
+scores of BMI and ASIA, the magnitude of change was higher in 
+participants of IYP group compared to participants of the PT group. 
+This indicates that add-on of yoga therapy with physiotherapy, 
+increases basal metabolic rate, enhancing metabolism and more fat 
+oxidation [46]. Therefore, better metabolic regulation has resulted in 
+weight reduction and improvement in sensory and motor function 
+leading to better mobility.
+LIMITATION
+The main limitation of the study was that it was conducted on 
+paraplegia patients belonging to one rehabilitation centre and the 
+results were not able to rule out the effect of other rehabilitation 
+activities such as vocational training and occupational therapy. 
+Hence more studies are needed including more centres.
+CONCLUSION
+Authors conclude that improvements in stress resulted in a 
+decrease in inflammation and enhanced emotional stability resulting 
+from better autonomic modulation. Improvement in psychological 
+states resulted in better QoL, and reduction in BMI increased Basal 
+Metabolic Rate (BMR), leading to significant improvement in overall 
+functional independence. The study might be improvised in design 
+by further conducting a multi-centric trial and including radiological 
+investigations for a better understanding of the underlying processes 
+involved.
+Acknowledgements
+Authors are thankful to all the participants of this study. Authors 
+would like to thank all the staff members of Swami Vivekananda 
+National Institute of Rehabilitation and Training (SVNIRTAR), Odisha, 
+for their generous support and technical help towards the completion 
+of the study.
+Monali Madhusmita et al., Comparison of Add-on of Integrated Yoga Therapy on Spinal Cord Injury Patients/(Paraplegics)	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2019 Mar, Vol-13(3): KC01-KC06
+6
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+PARTICULARS OF CONTRIBUTORS:
+1.	 PhD Scholar, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bangaluru, Karnataka, India.
+2.	 Head of the Deparment, Department of Orthopaedics, Ebnezar Orthopaedic Centre, Parimala Speciality Hospital, Bangaluru, Karnataka, India.
+3.	 Visiting Professor, Division of Yoga and Physical Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bangaluru, Karnataka, India.
+4.	 Associate Professor and Head, Department of Physiotherapy, Swami Vivekanand National Institute of Rehabilitation Training and Research, Cuttack, Odisha, India.
+5.	 Assistant Professor, Department of Yoga and Cognitive Neuroscience, Swami Vivekananda Yoga Anusandhana Samsthana, Bangaluru, Karnataka, India.
+6.	 Assistant Professor, Division of Yoga and Humanities, Swami Vivekananda Yoga Anusandhana Samsthana, Bangaluru, Karnataka, India.
+NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
+Monali Madhusmita,
+PhD Scholar, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, 
+19, Eknath Bhavan, Gavipuram Circle, KG Nagar, Bangaluru-560019, Karnataka, India.
+E-mail: [email protected]
+Financial OR OTHER COMPETING INTERESTS: None.
+Date of Submission: Dec 03, 2018
+Date of Peer Review: Dec 17, 2018
+Date of Acceptance: Jan 29, 2019
+Date of Publishing: Mar 01, 2019
+View publication stats
+View publication stats

subfolder_0/Evaluation of cardiovascular functions during the practice of different types of yogic breathing techniques.txt

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+© 2021 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+158
+Introduction
+Yoga is the science of right living and 
+can be included in daily life.[1] It consists 
+of the practice of definite posture  (asana), 
+controlled 
+breathing 
+(pranayama), 
+etc.[2] 
+Breathing 
+forms 
+the 
+bridge 
+between the voluntary and autonomic 
+nervous systems. The yogic breathing 
+techniques 
+(YBTs) 
+involve 
+nostrils 
+manipulation, 
+breathe 
+holding/retention, 
+modification 
+in 
+the 
+pace 
+of 
+breath, 
+production of humming sounds, etc.[3,4] 
+Different types of YBT have been shown 
+to 
+produce 
+different 
+cardiovascular[5] 
+and autonomic effects.[6] Many studies 
+have evaluated the autonomic functions 
+during 
+various 
+yoga 
+practices 
+such 
+as breath awareness, alternate nostril 
+breathing 
+(ANB),[7] 
+yoga‑based–guided 
+relaxation,[8] 
+and 
+meditative 
+states.[9] 
+Likewise, many studies have documented 
+Address for correspondence: 
+Dr. L. Nivethitha, 
+Department of Naturopathy, 
+Government Yoga and 
+Naturopathy Medical 
+College, Arumbakkam, 
+Chennai ‑ 600 106, Tamil Nadu, 
+India.  
+E‑mail: dr.nivethithathenature@ 
+gmail.com
+Access this article online
+Website: www.ijoy.org.in
+DOI: 10.4103/ijoy.IJOY_61_20
+Quick Response Code:
+Abstract
+Introduction: Yoga is the science of right living practice to promote health. Many studies have 
+documented the cardiovascular effects of various yogic breathing techniques (YBTs), comparing the 
+cardiovascular changes before and after the practice. However, there is a lack of study reporting 
+the cardiovascular changes during the practice of YBT. Materials and Methods: Twenty healthy 
+individuals performed four different YBTs  (Bhastrika, Bhramari, Kapalbhati, and Kumbhaka) 
+in four different orders. Cardiovascular variables such as systolic blood pressure  (SBP), diastolic 
+blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), stroke volume (SV), cardiac 
+output (CO), pulse interval (PI), and total peripheral resistant (TPR) were assessed using a continuous 
+noninvasive blood pressure monitoring system, before, during, and immediately after each YBT. 
+Data were analyzed using repeated measures analysis of variance followed by post hoc analysis with 
+Bonferroni adjustment for multiple comparisons using Statistical Package for the Social Sciences, 
+Version  16.0. Results: Results of this study showed a significant increase in DBP, MAP, HR, and 
+CO along with a reduction in PI during Bhastrika; a significant increase in DBP, MAP, HR, and 
+TPR with a reduction in SV, CO, and PI during Bhramari pranayama; a significant increase in SBP, 
+DBP, MAP, HR, and CO with a reduction in PI during Kapalbhati; and a significant increase in SBP, 
+DBP, MAP, and TPR with a reduction in SV and CO during Kumbhaka practice. Conclusion: In 
+healthy individuals, cardiovascular changes during the practice of Bhastrika and Kapalbhati are more 
+or less similar to each other and are different from those of Bhramari and Kumbhaka in most of the 
+variables.
+Keywords: Blood pressure, cardiovascular functions, pranayama, yoga
+Evaluation of Cardiovascular Functions during the Practice of Different 
+Types of Yogic Breathing Techniques
+L. Nivethitha1,2,
+A. Mooventhan3,
+N. K. Manjunath4
+1Division of Yoga and Life 
+Sciences, S‑VYASA Deemed to 
+be University, 4Devision of Yoga 
+and Life Sciences, S‑VYASA 
+Deemed to be University, 
+Bengaluru, Karnataka, 
+Departments of 2Naturopathy 
+and 3Research, Government 
+Yoga and Naturopathy Medical 
+College, Chennai, Tamil Nadu, 
+India
+How to cite this article: Nivethitha L, Mooventhan A, 
+Manjunath NK. Evaluation of cardiovascular functions 
+during the practice of different types of yogic breathing 
+techniques. Int J Yoga 2021;14:158-62.
+Submitted: 09‑Jun‑2020  
+Revised: 30‑Sep‑2020 
+Accepted: 26‑Feb‑2021           Published: 10-May-2021
+the cardiovascular effect of various YBTs 
+such as breath awareness, right nostril 
+breathing, left nostril breathing,[6] ANB,[6,10] 
+Kapalbhati, Bhastrika, Kukuriya, Savitri, 
+Pranav,[10] and Bhramari pranayama,[11] 
+comparing before and after the practice. 
+However, only very few studies have 
+documented the cardiovascular changes 
+during the practice of YBTs such as breath 
+awareness and ANB.[7] It suggests that there 
+is a lack of scientific evidence reporting the 
+cardiovascular changes during the practice 
+of various YBTs that are commonly 
+practiced in India and in many parts of 
+the world such as Bhastrika  (bellows 
+breath), Bhramari  (humming bee breath), 
+Kapalbhati 
+(frontal 
+brain 
+cleansing 
+breathing), 
+and 
+Kumbhaka 
+(voluntary 
+breath retention). Hence, this study was 
+conducted to evaluate the cardiovascular 
+effect of Bhastrika, Bhramari, Kapalbhati, 
+and Kumbhaka in healthy individuals.
+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: WKHLRPMedknow_reprints@wolterskluwer
+.com
+Short Communication
+[Downloaded free from http://www.ijoy.org.in on Tuesday, June 15, 2021, IP: 136.232.192.146]
+Nivethitha, et al.: Yogic breathing techniques and cardiovascular functions
+159
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+Materials and Methods
+Participants
+Twenty healthy individuals with the mean  (standard 
+deviation) age of 23.40 (3.05) years were recruited from a 
+residential university located in South India. Both male and 
+female participants aged 18 years and above and willing to 
+participate in the study were included, while participants 
+with a history of any illness (systemic or mental), chronic 
+smoking, or alcoholism and the participant who is not 
+able to perform the selected YBT were excluded. The 
+study protocol was approved by the Institutional Ethics 
+Committee, 
+S‑VYASA 
+(Deemed 
+to 
+be 
+University), 
+Bengaluru 
+(RES/IEC‑SVYASA/76/2015), 
+and 
+signed 
+written informed consents were obtained from participants.
+The study design
+A single‑group repeated measures design was adopted, 
+in which all participants performed four different types 
+of YBT in four different orders. The order was randomly 
+selected using a lottery method as follows: twenty 
+papers (five containing the word “Bhastrika” [i.e., 1st order], 
+five containing the word “Bhramari”  [i.e., 2nd order], five 
+containing the word “Kapalbhati” [i.e., 3rd order], and five 
+containing the word “Kumbhaka” [i.e., 4th order]) were put 
+in an envelope, and each participant was asked to draw 
+a paper from the envelope. The paper each participant 
+drew out determined the order in which the respective 
+YBTs were done.[2] In the first order  (n  =  5), participants 
+performed Bhastrika followed by Bhramari, Kapalbhati, 
+and Kumbhaka; in the second order  (n  =  5), participants 
+performed Bhramari followed by Kapalbhati, Kumbhaka, 
+and Bhastrika; in the third order  (n  =  5), participants 
+performed Kapalbhati followed by Kumbhaka, Bhastrika, 
+and Bhramari; and in the fourth order (n = 5), participants 
+performed Kumbhaka followed by Bhastrika, Bhramari, 
+and Kapalbhati with the interval of 5  min between each 
+YBT. Baseline assessment was taken at rest before starting 
+of the YBT, whereas during and post assessments were 
+taken during and immediately after each YBT.
+Assessments
+Cardiovascular 
+variables 
+such 
+as 
+systolic 
+blood 
+pressure 
+(SBP), 
+diastolic 
+blood 
+pressure 
+(DBP), 
+mean arterial pressure  (MAP), heart rate  (HR), stroke 
+volume  (SV), cardiac output  (CO), pulse interval  (PI), 
+and total peripheral resistant  (TPR) were assessed in a 
+sitting position using a noninvasive blood pressure  (BP) 
+monitoring system  (Finapres Continuous Non‑Invasive 
+Blood Pressure Systems, Netherlands). A  finger cuff was 
+positioned in between the interphalangeal joints of the 
+left middle finger. A  noninvasive BP cuff was positioned 
+on the left upper arm at heart level and ensured that the 
+cuff marker was directly above the brachial artery. The 
+elbows were flexed and the hands were kept on the knees. 
+The brachial correction was made before assessment and 
+assessments were taken at rest  (during normal breathing) 
+before starting of the YBT  (baseline), during, and 
+immediately after each YBT.
+Intervention
+Bhastrika (5 min)
+Participants were asked to perform forceful inhalation and 
+forceful exhalation through both nostrils for the duration 
+of 1  min. This is one round and it was repeated for three 
+rounds with a rest (normal breath) period of 1 min between 
+each round.[1]
+Bhramari (5 min)
+Participants were asked to perform inhalation through both 
+nostrils and then while exhaling should produce sound of a 
+humming bee for the duration of 5 min.[2]
+Kapalbhati (5 min)
+Participants were asked to perform forceful exhalation 
+followed by normal inhalation through both nostrils[1] 
+for the duration of 1  min. This is one round and it was 
+repeated for three rounds with a rest (normal breath) period 
+of 1 min between each round.
+Kumbhaka (breath retention) (5 min)
+Participants were asked to take a deep inhalation through both 
+nostrils, followed by a voluntary breath‑holding/retention[1] 
+by closing the right and left nostrils using participants’ 
+thumb and ring finger of the right hand, respectively, for 
+the duration of 1 min. Then, the participants were asked to 
+slowly exhale through both nostrils and maintain the normal 
+breath for 1  min. The same procedure was repeated for 
+another two times  (total 3  times of breath‑holding  [1  min 
+each] with a rest  [normal breath] period of 1  min between 
+each breath‑holding). The time of breath‑holding and rest 
+period was maintained using a stopwatch. To ensure the 
+breath‑holding, respiration was monitored using a volumetric 
+pressure transducer fixed around the trunk about 8 cm below 
+the lower costal margin while the participants sat erect.
+Data extraction
+Brachial artery SBP and DBP were derived from finger 
+arterial pressure using a height correction unit and 
+waveform filtering and level correction methods supplied by 
+the BeatScope software package (Finapres Medical Systems 
+B.V., 184 Netherlands).[3, 12] SV, CO, and TPR were also 
+derived from the standard formula using BeatScope Easy 
+version  2.0  (Smart Medical, Cotswold Business Village, 
+Moreton‑in‑Marsh, 
+United 
+Kingdom) 
+computer‑based 
+program. The data obtained were transformed into a 
+Microsoft Excel sheet for data analysis.[12]
+Data analysis
+Statistical analysis was performed using repeated measures 
+analysis of variance  (RMANOVA). If there was a 
+[Downloaded free from http://www.ijoy.org.in on Tuesday, June 15, 2021, IP: 136.232.192.146]
+Nivethitha, et al.: Yogic breathing techniques and cardiovascular functions
+160
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+significant difference exists in RMANOVA, then a post hoc 
+analysis with Bonferroni adjustment was performed for 
+multiple comparisons using Statistical Package for the 
+Social Sciences (SPSS) for Windows, Version 16.0. 
+Chicago, SPSS Inc. A P < 0.05 was considered statistically 
+significant.
+Results
+Of 36 participants, 16 participants did not fulfill the 
+inclusion criteria and hence did not include in the study. 
+Recruited twenty participants’ data were collected and 
+performed the analysis. The details of the results are 
+provided in Table 1.
+Bhastrika
+During Bhastrika practice, a significant increase in DBP, 
+MAP, HR, and CO along with a significant reduction in PI 
+was observed. In the recovery period, the increase in DBP, 
+MAP, and HR along with a reduction in PI was sustained.
+Bhramari
+During Bhramari practice, a significant increase in DBP, 
+MAP, HR, and TPR with a significant reduction in SV, CO, 
+and PI was observed. In the recovery period, the reduction 
+in SV and CO was sustained, whereas the rest of the 
+variables revert back to normal.
+Kapalbhati
+During Kapalbhati practice, a significant increase in SBP, 
+DBP, MAP, HR, and CO with a significant reduction in PI 
+was observed. In the recovery period, the increase in DBP 
+and HR along with a reduction in PI was sustained.
+Kumbhaka
+During Kumbhaka practice, a significant increase in SBP, 
+DBP, MAP, and TPR with a significant reduction in SV and 
+CO was observed. In the recovery period, the increase in 
+MAP was sustained, whereas the rest of the variables revert 
+back to normal.
+Discussion
+Autonomic nervous system plays a vital role in regulating 
+and maintaining the cardiovascular functions, such as 
+SBP, DBP, and HR.[13] Literature suggests that SBP is the 
+byproduct of peripheral resistance (PR) and CO, in which CO 
+is the byproduct of SV and HR.[14] The results of this study 
+showed a significant increase in SBP during the practice of 
+Kapalbhati and Kumbhaka  (Kumbhaka  >  Kapalbhati). In 
+Kapalbhati, a significant increase in SBP might attribute to 
+the significant increase in CO due to a significant increase 
+in HR during the practice. However, in Kumbhaka, the 
+significant increase in SBP might attribute to the significant 
+increase in TPR during the practice. Hence, Kapalbhati 
+increases SBP by increasing CO through increased HR, 
+whereas Kumbhaka increases SBP by increasing TPR.
+Table 1: Cardiovascular changes while practicing various pranayama techniques (repeated measures analysis of variance and post-hoc analysis with 
+Bonferroni adjustment for multiple comparisons)
+Pranayama techniques
+Assessments
+SBP (mmHg)
+DBP (mmHg)
+MAP (mmHg)
+HR (beats/min)
+SV (l)
+CO (l/min)
+Pulse interval (ms)
+TPR (mmHg.min/l)
+Baseline
+115.03±14.54
+70.82±9.23
+87.91±10.64
+83.97±10.91
+70.29±13.00
+5.84±1.23
+735.84±98.40
+1.03±0.28
+Bhastrika
+During
+119.50±14.14
+74.91±9.23*
+91.99±10.69*
+114.20±13.92*
+66.46±12.05
+7.50±1.58*
+570.27±80.90*
+0.97±0.29
+Post
+122.06±14.11
+77.31±10.88*
+94.61±12.12*
+93.74±14.80*
+63.99±9.90
+5.95±1.26
+679.75±114.09*
+1.13±0.38
+Bhramari
+During
+119.82±15.17
+78.40±10.67*
+94.34±11.72*
+92.40±11.28*
+58.25±8.94*
+5.30±1.06*
+673.11±81.04*
+1.23±0.36*
+Post
+111.98±13.82
+72.11±8.79
+88.08±9.90
+86.45±12.47
+62.48±9.93*
+5.34±1.08*
+719.30±106.70
+1.12±0.40
+Kapalbhati
+During
+123.81±12.97*
+76.73±8.89*
+96.03±10.31*
+106.90±13.01*
+71.27±12.39
+7.58±1.79*
+592.33±76.40*
+1.00±0.30
+Post
+116.97±12.96
+75.23±8.30*
+91.68±9.26
+92.01±11.32*
+63.61±11.15
+5.78±1.12
+676.74±91.34*
+1.07±0.31
+Kumbhaka
+During
+126.47±18.60*
+82.44±8.98*
+99.54±12.51*
+88.75±11.47
+59.43±16.24*
+5.15±1.39*
+698.56±93.99
+1.31±0.37*
+Post
+120.05±11.40
+73.26±8.03
+91.95±8.71*
+85.77±11.43
+73.02±10.89
+6.19±1.16
+728.46±114.98
+1.13±0.83
+All values are in mean±SD. *P<0.05. SBP=Systolic blood pressure, DBP=Diastolic blood pressure, MAP=Mean arterial pressure, HR=Heart rate, SV=Stroke volume, CO=Cardiac 
+output, TPR=Total peripheral resistant, SD=Standard deviation
+[Downloaded free from http://www.ijoy.org.in on Tuesday, June 15, 2021, IP: 136.232.192.146]
+Nivethitha, et al.: Yogic breathing techniques and cardiovascular functions
+161
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+Although there was a significant increase in DBP during all 
+YBTs (Kumbhaka > Bhramari > Kapalbhati > Bhastrika), 
+it was sustained in the recovery period only after 
+Bhastrika  >Kapalbhati and revert back to normal after 
+Bhramari and Kumbhaka. Here, even though DBP increases 
+during all YBTs, the contributing factors are different in 
+different YBTs. For example, the increased DBP during 
+Bhastrika and Kapalbhati might attribute to the significant 
+increase in HR and CO; during the Bhramari, it might 
+attribute to the significant increase in HR and TPR; and 
+during the Kumbhaka, it might attribute to the significant 
+increase in TPR. The sustained increase in DBP even after 
+the practice of Kapalbhati and Bhastrika could be due to 
+the sustained increased level of HR after these practices.
+A 
+significant 
+increase 
+in 
+MAP 
+during 
+all 
+YBTs  (Kumbhaka  >  Kapalbhati  >  Bhramari  >  Bhastrika) 
+might attribute to the significant increase in DBP during 
+all the practices because MAP is the byproduct of DBP 
+and pulse pressure. MAP reverts back to normal only after 
+Bhramari and Kapalbhati, and this could possibly be due 
+to the reduction in the TPR after Bhramari and CO after 
+Kapalbhati.
+A significant increase in HR and reduction in PI were 
+observed in Bhastrika  >  Kapalbhati  >  Bhramari, no such 
+significant change was observed during Kumbhaka, and 
+it was sustained after Bhastrika  >  Kapalbhati and revert 
+back to normal after Bhramari. It might have attributed to 
+the increased breath rate during the practice of Bhastrika 
+and Kapalbhati, whereas the significant increase in HR 
+and reduction in PI during Bhramari might attribute to 
+parasympathetic withdrawal.[15]
+During 
+Bhramari 
+and 
+Kumbhaka, 
+a 
+significant 
+reduction 
+in 
+SV 
+(Bhramari 
+> 
+Kumbhaka) 
+and 
+CO  (Kumbhaka  >  Bhramari) was observed but the 
+reduction was sustained only after Bhramari and revert 
+back to normal after Kumbhaka. The reduction in the CO 
+might be due to the significant reduction in the SV. In 
+contrast to Bhramari and Kumbhaka, there was a significant 
+increase in CO during Kapalbhati and Bhastrika. This 
+effect could be due to the significant increase in HR during 
+these practices.
+During Bhramari and Kumbhaka, a significant increase 
+in TPR  (Kumbhaka  >  Bhramari) was observed and revert 
+back to normal after the practice. The reason for this 
+change is not clear, and thus, it needs to be explored in the 
+future studies.
+The exact mechanism of the YBT on cardiovascular 
+functions is not well defined. However, the possible 
+mechanisms 
+for 
+the 
+effect 
+of 
+various YBTs 
+are 
+as 
+follows: 
+Literature 
+suggests 
+that 
+slow‑pace 
+Bhastrika  (6 breaths/minute) produces a reduction in 
+BP and HR  (indicative of parasympathetic activation), 
+while fast‑pace Bhastrika  (>60 breaths/minute) produces 
+an increase in HR, rate pressure product, and double 
+product[13] (indicative of an increase in load on the heart and 
+subsequent reduction in HR variability  [HRV]).[14] Thus, 
+the cardiovascular effect of fast‑pace Bhastrika provided 
+in our study might be attributed to increased workload on 
+the heart and reduced HRV due to increased sympathetic 
+activation or reduced parasympathetic activity.
+Evidence suggests that Kapalbhati increases low‑frequency 
+(LF) spectrum of HRV, and LF: HF ratio and reduces 
+high‑frequency (HF) spectrum of HRV, indicating increase 
+in sympathetic activity[4] or reduction in parasympathetic 
+activity and arterial baroreflex sensitivity.[4,13,16] The 
+cardiovascular findings of the study during Kapalbhati are 
+consistent with the previous study findings (i.e., increase in 
+SBP, DBP, and HR).[16] Thus, the cardiovascular changes 
+during the Kapalbhati practice might be attributed to 
+sympathetic arousal or reduced vagal tone and/or reduced 
+baroreflex sensitivity.
+A previous study showed an increase in the LF spectrum 
+of HRV and a reduction in the HF spectrum of HRV and 
+time‑domain variables  (indicative of parasympathetic 
+withdrawal) 
+during 
+Bhramari 
+practice.[15] 
+Likewise, 
+literature suggests that breath retention leads to increased 
+sympathetic tone in response to hypoxia and hypercapnia.[3] 
+Results of the present study showed a significant increase 
+in TPR  (indicative of a possible sympathetic shift in the 
+autonomic activity)[4] during Bhramari and Kumbhaka 
+practice. Breathing at the resonant frequency and breath 
+retention has been shown to reduce the circulatory load 
+by improving oxygen saturation and gaseous exchange. 
+Thus, the reduction in SV and CO during Bhramari and 
+Kumbhaka might be a result of the body’s compensatory 
+mechanism to either increased TPR or low circulatory 
+load.[4] Hence, cardiovascular changes during Bhramari 
+and Kumbhaka might be due to either parasympathetic 
+withdrawal or sympathetic activity.
+In summary, cardiovascular changes during Bhastrika, 
+Kapalbhati, Bhramari, and Kapalbhati might be due 
+to either parasympathetic withdrawal or sympathetic 
+activity. It might be due to the nature of intervention that 
+needed constant attention during the practice. However, 
+the results of the study suggest that during the fast YBT, 
+parasympathetic withdrawal or sympathetic activity might 
+have influenced the cardiovascular functions by directly 
+acting on the central, i.e., the heart (i.e., by increasing the 
+workload of the heart as indicated by increased HR and 
+CO), while during Bhramari and Kumbhaka, it might have 
+influenced the cardiovascular functions by acting on the 
+peripheral  (i.e., by increasing peripheral vasoconstriction 
+as indicated by increased TPR). Moreover, the results of 
+the study also suggest that the parasympathetic withdrawal 
+or sympathetic activity was sustained even after fast 
+YBT  (i.e., Bhastrika and Kapalbhati), while it was 
+reverted back to normal immediately after Bhramari and 
+[Downloaded free from http://www.ijoy.org.in on Tuesday, June 15, 2021, IP: 136.232.192.146]
+Nivethitha, et al.: Yogic breathing techniques and cardiovascular functions
+162
+International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021
+Kumbhaka. However, the reason for the above statement is 
+not clear, and thus, the exact underlying mechanisms needs 
+to be studied in the future studies.
+Strengths of the study are  (i) this is the first study 
+evaluating the cardiovascular effect of selected YBT during 
+the practice itself, and  (ii) beat‑to‑beat changes in the BP 
+were measured using a standard, advanced, noninvasive BP 
+monitoring system.  Limitations of the study are  (i) small 
+sample size, (ii) the sample size calculation was not made 
+based on any previous study, and  (iii) assessments such 
+as HRV and baroreflex sensitivity would have provided 
+more information. Hence, further studies are required with 
+larger sample size using all the above‑mentioned objective 
+variables for the better understanding.
+Conclusion
+In healthy individuals, cardiovascular changes during 
+the practice of Bhastrika and Kapalbhati are more or 
+less similar to each other and are different from those of 
+Bhramari and Kumbhaka in most of the variables.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+References
+1.	
+Saraswati  S. Asana Pranayama Mudra Bandha. 4th Revised 
+Edition. Unger, Bihar, India: Yoga Publications Trust; 2008.
+2.	
+Mooventhan  A, Khode  V. Effect of Bhramari pranayama and 
+OM chanting on pulmonary function in healthy individuals: 
+A prospective randomized control trial. Int J Yoga 2014;7:104‑10.
+3.	
+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;62:41‑50.
+4.	
+Saoji  AA, Raghavendra  BR, Manjunath  NK. Effects of yogic 
+breath regulation: A  narrative review of scientific evidence. 
+J Ayurveda Integr Med 2019;10:50‑8.
+5.	
+Ankad  RB, Herur  A, Patil  S, Shashikala  GV, Chinagudi  S. 
+Effect of short‑term pranayama and meditation on cardiovascular 
+functions in healthy individuals. Heart Views 2011;12:58‑62.
+6.	
+Raghuraj  P, Telles  S. Immediate effect of specific nostril 
+manipulating yoga breathing practices on autonomic and 
+respiratory 
+variables. 
+Appl 
+Psychophysiol 
+Biofeedback 
+2008;33:65‑75.
+7.	
+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.
+8.	
+Vempati  RP, Telles  S. Yoga‑based guided relaxation reduces 
+sympathetic activity judged from baseline levels. Psychol Rep 
+2002;90:487‑94.
+9.	
+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.
+10.	 Sharma  VK, Trakroo  M, Subramaniam  V, Rajajeyakumar  M, 
+Bhavanani  AB, Sahai  A. Effect of fast and slow pranayama 
+on perceived stress and cardiovascular parameters in young 
+health‑care students. Int J Yoga 2013;6:104‑10.
+11.	 Pramanik T, Pudasaini B, Prajapati R. Immediate effect of a slow 
+pace breathing exercise Bhramari pranayama on blood pressure 
+and heart rate. Nepal Med Coll J 2010;12:154‑7.
+12.	 Metri KG, Pradhan��B, Singh A, Nagendra HR. Effect of 1‑week 
+yoga‑based residential program on cardiovascular variables 
+of hypertensive patients: A  comparative study. Int J Yoga 
+2018;11:170‑4.
+13.	 Nivethitha L, Mooventhan A, Manjunath NK. Effects of various 
+Prāṇāyāma on cardiovascular and autonomic variables. Anc Sci 
+Life 2016;36:72‑7.
+14.	 Das  SV, Mooventhan A, Manjunath  NK. A  study on immediate 
+effect of cold abdominal pack on blood glucose level and 
+cardiovascular functions in patients with type 2 diabetes mellitus. 
+J Clin Diagn Res 2018;12:KC01‑4.
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+variability changes during and after the practice of Bhramari 
+pranayama. Int J Yoga 2017;10:99‑102.
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+Dostálek 
+C. 
+Kapalabhati‑‑yogic 
+cleansing 
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+Cardiovascular and respiratory changes. Homeost Health Dis 
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subfolder_0/Evidence based effects of yoga practice on various health related problems of elderly people A review.txt

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+PREVENTION & REHABILITATION: LITERATURE REVIEW
+Evidence based effects of yoga practice on various health related
+problems of elderly people: A review
+A. Mooventhan*, L. Nivethitha
+Department of Research and Development, S-VYASA University, #19, Eknath Bhavan, Kavipuram Circle, Kempegowda Nagar, Bengaluru, 560019, Karnataka,
+India
+Keywords:
+Elderly peoples
+Health related problems
+Yoga
+a b s t r a c t
+More than 50% of the elderly above 60 years of age suffer from chronic medical conditions, the preva-
+lence of which increases with age. Though Yoga has been reported as an effective modality in improving
+various physical and psychological aspects of elderly populations, a comprehensive review of Yoga and
+its effects on various health related problems of elderly populations has not yet been reported. Hence, we
+performed PubMed/Medline search to review relevant articles, using keyword “yoga and elderly”. Rele-
+vant articles published since inception till 6th October 2016 were included for the review. Based on the
+available scientific literature, this review suggests that the regular practice of Yoga can be considered as
+an effective intervention in improving physical (reduces heart rate, blood pressure, blood glucose,
+oxidative damage, fatigue, weakness, fear of fall, and improve heart rate variability, baroreflex sensitivity,
+insulin sensitivity, physical functions, mobility, flexibility, and urinary incontinence), mental (reduces
+depression, anxiety), emotional (reduces anger, stress, tension and improve self-efficacy), social (improve
+life satisfaction), and vital (improved vitality) planes of elderly individuals, offering a better quality of
+sleep and quality of life.
+© 2017 Elsevier Ltd. All rights reserved.
+1. Background
+Developing countries such as India, China, and Indonesia are
+projected to have the largest number of elderly by 2025 (Hariprasad
+et al., 2013a,b,c,d). The elderly population in India is estimated to
+increase from 71 million in 2001 to 179 million in 2031 (Hariprasad
+et al., 2013a,b,c,d). Similarly, in developed countries like United
+States of America, between 1980 and 2010, the proportion of over-
+65 years rose from 11% to 13% (varies from 8% in Alaska to 17% in
+Florida) and by 2030, and 2050, the proportions would be expected
+to rise up to 19%, and 20% respectively (Barbieri and Ouellette,
+2012). More than 50% of the elderly above 60 years of age, suffer
+from chronic medical conditions and its prevalence and severity
+increases with age (Hariprasad et al., 2013a,b,c,d). The aging pro-
+cess always involves functional, physiological and biochemical
+changes that reduce one's ability to perform daily activities
+(Ramos-Jim

+enez et al., 2009). Aging is also associated with multiple
+medical conditions (both physical and psychological) mainly due to
+deteriorating
+physiological
+reserves
+and
+impaired
+immune
+mechanisms which lead to poor quality of sleep and quality of life
+(Hariprasad et al., 2013a,b,c,d).
+Yoga is an ancient Vedic science and a way of life, believed to
+have originated in India around 5000 BC which is being increas-
+ingly applied in the field of therapeutics (Singh et al., 2008). It in-
+cludes the practice of moral observances (Yama), self-disciplines
+(Niyamas), specific posture (asana), regulated breathing (Pra-
+nayama), Sensory withdrawal (Pratyahara), Concentration (Dhar-
+ana), Meditation (Dhyana), and self-realization (Samadhi) (Gard
+et al., 2014). Increasing number of elderly adults are practising
+yoga in recent years (Wang et al., 2013) and these yogic practices
+are also reported to promote healthy aging (Hariprasad et al.,
+2013a,b,c,d). Though Yoga has been reported as an effective mo-
+dality in improving various physical and psychological aspects of
+elderly populations, a comprehensive review on the effects of yoga
+on the health problems faced by elderly population is not available.
+Hence, this current review aims to provide a comprehensive review
+using the current available scientific literature on the effect of yoga
+in elderly.
+* Corresponding author.
+E-mail address: [email protected] (A. Mooventhan).
+Contents lists available at ScienceDirect
+Journal of Bodywork & Movement Therapies
+journal homepage: www.elsevier.com/jbmt
+http://dx.doi.org/10.1016/j.jbmt.2017.01.004
+1360-8592/© 2017 Elsevier Ltd. All rights reserved.
+Journal of Bodywork & Movement Therapies 21 (2017) 1028e1032
+2. Methods
+We performed a comprehensive search in the PubMed/Medline
+electronic database to review relevant articles, using keywords
+“yoga and elderly”. A total of 1044 articles published from 1965 to
+06th October 2016 were available. All the relevant articles that fit
+into the following inclusion and exclusion criteria were reported in
+this review. Inclusion criteria: Clinical trials, controlled trials, ran-
+domized controlled trials, systematic reviews and meta-analysis
+that are dealing with Yoga alone or in combination with conven-
+tional medicines in elderly. Exclusion criteria: Research protocols,
+comments, articles that do not have either abstract or full text,
+articles that are dealing with Yoga in combination with other
+complementary and alternative therapies, articles with lack/repe-
+tition of the same kind of information. Of 1044 articles, 47 articles
+published from 1997 to 6th October 2016 were included in this
+review.
+3. Practice of yoga and its effects in elderly peoples
+In general, Yoga was reported to have beneficial effect on
+physical function, mental/emotional state (Alexander et al., 2013),
+social, vitality (Halpern et al., 2014), and lifestyle choices. And thus,
+it might be useful as a health promotion strategy in the prevention
+and management of chronic disease in older adults (Alexander
+et al., 2013). According to a systematic review and meta-analysis
+Yoga is superior to conventional physical activity interventions in
+elderly people especially in improving for self-rated health status,
+aerobic fitness, and strength (Patel et al., 2012). The effect of Yoga
+on various systems and its related problems were discussed below.
+3.1. Cardiovascular system and its related problems
+Ageing is associated with a decline in heart rate variability and
+spontaneous decline in baroreceptor sensitivity whereas 4-month
+(2 classes/week plus home exercises) of yogic respiratory training
+was reported to produce beneficial effects by reducing cardiac
+sympathetic activity and improved sympathovagal balance in
+elderly individuals (Santaella et al., 2011). Oxidative stress has been
+implicated as one of the underlying cause of hypertension. Hy-
+pertension, especially in the elderly is a strong risk factor for car-
+diovascular mortality and morbidity. A 3-month Yoga (1-h in the
+morning for 6-days per week) intervention has shown to reduce
+oxidative stress by showing a significant reduction in serum
+malondialdehyde levels and an increase in antioxidant levels
+(serum superoxide dismutase activity, serum glutathione, and
+vitamin C). Thus, Yoga was reported to be effective in reducing
+oxidative stress and to improve antioxidant defense in elderly hy-
+pertensive individuals (Patil et al., 2014).
+Twelve week of Yoga has shown to produce significant reduc-
+tion in heart rate (Bezerra et al., 2014) and 11 week of Hatha-Yoga (5
+sessions/week for 90 min) was shown to produce significant in-
+crease in maximal oxygen consumption and maximal expired air
+volume and high-density lipoprotein cholesterol in elderly women
+(Ramos-Jim

+enez et al., 2009). In a study involving 12 weeks (1-h in
+the morning for 6 days in a week) of Yoga a significant reduction in
+arterial stiffness, blood pressure, sympathetic activity and an
+improvement in endothelial function and enhanced bioavailability
+of nitric oxide was observed in elderly individuals, along with an
+increase in pulse pressure (Patil et al., 2015). In another study 8-
+weeks of Bikram yoga (90 min per session, three times per week),
+an improvement in arterial stiffness was reported only in young,
+but not in older adults (Hunter et al., 2013a,b).
+Baroreflex sensitivity is quantified by the alpha-index, at high
+frequency (0.15e0.35 Hz, reflecting parasympathetic activity) and
+mid-frequency (MF; 0.05e0.15 Hz, reflecting sympathetic activity)
+derived from spectral and cross-spectral analysis of spontaneous
+fluctuations in heart rate and blood pressure. Six weeks of Yoga
+practice was shown to reduce heart rate and increase alpha high
+frequency, suggestive of parasympathetic activity in healthy elderly
+persons (Bowman et al., 1997).
+3.2. Respiratory system and its related problems
+Ageing is associated with a decline in pulmonary function but 4-
+months of (2 classes/week plus home exercises) Yogic breathing
+practices have shown to be beneficial in improving respiratory
+functions in elderly (Santaella et al., 2011) by reducing respiratory
+rate and improving tidal volume, vital capacity, minute ventilation,
+maximal inspiratory and expiratory pressure (Bezerra et al., 2014).
+In elderly individuals, respiratory function may be seriously
+compromised when a marked decrease in respiratory muscle
+strength coexists with co-morbidity and activity limitation. But, 6
+weeks (5 days per week) of Yogic breathing practice was reported
+to be an effective and well-tolerated exercise regimen in elderly
+individuals. Hence, yoga can be considered as a useful alternative to
+inspiratory threshold training, or no training, to improve respira-
+tory muscle function in elderly individuals, when whole-body ex-
+ercise training is not possible (Cebri
+a i Iranzo et al., 2014).
+3.3. Nervous system and its related problems
+3.3.1. Physical performance in parkinson disease
+A 12 week Yoga study showed a significant improvement in
+physical performance in elderly individuals with Parkinson disease
+measured using the Unified Parkinson Disease Rating Scale motor
+score, Berg Balance Scale, Mini-Balance Evaluation Systems Test,
+Timed Up and Go, single leg stance, postural sway test, 10-m usual
+and maximal walking speed tests, 1 repetition maximum and peak
+power for leg press (Ni et al., 2016).
+3.3.2. Cognitive impairment and dementia
+The elderly have an increased risk of cognitive impairment and
+dementia (Hariprasad et al., 2013a,b,c,d). Yoga-based intervention
+was reported to be a feasible intervention in the elderly with
+cognitive impairments (Hariprasad et al., 2013a,b,c,d). The practice
+of Yoga for 6 months was shown to be effective in increasing hip-
+pocampal grey matter (Hariprasad et al., 2013a,b,c,d); in improving
+immediate and delayed recall of verbal (Rey's Auditory Verbal
+Learning Test) and visual memory (Rey's complex figure test),
+attention and working memory (Wechsler's Memory Scale-spatial
+span), verbal fluency (Controlled Oral Word Association), execu-
+tive function (Stroop interference) and processing speed (Trail
+Making Test-A) (Hariprasad et al., 2013a,b,c,d). One month practice
+of Trataka (a Yogic visual cleansing technique), was shown to pro-
+duce significant improvement in various cognitive tasks such as
+Digit Span Scores, Six Letter Cancellation Test Scores and Trail
+Making Test-B scores in elderly. Yoga could thus prove to be a
+valuable tool to enhance cognition in the elderly (Talwadkar et al.,
+2014). Whereas, another study on 6 months of Hatha-Yoga, re-
+ported no such significant improvement in cognitive functions
+(Oken et al., 2006).
+A study of 12-week (three 55-min sessions per week) Yoga
+practice showed beneficial effects in individuals with dementia,
+living in long-term care facilities in improving both physical (low-
+ered blood pressure, reduced respiration rate, strengthened car-
+diopulmonary fitness, enhanced body flexibility, improved muscle
+strength and endurance, improved balance, and increased joints
+motion) and mental health (reduction in depression state and
+problem behaviours). Hence, yoga could usefully be recommended
+A. Mooventhan, L. Nivethitha / Journal of Bodywork & Movement Therapies 21 (2017) 1028e1032
+1029
+as one of the routine activities in the long-term care facilities (Fan
+and Chen, 2011).
+3.4. Mental health and its related problems
+Yoga influences both the physiological and psychological as-
+pects of aging (Wang et al., 2014). In a study, 6-week of yoga was
+demonstrated to be effective in improving psychological wellbeing
+by reducing anger, anxiety, depression and self-efficacy for daily
+living of elderly individuals (Bonura and Tenenbaum, 2014). In
+other studies, 7-week of Yoga was demonstrated to be effective in
+improving mental/emotional wellness, exhaustion levels, and
+stress levels (Lindahl et al., 2016); and 8-week of yoga effectively
+improved the performance of executive function measures such as
+working memory capacity and efficiency in mental set shifting in
+elderly individuals (Gothe et al., 2014).
+A 24 weeks (7 h 30 min per week) study of an integrated
+approach of yoga including the mental and philosophical aspects, in
+addition to the physical practices, was shown to help in reducing
+depression in institutionalized older individuals (Krishnamurthy
+and Telles, 2007). In another study, laughter Yoga reduced
+depression and improved life satisfaction of elderly depressed
+women and was found to be as effective as group exercise pro-
+grams. (Shahidi et al., 2011). A systematic review also reported Yoga
+to be effective in reducing depressive symptoms of elderly people
+living in institutions and in the community (Wang et al., 2014).
+3.5. Musculoskeletal system and its related problems
+Falls are amongst the most common problems affecting elderly
+individuals. At least 50% of those over the age of 80 fall annually
+(Galantino et al., 2012). Twelve weeks of Yoga practice was shown
+to be as effective as Tai-Chi and standard balance training in
+improving postural stability in the elderly (Ni et al., 2014). In a
+systematic review and Meta-analysis, yoga was reported to result in
+small improvements in balance and medium improvements in
+physical mobility in elderly people (Youkhana et al., 2016). An 8-
+week (two 90-min sessions per week, and at least 20 min of on
+alternate days) Iyengar Hatha yoga program specifically tailored to
+the elderly was reported to be safe, feasible and to provide a
+beneficial effect in preventing or reducing age-related changes of
+gait function (Di Benedetto et al., 2005), while a chair based yoga
+program was reported to be effective in improving mobility and
+reducing the fear of falling. Moreover, there were no adverse events
+during the Yoga sessions (Galantino et al., 2012).
+Yoga was reported to have ancillary benefits in terms of
+improved physical function (Alexander et al., 2013), and reduced
+fatigue (Halpern et al., 2014). A previous study on 32 weeks (two
+60-min sessions per week) of Hatha yoga for elderly people
+demonstrated the demand of various individual standing yoga
+poses at the ankle, knee and hip, in the frontal and sagittal planes.
+In these, the Crescent, Chair, Warrior II, and One-legged Balance
+poses were shown to generate the greatest average support mo-
+ments; Side Stretch was shown to generate the greatest average hip
+extensor and knee flexor joint moments of force (JMOFs); Crescent
+pose was shown to have the highest demands on the hip flexors and
+knee extensors; and all the poses were shown to produce ankle
+plantar-flexor JMOFs. In the frontal plane, the Tree pose was shown
+to generate the greatest average hip and knee abductor JMOFs;
+whereas Warrior II pose was shown to generate the greatest
+average hip and knee adductor JMOFs. The Warrior II and One-
+legged Balance induced the largest average ankle evertor and
+invertor JMOFs, respectively. The electromyographic findings were
+also shown to be consistent with the JMOF results (Wang et al.,
+2013).
+In various previous studies, practice of Yoga improved flexibility
+(Oken et al., 2006; Farinatti et al., 2014), hip extension, stride length
+(Di Benedetto et al., 2005), range of motion (Gonçalves et al., 2011),
+standing balance, sit-to-stand test (Tiedemann et al., 2013), one-
+legged stand with eyes closed test score (Oken et al., 2006;
+Tiedemann et al., 2013), Four Minute Walk Test score (Tiedemann
+et al., 2013), Six-Minute Walk Test score (McCaffrey et al., 2014),
+mobility (Kelley et al., 2014), postural control and gait (McCaffrey
+et al., 2014; Kelley et al., 2014; Zettergren et al., 2011) and
+decreased anterior pelvic tilt (Di Benedetto et al., 2005).
+A cross-sectional survey of a nationally-representative sample
+of women aged 60e65 years from the Australian Longitudinal
+Study on Women's Health (ALSWH) showed the use of yoga/
+meditation to be useful for management of back pain (Murthy et al.,
+2014). In a study on older women with knee osteoarthritis, 8-week
+Yoga program was shown to be safe, feasible, acceptable and
+effective in providing therapeutic benefits such as a significant
+improvement in The Western Ontario and McMaster Universities
+Arthritis Index (WOMAC) pain, stiffness and short physical perfor-
+mance battery with no yoga related adverse events (Cheung et al.,
+2014). Similarly, a review was also reported as demonstratingYoga
+to be useful in reducing pain in knee osteoarthritis without side
+effects (Field, 2016).
+3.6. Metabolic disorders and its related problems
+In a study of older adults with metabolic syndrome, 1-year of
+Yoga practice was shown to improve the cardiovascular risk factors
+including central obesity and blood pressure (Siu et al., 2015).
+Bikram Yoga is an exotic form of physical activity combining hatha
+yoga and thermal therapy that could positively impact metabolic
+health. 8-week studies of Bikram Yoga were reported to produce a
+significant improvement in glucose tolerance in elderly individuals
+(Hunter et al., 2013a,b) and a significant reduction in insulin
+resistance index in elderly individuals with obesity (Hunter et al.,
+2013a,b).
+3.7. Uro-genital system and its related problems
+In a case study, a 63-year-old overweight female previously
+diagnosed with stress urinary incontinence presented with exac-
+erbated events of urine leakage. She was advised a residential
+lifestyle and behavioural program, primarily consisting of a moni-
+tored yoga therapy, apart from her ongoing anti-cholinergic med-
+icine, for 21 days. Improvements were reported as “a total of 1.9 kg
+of weight lossduring her stay. Usage of pad, as reported in her diary,
+reduced from 3 to 1 per day. Her International Consultation on
+Incontinence Modular Questionnaire-Urinary Incontinence Short
+Form score reduced from 16 to 9, indicating better continence and
+she expressed subjective well-being and confidence in her social
+interactions” (Vinchurkar and Arankalle, 2015), suggesting that
+yoga could be a possible complementary practise in the manage-
+ment of incontinence and other uro-genital problems often asso-
+ciated with age.
+3.8. Cancer and its related problems
+Cancer and its treatments lead to cancer-related fatigue and
+many other side effects, in turn, creating a substantial global side-
+effect burden (total burden from all side effects) which, ulti-
+mately, compromises functional independence and quality of life.
+In a study, 4-week Yoga intervention was reported to be effective in
+reducing cancer-related fatigue, physical fatigue, mental fatigue,
+and global side-effect burden among older cancer survivors,
+compared with standard care (Sprod et al., 2015). A study of a
+A. Mooventhan, L. Nivethitha / Journal of Bodywork & Movement Therapies 21 (2017) 1028e1032
+1030
+classical
+Yoga
+program (8-sessions), showed
+a
+reduction
+in
+depression, pain, fatigue amongst cancer patients with enhanced
+performance of daily and routine activities, and increases in the
+quality of life in elderly patients with breast cancer (Yagli and Ulger,
+2015).
+3.9. Quality of sleep and quality of life
+The aging process is associated with physiological changes that
+affect sleep. Sleep disturbances and decline in physical function-
+ality are common conditions associated with aging (Bankar et al.,
+2013). Sleep in older persons is characterized by decreased ability
+to stay asleep, resulting in fragmented sleep and reduced daytime
+alertness (Manjunath and Telles, 2005). In older adults, undiag-
+nosed and untreated insomnia may cause impaired daily function
+and reduced quality of life. Insomnia is also a risk factor for acci-
+dents and falls that are the main cause of accidental death in older
+adults and, therefore associated with higher morbidity and mor-
+tality rates in older populations (Halpern et al., 2014).
+The pharmacological treatment of sleep disturbances (Bankar
+et al., 2013) and insomnia in older persons (Manjunath and
+Telles, 2005) is associated with various adverse effects (Bankar
+et al., 2013; Manjunath and Telles, 2005). Whereas, practice of
+Yoga has been shown to be effective in reducing the time taken to
+fall asleep; in increasing the total number of hours slept (Halpern
+et al., 2014; Manjunath and Telles, 2005) and in the feeling of be-
+ing rested in the morning (Manjunath and Telles, 2005); in
+improving overall sleep quality, sleep efficiency, and self-assessed
+sleep quality (Halpern et al., 2014). Hence, regular practice of
+Yoga was reported to be a safe intervention (Halpern et al., 2014;
+Bankar et al., 2013) in improving different aspects of sleep
+(Halpern et al., 2014; Manjunath and Telles, 2005), quality of sleep
+(Hariprasad et al., 2013a,b,c,d; Bankar et al., 2013) and quality of life
+(Hariprasad et al., 2013a,b,c,d; Halpern et al., 2014; Oken et al.,
+2006)
+in
+elderly
+individuals
+(Hariprasad
+et
+al.,
+2013a,b,c,d;
+Halpern et al., 2014; Oken et al., 2006; Bankar et al., 2013). The
+systematic reviews on Meditative Movement Intervention (a new
+category of exercise integrating physical activity and meditation)
+(Wu et al., 2015) and on Yoga (Wang et al., 2014) were also reported
+to result in beneficial effects in improving the quality of sleep in
+elder people (Wang et al., 2014; Wu et al., 2015).
+4. Conclusion
+Based on the available scientific literature, this review suggests
+that the regular practice of Yoga can be considered as an effective
+intervention in improving various health related problems of
+elderly people.
+Conflicts of interest
+None Declared.
+Source of funding
+We did not receive any specific grant from funding agencies in
+the public, commercial, or not-for-profit sectors for conducting this
+review.
+Acknowledgement
+We thank Dr. Venugopal, MSc Diabetes (UK) for his help in
+editing the manuscript.
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+1032

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+Submit Manuscript | http://medcraveonline.com
+Introduction 
+ Obesity  is a  metabolic disorder with excessive accumulation 
+of fat cells which leads to adverse impacts on physical as well as 
+psychological functions of theperson.1 Energy-dense overeating, 
+nutrient-poor foods and a sedentary lifestyle have led to an epidemic 
+of obesity all over the world.2 Apart from physical problems there 
+are issues which affect psychological well-being of an individual. 
+Depression is the commonest psychological co-morbidity of obesity. 
+A wide range of treatment options are available for obesity but, 
+balanced nutritional food intake and regular exercise are considered 
+to be the safest and the easiest option.3 The most common reason of 
+obesity is increased high calorie & irregular food intake, insufficient 
+exercise, and hereditary body pattern. 4 As per the leading scientist, if 
+not controlled vigorously it may end up in a serious health challenge 
+to the society.5 According to WHO, UNICEF & CARE it is one of the 
+most neglected public health problem in recent years.6
+Adolescence is a transitional stage of physical and psychological 
+human development that occurs between the age of 13 and 19years.7 
+Overweight or obese children may continue this body pattern in 
+adulthood with same or increased levels which may lead to high risk 
+of developing disorders like diabetes, hypertension, cardiovascular 
+diseases and cancers.8 It has been observed that obesity in children has 
+dramatically increased over the past two decades.9 In the last decade, 
+43million children were found overweight or obese. 35million of 
+this data were living in developing countries. This data may cross 60 
+million in coming dead if not managed with systematic & scientific 
+channels. Two systematic reviewpapers10,11 and one clinical review 
+paper12 suggest that yoga has beneficial effects on mental and 
+physical health in children and adolescents.
+ Yoga has been proved its efficacy in psychosomatic disorders 
+along with scientific evidence in past decade. Few national surveys 
+has reported that more than 10 million Americans are practicing yoga 
+for different health challenges since last 15yearss.13,14 Diseases due 
+to stress are found to be well managed with Yoga therapy according 
+to many scientific research article.15 Different schools of yoga have 
+varying proportions of physical, breathing, and mind activities 
+executed through varied practices. Most of these studies found a 
+varied range of positive benefits on obesity. They have a common 
+objective of voluntary mastery over the modifications of the mind.15 
+In order to provide yoga for adolescent obesity, we have designed 
+& developed an integrated yoga module for Obesity in adolescents 
+from authentic Yoga texts which were result of group discussion of 
+16 subject matter experts. The module has been checked for content 
+validity by using Lawshe’s content validity ratio. This study is 
+accepted for publication in another publication. Now before going 
+for a proper randomised trial control in larger population, it needs 
+to be checked for feasibility on pilot basis. This study is designed to 
+provide feasibility of Integrated Yoga Module in overweight & obese 
+Adolescents. It also aims to objectively and rationally uncover the 
+strengths and weaknesses of the module. 17 It evaluates the project’s 
+potential for success. 
+Materials and methods
+Two armed perspective RCT (Randomized Controlled Trial) has 
+Int J Complement Alt Med. 2019;12(4):129‒133.
+129
+© 2019 Rathi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which 
+permits unrestricted use, distribution, and build upon your work non-commercially.
+Feasibility study of integrated yoga module in 
+overweight & obese adolescents
+Volume 12 Issue 4 - 2019
+Sunanda Rathi,1 Nagaratna RN,2 
+Tekurpadmini,2 Joshi Ruchira R1
+1Department of 
+Yoga, Chiranjiv foundation, India
+2Department of Yoga, Swami Vivekananda 
+Yoga Anusandhana 
+Samsthana, India
+Correspondence: Sunanda Rathi, Director, Chiranjiv 
+Foundation,pune, Sadashivpeth, Tilak road, Pune, India, Tel 
+9673008349, Email 
+Received: April 11, 2018 | Published: July 31, 2019
+Background
+Yoga has been known to have stimulatory or inhibitory effects on the metabolic 
+parameters and to be uncomplicated therapy for obesity. Adolescence is more prone to 
+get obese due to lack of physical activity making them more sedentary. 
+Aim: To identify feasibility of validated Integrated Approach of yoga Therapy module 
+(IAYTM) for Obesity in adolescents.
+Method: RCT (Randomized Controlled Trial) was conducted on overweight & obese 
+adolescents. Special yoga training was conducted for yoga group parameters like 
+weight, Body Mass Index (BMI), pulse rate , blood pressure, MAC (Mid Upper Arm 
+Circumferences), Waist Circumference (WC), HC (Hip Circumference), Fasting blood 
+sugar, total cholesterol, High-density lipoproteins, low-density lipoproteins, very low-
+density lipoprotein & Sr. triglycerides were assessed before and after intervention for 
+both yoga and control groups. Within and between group analyses of the variables 
+were carried out.
+Result: The study showed significant reduction in weight, body mass index, very low-
+density lipoprotein & Sr. triglycerides, circumference & Serum cholesterol in yoga 
+group &percentage of improvement is more in yoga group than that of control group.
+Conclusion: Integrated Approach of yoga Therapy module (IAYTM) is effective 
+in management of weight, serum triglyceride & very low - density lipoprotein in 
+adolescent obesity. 
+Keywords: integrated approach of yoga therapy module, IAYTM, obesity, 
+adolescence, yoga, feasibility
+International Journal of Complementary & Alternative Medicine
+Research Article
+Open Access
+Feasibility study of integrated yoga module in overweight & obese adolescents
+130
+Copyright:
+©2019 Rathi et al.
+Citation: Rathi S, Nagaratna RN, Tekurpadmini, et al. Feasibility study of integrated yoga module in overweight & obese adolescents. Int J Complement Alt Med. 
+2019;12(4):129‒133. DOI: 10.15406/ijcam.2019.12.00462
+been conducted for 1month with overweight & obese adolescents 
+of a residential school in Sangamner, pune, and Maharashtra, India 
+who did not had any exposure to Yoga previously. Adolescents 
+having any physical disability, any medical disorder or complication 
+were not included in the study, overweight & obese adolescents (15 
+male and 8 female) between 11 & 17years of age who consented top 
+anticipate in the study were selected for the study. All the participants 
+were allocated in two groups (Yoga n=14 and control n=9). Signed 
+informed consent was obtained from all participants and their parents 
+or guardians in the prior stage of intervention.
+During intervention, Yoga group followed the Integrative Yoga 
+Therapy module for obesity in adolescents which contains body 
+posture, breathing tools, Relaxation and Meditation techniques. All 
+the techniques were conducted under guidance & expert’s observation. 
+Duration of each session of the intervention was 60minutes & sessions 
+were conducted for five days in a week for 1month. The control group 
+were doing regular physical activities. All participants received same 
+type of meal throughout the month. All the participants were assessed 
+for weight, BMI, pulse, blood pressure, mid-arm circumference 
+waist circumference, hip circumference, fasting blood sugar, serum 
+total cholesterol, high-density lipoprotein, low- density lipoprotein, 
+very low- density lipoprotein, serum triglycerides respectively at 
+baseline and after 1-month of the intervention. All the 23 adolescents 
+completed the intervention. There were no adverse effects observed 
+during the study period.
+Data analysis
+The data analysis was performed with SPSS software 20 th version. 
+In very beginning, the data was analysed for normal distribution. 
+Within groups analysis was analysed with all the variables. Between 
+groups analysis was conducted for the post variables of both the 
+groups. 
+Results 
+The basic demographic data of age and height of the yoga and 
+control group are given in Table 1. The average age of Yoga group was 
+14.21±1.84 and that of control group was 15.22±1.09. The average 
+height of Yoga group was 1.64±0.09and that of control group was 
+1.66±0.09. The minimum age in yoga group was 11 years whereas that 
+in control group was 14years and the maximum age in both groups 
+was 17years. The minimum height in yoga group was 1.51 meter and 
+that of control group was 1.54meter. The maximum height in yoga 
+group was 1.85 meter and that of control group was 1.75 meter. 
+Table 1 Baseline data of age and height
+Variables
+Yoga Gr. n = 14
+Control Gr. n = 9
+Age 
+14.21±1.84
+15.22±1.09
+Height
+1.64±0.09
+1.66 ±0.09 
+ Results of within group analysis of the normally distributed 
+variables of Yoga group are given in Table 2. Weight, blood pressure, 
+mid-arm circumference, waist circumference, fasting blood sugar, 
+high-density lipoprotein,  very low- density lipoprotein, serum 
+triglycerides were normally distributed with Yoga group. There is 
+significant reduction in weight (p=0.000), diastolic blood pressure 
+(p=0.018), fasting blood sugar (p=0.059), very low- density lipoprotein 
+(p=0.001), serum triglycerides (p=0.001) after intervention. There 
+is significant increase in mid-arm circumference (p=0.01). There is 
+non-significant reduction in systolic blood pressure (p=0.08), waist 
+circumference (p=0.45) & high-density lipoprotein (p=0.75). 
+Table 2 Within group analysis results (Parametric test) of yoga Group (n=14)
+Variables
+Pre
+Post
+T
+Sig.
+Weight
+81.64±13.79
+78.99±13.47
+7.29
+0.000**
+Systolic blood 
+pressure
+124.57±10.18
+121.85±7.87
+1.84
+0.08
+Diastolic blood 
+pressure
+81.74±12.28
+78.21±8.54
+2.71
+0.01*
+Mid arm 
+circumference
+30.20±2.34
+31.67±1.68
+-2.80
+0.01*
+Waist circumference
+100.5±9.81
+99.21±8.57
+0.77
+0.45
+Fasting blood sugar
+75.61±7.06
+70.49±8.46
+2.06
+0.05*
+HDL
+40.25±2.64
+40.05±1.89
+0.32
+0.75
+Triglycerides
+115.85±30.07
+104.54±32.27
+4.02
+0.001**
+VLDL
+23.19±6.03
+20.90±6,45
+4.15
+0.001**
+*Significance at the level of 0.05
+**Significance at the level of 0.001
+Results of within group analysis of the not normally distributed 
+variables of Yoga group are given in Table 3. BMI, pulse rate, hip 
+circumference, serum total cholesterol, low- density lipoprotein were 
+not normally distributed in Yoga group. There is significant reduction 
+in BMI (p=0.00), pulse rate (p=0.03), hip circumference (p=0.01), 
+serum total cholesterol (p=0.03). There is non-significant reduction in 
+low- density lipoprotein (p=0.24). 
+Table 3 Within group analysis results (Non-Parametric test) of Yoga group 
+(n=14)
+Variables
+Pre
+Post
+Z
+Sig.
+BMI
+30.17±4.37
+29.19±4.26
+3.29
+0.001**
+Pulse rate
+77.35±4.60
+75.35±4.76
+2.07 
+0.038*
+Hip 
+circumference
+109.27±11.98
+108.08±12.03
+2.55 
+0.011*
+Sr. cholesterol 
+107.61±30.54
+97.90±20.23
+2.10 
+0.035*
+LDL
+44.16±29.29
+36.93±20.42
+1.16 
+0.245
+*Significance at the level of 0.05
+**Significance at the level of 0.001
+Results of within group analysis of the normally distributed 
+variables of control group are given in Table 4. Weight, BMI, blood 
+pressure, waist circumference, fasting blood sugar, Serum cholesterol, 
+shigh-density lipoprotein, low- density lipoprotein, very low- density 
+lipoprotein , serum triglycerides were normally distributed in control 
+group. There is significant reduction in high-density lipoprotein 
+(p=0.15), serum triglycerides (p=0.009) & very low- density 
+lipoprotein (p=0.009). There is reduction in weight (p=0.634), 
+BMI (p= 0.616), systolic blood pressure (p=0.152), diastolic blood 
+pressure (p=0.055), waist circumference (p=621), fasting blood 
+Feasibility study of integrated yoga module in overweight & obese adolescents
+131
+Copyright:
+©2019 Rathi et al.
+Citation: Rathi S, Nagaratna RN, Tekurpadmini, et al. Feasibility study of integrated yoga module in overweight & obese adolescents. Int J Complement Alt Med. 
+2019;12(4):129‒133. DOI: 10.15406/ijcam.2019.12.00462
+sugar (p=0.851), serum total cholesterol (p=0.260) & low- density 
+lipoprotein (p=749) but without significance. 
+Results of within group analysis of the not normally distributed 
+variables of control group are given in Table 5. 
+Pulse rate, mid arm circumference & hip circumference were not 
+normally distributed in control group. There is significant increase in 
+mid arm circumference (p=0.015). There is reduction in pulse rate 
+(p=0.223), & hip circumference (p=0.916) but without significance. 
+Between group analysis results are given in Table 6.
+Table 4 Within group analysis results (Parametric test) of Control group (n=9)
+Variables
+Pre
+Post
+T
+Sig.
+Weight
+75.11±10.11
+75.36±10.46 
+-0.495
+0.634
+BMI
+26.87±1.71
+26.97±1.99
+-0.522
+0.616
+Systolic blood pressure
+131.11±10.89
+127.44±6.02
+1.584
+0.152
+Diastolic blood pressure
+85.33±8.26
+82.33±5.61
+2.250
+0.055
+Waist circumference
+93.86±5.95
+94.47±5.50
+-0.514
+0.621
+Fasting blood sugar
+74.55±5.20
+74±9.63
+0.194
+0.851
+Sr. cholesterol 
+94.89±10.06
+91.66±8.13
+0.260
+0.260
+HDL
+41.80±1.63
+42.85±1.86
+-3.088
+0.015*
+Triglycerides
+110.98±21.38
+94.88±11.68
+3.437
+0.009*
+LDL
+30.89±12.07
+29.82±9.92
+0.331
+0.749
+VLDL
+22.19±4.27
+18.97±2.33
+3.438
+0.009*
+*Significance at the level of 0.05
+Table 5 Within group analysis results Non- Parametric test) of Control group (n=9)
+Variables
+Pre
+Post
+Z
+Sig.
+Pulse 
+71.33±4.60
+69.88±5.10
+-1.219 
+0.223
+Midarm circumference
+29.61±2.11
+31.89±1.48
+-2.433
+0.015*
+Hip circumference
+107.03±3.61
+106.92±3.93
+-0.105
+0.916
+*Significance at the level of 0.05
+Table 6 Analysis results of comparison between Yoga & Control Group
+Variables
+Yoga Gr. (n = 
+14)
+ 
+Control Gr. ( 
+n = 9)
+ 
+T
+Sig.
+Diff. in % of 
+Improvement
+ 
+Post Mean
+% of 
+Improvement
+Post Mean
+% of 
+Improvement
+ 
+ 
+ 
+Weight
+78.99±13.47
+3.24%
+75.36±10.46
+-0.34%
+0.684
+501
+3.5
+BMI
+29.19±4.26
+3.25%
+26.97±1.99
+-0.35%
+1.457
+0.16
+3.61
+Pulse
+75.35±4.76
+2.58%
+69.88±5.10
+2.02%
+2.612
+.016*
+0.56
+Sys. BP
+121.85±7.87
+2.17%
+127.44±6.02
+2.79%
+-0.81
+0.085
+-0.61
+Dia. BP
+78.21±8.54
+4.28%
+82.33±5.61
+3.51%
+-0.275
+0.216
+0.76
+MAC
+31.67±1.68
+-4.86%
+31.81±1.48
+-7.42%
+-0.203
+0.841
+2.55
+WC
+99.21± 8.57
+1.28%
+94.47±5.50
+-0.64%
+1.468
+0.157
+1.92
+HC
+108.08±12.03
+1.08%
+106.92±3.93
+0.09%
+0.277
+0.785
+0.98
+FBS
+70.49±8.46
+6.76%
+74±9.63
+0.74%
+-0.918
+0.369
+6.02
+Sr. Cholesterol
+97.90±20.23
+9.02%
+91.66±8.13
+3.40%
+0.875
+0.391
+5.61
+HDL
+40.05±1.89
+0.48%
+42.88±1.86
+-2.51%
+-0.487
+.002*
+3
+Sr. Triglycerides
+104.54±32.27
+9.76%
+94.88±1.68
+14.50%
+0.856
+401
+-4.74
+LDL
+36.93±20.42
+16.36%
+29.82±9.92
+3.45%
+0.968
+0.344
+12.91
+VLDL
+20.90±6.45
+9.87%
+8.97±2.33
+14.51%
+0.857
+0.401
+-4.64
+*Significance at the level of 0.05
+Feasibility study of integrated yoga module in overweight & obese adolescents
+132
+Copyright:
+©2019 Rathi et al.
+Citation: Rathi S, Nagaratna RN, Tekurpadmini, et al. Feasibility study of integrated yoga module in overweight & obese adolescents. Int J Complement Alt Med. 
+2019;12(4):129‒133. DOI: 10.15406/ijcam.2019.12.00462
+Percentage of improvement (reduction) of weight & serum 
+cholesterol, 
+waist 
+circumference, 
+hip 
+circumference, 
+serum 
+cholesterol, low- density lipoprotein, high- density lipoprotein is more 
+in yoga group than that of control group. Percentage of improvement 
+(reduction) of serum triglycerides & very low -density lipoprotein 
+were more in control group than that of yoga group. 
+Discussion
+23 adolescents were intervened by validated IYTM (36practices), 
+and they were assessed pre- and post-intervention for variables 
+out of which weight (P<0.001), Serum triglyceride & triglycerides 
+(P<0.001) & very low- density lipoprotein (P<0.001) showed 
+statistically significant reduction whereas waist circumference (P< 
+0.45) & high - density lipoprotein (P<0.75) showed statistically non-
+significant reduction by validated IYTM on obesity in yoga group. 
+This could be due to short duration of study. There was significant 
+reduction in BMI (p=0.001), pulse rate (p=0.038), hip circumference 
+(p=0.011), serum total cholesterol (p=0.035) in non –parametric test. 
+So this result cannot be implicated for the universe.
+There is significant increase in mid-arm circumference (p=0.01) 
+with yoga group & (p=0.015) in control group. This could be 
+because that integrated approach of yoga therapy module for obesity 
+practises are having more emphasis on below naval part of body 
+especially focused on hips & thighs. Few practises were there like 
+suryanamaskara, chakarsana & Bhujangasana which was having 
+effect on arm muscles but they were not significant.
+Percentage of improvement (reduction) of serum triglycerides & 
+very low -density lipoprotein were more in control group than that 
+of yoga group. The reason of this could be that all subjects were 
+from same hostel & blinding on the intervention was not possible. 
+When yoga group inducted for Yoga intervention, the control group 
+were aware of the yoga programme but practical details were not 
+conveyed to them. This might have also given them some motivation 
+to do regular physical activities because of which improvement was 
+observed with their variables also. All 14 adolescents completed the 
+intervention, there were no adverse effects noticed during the study. 
+However, RCT with larger samples are needed to validate its efficacy 
+as a primary intervention.
+Strengths & limitations
+This is a unique study on adolescent obesity with control group. 
+It is found that INTEGRATED APPROACH OF YOGA THERAPY 
+MODULE has been proved effective in obesity parameters 
+management. Further both the groups were belonging to similar age 
+limits which leads to reduction of confounding factors. Blind study 
+was difficult as participants of both the groups were studying in same 
+campus. The food plan was same for both the groups. Current study 
+confirms that the one hour INTEGRATED APPROACH OF YOGA 
+THERAPY MODULE is an effective alternative in adolescent obesity. 
+Larger sample study along with psychological parameters is needed to 
+strengthen its efficacy as a primary intervention.
+Conclusion
+Integrated approach of yoga therapy module having 36practices 
+for adolescent obesity is effective in management of weight, serum 
+triglyceride & very low-density lipoprotein, hip circumference & 
+serum cholesterol. Yoga group has improved better than control group 
+with INTEGRATED APPROACH OF YOGA THERAPY MODULE. 
+This module hasproved efficient in management of adolescent obesity. 
+Acknowledgement
+We would like to thank Dr. Sanjay Malpani of Dhruv academy, 
+Sangamner where feasibility study was conducted & Mr. Ramkumar 
+Rathi whoprovided finance for the study.
+Conflicts of interest
+No conflicts of interest.
+References
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subfolder_0/Health and therapeutic benefits of Shatkarma A narrative review of scientific studies.txt

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+Review Article
+Health and therapeutic benefits of Shatkarma: A narrative review of
+scientific studies
+P.S. Swathi*, B.R. Raghavendra, Apar Avinash Saoji
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), 19, Eknath Bhavan, Gavipuram Circle, KG Nagar,
+Bengaluru, 560019, India
+a r t i c l e
+i n f o
+Article history:
+Received 7 May 2020
+Received in revised form
+20 October 2020
+Accepted 24 November 2020
+Available online 13 January 2021
+Keywords:
+Shatkarma
+Shatkriya
+Yoga
+Yogic cleansing technique
+Physiological effects
+a b s t r a c t
+Shatkarma, also known as Shatkriya are a set of six yogic cleansing techniques described in the Hatha
+Yoga texts. Several health benefits of these procedures are indicated in the traditional texts of Yoga.
+However, there is no comprehensive literature about the scientific evidence on Shatkriya. Hence, we
+searched in PubMed, PubMed Central and Google Scholar databases to review relevant articles in English.
+The search yielded a total 723 references, published from 1976 to April 2020. Based on the inclusion and
+exclusion criteria, 37 articles were included in this review. We found scientific studies on four out of six
+cleansing techniques. The limited evidence on Shatkriya suggests positive effects on various physiological
+and clinical domains. The practice of dhauti was found to enhance respiratory functions and was useful in
+digestive disorders. Nasal cleansing, neti was particularly found beneficial in managing the rhinosinusitis
+in age groups ranging from children to adults. Although trataka practice was found to enhance cognition
+and bring a state of relaxation, but there was no evidence supporting its role in eye disorders. Kapalabhati
+practice appears to have a beneficial role in the activation of sympathetic nervous system, enhance
+cognition, and improve overall metabolism. Further large-scale clinical trials with robust designs are
+warranted to evaluate the effects of Shatkriya in health and disease.
+© 2020 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences
+and Technology and World Ayurveda Foundation. This is an open access article under the CC BY-NC-ND
+license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
+1. Introduction
+Cleansing practices are part of most indegenous health sys-
+tems, be it Yoga, Naturopathy, Ayurveda, or Chinese Medicine. In
+Yoga, six cleansing practices are described in the Hatha Yoga
+tradition, which are known to balance the constitution of an in-
+dividual. These six cleansing practices in Yoga are known as
+Shatkarma or Shatkriya, which are said to promote health and
+well-being by purifying the whole body. Hatha Yoga Pradipika (ch:
+2, v. 21 and 22) of Swatmarama recommends the practice Shatk-
+riya prior to practice of pranayama (yogic breath regulation). The
+Shatkriya techniques include dhauti (internal cleansing), basti
+(yogic enema), neti (nasal cleansing), trataka (concentrated ga-
+zing), nauli (abdominal massaging) and kapalabhati (frontal sinus
+cleansing) [1]. Although several health benefits of Shatkriya are
+narrated in HathaYoga texts, there is a lack of comprehensive
+literature on scientific studies in the subject matter. Thus, the
+current review was undertaken to summarize the scientific evi-
+dence on the physiological and therapeutic effects of the
+Shatkriya.
+1.1. Traditional references for Shatkriya
+There are four major texts of Hatha Yoga tradition viz. Hatha Yoga
+Pradipika, Gheranda Samhita, Shiva Samhita and Hatharatnavali.
+Among them Gheranda samhita and Hatha Yoga Pradipika describe
+the purification of the body, with reference to six variants of the
+cleansing procedures [1,2]. Gheranda Samhita has an elaborate
+description of the sub-types and benefits of the Shatkriya. Hathar-
+atnavali, which is the latest among the Hatha Yoga texts, narrates
+eight variants of cleansing techniques [3]. However, the six cleansing
+techniques described in the Hatha Yoga Pradipika of Swami Swat-
+marama are most popular among the Yoga practitioners. The main
+objective of Shatkriya is to balance the three humours (tridosha) in
+the body, mucus (kapha), bile (pitta) and wind (vata) [1].
+Though there are a few similarities in the cleansing procedures
+described in Yoga and Ayurveda (such as basti and vamana dhauti),
+* Corresponding author.
+E-mail: [email protected]
+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.2020.11.008
+0975-9476/© 2020 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences and Technology and World Ayurveda Foundation. This is
+an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
+Journal of Ayurveda and Integrative Medicine 12 (2021) 206e212
+the yogic cleansing methods are unique for multiple reasons. The
+yogic cleansing is done by the practitioner himself under the
+guidance of Yoga teacher and without administration of any
+medicine.
+2. Methodology
+A comprehensive literature search in PubMed, PubMed Central,
+and Google Scholar databases was carried out for the keywords
+“shatkriya, shatkarma, dhauti. yogic stomach wash, basti, yogic
+enema, neti, yogic nasal cleansing, nasal irrigation, trataka, yogic
+visual concentration, nauli, yogic abdominal massage, kapalabhati,
+yogic frontal sinus cleansing, high frequency Yoga breathing”. The
+search yielded a total number of 665 references from the year 1976
+till April 2020 for the above-mentioned keywords. Experimental
+and quasi-experimental studies and case reports in English, with
+yogic cleansing techniques as an intervention were included in the
+review. The studies that had combination of Yoga practices were
+excluded. After applying the inclusion and exclusion criteria and
+removing the duplicates, a total of 37 studies were selected for the
+final review. The studies are presented based on the cleansing
+techniques.
+3. Summary of scientific evidence on yogic cleansing
+techniques
+3.1. Dhauti
+A literal meaning of dhauti is internal cleansing. Four major
+forms of dhauti kriya as described in the Gheranda Samhita viz. antar
+(internal), danta (teeth), hrid (cardiac) and moola shodhana (puri-
+fication of the anus) [1,2]. The most popular forms of dhauti include
+vamana dhauti, also known as kunjala kriya, vastra dhauti and
+shankha prakshalana. Kunjala kriya includes drinking warm saline
+water and voluntarily inducing vomiting to clear the contents of
+stomach. In vastra dhauti, the practitioner swallows a soft cotton
+cloth of about 2 m length and 4 cm width and removes the same.
+The practice of shankha prakshalana includes drinking warm saline
+water and passing it in the bowels by inducing peristalsis through
+certain postures [1]. It aids in reducing ailments of the digestive
+system like constipation, biliousness, indigestion, chronic gastritis,
+reflux acts. It even helps to reduce accessory organ ailments of
+digestive systems like torpid liver, sluggish pancreas, urinary
+elimination, renal complaints, and dyspeptic condition. Indirectly it
+strengthens the heart and respiratory systems like cough, asthma,
+tonsillitis and teeth problems. It even benefits in arthritis, diabetes,
+and loosening of weight [4].
+3.1.1. Effects of dhauti on respiratory system
+A study was conducted to assess the effect of kunjala kriya on the
+pulmonary functions in healthy volunteers. The authors found the
+practice to play a role in enhancing pulmonary functions along with
+increased vagal tone. These findings were based on the increase in
+slow vital capacity, forced inspiratory volume along with a reduc-
+tion in expiratory reserve volume and respiratory rate. The findings
+also indicate a possible increase in endurance of the respiratory
+muscles, decreased airway resistance, better emptying of lungs,
+which may play a role in restrictive lung disorders [5].
+3.1.2. Effect of dhauti on bowel health
+A recent randomized controlled study done on 60 healthy in-
+dividuals, demonstrated beneficial effects of laghu shankha prak-
+shalana in bowel health. Thirty volunteers who received the
+intervention once in a week for 4 weeks demonstrated better scores
+in the Cleveland clinic constipation scale. The control group
+showed no significant change during the follow-up period [6].
+3.1.3. Effect of dhauti in chronic low back pain
+A self as controlled study was conducted in 40 in-patients,
+randomly assigned to receive laghu shankha prakshalana and back
+pain yogic special technique on specific days. Assessments were
+performed before and immediately after the sessions. Pain and
+disability were assessed using Oswestry disability index, state
+anxiety using the state subscale of Spieldberger’s state and trait
+anxiety inventory, spinal flexibility, and straight leg raising tests
+using Leighton type goniometer and caliper type goniometer
+respectively. Both Yoga sessions were found to beneficial to the
+patients, but the magnitude of change was higher following the
+laghu shankha prakshalana session. Thus, laghu shankha prak-
+shalana practice was found to reduce pain, disability, anxiety, and
+help to increase in flexibility [7].
+3.1.4. A complication of dhauti
+Practice of dhauti is generally considered safe when it is done
+under the guidance of a teacher. One case study was found to report
+the adverse effect of dhauti during the literature review. A case of
+dental erosion diagnosed using the Tooth Wear Index was reported
+by Meshramkar and Patil (2007) which they had attributed to the
+regular practice of kunjala kriya for 12 years [8].
+Thus, from the limited evidence available on dhauti kriya, it was
+found useful as a therapeutic modality in the management of res-
+piratory and digestive disorders. The practice should be done under
+the guidance of a trained teacher, which may help to avoid possible
+complications. Further large-scale clinical trials are required to
+establish the usefulness of dhauti as therapeutic modality. We have
+summarized the studies on dhauti in Table 1.
+3.2. Neti (yogic nasal cleansing)
+The practice of Neti is advised in Hatha Yoga to clean the nasal
+passage. In classical reference of Hatha Yoga Pradipka only sutra neti
+is explained however in general four variations of Neti practiced,
+which includes jala (water), sutra (thread), dugdha (milk), and
+ghritha (ghee) [1,9]. The most popular forms of Neti practice are jala
+and sutra neti. In Jala neti, saline warm water is passed from one
+nostril to another using a specially designed pot. The classical
+practice of sutra neti involves inserting a thread in the nostril and
+removing it from the mouth. In modern times instead of thread, a
+sterile catheter is used. Neti removes mucus from nostrils, sinuses
+which helps to allow the air easily without obstruction. This help in
+reducing allergic rhinitis, tonsillitis and to prevent cough, cold and
+tension headache due to eye strain.
+3.2.1. Use of Neti for rhino-sinusitis
+A study done on 150 subjects with chronic sinusitis assigned
+them in 3 treatment groups: nasal irrigation with a bulb syringe or
+jala neti, or reflexology massage. The follow-up duration was for 2
+weeks. All three groups demonstrated improvement in rhinosinu-
+sitis outcome measures [10]. More than 70 percent of the partici-
+pants wanted to continue practicing nasal irrigation even after
+completion of the study. The study also depicted that the im-
+provements in the symptoms were better in male population.
+Smokers in the study did not show improvement in the symptoms.
+Sinusitis is a common problem among children. Shoseyov et al.
+(1998) conducted a double blind RCT to illustrate the efficacy of
+normal water verses jala neti in children with chronic sinusitis. The
+outcome measures used were cough, nasal secretion and radio-
+logical assessment tools. They found significant improvements in
+four-weeks in the group which used jala neti, when compared to
+P.S. Swathi, B.R. Raghavendra and A.A. Saoji
+Journal of Ayurveda and Integrative Medicine 12 (2021) 206e212
+207
+normal saline. The effects were sustained for a follow-up period of
+one month after the conclusion of the trial [11].
+A case series was conducted to report effects of jala neti in 10
+cases of sinusitis among children (age range: 3e9 years). The au-
+thors found improvement in the disease-related Quality of life and
+in symptom management [12].
+An early study assessed the inflammatory markers in thirty
+symptomatic patients with active perennial allergic rhinitis. The
+three interventions compared were nasal heated water particles
+at 43 degrees C for 20 min, heated molecular water vapor at 41
C
+for 20 min, and simple jala neti at 39
C solution for 15 min at
+weekly intervals. Nasal washes were done before and immedi-
+ately after the treatments, at 30 min, 2 h, 4 h, 6 h. Inflammatory
+mediators such as histamine, prostaglandin D2, leukotriene
+C4 concentrations were assessed using a competitive radioim-
+munoassay.
+Inflammatory
+mediators
+in
+nasal
+secretions
+decreased substantially after jala neti. It reduced histamine for a
+period of 6 h, after a single 15 min treatment, illustrating the
+beneficial effect of jala neti in reducing allergic response and
+inflammation [13].
+A study (SNIFS Trial) assessing the efficacy of self-management
+tools for recurrent sinusitis compared jala neti with steam inhala-
+tion. The investigators of the study followed 32 participants for a
+period of six months. They concluded both interventions were
+acceptable to the patients, but jala neti was found to be effective in
+symptom management [14]. A large scale RCT involving 871 par-
+ticipants indicated that jala neti being better in managing symp-
+toms of rhino-sinusitis and being acceptable to participants than
+steam inhalation [15].
+A randomized control trial with seventy-six subjects followed
+patients with sinusits for a period of six months. The investigators
+found improved quality of life, reduced symptoms, and need for
+medications in patients who performed jala neti daily for six-
+months [16].
+3.2.2. Neti for post-irradiation rhinosinusitis in nasopharyngeal
+carcinoma
+Sinusitis and nasopharyngeal irritation are common following
+radiotherapy for nasopharyngeal carcinoma. A five-year follow-up
+study demonstrated that long term nasal irrigation helped in
+improving quality of life (QoL) of patients affected with nasopha-
+ryngeal carcinoma within a one year of intervention there was a
+relief in nasal symptoms [17]. Similar observation of improved
+quality of life and reduced symptoms were observed in a trial
+involving 107 nasopharyngeal carcinoma patients after irradiation.
+The follow-up duration for the study was six months [18].
+3.2.3. Complication of Sutra neti
+There was a case of 67 year old man presenting with change of
+voice, loss of sensation of smell, nose blockage and mouth
+breathing after regular practice of Sutra neti. He had to undergo a
+controlled ablation for release of the nostrils. The investigators
+suggested to avoid vigorous practice of sutra neti [19].
+Thus, Neti, being one of the easiest cleansing procedures in Yoga,
+plays advantageous role in management of rhino-sinusitis. A case
+study also indicates beneficial effect of sutra neti on obstructive
+sleep apnea and snoring. The results indicate that the traditional
+explanation from Hatha Yoga Pradipika stating neti can help to cure
+disease above the throat appear to be supported with scientific
+evidence. The evidence based effects of neti kriya are summarized
+in Table 2.
+3.3. Trataka (yogic visual concentration)
+The practice of trataka involves concentrated gazing on a small
+object (usually a candle flame). The classical explanation of the
+practice involves gazing at an object without blinking the eyes, till
+tears roll out. The technique is said to reduce the eye disorders and
+to reduce the laziness [1]. The scientific studies on Trataka used
+cognitive functions and vision as their outcome measures.
+3.3.1. Effect of trataka on attention and cognition
+A self as control study assessed effect of trataka on critical
+flicker fusion (CFF). CFF is defined as the frequency at which a
+flickering stimulus perceived to be continuous. Thirty subjects
+were recruited for the study who were conditioned for the prac-
+tice
+through
+five
+sessions
+on
+different
+days
+before
+the
+commencement of assessments. Subjects were assessed individ-
+ually for CFF immediately before and after the trataka or control
+sessions. The trataka session involved eye exercise followed by
+gazing at the candle flame whereas control session had only eye
+exercise. The CFF was assessed with increasing and decreasing
+frequencies. The trataka group shown a significant increase in CFF,
+and there was a nonsignificant reduction in CFF following the
+control session [21].
+Another study with similar sample size (n ¼ 30) and design
+evaluated the cognitive performance using the adult version of the
+Stroop-color-word
+test.
+The
+results
+indicated
+improvement
+in
+Table 1
+Evidence summary on Dhauti.
+Author
+Sample size
+Study type and Duration of
+Intervention
+Variables studied
+Findings
+Kiran et al., 2019 [6]
+60 (Experimental ¼ 30,
+Control ¼ 30)
+RCT
+Once a week for 4 weeks for study
+group & control group did not
+receive intervention
+Cleveland Clinic Constipation
+Score
+Four sessions of laghu shanka
+prakshalana reduced constipation
+score
+Balakrishnan et al., 2018 [5]
+18 (Experienced ¼ 9,
+naïve ¼ 9)
+Comparative Study between
+naïve and experienced
+practitioners.
+Single session
+Slow & forced vital capacity,
+Inspiratory & expiratory reserve
+volume, Respiratory rate & tidal
+volume
+Improved respiratory functions
+were observed after Kunjal kriya
+practice.
+Haldavenkar et al., 2014 [7]
+40
+Self as control study
+Single sessions of laghu shanka
+prakshalana and back pain
+specific yoga techniques were
+compared after 3 days of training
+Pain & disability, state anxiety,
+spine flexibility and straight leg
+raising
+A single session of Laghu shanka
+prakshalana was found better
+than back pain specific yoga
+session in reducing disability,
+anxiety & improved spine
+flexibility in patients with chronic
+low back
+Meshramkar et al., 2007 [8]
+1
+Single case report
+Tooth wear index of Smith &
+Knight
+The regular practice of kunjal
+kriya for a prolonged time led to
+dental erosion
+P.S. Swathi, B.R. Raghavendra and A.A. Saoji
+Journal of Ayurveda and Integrative Medicine 12 (2021) 206e212
+208
+selective
+attention,
+response
+inhibition,
+cognitive
+flexibility
+following trataka session [22].
+A randomized controlled trial done in elderly population evalu-
+ated the effect of trataka on cognitive function. There was improve-
+ment in the performance in the cognitive tasks such as digit span, six-
+letter cancellation test, and tail making test following a 26-day
+intervention compared to the baseline. This study indicates a
+possible role of trataka in preventing cognitive decline in elderly [23].
+3.3.2. Effect of trataka in autonomic functions
+A study assessed the immediate effect of trataka on heart rate
+variability (HRV) and breathing rate following two sessions on two
+different days. The investigators found an increased in vagal tone
+following trataka depicted by a decrease in heart rate and breath
+rate, low frequency component of HRV and increase in high fre-
+quency component. No changes were observed following the con-
+trol session [24].
+3.3.3. Clinical trials on trataka and eye disorders
+A study assessing outcomes of ametropia and presbyopia
+compared the effects of two forms of eye exercises viz. Bates
+method and trataka. The investigators reported subjective im-
+provements in the vision without any change in objective assess-
+ment tools following both forms of eye exercises [25,26]. Table 3
+illustrates the studies on trataka. Although, traditional texts quote
+trataka can be used to treat eye disorders, but not many studies
+have evaluated the role of trataka in eye disorders. The limited
+evidence does not support role of trataka in eye disorders, thus
+there is scope for further scientific evaluation in the subject area
+The studies also demonstrat enhanced cognitive functions and
+autonomic relaxation immediately following the practice. Thus,
+there is a need to explore long term effects of trataka in physio-
+logical and clinical settings.
+3.4. Kapalabhati (yogic frontal brain cleansing)
+Kapalabhati is a combination of two syllables, kapala means
+forehead and bhati means shining. The practice of kapalabhati
+involves breathing out at a rapid pace (~1e2 Hz) by flapping the
+abdomen. Classical texts indicate beneficial role of Kapalabhati in
+respiratory disorders [1] It is also known as high frequency Yoga
+breathing due to the nature of practice. Generally the practice of
+Table 2
+Evidence summary of Neti.
+Author
+Sample size
+Study type and duration of
+Intervention
+Variables studied
+Findings
+Tiwana et al., 2019 [19]
+1
+Single case report
+Nasal endoscopy
+Vigorous practice of sutra neti
+led to velopharyngeal stenosis
+requiring surgical intervention.
+Leydon et al., 2017 [14]
+32
+Qualitative semi-structured
+interview study
+Six months
+Medication score, symptom
+checklist
+Neti was found better than
+steam inhalation in reducing
+symptoms of rhinosinusitis.
+Little et al., 2016 [15]
+871 (Usual care ¼ 210, Nasal
+irrigation ¼ 219, Steam
+inhalation ¼ 232,
+Combined ¼ 210)
+RCT
+Six months
+Rhinosinusitis Disability Index
+(RSDI)
+Neti was found better than
+steam inhalation in reducing
+symptoms of rhinosinusitis.
+Lin et al., 2015 [12]
+10
+Pre and Post study
+Daily for one month of nasal
+irrigation
+Sinus & Nasal Quality of Life
+survey, Overall Nasal Quality of
+Life
+Neti helped to reduce chronic
+nasal symptoms and improved
+quality of life
+Luo et al., 2014 [17]
+1134 (GroupA ¼ Nasal irrigator,
+Group B ¼ homemade nasal
+irrigation connector combined
+with enemator, Group C used
+nasal sprayer)
+Follow up study
+Five years
+Sinus & Nasal Quality of Life
+survey
+Long term use of neti helped in
+improvement of quality of life
+in nasal sinusitis patients
+Liang et al., 2008 [18]
+107 (Nasal irrigation ¼ 44, Non
+irrigation ¼ 63)
+RCT
+Once daily upto six months of
+nasal irrigation
+Questionnaire and radiological
+assessment of rhinosinusitis
+The 6 months of follow up study
+of neti after radiotherapy, neti
+seems to improve the quality of
+life and symptoms.
+Rabago et al., 2002 [16]
+76 (Experimental ¼ 52,
+Control ¼ 24)
+RCT
+Daily hypertonic saline nasal
+irrigation upto six months and
+control group didn’t receive
+intervention
+Medical outcome survey short
+form, Rhinosinusitis Disability
+Index, Single- Item- Sinus
+Symptom Severity assessment
+Neti helped in reduction of
+symptoms and medication,
+even improved in quality of life
+in sinusitis patients.
+Heatley et al., 2001 [10]
+150 (Nasal irrigation with bulb
+syringe ¼ 43, nasal irrigation
+with irrigation pot ¼ 39, &
+reflexology massage ¼ 46)
+RCT
+Each group underwent 2 weeks
+of intervention
+Rhinosinusitis outcome
+measures, Daily medication use
+Neti was found equally effective
+for the management of
+rhinosinusitis, when compared
+with reflexology massage and
+nasal irrigation using bulb
+syringe.
+Shoseyov et al., 1998 [11]
+30 (Hypertonic saline ¼ 15,
+Normal saline ¼ 15)
+Randomized double blind study
+Four weeks of hypertonic saline
+and nasal saline
+Radiology score & nasal
+secretion, cough or postnasal
+drip for rhinosinusitis
+There was significant reduction
+in nasal secretions, cough &
+postnasal drip in hypertonic
+solution group than neti group
+Georgitis; 1994 [13]
+30
+Self as control study
+Nasal secretions - histamine,
+prostaglandin D2, leukotriene
+C4
+Neti and large particle water
+vapour reduced nasal
+histamines & leukotriene C4
+indicative of reduced nasal
+inflammation.
+Ramalingam and
+Smith; 1990 [20]
+1
+Single case report
+Self-assessment of symptoms
+Practice of sutra neti helped
+person to reduce snoring and
+obstructive sleep apnea
+P.S. Swathi, B.R. Raghavendra and A.A. Saoji
+Journal of Ayurveda and Integrative Medicine 12 (2021) 206e212
+209
+Kapalabhati is
+done
+prior
+to
+practice
+of
+pranayama
+(yogic
+breathing practices). Some masters categorize the practice of
+kapalabhati as one of the pranayama itself. However, the practice
+is classified as one of the Shatkriya as per the traditional Yoga
+texts [27].
+3.4.1. Effect of kapalabhati on metabolism
+One of the earliest studies on kapalabhati showed a decrease in
+blood urea with an increase in creatinine and tyrosine following
+one minute of practice in twelve healthy subjects. These changes
+were attributed to a possible promotion of decarboxylation and
+oxidation [28].
+3.4.2. Effect of kapalabhati on respiratory and cardiovascular
+changes
+Stancak and colleagues conducted a group of experiments to
+determine physiological changes associated with kapalabhati as
+early as in 1991. Their experiments demonstrated reduction in
+baroreflex sensitivity and vagal tone, associated with increase in
+blood pressure and heart rate following kapalabhati. They could
+also demonstrate slower brain waves in the EEG topography which
+were attributed to the subjective relaxation in the participants
+[29e31].
+Series of studies were conducted by Telles et al. on the effects of
+kapalabhati. They found kapalabhati improves cognitive perfor-
+mance and attention assessed through event related potentials
+[32], associated with decreased anxiety [33]. Similar positive out-
+comes were found with motor performance [34] and finger dex-
+terity [35] and spatial and working memory tasks [36] following
+Kapalabhati. They also observed sympathetic arousal [37,38], and
+metabolic activation [39], during kapalabhati however, the practice
+does not cause increase in the prefrontal cerebral circulation [40].
+A study conducted on effect of kapalabhati on cognitive func-
+tions demonstrated improvements in the cognitive tasks [41].
+Transcranial doppler was used to assess the cerebral blood flow
+changes during practice of kapalabhati. There was a reduction noted
+in the end diastolic velocity and mean flow velocity indicating a
+decrease in cerebral blood flow. Such change could be due to
+reduction of partial pressure of CO2 during the practice which in-
+volves breathing at a high frequency [42].
+An RCT performed on 60 mild to moderate asthma patients
+demonstrated 10 min of practice of kapalabhati can enhance the
+forced vital capacity, forced expiratory volume in one second and
+their ratio. These finding indicate a possible role of kapalabhati in
+management of bronchial asthma [43].
+3.4.3. The complication of kapalabhati
+A case report presented a 29-year-old healthy woman, who
+developed the spontaneous pneumothorax caused due to extreme
+practice of kapalabhati. The investigators attributed such compli-
+cation to pushing the practice to physiological extreme limits [44].
+Thus, the studies on kapalabhati illustrate the beneficial effects
+of the technique in enhancing cognitive and respiratory functions
+and leading to a state of physiological arousal. Such changes can be
+used in clinical situations such as bronchial asthma. However, one
+should be careful not to strain while performing the practice of
+kapalabhati, which may also lead to complications. The evidence
+summary on kapalabhati is summarized in Table S1.
+3.5. Basti (yogic enema)
+There are two forms of Basti described in Hatha Yoga, jala (wa-
+ter) and sthala (dry). Both basti practices involve the cleansing of
+the colon. Swami Swatmarama considers the practice of basti
+beneficial for balancing tridosha and dhatus and to purify mind and
+senses [1]. According to sage Gherenda, basti reduces the disorders
+of vata and is beneficial in urinary and digestive problems. It is also
+known to improve digestion [2].
+Table 3
+Evidence summary of Trataka.
+Author & Year
+Sample size
+Study type and duration of
+Intervention
+Variables studied
+Findings
+Tiwari et al., 2018 [26]
+48
+(Trataka yoga
+kriya ¼ 24, Eye
+exercise ¼ 24)
+Comparative study
+Eight weeks of either trataka or
+eye exercise group
+Snellen’s Chart
+Trataka and eye exercise did not
+show any significant changes in
+refractive errors
+Raghavendra and Singh;
+2016 [22]
+30
+Self as control study
+After 15 days of orientation
+programme in trataka,
+immediate effect of 25 min
+assessed for trataka & control
+session
+Stroop colour-word test
+Improvement in selective
+attention, cognitive flexibility,
+and response inhibition was
+found following trataka session
+Talwadkar et al., 2014 [23]
+60
+(Trataka group ¼ 36,
+control group ¼ 24)
+RCT
+One month (26 days) of trataka
+or control group
+Digit span test, six letter
+cancellation test, trail making
+test
+Trataka session in elderly
+population shown significant
+increase in cognitive levels
+compare to control group
+Raghavendra and
+Ramamurthy; 2014 [24]
+30
+Self as control study
+After 15 days of orientation
+programme in trataka,
+immediate effect of 25 min
+assessed for trataka & control
+session
+Heart rate variability (HRV) &
+respiration rate
+Trataka group shown decrease
+in heart rate, breath rate, low
+frequency component of HRV
+and increase in high frequency
+component of HRV
+Gopinathan et al., 2012 [25]
+66
+(Eye exercise ¼ 32,
+trataka yoga kriya ¼ 34)
+RCT
+Once daily for three weeks of
+eye exercise or trataka
+Signs and symptoms of
+presbyopia, retinoscopy,
+autorefractometer, keratometer
+Both Trataka and eye exercise
+improve subjective signs and
+symptoms, but no change in
+both groups on objective
+assessments
+Mallick and Kulkarni; 2010
+[21]
+30
+Self as control study
+Five practice session of trataka
+(30 min) introduced before the
+immediate assessment.
+Critical Flicker fusion
+After the practice of trataka
+there was a significant increase
+in critical flicker fusion
+compare to eye exercise group
+P.S. Swathi, B.R. Raghavendra and A.A. Saoji
+Journal of Ayurveda and Integrative Medicine 12 (2021) 206e212
+210
+3.6. Nauli (yogic abdominal massaging)
+Nauli is a practice of contracting and isolating the rectus
+abdominis muscle and churning the abdominal muscles. There are
+three variations based on the position of isolation of the muscles,
+namely dakshina nauli (right), vama nauli (left), madhyama (center).
+This practice is said to strengthen the secretion of gastric juice
+including endocrine and exocrine functions of the pancreas [1,9].
+Since the practices of basti and nauli are considered to be an
+advance practice, we could not find any scientific study on the
+practice of nauli during our literature review.
+4. Conclusion
+The practice of shatkriya or shatkarma is recommended in the
+Hathayoga tradition. Studies exploring the effects of four out of six
+cleansing procedures were found in physiological as well as clinical
+settings. No studies were available on basti and nauli which could
+be due to the difficult nature of the practice. The practice of dhauti
+was found to enhance respiratory functions and was useful in
+digestive disorders. Nasal cleansing, neti was particularly found
+beneficial in managing the rhinosinusitis in age groups ranging
+from children to adults. Although trataka practice was found to
+enhance cognition and bring a state of relaxation, but there was no
+evidence supporting its role in eye disorders. Kapalabhati was the
+most studies among the Shatkriya practices. The ranges of studies
+on kapalabhati included assessing the neurocognitive assessments,
+autonomic, and metabolic activity. The practice appears to have a
+beneficial role in the activation of sympathetic nervous system,
+enhances cognition, and improves overall metabolism. It was also
+found to enhance the respiratory functions in patients with asthma.
+Single case reports (one each) were also found for practices of
+dhauti, neti and kapalabhati and it was attributed to pushing the
+body to the physiological extreme.
+This literature review was limited to online free databases only
+and due to the keywords chosen. Although we tried, including a
+variety of key-words related to shatkriya, there may have been
+studies that were missed in the current review because of exclusion
+through the keywords and databases.
+The beneficial role of shatkriyas narrated in both traditional texts
+and evident from the small body of empirical work warrants
+further rigorous scientific exploration. From the available literature,
+we found the practice of yogic cleansing technique safe, when
+practiced under the guidance of a trained teacher and has a po-
+tential role in health and disease.
+Source(s) of funding
+None.
+Conflict of interest
+None.
+Appendix A. Supplementary data
+Supplementary data to this article can be found online at
+https://doi.org/10.1016/j.jaim.2020.11.008.
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