diff --git a/subfolder_0/A Holistic Antenatal Model Based on Yoga, Ayurveda, and Vedic Guidelines.txt b/subfolder_0/A Holistic Antenatal Model Based on Yoga, Ayurveda, and Vedic Guidelines.txt new file mode 100644 index 0000000000000000000000000000000000000000..a75a1f2da152433655d9a92a13df2180c62d50b4 --- /dev/null +++ b/subfolder_0/A Holistic Antenatal Model Based on Yoga, Ayurveda, and Vedic Guidelines.txt @@ -0,0 +1,1190 @@ +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: abbas616@gmail.com +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. +REFERENCES +Alter, J. S. (1997). Seminal truth: A modern science of male celibacy in north India. +Medical Anthropology Quarterly, 11(3), 275–298. +Babbar, S., Parks-Savage, A. C., & Chauhan, S. P. (2012). Yoga during pregnancy: A +review. American Journal of Perinatology, 29(6), 459–464. +Badarayana, V. M. A. (1960). Brahma-Sutra-Shankara-Bhashya. Bombay, India: +Popular Book Depot. +Beddoe, A. E., Lee, K. A., Weiss, S. J., Kennedy, H. P., & Yang, C. P. (2010). Effects +of mindful yoga on sleep in pregnant women: A pilot study. Biological Research +for Nursing, 11(4), 363–370. +Beers, M. H., Fletcher, A. J., Jones, T. V., & Porter, R. (2003). The Merck manual of +medical information (2nd ed.). New York, NY: Simon & Schuster. +Benson, H., & McCallie, D. P., Jr. (1979). Angina pectoris and the placebo effect. +New England Journal of Medicine, 300(25), 1424–1429. +Holistic Antenatal Model +273 +Bhishagratna, K. L. (1991). S¯ +ar¯ +ira Sth¯ +ana. In Su´ +sruta Sa ˙ +mhit¯ +a (4th ed., pp. 217–218). +Varanasi, India: Chowkhambha Sanskrit Series Office. +Bijlani, R. L. (2008). Yoga: An ancient tool in modern medicine. The National Medical +Journal of India, 21(5), 215–216. +Bowman, A. J., Clayton, R. H., Murray, A., Reed, J. W., Subhan, M. M., & Ford, G. A. +(1997). Effects of aerobic exercise training and yoga on the baroreflex in healthy +elderly persons. European Journal of Clinical Investigation, 27(5), 443–449. +Chandler, K. (2001). The emerging field of yoga therapy. Hawaii Medical Journal, +60, 286–287. +Chuntharapat, S., Petpichetchian, W., & Hatthakit, U. (2008). Yoga during pregnancy: +Effects on maternal comfort, labor pain and birth outcomes. Complementary +Therapies in Clinical Practice, 14(2), 105–115. +Dasji, S. S. (2010). Sixteen Samskaras. Bhuj, India: Shree Swaminarayan Mandir. +Drake, A. J., McPherson, R. C., Godfrey, K. M., Cooper, C., Lillycrop, K. A., Hanson, +M. A., . . . Reynolds, R. (2012). An unbalanced maternal diet in pregnancy as- +sociates with offspring epigenetic changes in genes controlling glucocorticoid +action and fetal growth. Clinical Endocrinology, 77(6), 808–815. +The Endowment for Human Development. (2010). Prenatal form and function—The +making of an Earth suit. Retrieved from http://www.ehd.org/dev_article_ +intro.php. Last visited 08-08-14) +Field, T. (2011). Yoga clinical research review. Complementary Therapies in Clinical +Practice, 17(1), 1–8. +Frawley, D. (1999). Yoga & Ayurveda: Self-healing and self-realization (1st ed.). New +Delhi, India: Lotus Press. +Grammatopoulos, D. K. (2008). Placental corticotrophin-releasing hormone and its +receptors in human pregnancy and labour: Still a scientific enigma. Journal of +Neuroendocrinology, 20(4), 432–438. +Gupta, R. M., & Valpey, K. R. (2013). The Bhagavata Purana: Sacred text and living +tradition. New York, NY: Columbia University Press. +Hamon, R. R., & Ingoldsby, B. B. (2003). Mate selection across cultures. Thousand +Oaks, CA: Sage. +Hanser, S. B. (2009). From ancient to integrative medicine. Music and Medicine, +1(2), 87. +Hecht, J. L., Allred, E. N., Kliman, H. J., Zambrano, E., Doss, B. J., Husain, A., . . . +Leviton, A. (2008). Histological characteristics of singleton placentas delivered +before the 28th week of gestation. Pathology, 40(4), 372–376. +Hsieh, T. T., Chen, S. F., Lo, L. M., Li, M. J., Yeh, Y. L., & Hung, T. H. (2012). The +association between maternal oxidative stress at mid-gestation and subsequent +pregnancy complications. Reproductive Science, 19(5), 505–512. +Jacobson, D., & Wadley, S. S. (1992). Women in India: Two perspectives. New Delhi, +India: Manohar Publishers & Distributors. +Jayashree, R., Malini, A., Rakhshani, A., Nagendra, H. R., & Nagarathna, R. (2013). +Effect of integrated approach of yoga therapy (IAYT) on platelet count and uric +acid in pregnancy—A multi-stratified randomized single-blind study. Interna- +tional Journal of Yoga, 6(1), 39–46. +Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and +mind to face stress, pain, and illness. New York, NY: Dell. +274 +A. Rakhshani et al. +Kamboj, P., Aggarwal, M., Puri, S., & Singla, S. K. (2011). Effect of aqueous extract +of Tribulus terrestris on oxalate-induced oxidative stress in rats. Indian Journal +of Nephrology, 21(3), 154–159. +Kamei, T., Toriumi, Y., Kimura, H., Ohno, S., Kumano, H., & Kimura, K. (2000). +Decrease in serum cortisol during yoga exercise is correlated with alpha wave +activation. Perceptual and Motor Skills, 90(3 Pt. 1), 1027–1032. +Krishna, P. V., & Harigopal, K. (1979). The three gunas and ESP: An exploratory +investigation. Journal of Indian Psychology, 2(1), 63–68. +Larson, J. S. (2006). The World Health Organization’s definition of health: Social +versus spiritual health. Social Indicators Research, 38(2), 181–192. +Li, D. K., & Wi, S. (1999). Maternal placental abnormality and the risk of sudden +infant death syndrome. American Journal of Epidemiology, 149(7), 608–611. +McCall, T. (2007). Yoga as medicine: The yogic prescription for health & healing: A +yoga journal book. New York, NY: Bantam. +Nagarathna, R., & Nagendra, H. R. (2001). Yoga for promotion of positive health. +Bangalore, India: Swami Vivekananda Yoga Prakashana. +Narendran, S., Nagarathna, R., & Nagendra, H. R. (2005a). Effects of stress on preg- +nancy. In Yoga for pregnancy (pp. 41–48). Bangalore, India: SVYP. +Narendran, S., Nagarathna, R., & Nagendra, H. R. (2008). Medical facts about preg- +nancy. In Yoga for Pregnancy (pp. 1–38). Bangalore, India: Vivekananda Yoga +Research Foundation. +Narendran, S., Nagarathna, R., Narendran, V., Gunasheela, S., & Nagendra, H. R. +(2005b). Efficacy of yoga on pregnancy outcome. Journal of Alternative and +Complementary Medicine, 11(2), 237–244. +Pandey, R. B. (2002). Hindu Samskaras: Socio-religious study of the Hindu sacra- +ments. Delhi, India: Motilal Banarsidass. +Pandey, R. B. (2003). The Hindu sacraments (Sa ˙ +msk¯ +ara). In S. Radhakrishnan (Ed.), +The Cultural Heritage of India (pp. 390–413). Kolkata, India: The Ramakrishna +Mission Institute of Culture. +Pinar, H., & Carpenter, M. (2010). Placenta and umbilical cord abnormalities seen +with stillbirth. Clinical Obstetrics and Gynecology, 53(3), 656–672. +Porter, R. (2009). The Merck manual home health handbook. Hoboken, NJ: Wiley. +Rakhshani, A. (2013). Yoga and quality of life. In A. C. Michalos (Ed.), Encyclopedia +of quality of life research (pp. 7281–7286). Dordrecht, the Netherlands: Springer. +Rakhshani, A., Maharana, S., Raghuram, N., Nagendra, H. R., & Venkatram, P. (2010). +Effects of integrated yoga on quality of life and interpersonal relationship of +pregnant women. Quality of Life Research, 19(10), 1447–1455. +Rakhshani, A., Nagarathna, R., Mhaskar, R., Mhaskar, A., Thomas, A., & Gunasheela, +S. (2012). The effects of yoga in prevention of pregnancy complications in high- +risk pregnancies: A randomized controlled trial. Preventive Medicine, 55(4), +333–340. +Ranganathananda, S. (2000). Universal message of the Bhagavad Gita (vol. 1. 2, 91). +Champawat, India: Advaita Ashrama. +Rao, M. R., Raghuram, N., Nagendra, H. R., Gopinath, K. S., Srinath, B. S., Diwakar, R. +B., . . . Varambally, S. (2009). Anxiolytic effects of a yoga program in early breast +cancer patients undergoing conventional treatment: A randomized controlled +trial. Complementary Therapies in Medicine, 17(1), 1–8. +Holistic Antenatal Model +275 +Reis, P. (2012). Cochrane review: Relaxation and yoga may decrease pain during +labour and increase satisfaction with pain relief, but better quality evidence is +needed. Evidence Based Nursing, 15(4), 105–106. +Roy-Matton, N., Moutquin, J. M., Brown, C., Carrier, N., & Bell, L. (2011). The impact +of perceived maternal stress and other psychosocial risk factors on pregnancy +complications. Journal of Obstetrics and Gynecology Canada, 33(4), 344–352. +Saraswati, C. (2008). Hindu dharma: The universal way of life. Mumbai, India: +Bharatiya Vidya Bhavan. +Satyapriya, M., Nagendra, H. R., Nagarathna, R., & Padmalatha, V. (2009). Effect +of integrated yoga on stress and heart rate variability in pregnant women. +International Journal of Gynecology and Obstetrics, 104(3), 218–222. +Seibel, M. M., Kiessling, A., Bernstein, J., Bernstein, S. L., & Seibel, J. (1993). A +historical perspective of obstetrics and gynecology: A backdrop for reproductive +technology. In M. M. Siebel, A. A. Kiessling, J, Bernstein, & S. R. Levin (Eds.), +Technology and infertility: Clinical, psychosocial, legal, and ethical aspects (1st +ed., pp. 1–10). New York, NY: Springer–Verlag. +Sharma, R. K., & Bhagwan, D. (1992). J¯ +ati s¯ +utr¯ +iya´ +s¯ +ar¯ +ir¯ +adhy¯ +aya—S¯ +ar¯ +ira Sth¯ +ana. In +Caraka Sa ˙ +mhit¯ +a. Varanasi, India: Chowkhambha Sanskrit Series Office. +Shastri, P. (2009). S¯ +ar¯ +ira Sth¯ +ana. In Su´ +sruta Sa ˙ +mhit¯ +a. New Delhi, India: Chaukhambha +Sanskrit Sansthan. +Tambe, B. (2011). Ayurvedic Garbha Sanskar—The art and science of pregnancy. +Pune, India: Balaji Tambe Foundation. +Taylor, A. G., Goehler, L. E., Galper, D. I., Innes, K. E., & Bourguignon, C. (2010). +Top-down and bottom-up mechanisms in mind-body medicine: Development +of an integrative framework for psychophysiological research. Explore (NY), +6(1), 29–41. +Taylor, M. J. (2003). Yoga therapy in rehabilitation. In C. Davis (Ed.), Complementary +therapies in rehabilitation: Evidenced based practices. New York, NY: Slack. +Tripathi, H. (2009). S¯ +ar¯ +ira Sth¯ +ana. In Asht¨ +anga Hrdayam (p. 350). New Delhi, India: +Chaukhambha Sanskrit Pratishthan. +Tull, H. W. (2008). Birth in Hinduism. In Y. K. Greenberg (Ed.), Encyclopedia of +Love in World Religions (pp. 81–83). Santa Barbara, CA: ABC CLIO, Inc. +Venkatesananda, S. (1984). The concise yoga Vasistha. New York, NY: State Univer- +sity of New York Press. +Wadley, S. S. (1977). Women and the Hindu tradition. Signs, 3(1), 113–125. +Walker, D., Bird, A., Flora, T., & O’Sullivan, B. (1992). Some effects of feeding Tribu- +lus terrestris, Ipomoea lonchophylla and the seed of Abelmoschus ficulneus on +fetal development and the outcome of pregnancy in sheep. Reproduction, Fer- +tility and Development, 4(2), 135–144. +West, J., Otte, C., Geher, K., Johnson, J., & Mohr, D. C. (2004). Effects of Hatha yoga +and African dance on perceived stress, affect, and salivary cortisol. Annals of +Behavioral Medicine, 28(2), 114–118. +Woods, J. H. (2003). The Yoga Sutras of Patanjali. New York, NY: Dover. +World Health Organization (WHO). (2009). Reproductive health and research +publications: Making pregnancy safer. Retrieved from http://www.searo. +who.int/EN/Section13/Section36/Section129/Section396_1450.htm +Zamorski, M. A., & Green, L. A. (1996). Preeclampsia and hypertensive disorders of +pregnancy. American Family Physician, 5(53), 1595–1610. +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. diff --git a/subfolder_0/A Perspective on Yoga as a Preventive Strategy for Coronavirus Disease 2019.txt b/subfolder_0/A Perspective on Yoga as a Preventive Strategy for Coronavirus Disease 2019.txt new file mode 100644 index 0000000000000000000000000000000000000000..0e57cbef701990d0e88eaaddf2cb026a466138d8 --- /dev/null +++ b/subfolder_0/A Perspective on Yoga as a Preventive Strategy for Coronavirus Disease 2019.txt @@ -0,0 +1,750 @@ +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: majumdar.vijaya@gmail.com +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 +References +1. World Health Organization. Coronavirus Disease (COVID-19) Outbreak. World Health +Organization; 2020. [Last accessed on 2020 Feb 12]. Available from: +https://wwwwhoint/emergencies/diseases/novel-coronavirus-2019 . [Google Scholar] +2. Raoult D, Zumla A, Locatelli F, Ippolito G, Kroemer G. Coronavirus infections: Epidemiological, +clinical and immunological features and hypotheses. Cell Stress. 2020 Doi: 1015698/cst202004216. +[PMC free article] [PubMed] [Google Scholar] +3. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized +patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;7:e201585. +[PMC free article] [PubMed] [Google Scholar] +4. Bedford J, Enria D, Giesecke J, Heymann DL, Ihekweazu C, Kobinger G, et al. COVID-19: Towards +controlling of a pandemic. Lancet. 2020;395:1015–8. [PMC free article] [PubMed] [Google Scholar] +5. Baud D, Qi X, Nielsen-Saines K, Musso D, Pomar L, Favre G. Real estimates of mortality following +COVID-19 infection. Lancet Infect Dis. 2020 S1473-3099(20)30195-X. [PMC free article] [PubMed] +[Google Scholar] +6. Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, et al. Epidemiology, causes, clinical +manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the +early outbreak period: A scoping review. Infect Dis Poverty. 2020;9:29. [PMC free article] [PubMed] +[Google Scholar] +7. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel coronavirus from patients with +pneumonia in China, 2019. N Engl J Med. 2020;382:727–33. [PMC free article] [PubMed] +[Google Scholar] +8. Cascella M, Rajnik M, Cuomo A, Dulebohn S, Napoli R. StatPearls. Treasure Island (FL): StatPearls +Publishing; 2020. [Last updated on 2020 Mar 08]. Features, evaluation and treatment coronavirus +(COVID-19) Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/ [Google Scholar] +9. Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, et al. The origin, transmission and clinical +therapies on coronavirus disease 2019 (COVID-19) outbreak-An update on the status. Mil Med Res. +2020;7:11. [PMC free article] [PubMed] [Google Scholar] +10. Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al. A familial cluster of pneumonia associated +with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. +Lancet. 2020;395:514–23. [PMC free article] [PubMed] [Google Scholar] +11. Weiss SR, Leibowitz JL. Coronavirus pathogenesis. Adv Virus Res. 2011;81:85–164. +[PMC free article] [PubMed] [Google Scholar] +12. Cui J, Li F, Shi ZL. Origin and evolution of pathogenic coronaviruses. Nat Rev Microbiol. +2019;17:181–92. [PMC free article] [PubMed] [Google Scholar] +13. Matthews CE, Ockene IS, Freedson PS, Rosal MC, Merriam PA, Hebert JR. Moderate to vigorous +physical activity and risk of upper-respiratory tract infection. Med Sci Sports Exerc. 2002;34:1242–8. +[PubMed] [Google Scholar] +14. Fauci AS, Lane HC, Redfield RR. Covid-19-Navigating the uncharted. N Engl J Med. +2020;382:1268–9. [PMC free article] [PubMed] [Google Scholar] +15. World Health Organization. Coronavirus Disease (COVID-2019) Situation Reports Situation +Report-55. [Last accessed on 2020 Mar 15]. Available from: https://wwwwhoint/docs/default- +source/coronaviruse/situation-reports/20200315-sitrep-55-covid-19pdfsfvrsn=33daa5cb_6 . +16. Parodi SM, Liu VX. From containment to mitigation of COVID-19 in the US. 2020 Epub ahead of +print. [PubMed] [Google Scholar] +17. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 +novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506. [PMC free article] [PubMed] +[Google Scholar] +18. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased +risk for COVID-19 infection? Lancet Respir Med. 2020;8:e21. [PMC free article] [PubMed] +[Google Scholar] +19. Zhang J, Zhou L, Yang Y, Peng W, Wang W, Chen X. Therapeutic and triage strategies for 2019 +novel coronavirus disease in fever clinics. Lancet Respir Med. 2020;8:e11–2. [PMC free article] +[PubMed] [Google Scholar] +20. The Lancet Respiratory Medicine. COVID-19: Delay, mitigate, and communicate. Lancet Respir +Med. 2020;8:321. [PMC free article] [PubMed] [Google Scholar] +21. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based +mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020;395:931–4. +[PMC free article] [PubMed] [Google Scholar] +22. Colson P, Rolain JM, Lagier JC, Brouqui P, Raoult D. Chloroquine and hydroxychloroquine as +available weapons to fight COVID-19? Int J Antimicrob Agents. 2020:105932. doi: +10.1016/j.ijantimicag.2020. Epub ahead of print. [PMC free article] [PubMed] [Google Scholar] +23. Chen Z, Hu J, Zhang Z, Jiang SS, Han S, Yan D, et al. Efficacy of hydroxychloroquine in patients +with COVID-19: Results of a randomized clinical trial. medRxiv. 2020032220040758; doi: +https://doiorg/101101/2020032220040758. [Google Scholar] +24. Mitjà O, Clotet B. Use of antiviral drugs to reduce COVID-19 transmission. Lancet Glob Health. +2020 doi: 101016/S2214-109X(20)30114-5 Epub ahead of print. [PMC free article] [PubMed] +[Google Scholar] +25. Gard T, Noggle JJ, Park CL, Vago DR, Wilson A. Potential self-regulatory mechanisms of yoga for +psychological health. Front Hum Neurosci. 2014;8:770. [PMC free article] [PubMed] [Google Scholar] +26. Telles S, Naveen KV, Dash M. Yoga reduces symptoms of distress in tsunami survivors in the +Andaman Islands. Evid Based Complement Alternat Med. 2007;4:503–9. [PMC free article] [PubMed] +[Google Scholar] +27. Cramer H, Lauche R, Anheyer D, Pilkington K, de Manincor M, Dobos G, et al. Yoga for anxiety: +A systematic review and meta-analysis of randomized controlled trials. Depress Anxiety. 2018;35:830– +43. [PubMed] [Google Scholar] +28. Telles S, Singh N, Joshi M. Risk of posttraumatic stress disorder and depression in survivors of the +floods in Bihar, India. Indian J Med Sci. 2009;63:330–4. [PubMed] [Google Scholar] +29. Nagarathna R, Nagendra HR. Yoga for bronchial asthma: A controlled study. Br Med J (Clin Res +Ed) 1985;291:1077–9. [PMC free article] [PubMed] [Google Scholar] +30. Cramer H, Posadzki P, Dobos G, Langhorst J. Yoga for asthma: A systematic review and meta- +analysis. Ann Allergy Asthma Immunol. 2014;112:503–10. [PubMed] [Google Scholar] +31. Nivethitha L, Mooventhan A, Manjunath NK. Effects of various prāṇāyāma on cardiovascular and +autonomic variables. Anc Sci Life. 2016;36:72–7. [PMC free article] [PubMed] [Google Scholar] +32. Hagins M, States R, Selfe T, Innes K. Effectiveness of yoga for hypertension: Systematic review +and meta-analysis. Evid Based Complement Alternat Med. 2013;2013:649836. [PMC free article] +[PubMed] [Google Scholar] +33. Pullen PR, Seffens WS, Thompson WR. Yoga for Heart Failure: A Review and Future Research. +Int J Yoga. 2018;11:91–8. [PMC free article] [PubMed] [Google Scholar] +34. Nagarathna R, Ram CV, Rajesh SK, Singh A, Majumdar V, Patil S, et al. Nagendra diabetes +prevention through yoga-based lifestyle: A pan-India randomized controlled trial. Diabetes. +2019;68(Suppl 1):129. [Google Scholar] +35. Raveendran AV, Deshpandae A, Joshi SR. Therapeutic role of yoga in type 2 diabetes. Endocrinol +Metab (Seoul) 2018;33:307–17. [PMC free article] [PubMed] [Google Scholar] +36. Innes KE, Selfe TK. Yoga for adults with type 2 diabetes: A systematic review of controlled trials. J +Diabetes Res. 2016;2016:6979370. [PMC free article] [PubMed] [Google Scholar] +37. McDermott KA, Rao MR, Nagarathna R, Murphy EJ, Burke A, Nagendra RH, et al. A yoga +intervention for type 2 diabetes risk reduction: A pilot randomized controlled trial. BMC Complement +Altern Med. 2014;14:212. [PMC free article] [PubMed] [Google Scholar] +38. Singh AK, Kaur N, Kaushal S, Tyagi R, Mathur D, Sivapuram MS, et al. Partitioning of +radiological, stress and biochemical changes in pre-diabetic women subjected to Diabetic Yoga +Protocol. Diabetes Metab Syndr. 2019;13:2705–13. [PubMed] [Google Scholar] +39. Obasi CN, Brown R, Ewers T, Barlow S, Gassman M, Zgierska A, et al. Advantage of meditation +over exercise in reducing cold and flu illness is related to improved function and quality of life. +Influenza Other Respir Viruses. 2013;7:938–44. [PMC free article] [PubMed] [Google Scholar] +40. Barrett B, Hayney MS, Muller D, Rakel D, Ward A, Obasi CN, et al. Meditation or exercise for +preventing acute respiratory infection: A randomized controlled trial. Ann Fam Med. 2012;10:337–46. +[PMC free article] [PubMed] [Google Scholar] +41. Visweswaraiah NK, Telles S. Randomized trial of yoga as a complementary therapy for pulmonary +tuberculosis. Respirology. 2004;9:96–101. [PubMed] [Google Scholar] +42. Naoroibam R, Metri KG, Bhargav H, Nagaratna R, Nagendra HR. Effect of Integrated Yoga (IY) +on psychological states and CD4 counts of HIV-1 infected patients: A randomized controlled pilot +study. Int J Yoga. 2016;9:57–61. [PMC free article] [PubMed] [Google Scholar] +43. Dunne EM, Balletto BL, Donahue ML, Feulner MM, DeCosta J, Cruess DG, et al. The benefits of +yoga for people living with HIV/AIDS: A systematic review and meta-analysis. Complement Ther Clin +Pract. 2019;34:157–64. [PMC free article] [PubMed] [Google Scholar] +44. Hari Chandra BP, Ramesh MN, Nagendra HR. Effect of Yoga on Immune Parameters, Cognitive +Functions, and Quality of Life among HIV-Positive Children/Adolescents: A Pilot Study. Int J Yoga. +2019;12:132–8. [PMC free article] [PubMed] [Google Scholar] +45. Marsland AL, Bachen EA, Cohen S, Rabin B, Manuck SB. Stress, immune reactivity and +susceptibility to infectious disease. Physiol Behav. 2002;77:711–6. [PubMed] [Google Scholar] +46. Falkenberg RI, Eising C, Peters ML. Yoga and immune system functioning: A systematic review of +randomized controlled trials. J Behav Med. 2018;41:467–82. [PubMed] [Google Scholar] +47. Morgan N, Irwin MR, Chung M, Wang C. The effects of mind-body therapies on the immune +system: Meta-analysis. PLoS One. 2014;9:e100903. [PMC free article] [PubMed] [Google Scholar] +48. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the +2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7:228–9. +[PMC free article] [PubMed] [Google Scholar] +49. Lim SA, Cheong KJ. Regular yoga practice improves antioxidant status, immune function, and +stress hormone releases in young healthy people: A randomized, double-blind, controlled pilot study. J +Altern Complement Med. 2015;21:530–8. [PubMed] [Google Scholar] +50. Gopal A, Mondal S, Gandhi A, Arora S, Bhattacharjee J. Effect of integrated yoga practices on +immune responses in examination stress-A preliminary study. Int J Yoga. 2011;4:26–32. +[PMC free article] [PubMed] [Google Scholar] +51. Shi Y, Wang Y, Shao C, Huang J, Gan J, Huang X, et al. COVID-19 infection: The perspectives on +immune responses. Cell Death Differ. 2020 doi: 101038/s41418-020-0530-3 Epub ahead of print. +[PMC free article] [PubMed] [Google Scholar] +52. Infante JR, Peran F, Rayo JI, Serrano J, Domínguez ML, Garcia L, et al. Levels of immune cells in +transcendental meditation practitioners. Int J Yoga. 2014;7:147–51. [PMC free article] [PubMed] +[Google Scholar] +53. Kamei T, Toriumi Y, Kimura H, Kimura K. Correlation between alpha rhythms and natural killer +cell activity during yogic respiratory exercise. Stress Health. 2001;17:141–5. [Google Scholar] +54. Tooley GA, Armstrong SM, Norman TR, Sali A. Acute increases in night-time plasma melatonin +levels following a period of meditation. Biol Psychol. 2000;53:69–78. [PubMed] [Google Scholar] +55. Witek-Janusek L, Albuquerque K, Chroniak KR, Chroniak C, Durazo-Arvizu R, Mathews HL. +Effect of mindfulness based stress reduction on immune function, quality of life and coping in women +newly diagnosed with early stage breast cancer. Brain Behav Immun. 2008;22:969–81. +[PMC free article] [PubMed] [Google Scholar] +56. Chen PJ, Yang L, Chou CC, Li CC, Chang YC, Liaw JJ. Effects of prenatal yoga on women's stress +and immune function across pregnancy: A randomized controlled trial. Complement Ther Med. +2017;31:109–17. [PubMed] [Google Scholar] +57. Pedersen SF, Ho YC. SARS-CoV-2: A storm is raging. J Clin Invest. 2020 pii: 137647. +[PMC free article] [PubMed] [Google Scholar] +58. Casqueiro J, Casqueiro J, Alves C. Infections in patients with diabetes mellitus: A review of +pathogenesis. Indian J Endocrinol Metab. 2012;16(Suppl 1):S27–36. [PMC free article] [PubMed] +[Google Scholar] +59. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill +patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, +observational study. Lancet Respir Med. 2020;8:e26. [PMC free article] [PubMed] [Google Scholar] +60. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, et al. China medical treatment expert +group for covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 +NEJMoa2002032. Epub ahead of print. [PMC free article] [PubMed] [Google Scholar] +61. Fang L, Karakiulakis G, Roth M. Antihypertensive drugs and risk of COVID-19 – Authors' reply. +Lancet Respir Med. 2020 S2213-2600(20)30159-4. [PMC free article] [PubMed] [Google Scholar] +62. Li G, Hu R, Zhang X. Antihypertensive treatment with ACEI/ARB of patients with COVID-19 +complicated by hypertension. Hypertens Res. 2020:1–3. [PMC free article] [PubMed] [Google Scholar] +63. Gralinski LE, Menachery VD. Return of the Coronavirus: 2019-nCoV. Viruses. 2020;12:135. +[PMC free article] [PubMed] [Google Scholar] +64. Nivethitha L, Mooventhan A, Manjunath NK. Effects of various prāṇāyāma on cardiovascular and +autonomic variables. Anc Sci Life. 2016;36s:72–7. [PMC free article] [PubMed] [Google Scholar] +65. Cernes R, Zimlichman R. RESPeRATE: The role of paced breathing in hypertension treatment. J +Am Soc Hypertens. 2015;9:38–47. [PubMed] [Google Scholar] +66. 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. [PMC free article] [PubMed] +[Google Scholar] +67. Santaella DF, Devesa CR, Rojo MR, Amato MB, Drager LF, Casali KR, et al. Yoga respiratory +training improves respiratory function and cardiac sympathovagal balance in elderly subjects: A +randomised controlled trial. BMJ Open. 2011;1:e000085. [PMC free article] [PubMed] +[Google Scholar] +68. Madan M, Thombre DP, Balakumar B, Nambinarayanan TK, Thakur S, Krishnamurthy N, et al. +Effect of yoga training on reaction time, respiratory endurance and muscle strength. Indian J Physiol +Pharmacol. 1992;36:229–33. [PubMed] [Google Scholar] +69. Joshi LN, Joshi VD, Gokhale LV. Effect of short term 'Pranayam' practice on breathing rate and +ventilatory functions of lung. Indian J Physiol Pharmacol. 1992;36:105–8. [PubMed] [Google Scholar] +70. Karthik PS, Chandrasekhar M, Ambareesha K, Nikhil C. Effect of pranayama and suryanamaskar +on pulmonary functions in medical students. J Clin Diagn Res. 2014;8:BC04–6. [PMC free article] +[PubMed] [Google Scholar] +71. Hakked CS, Balakrishnan R, Krishnamurthy MN. Yogic breathing practices improve lung functions +of competitive young swimmers. J Ayurveda Integr Med. 2017;8:99–104. [PMC free article] [PubMed] +[Google Scholar] +72. Liu XC, Pan L, Hu Q, Dong WP, Yan JH, Dong L. Effects of yoga training in patients with chronic +obstructive pulmonary disease: A systematic review and meta-analysis. J Thorac Dis. 2014;6:795–802. +[PMC free article] [PubMed] [Google Scholar] +73. Gupta A, Gupta R, Sood S, Arkham M. Pranayam for treatment of chronic obstructive pulmonary +disease: Results from a randomized, controlled trial. Integr Med (Encinitas) 2014;13:26–31. +[PMC free article] [PubMed] [Google Scholar] +74. Donesky-Cuenco D, Nguyen HQ, Paul S, Carrieri-Kohlman V. Yoga therapy decreases dyspnea- +related distress and improves functional performance in people with chronic obstructive pulmonary +disease: A pilot study. J Altern Complement Med. 2009;15:225–34. [PMC free article] [PubMed] +[Google Scholar] +75. Ranjita R, Hankey A, Nagendra HR, Mohanty S. Yoga-based pulmonary rehabilitation for the +management of dyspnea in coal miners with chronic obstructive pulmonary disease: A randomized +controlled trial. J Ayurveda Integr Med. 2016;7:158–66. [PMC free article] [PubMed] [Google Scholar] +76. Fulambarker A, Farooki B, Kheir F, Copur AS, Srinivasan L, Schultz S. Effect of yoga in chronic +obstructive pulmonary disease. Am J Ther. 2012;19:96–100. [PubMed] [Google Scholar] +77. Pomidori L, Campigotto F, Amatya TM, Bernardi L, Cogo A. Efficacy and tolerability of yoga +breathing in patients with chronic obstructive pulmonary disease: A pilot study. J Cardiopulm Rehabil +Prev. 2009;29:133–7. [PubMed] [Google Scholar] +78. de Boer PT, van Maanen BM, Damm O, Ultsch B, Dolk FC, Crepey P, et al. A systematic review of +the health economic consequences of quadrivalent influenza vaccination. Expert Rev Pharmacoecon +Outcomes Res. 2017;17:249–65. [PubMed] [Google Scholar] +79. Arinaminpathy N, Kim IK, Gargiullo P, Haber M, Foppa IM, Gambhir M, et al. Estimating direct +and indirect protective effect of influenza vaccination in the United States. Am J Epidemiol. 2017:1–9. +3089949. [PMC free article] [PubMed] [Google Scholar] +80. Bridges CB, Thompson WW, Meltzer MI, Reeve GR, Talamonti WJ, Cox NJ, et al. Effectiveness +and cost-benefit of influenza vaccination of healthy working adults: A randomized controlled trial. +JAMA. 2000;284:1655–63. [PubMed] [Google Scholar] +81. Gatwood J, Meltzer MI, Messonnier M, Ortega-Sanchez IR, Balkrishnan R, Prosser LA. Seasonal +influenza vaccination of healthy working-age adults: A review of economic evaluations. Drugs. +2012;72:35–48. [PubMed] [Google Scholar] +82. Postma MJ, Baltussen RM, Heijnen ML, de Berg LT, Jager JC. Pharmacoeconomics of influenza +vaccination in the elderly: Reviewing the available evidence. Drugs Aging. 2000;17:217–27. [PubMed] +[Google Scholar] +83. Bhanushali D, Tyagi R, Limaye Rishi Nityapragya N, Anand A. Effect of mindfulness meditation +protocol in subjects with various psychometric characteristics at high altitude. Brain Behav. +2020:e01604. Doi: 101002/brb31604. [PMC free article] [PubMed] [Google Scholar] +Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow +Publications diff --git a/subfolder_0/A RANDOMIZED TRIAL COMPARING THE EFFECTS OF YOGA AND PHYSICAL ACTIVITY PROGRAMS ON DEPTH PERCEPTION IN SCHOOL CHILDREN.txt b/subfolder_0/A RANDOMIZED TRIAL COMPARING THE EFFECTS OF YOGA AND PHYSICAL ACTIVITY PROGRAMS ON DEPTH PERCEPTION IN SCHOOL CHILDREN.txt new file mode 100644 index 0000000000000000000000000000000000000000..6be30bcbb91a507f0e9b4e319dccd4c360090c99 --- /dev/null +++ b/subfolder_0/A RANDOMIZED TRIAL COMPARING THE EFFECTS OF YOGA AND PHYSICAL ACTIVITY PROGRAMS ON DEPTH PERCEPTION IN SCHOOL CHILDREN.txt @@ -0,0 +1,6 @@ + + + + + + diff --git a/subfolder_0/A narrative review on yoga a potential intervention for augmenting immunomodulation and mental health in COVID-19.txt b/subfolder_0/A narrative review on yoga a potential intervention for augmenting immunomodulation and mental health in COVID-19.txt new file mode 100644 index 0000000000000000000000000000000000000000..02c821f3c84ed9e343348101d48833daa665f3c9 --- /dev/null +++ b/subfolder_0/A narrative review on yoga a potential intervention for augmenting immunomodulation and mental health in COVID-19.txt @@ -0,0 +1,1921 @@ +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 +original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or +other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line +to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory +regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this +licence, visit http://​ +creat​ +iveco​ +mmons.​ +org/​ +licen​ +ses/​ +by/4.​ +0/. The Creative Commons Public Domain Dedication waiver (http://​ +creat​ +iveco​ +mmons.​ +org/​ +publi​ +cdoma​ +in/​ +zero/1.​ +0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. +Open Access +BMC Complementary +Medicine and Therapies +*Correspondence: indranill.basu-ray@va.gov +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 +References + 1. +Basu-Ray I, Almaddah N, Adeboye A, Soos MP. Cardiac manifestations +of coronavirus (COVID-19). In: StatPearls. Treasure Island FL: StatPearls +Publishing LLC; 2020. + 2. +Basu-Ray I, Metri K. Yoga as a potential intervention for preventing +cardiac complications in COVID-19: augmenting immuno-modulation +and bolstering mental health in the the principles and practice of yoga +in cardiovascular medicine. Rd: Basu-Ray I & Mehta D Springer Nature, +Chapter:29. 2022. + 3. +Basu-Ray I. Yoga In Covid-19 Pandemic: Protective Envelope or Mere +Ritual?. Science India. 2021. + 4. +Weiss SR, Navas-Martin S. Coronavirus pathogenesis and the emerging +pathogen severe acute respiratory syndrome coronavirus. Microbiol Mol +Biol Rev. 2005;69:635–64. https://​ +doi.​ +org/​ +10.​ +1128/​ +MMBR.​ +69.4.​ +635-​ +664.​ +2005. + 5. +World Health Organization. Coronavirus disease (COVID-2019) situation +reports. (2020). Available online at: https://​ +www.​ +who.​ +int/​ +emerg​ +encies/​ +disea​ +ses/​ +novel-​ +coron​ +avirus-​ +2019/​ +situa​ +tion-​ +repor​ +ts (Accessed Jun 30, 2020). + 6. +Elson BD, Hauri P, Cunis D. Physiological changes in yoga meditation. +Psychophysiology. 1977;14:52–7. https://​ +doi.​ +org/​ +10.​ +1111/j.​ +1469-​ +8986.​ +1977.​ +tb011​ +55.x. + 7. +Innes KE, Selfe TK. Yoga for adults with type 2 diabetes: a systematic +review of controlled trials. J Diabetes Res. 2016;2016:6979370. + 8. +Desveaux L, Lee A, Goldstein R, Brooks D. Yoga in the management +of chronic disease: a systematic review and meta-analysis. Med Care. +2015;53:653–61. https://​ +doi.​ +org/​ +10.​ +1097/​ +MLR.​ +00000​ +00000​ +000372. + 9. +Prinster T. Yoga for Cancer: a guide to managing side effects, boosting +immunity, and improving recovery for Cancer survivors. Rochester VT: +Healing Arts Press; 2014. p. 324. + 10. Harinath K, Malhotra AS, Pal K, Prasad R, Kumar R, Kain TC, et al. Effects of +hatha yoga and Omkar meditation on cardiorespiratory performance, +psychologic profile, and melatonin secretion. J Altern Complement Med. +2004;10:261–8. https://​ +doi.​ +org/​ +10.​ +1089/​ +10755​ +53043​ +23062​ +257. + 11. Hagen I, Nayar US. Yoga for children and young people’s mental health +and well-being: research review and reflections on the mental health +potentials of yoga. Front Psychiatry. 2014;5:35. https://​ +doi.​ +org/​ +10.​ +3389/​ +fpsyt.​ +2014.​ +00035. + 12. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of +138 hospitalized patients with 2019 novel coronavirus-infected pneumo‑ +nia in Wuhan, China. JAMA. 2020;323:1061–9. https://​ +doi.​ +org/​ +10.​ +1001/​ +jama.​ +2020.​ +1585. + 13. Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al. Pathological find‑ +ings of COVID-19 associated with acute respiratory distress syndrome. +Lancet Respir Med. 2020;8:420–2. https://​ +doi.​ +org/​ +10.​ +1016/​ +S2213-​ +2600(20)​ +30076-X. + 14. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular +system. Nat Rev Cardiol. 2020;17:259–60. https://​ +doi.​ +org/​ +10.​ +1038/​ +s41569-​ +020-​ +0360-5. + 15. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of +patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. +2020;395:497–506. https://​ +doi.​ +org/​ +10.​ +1016/​ +S0140-​ +6736(20)​ +30183-5. + 16. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury +with mortality in hospitalized patients with COVID-19 in Wuhan, China. +JAMA Cardiol. 2020. https://​ +doi.​ +org/​ +10.​ +1001/​ +jamac​ +ardio.​ +2020.​ +0950. + 17. Sette A, Crotty S. Adaptive immunity to SARS-CoV-2 and COVID-19. Cell. +2021;184(4):861–80. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +cell.​ +2021.​ +01.​ +007. + 18. Cao X. COVID-19: immunopathology and its implications for ther‑ +apy. Nat Rev Immunol. 2020;20:269–70. https://​ +doi.​ +org/​ +10.​ +1038/​ +s41577-​ +020-​ +0308-3. + 19. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. +COVID-19: consider cytokine storm syndromes and immunosuppression. +Lancet. 2020;395:1033–4. https://​ +doi.​ +org/​ +10.​ +1016/​ +S0140-​ +6736(20)​ +30628-0. + 20. CDC Covid-Response Team. Severe outcomes among patients with +coronavirus disease 2019 (COVID-19) - United States, February 12-march +16, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:343–6. https://​ +doi.​ +org/​ +10.​ +15585/​ +mmwr.​ +mm691​ +2e2. + 21. Arora S, Bhattacharjee J. Modulation of immune responses in stress by +yoga. Int J Yoga. 2008;1:45–55. https://​ +doi.​ +org/​ +10.​ +4103/​ +0973-​ +6131.​ +43541. + 22. Channappanavar R, Perlman S. Pathogenic human coronavirus infec‑ +tions: causes and consequences of cytokine storm and immunopathol‑ +ogy. Semin Immunopathol. 2017;39:529–39. https://​ +doi.​ +org/​ +10.​ +1007/​ +s00281-​ +017-​ +0629-x. + 23. Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Remdesivir in adults +with severe COVID-19: a randomised, double-blind, placebo-controlled, +multicentre trial. Lancet. 2020;395:1569–78. https://​ +doi.​ +org/​ +10.​ +1016/​ +S0140-​ +6736(20)​ +31022-9. + 24. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. +Prevalence of depression, anxiety, and insomnia among healthcare workers +during the COVID-19 pandemic: a systematic review and meta-analysis. +Brain Behav Immun. 2020. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +bbi.​ +2020.​ +05.​ +026. + 25. Godinić D, Obrenovic B, Khudaykulov A. Effects of economic uncertainty +on mental health in the COVID-19 pandemic context: social identity +disturbance, job uncertainty and psychological well-being model. Int J +Innov Econ Dev. 2020;6:61–74. https://​ +doi.​ +org/​ +10.​ +18775/​ +ijied.​ +1849-​ +7551-​ +7020.​ +2015.​ +61.​ +2005. + 26. Ackerman KD, Martino M, Heyman R, Moyna NM, Rabin BS. Immunologic +response to acute psychological stress in MS patients and controls. J Neuro‑ +immunol. 1996;68:85–94. https://​ +doi.​ +org/​ +10.​ +1016/​ +0165-​ +5728(96)​ +00077-x. + 27. Locke S, Hurst M, Heisel J, Kraus L, Williams M. The influence of stress and +other psychosocial factors on human immunity. Paper presented at the +36th Annual Meeting of the Psychosomatic Society, Dallas TX. 1979. + 28. Vedhara K, Cox NK, Wilcock GK, Perks P, Hunt M, Anderson S, et al. Chronic +stress in elderly carers of dementia patients and antibody response to +influenza vaccination. Lancet. 1999;353:627–31. https://​ +doi.​ +org/​ +10.​ +1016/​ +S0140-​ +6736(98)​ +06098-X. + 29. Lambert EA, Lambert GW. Stress and its role in sympathetic nervous sys‑ +tem activation in hypertension and the metabolic syndrome. Curr Hyper‑ +tens Rep. 2011;13:244–8. https://​ +doi.​ +org/​ +10.​ +1007/​ +s11906-​ +011-​ +0186-y. + 30. Van Westerloo DJ, Choi G, Löwenberg EC, Truijen J, de Vos AF, Endert E, +et al. Acute stress elicited by bungee jumping suppresses human innate +immunity. Mol Med. 2011;17:180–8. https://​ +doi.​ +org/​ +10.​ +2119/​ +molmed.​ +2010.​ +00204. + 31. Joseph JJ, Golden SH. Cortisol dysregulation: the bidirectional link +between stress, depression, and type 2 diabetes mellitus. Ann N Y Acad +Sci. 2017;1391:20–34. https://​ +doi.​ +org/​ +10.​ +1111/​ +nyas.​ +13217. + 32. Pedersen A, Zachariae R, Bovbjerg DH. Influence of psychological stress +on upper respiratory infection--a meta-analysis of prospective studies. +Psychosom Med. 2010;72:823–32. https://​ +doi.​ +org/​ +10.​ +1097/​ +PSY.​ +0b013​ +e3181​ +f1d003. + 33. Vedhara K, McDermott MP, Evans TG, Treanor JJ, Plummer S, Tallon D, et al. +Chronic stress in nonelderly caregivers: psychological, endocrine and +immune implications. J Psychosom Res. 2002;53:1153–61. https://​ +doi.​ +org/​ +10.​ +1016/​ +s0022-​ +3999(02)​ +00343-4. +Page 12 of 13 +Basu‑Ray et al. BMC Complementary Medicine and Therapies (2022) 22:191 + 34. Miller GE, Cohen S, Ritchey AK. Chronic psychological stress and the regula‑ +tion of pro-inflammatory cytokines: a glucocorticoid-resistance model. +Health Psychol. 2002;21:531–41. https://​ +doi.​ +org/​ +10.​ +1037//​ +0278-​ +6133.​ +21.6.​ +531. + 35. Miller GE, Chen E, Fok AK, Walker H, Lim A, Nicholls EF, et al. Low early-life +social class leaves a biological residue manifested by decreased glucocor‑ +ticoid and increased proinflammatory signaling. Proc Natl Acad Sci U S A. +2009;106:14716–21. https://​ +doi.​ +org/​ +10.​ +1073/​ +pnas.​ +09029​ +71106. + 36. Furman D, Campisi J, Verdin E, Carrera-Bastos P, Targ S, Franceschi C, et al. +Chronic inflammation in the etiology of disease across the life span. Nat +Med. 2019;25:1822–32. https://​ +doi.​ +org/​ +10.​ +1038/​ +s41591-​ +019-​ +0675-0. + 37. Wang Q, Xu R, Volkow ND. Increased risk of COVID-19 infection and +mortality in people with mental disorders: analysis from electronic health +records in the United States. + 38. Slavich GM, Irwin MR. From stress to inflammation and major depressive +disorder: a social signal transduction theory of depression. Psychol Bull. +2014;140(3):774–815. https://​ +doi.​ +org/​ +10.​ +1037/​ +a0035​ +302. + 39. Targum SD, Sullivan AC, Byrnes SM. Neuroendocrine interrelationships in +major depressive disorder. Am J Psychiatry. 1982;139:282–6. https://​ +doi.​ +org/​ +10.​ +1176/​ +ajp.​ +139.3.​ +282. + 40. Olff M. Stress, depression and immunity: the role of defense and coping +styles. Psychiatry Res. 1999;85:7–15. https://​ +doi.​ +org/​ +10.​ +1016/​ +s0165-​ +1781(98)​ +00139-5. + 41. Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations +between covid-19 and psychiatric disorder: retrospective cohort studies +of 62 354 COVID-19 cases in the USA. Lancet Psychiatry. 2021;8(2):130–40. +https://​ +doi.​ +org/​ +10.​ +1016/​ +s2215-​ +0366(20)​ +30462-4. + 42. Agnihotri S, Kant S, Kumar S, Mishra RK, Mishra SK. Impact of yoga on +biochemical profile of asthmatics: a randomized controlled study. Int J +Yoga. 2014;7:17–21. https://​ +doi.​ +org/​ +10.​ +4103/​ +0973-​ +6131.​ +123473. + 43. Koh KB, Lee Y. Reduced anxiety level by therapeutic interventions and +cell-mediated immunity in panic disorder patients. Psychother Psycho‑ +som. 2004;73:286–92. https://​ +doi.​ +org/​ +10.​ +1159/​ +00007​ +8845. + 44. Nagata T, Yamada H, Iketani T, Kiriike N. Relationship between plasma +concentrations of cytokines, ratio of CD4 and CD8, lymphocyte prolifera‑ +tive responses, and depressive and anxiety state in bulimia nervosa. J +Psychosom Res. 2006;60:99–103. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +jpsyc​ +hores.​ +2005.​ +06.​ +058. + 45. Michopoulos V, Powers A, Gillespie CF, Ressler KJ, Jovanovic T. Inflam‑ +mation in fear- and anxiety-based disorders: PTSD, GAD, and beyond. +Neuropsychopharmacology. 2017;42:254–70. https://​ +doi.​ +org/​ +10.​ +1038/​ +npp.​ +2016.​ +146. + 46. Atanackovic D, Kröger H, Serke S, Deter HC. Immune parameters in +patients with anxiety or depression during psychotherapy. J Affect +Disord. 2004;81:201–9. https://​ +doi.​ +org/​ +10.​ +1016/​ +S0165-​ +0327(03)​ +00165-4. + 47. Naoroibam R, Metri KG, Bhargav H, Nagaratna R, Nagendra HR. Effect +of integrated yoga (IY) on psychological states and CD4 counts of +HIV-1 infected patients: a randomized controlled pilot study. Int J Yoga. +2016;9:57–61. https://​ +doi.​ +org/​ +10.​ +4103/​ +0973-​ +6131.​ +171723. + 48. Gopal A, Mondal S, Gandhi A, Arora S, Bhattacharjee J. Effect of integrated +yoga practices on immune responses in examination stress - a prelimi‑ +nary study. Int J Yoga. 2011;4:26–32. https://​ +doi.​ +org/​ +10.​ +4103/​ +0973-​ +6131.​ +78178. + 49. Hari Chandra BP, Ramesh MN, Nagendra HR. Effect of yoga on immune +parameters, cognitive functions, and quality of life among HIV-positive +children/adolescents: a pilot study. Int J Yoga. 2019;12:132–8. https://​ +doi.​ +org/​ +10.​ +4103/​ +ijoy.​ +IJOY_​ +51_​ +18. + 50. Vijayaraghava A, Doreswamy V, Narasipur OS, Kunnavil R, Srinivasamurthy +N. Effect of yoga practice on levels of inflammatory markers after moder‑ +ate and strenuous exercise. J Clin Diagn Res. 2015;9:CC08–12. https://​ +doi.​ +org/​ +10.​ +7860/​ +JCDR/​ +2015/​ +12851.​ +6021. + 51. Rao RM, Nagendra HR, Raghuram N, Vinay C, Chandrashekara S, Gopinath +KS, et al. Influence of yoga on mood states, distress, quality of life and +immune outcomes in early stage breast cancer patients undergoing sur‑ +gery. Int J Yoga. 2008;1:11–20. https://​ +doi.​ +org/​ +10.​ +4103/​ +0973-​ +6131.​ +36789. + 52. Cook-Cottone CP. Mindfulness and yoga for self-regulation: a primer for +mental health professionals. New York: Springer Publishing Company; +2015. p. 322. + 53. Chen PJ, Yang L, Chou CC, Li CC, Chang YC, Liaw JJ. Effects of prenatal +yoga on women’s stress and immune function across pregnancy: a rand‑ +omized controlled trial. Complement Ther Med. 2017;31:109–17. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +ctim.​ +2017.​ +03.​ +003. + 54. Bradley PA, Bourne FJ, Brown PJ. The respiratory tract immune system in +the pig. I. Distribution of immunoglobulin-containing cells in the respira‑ +tory tract mucosa. Vet Pathol. 1976;13:81–9. https://​ +doi.​ +org/​ +10.​ +1177/​ +03009​ +85876​ +01300​ +201. + 55. Yadav RK, Magan D, Mehta N, Sharma R, Mahapatra SC. Efficacy of a short- +term yoga-based lifestyle intervention in reducing stress and inflam‑ +mation: preliminary results. J Altern Complement Med. 2012;18:662–7. +https://​ +doi.​ +org/​ +10.​ +1089/​ +acm.​ +2011.​ +0265. + 56. Kiloor A, Kumari S, Metri K. Impact of yoga on psychopathologies and +QoLin persons with HIV: a randomized controlled study. J Bodyw Mov +Ther. 2019;23:P278–83. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +jbmt.​ +2018.​ +10.​ +005. + 57. Musher DM, Abers MS, Corrales-Medina VF. Acute infection and myocar‑ +dial infarction. N Engl J Med. 2019;380:171–6. https://​ +doi.​ +org/​ +10.​ +1056/​ +NEJMr​ +a1808​ +137. + 58. Zhang C, Wu Z, Li JW, Zhao H, Wang GQ. Cytokine release syndrome in +severe COVID-19: interleukin-6 receptor antagonist tocilizumab may be +the key to reduce mortality. Int J Antimicrob Agents. 2020;55:105954. +https://​ +doi.​ +org/​ +10.​ +1016/j.​ +ijant​ +imicag.​ +2020.​ +105954. + 59. Luo P, Liu Y, Qiu L, Liu X, Liu D, Li J. Tocilizumab treatment in COVID-19: a +single center experience. J Med Virol. 2020;92:814–8. https://​ +doi.​ +org/​ +10.​ +1002/​ +jmv.​ +25801. + 60. Nagarathna R, Nagendra H, Majumdar V. A perspective on yoga as a +preventive strategy for coronavirus disease 2019. Int J Yoga. 2020;13:89–98. +https://​ +doi.​ +org/​ +10.​ +4103/​ +ijoy.​ +IJOY_​ +22_​ +20. + 61. Pullen PR, Thompson WR, Benardot D, Brandon LJ, Mehta PK, Rifai L, et al. +Benefits of yoga for African American heart failure patients. Med Sci +Sports Exerc. 2010;42:651–7. https://​ +doi.​ +org/​ +10.​ +1249/​ +MSS.​ +0b013​ +e3181​ +bf24c4. + 62. Chen N, Xia X, Qin L, Luo L, Han S, Wang G, et al. Effects of 8-week hatha +yoga training on metabolic and inflammatory markers in healthy, +female Chinese subjects: a randomized clinical trial. Biomed Res Int. +2016;2016:5387258. https://​ +doi.​ +org/​ +10.​ +1155/​ +2016/​ +53872​ +58. + 63. Kiecolt-Glaser JK, Bennett JM, Andridge R, Peng J, Shapiro CL, Malar‑ +key WB, et al. Yoga’s impact on inflammation, mood, and fatigue in +breast cancer survivors: a randomized controlled trial. J Clin Oncol. +2014;32:1040–9. https://​ +doi.​ +org/​ +10.​ +1200/​ +JCO.​ +2013.​ +51.​ +8860. + 64. Rajbhoj PH, Shete SU, Verma A, Bhogal RS. Effect of yoga module on +pro-inflammatory and anti-inflammatory cytokines in industrial workers +of Lonavla: a randomized controlled trial. J Clin Diagn Res. 2015;9:CC01–5. +https://​ +doi.​ +org/​ +10.​ +7860/​ +JCDR/​ +2015/​ +11426.​ +5551. + 65. Michalsen A, Grossman P, Acil A, Langhorst J, Lüdtke R, Esch T, et al. +Rapid stress reduction and anxiolysis among distressed women as a +consequence of a three-month intensive yoga program. Med Sci Monit. +2005;11:CR555–61. + 66. Patil SG, Aithala MR, Naregal GV, Shanmukhe AG, Chopade SS. Effect of +yoga on cardiac autonomic dysfunction and insulin resistance in non- +diabetic offspring of type-2-diabetes parents: a randomized controlled +study. Complement Ther Clin Pract. 2019;34:288–93. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +ctcp.​ +2019.​ +01.​ +003. + 67. Bower JE, Greendale G, Crosswell AD, Garet D, Sternlieb B, Ganz PA, et al. +Yoga reduces inflammatory signaling in fatigued breast cancer survivors: +a randomized controlled trial. Psychoneuroendocrinology. 2014;43:20–9. +https://​ +doi.​ +org/​ +10.​ +1016/j.​ +psyne​ +uen.​ +2014.​ +01.​ +019. + 68. Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: a system‑ +atic review and meta-analysis. Depress Anxiety. 2013;30:1068–83. https://​ +doi.​ +org/​ +10.​ +1002/​ +da.​ +22166. + 69. Vempati RP, Telles S. Yoga-based guided relaxation reduces sympathetic +activity judged from baseline levels. Psychol Rep. 2002;90:487–94. https://​ +doi.​ +org/​ +10.​ +2466/​ +pr0.​ +2002.​ +90.2.​ +487. + 70. Smith C, Hancock H, Blake-Mortimer J, Eckert K. A randomised compara‑ +tive trial of yoga and relaxation to reduce stress and anxiety. Complement +Ther Med. 2007;15:77–83. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +ctim.​ +2006.​ +05.​ +001. + 71. Luu K, Hall PA. Hatha yoga and executive function: a systematic review. J +Altern Complement Med. 2016;22:125–33. https://​ +doi.​ +org/​ +10.​ +1089/​ +acm.​ +2014.​ +0091. + 72. West J, Otte C, Geher K, Johnson J, Mohr DC. Effects of hatha yoga and +African dance on perceived stress, affect, and salivary cortisol. Ann Behav +Med. 2004;28:114–8. https://​ +doi.​ +org/​ +10.​ +1207/​ +s1532​ +4796a​ +bm2802_6. + 73. Streeter CC, Gerbarg PL, Saper RB, Ciraulo DA, Brown RP. Effects of yoga +on the autonomic nervous system, gamma-aminobutyric-acid, and +Page 13 of 13 +Basu‑Ray et al. BMC Complementary Medicine and Therapies (2022) 22:191 + +• + +fast, convenient online submission + +• + +thorough peer review by experienced researchers in your field +• + +rapid publication on acceptance +• + +support for research data, including large and complex data types +• + +gold Open Access which fosters wider collaboration and increased citations + +maximum visibility for your research: over 100M website views per year +• + +At BMC, research is always in progress. +Learn more biomedcentral.com/submissions +Ready to submit your research +Ready to submit your research ? Choose BMC and benefit from: +? Choose BMC and benefit from: +allostasis in epilepsy, depression, and post-traumatic stress disorder. Med +Hypotheses. 2012;78:571–9. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +mehy.​ +2012.​ +01.​ +021. + 74. Naveen GH, Varambally S, Thirthalli J, Rao M, Christopher R, Gangadhar +BN. Serum cortisol and BDNF in patients with major depression--effect +of yoga. Int Rev Psychiatry. 2016;28:273–8. https://​ +doi.​ +org/​ +10.​ +1080/​ +09540​ +261.​ +2016.​ +11754​ +19. + 75. Janakiramaiah N, Gangadhar BN, Naga Venkatesha Murthy PJ, Harish MG, +Subbakrishna DK, Vedamurthachar A. Antidepressant efficacy of Sudarshan +Kriya yoga (SKY) in melancholia: a randomized comparison with electro‑ +convulsive therapy (ECT) and imipramine. J Affect Disord. 2000;57:255–9. +https://​ +doi.​ +org/​ +10.​ +1016/​ +s0165-​ +0327(99)​ +00079-8. + 76. Sarubin N, Nothdurfter C, Schüle C, Lieb M, Uhr M, Born C, et al. The +influence of hatha yoga as an add-on treatment in major depression on +hypothalamic-pituitary-adrenal-axis activity: a randomized trial. J Psychi‑ +atr Res. 2014;53:76–83. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +jpsyc​ +hires.​ +2014.​ +02.​ +022. + 77. Daubenmier JJ. The relationship of yoga, body awareness, and body +responsiveness to self-objectification and disordered eating. Psychol +Women Q. 2005;29:207–19. https://​ +doi.​ +org/​ +10.​ +1111/j.​ +1471-​ +6402.​ +2005.​ +00183.x. + 78. Shelov DV, Suchday S, Friedberg JP. A pilot study measuring the impact of +yoga on the trait of mindfulness. Behav Cogn Psychother. 2009;37:595–8. +https://​ +doi.​ +org/​ +10.​ +1017/​ +S1352​ +46580​ +99903​ +61. + 79. Posadzki P, Cramer H, Kuzdzal A, Lee MS, Ernst E. Yoga for hypertension: +a systematic review of randomized clinical trials. Complement Ther Med. +2014;22:511–22. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +ctim.​ +2014.​ +03.​ +009. + 80. Bhavanani AB, Ramanathan M, Balaji R, Pushpa D. Comparative immedi‑ +ate effect of different yoga asanas on heart rate and blood pressure in +healthy young volunteers. Int J Yoga. 2014;7:89–95. https://​ +doi.​ +org/​ +10.​ +4103/​ +0973-​ +6131.​ +133870. + 81. Lakkireddy D, Atkins D, Pillarisetti J, Ryschon K, Bommana S, Drisko J, et al. +Effect of yoga on arrhythmia burden, anxiety, depression, and quality of +life in paroxysmal atrial fibrillation: the YOGA my heart study. J Am Coll +Cardiol. 2013;61:1177–82. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +jacc.​ +2012.​ +11.​ +060. + 82. Hagins M, States R, Selfe T, Innes K. Effectiveness of yoga for hypertension: +systematic review and meta-analysis. Evid Based Complement Alternat +Med. 2013;2013:649836. https://​ +doi.​ +org/​ +10.​ +1155/​ +2013/​ +649836. + 83. Patel C, North WR. Randomised controlled trial of yoga and bio-feedback +in management of hypertension. Lancet. 1975;2:93–5. https://​ +doi.​ +org/​ +10.​ +1016/​ +s0140-​ +6736(75)​ +90002-1. + 84. Veerabhadrappa SG, Baljoshi VS, Khanapure S, Herur A, Patil S, Ankad +RB, et al. Effect of yogic bellows on cardiovascular autonomic reactivity. +J Cardiovasc Dis Res. 2011;2:223–7. https://​ +doi.​ +org/​ +10.​ +4103/​ +0975-​ +3583.​ +89806. + 85. Santaella DF, Lorenzi-Filho G, Rodrigues MR, Tinucci T, Malinauskas AP, +Mion-Júnior D, et al. Yoga relaxation (savasana) decreases cardiac sympa‑ +thovagal balance in hypertensive patients. MedicalExpress. 2014;1:233–8. + 86. Krishna BH, Pal P, Pal GK, Balachander J, Jayasettiaseelon E, Sreekanth Y, +et al. Effect of yoga therapy on heart rate, blood pressure and cardiac +autonomic function in heart failure. J Clin Diagn Res. 2014;8:14–6. https://​ +doi.​ +org/​ +10.​ +7860/​ +JCDR/​ +2014/​ +7844.​ +3983. + 87. Bowman AJ, Clayton RH, Murray A, Reed JW, Subhan MM, Ford GA. Effects +of aerobic exercise training and yoga on the baroreflex in healthy elderly +persons. Eur J Clin Investig. 1997;27:443–9. https://​ +doi.​ +org/​ +10.​ +1046/j.​ +1365-​ +2362.​ +1997.​ +13406​ +81.x. + 88. Rajak C, Verma R, Singh P, Singh A, Shiralkar M. Effect of yoga on serum +adrenaline, serum cortisol levels and cardiovascular parameters in hyper- +reactors to cold pressor test in young healthy volunteers. Eur J of Pharm +Med Res. 2016;3:496–502. + 89. Pullen PR, Nagamia SH, Mehta PK, Thompson WR, Benardot D, Hammoud +R, et al. Effects of yoga on inflammation and exercise capacity in patients +with chronic heart failure. J Card Fail. 2008;14:407–13. https://​ +doi.​ +org/​ +10.​ +1016/j.​ +cardf​ +ail.​ +2007.​ +12.​ +007. + 90. Sharma P, Poojary G, Dwivedi SN, Deepak KK. Effect of yoga-based inter‑ +vention in patients with inflammatory bowel disease. Int J Yoga Therap. +2015;25:101–12. https://​ +doi.​ +org/​ +10.​ +17761/​ +1531-​ +2054-​ +25.1.​ +101. +Publisher’s Note +Springer Nature remains neutral with regard to jurisdictional claims in pub‑ +lished maps and institutional affiliations. diff --git a/subfolder_0/A qualitative study on the needs of caregivers of inpatients with schizophrenia in India.txt b/subfolder_0/A qualitative study on the needs of caregivers of inpatients with schizophrenia in India.txt new file mode 100644 index 0000000000000000000000000000000000000000..1ff10c5f06d9367e96ac655d2c098f0f04cb2dec --- /dev/null +++ b/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. +REFERENCES +Angermeyer, M.C., Diaz Ruiz de Zarate, J. & Matschinger, H. (2000) Information and support needs of the family +of psychiatric patients. Gesundheitswesen, 62(10), 483–486. +Barrowclough, C., Marshall, M., Lockwood, A., Quinn, J. & Sellwood, W. (1998) Assessing relatives’ needs +for psychosocial interventions in schizophrenia: A relatives’ version of Cardinal Needs Schedule (RCNS). +Psychological Medicine, 28, 531–542. +Chafetz, L. & Barnes, L. (1989) Issues in psychiatric caregiving. Archives Psychiatric Nursing, 3(2), 61–68. +Chien, W.T. & Norman, I. (2003) Educational needs of families caring for Chinese patients with schizophrenia. +Journal of Advanced Nursing, 44(5), 490–498. +Cleary, M., Freeman, A., Hunt, G.E. & Walter, G. (2005) What patients and carers want to know: An exploration +of information and resource needs in adult mental health services. Australian and New Zealand Journal of +Psychiatry, 39, 507–513. +Cleary, M., Freeman, A., Hunt, G.E. & Walter, G. (2006) Patient and carer perceptions of need and associations with +caregiving burden in an integrated adult mental health service. Social Psychiatry and Psychiatric Epidemiology, +41, 208–214. +Consumer Health Sciences (2008) National Health and Wellness Survey 2008. Princeton: Consumer Health Sciences. +www.chsinternational.com + +JAGANNATHAN ET AL.: A QUALITATIVE STUDY ON THE NEEDS OF CAREGIVERS +191 +Gandon, P., Jenaro, C. & Lemos, S. (2008) Primary caregivers of schizophrenia outpatients: Burden and predictor +factors. Psychiatry Research, 158, 335–343. +Goswami, M. (2006) From a family caregiver to a caregiver at the community level – ‘Ashadeep Model’. In Mental +Health by the People (ed. R.S. Murthy). Bangalore: People’s Action for Mental Health (PAMH). +Hiday, V.A., Swartz, M.S., Swanson, J.W., Borum, R., Wagner, H.R. & D’Cruz, P. (2002) Families in society. Journal +of Contemporary Human Services, 83, 416–430. +Janardhan (2006) Community mental health and development model evolved through consulting people with mental +illness. In Mental Health by the People (ed. R.S. Murthy). Bangalore: People’s Action for Mental Health +(PAMH). +Johnson, D.L. (1994) Current issues in family research: Can the burden of mental illness be relieved? In Helping +Families Cope with the Mental Illness (eds. H.P. Lefley & M. Wasow), pp 309–328. Newark, NJ: Harwood +Academy. +Kare, M., Thirthalli, J., Varghese, R.S., Ross, D., Reddy, K.S., Jagannathan, A., Venkatasubramanian, G. & + +Gangadhar, B.N. (2008) Reducing the delay in treatment of psychosis. Where do we intervene? A study of +first-contact patients in NIMHANS. Best Poster Award at the Richmond Fellowship Asia-Pacific Conference +2008 on Rehabilitation Across Cultures. Bangalore: NIMHANS. +Leff, J. (1994) Working with families of schizophrenic patients. British Journal of Psychiatry, 164 (Supp 23), +71–76. +Madan, G.R. (1987) Indian Sociology. Revised Fourth Edition. New Delhi: Allied Publishers Private Ltd. +Magliano, J., Fadden, G., Economou, M., Held, T. & Xavier, M. (1998) Burden on the families of patients with +schizophrenia: Results of the BIOMED 1 Study. Social Psychiatry and Psychiatric Epidemiology, 33(9), +112–223. +Murthy, R.S. (2006) Mental Health by the People. Bangalore: People’s Action for Mental Health (PAMH). +Murthy, R.S. (2007) Family and Mental Healthcare in India. Bangalore: People’s Action for Mental Health +(PAMH). +North, C.S., Pollio, D.E., Sachar, B., Hong, B. & Isenberg, K. (1998) The family as caregiver: A group psychoeducation +model for schizophrenia. American Journal of Orthopsychiatry, 68(1), 39–46. +Office of the Registrar General and Census Commissioner, India (2001) Census of India 2001. New Delhi: Office of +the Registrar General and Census Commissioner, India. +Padget, D.K. (1998) Qualitative Methods in Social Work Research: Challenges and Rewards. New Delhi: Sage +Publications. +Padmavathi, R., Rajkumar, S. & Srinivasa, T.N. (1998) Schizophrenic patients who were never treated – A study in +an Indian urban community. Psychological Medicine, 28, 1113–1117. +Phelan, M., Slade, M., Thornicroft, G., Dunn, G., Holloway, F., Wykes, T., Strathdee, G., Loftus, L., McCrone, P. & +Hayward, P. (1995) The Camberwell Assessment of Need: The validity and reliability of an instrument to assess +the needs of people with severe mental illness. British Journal of Psychiatry, 167, 589–595. +Solomon, P. & Draine, J. (1994) Examination of Adoptive Coping Among Individuals with a Seriously Mentally Ill +Relative. Unpublished paper. Philadelphia: Hanerman University, Department of Psychiatry and Mental Health +Science. +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: jaganaarti@gmail.com diff --git a/subfolder_0/Additional Practice of Yoga Breathing with Intermittent Breath Holding Enhances Psychological Functions in Yoga Practitioners A Randomized Controll.txt b/subfolder_0/Additional Practice of Yoga Breathing with Intermittent Breath Holding Enhances Psychological Functions in Yoga Practitioners A Randomized Controll.txt new file mode 100644 index 0000000000000000000000000000000000000000..2f935f13962e6408995546261658960628862823 --- /dev/null +++ b/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; &:16 © 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: aparsaoji@gmail.com +© 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 (3436).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. +TAGEDH1REFERENCESTAGEDEND +1. Arch JJ, Craske MG. Mechanisms of mindfulness: emotion regula- +tion following a focused breathing induction; Behav Res Therapy. +2006;44(12):1849–1858. http://doi.org/10.1016/j.brat.2005.12.007. +2. Bhimani NT, Kulkarni NB, Kowale A, Salvi S. Effect of Pranayama +on stress and cardiovascular autonomic function. Ind J Physiol Phar- +macol. 2011;55(4):370–377. +3. Brown KW, Ryan RM. The benefits of being present: mindfulness +and its role in psychological well-being; J Personal Soc Psychol. +2003;84(4):822–848. http://doi.org/10.1037/0022-3514.84.4.822. +4. Deckro GR, Ballinger KM, Hoyt M, et al. The evaluation of a mind/ +body intervention to reduce psychological distress and perceived +stress in college students; J Am Coll Health. 2002;50(6):281–287. +http://doi.org/10.1080/07448480209603446. +5. Harper SK, Webb TL, Rayner K. The effectiveness of mindfulness- +based interventions for supporting people with intellectual disabil- +ities: a narrative review; Behav Modif. 2013;37(3):431–453. http:// +doi.org/10.1177/0145445513476085. +6. Hasenkamp W, Wilson-Mendenhall CD, Duncan E, Barsalou LW. +Mind-wandering and attention during focused meditation: a fine- +grained temporal analysis of fluctuating cognitive states; NeuroImage. +2012;59(1):750–760. http://doi.org/10.1016/j.neuroimage.2011.07.008. +7. Kabat-Zinn J. Mindfulness-based interventions in context: past, pres- +ent, +and +future; +Clin +Psychol +Sci +Pract. +2006;10(2):144–156. +http://doi.org/10.1093/clipsy.bpg016. +8. Killingsworth MA, Gilbert DT. A wandering mind is an unhappy mind; +Science. 2010;330(6006):932. http://doi.org/10.1126/science.1192439. +9. Mahmood L, Hopthrow T, Randsley de Moura G. A moment of +mindfulness: computer-mediated mindfulness practice increases +state mindfulness; PLOS ONE. 2016;11(4) e0153923. http://doi. +org/10.1371/journal.pone.0153923. +10. Marteau TM, Bekker H. The development of a six-item short-form of +the state scale of the Spielberger State-Trait Anxiety Inventory +(STAI); Brit J Clin Psychol. 1992;31(3):301–306. http://doi.org/ +10.1111/j.2044-8260.1992.tb00997.x. +11. Mason MF, Norton MI, Van Horn JD, Wegner DM, Grafton ST, +Macrae CN. Wandering minds: the default network and stimulus- +independent thought; Science. 2007;315(5810):393–395. New York, +N.Y.; http://doi.org/10.1126/science.1131295. +12. Mowlem FD, Skirrow C, Reid P, et al. Validation of the mind exces- +sively wandering scale and the relationship of Mind-wandering to +impairment in adult ADHD; J Attent Disorders 2016; http://doi.org/ +10.1177/1087054716651927. +13. Mrazek MD, Chin JM, Schmader T, Hartson KA, Smallwood J, +Schooler JW. Threatened to distraction: Mind-wandering as a conse- +quence +of +stereotype +threat; +J +Exp +Soc +Psychol. +2011;47(6): +1243–1248. http://doi.org/10.1016/j.jesp.2011.05.011. +14. Mrazek MD, Franklin MS, Phillips DT, Baird B, Schooler JW. +Mindfulness training improves working memory capacity and GRE +performance while reducing Mind-wandering; Psychol Sci. 2013;24 +(5):776–781. http://doi.org/10.1177/0956797612459659. +15. Mrazek MD, Phillips DT, Franklin MS, Broadway JM, Schooler JW. +Young and restless: validation of the Mind-Wandering Questionnaire +(MWQ) reveals disruptive impact of mind-wandering for youth; Front +Psychol. 2013;4:560. http://doi.org/10.3389/fpsyg.2013.00560. +16. Mrazek MD, Smallwood J, Schooler JW. Mindfulness and mind- +wandering: finding convergence through opposing constructs; Emot +Wash DC. 2012;12(3):442–448. http://doi.org/10.1037/a0026678. +ARTICLE IN PRESS +Yoga Breathing Enhance Psychological Wellbeing +EXPLORE & 2018, Vol. &, No. & +5 +17. Muktibodhananda S. Hatha Yoga Pradipika: Light on Hatha Yoga. +2nd ed. Bihar: Yoga Publication Trust; 2002. +18. Nemati A. The effect of pranayama on test anxiety and test perfor- +mance; Int J Yoga. 2013;6:55–60. http://doi.org/10.4103/0973- +6131.105947. +19. Peterson CT, Bauer SM, Chopra D, Mills PJ, Maturi RK. Effects of +Shambhavi Mahamudra Kriya, a multicomponent breath-based +yogic practice (pranayama), on perceived stress and general well- +being; J Evid Based Complement Alternat Med. 2017;22(4):788–797. +http://doi.org/10.1177/2156587217730934. +20. Randall JG, Oswald FL, Beier ME. Mind-wandering, cognition, and per- +formance: a theory-driven meta-analysis of attention regulation; Psychol +Bull. 2014;140(6):1411–1431. http://doi.org/10.1037/a0037428. +21. Saoji AA. Yoga: a strategy to cope up stress and enhance wellbeing +among medical students; North Am J Med Sci. 2016;8(4):200–202. +http://doi.org/10.4103/1947-2714.179962. +22. Saoji A, Mohanty S, Vinchurkar SA. Effect of a single session of a +yogic meditation technique on cognitive performance in medical +students: a randomized crossover trial; J Rel Health. 2017;56(1):141– +148. http://doi.org/10.1007/s10943-016-0195-x. +23. Saraswati SN. Prana Pranayama Prana Vidya. 2nd ed. Munger: Yoga +Publications Trust.; 2002. +24. Scheibner HJ, Bogler C, Gleich T, Haynes J-D, Bermpohl F. +Internal +and +external +attention +and +the +default +mode +network; NeuroImage. 2017;148:381–389. http://doi.org/10.1016/ +j.neuroimage.2017.01.044. +25. Shaw GA, Giambra L. Taskunrelated thoughts of college students +diagnosed as hyperactive in childhood; Dev Neuropsychol. 1993;9 +(1):17–30. http://doi.org/10.1080/87565649309540541. +26. Smallwood J, Fishman DJ, Schooler JW. Counting the cost of an +absent mind: Mind-wandering as an underrecognized influence on +educational performance; Psych Bull Rev. 2007;14(2):230–236. +http://doi.org/10.3758/BF03194057. +27. Smallwood J, Fitzgerald A, Miles LK, Phillips LH. Shifting moods, +wandering minds: Negative moods lead the mind to wander; Emo- +tion. 2009;9(2):271–276. http://doi.org/10.1037/a0014855. +28. Smallwood J, O’Connor RC, Sudbery MV, Obonsawin M. Mind- +wandering and dysphoria; Cognit Emot. 2007;21(4):816–842. http:// +doi.org/10.1080/02699930600911531. +29. Smallwood J, Schooler JW. The restless mind; Psychol Bull. 2006;132 +(6):946–958. http://doi.org/10.1037/0033-2909.132.6.946. +30. Turankar AV, Jain S, Patel SB, et al. Effects of slow breathing exercise +on cardiovascular functions, pulmonary functions & galvanic skin +resistance in healthy human volunteers - a pilot study. Ind J Med Res. +2013;137(5):916–921. +31. Vinchurkar S, Singh D, Visweswaraiah NK. Self-reported measures of +mindfulness in meditators and non-meditators: a cross-sectional +study; Int J Yoga. 2014;7(2):142–146. http://doi.org/10.4103/0973- +6131.133898. +32. Weaver LL, Darragh AR. Systematic review of yoga interventions for anx- +iety reduction among children and adolescents; Am J Occup Therapy. +2015;69(6). 6906180070p1-9; http://doi.org/10.5014/ajot.2015.020115. +ARTICLE IN PRESS +6 +EXPLORE & 2018, Vol. &, No. & +Yoga Breathing Enhance Psychological Wellbeing diff --git a/subfolder_0/Aerobic Fitness and Cognitive Functions in Economically Underprivileged Children Aged 7-9 Years.txt b/subfolder_0/Aerobic Fitness and Cognitive Functions in Economically Underprivileged Children Aged 7-9 Years.txt new file mode 100644 index 0000000000000000000000000000000000000000..8bb5c16152b2e2cf27e021454c5798cc5988c4f9 --- /dev/null +++ b/subfolder_0/Aerobic Fitness and Cognitive Functions in Economically Underprivileged Children Aged 7-9 Years.txt @@ -0,0 +1,352 @@ +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: +srinivasanstjohns@gmail.com. + + + +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. +REFERENCES +1. Trudeau F, Shephard RJ. Physical education, school physical activity, +school sports and academic performance. Int. J. Behav. Nutr. Phys. +Act. 2008; 25: 5-10. +2. Sibley BA, Etnier JL. The relationship between physical activity and +cognition in children: a meta analysis. Pediatr Exerc Sci. 2003; 15: +243-256. +3. Brisswalter J, Collardeau M, Rene A. Effects of acute physical exer- +cise characteristics on cognitive performance. Sports Med. 2002; 32: +555-566. +4. Etnier JL, Nowell PM, Landers DM, Sibley BA. A meta-regression to +examine the relationship between aerobic fitness and cognitive perfor- +mance. Brain Res. Rev. 2006; 52: 119-130. +5. Davis CL, Tomporowski PD, Boyle CA, Waller JL, et al. Effects of +aerobic exercise on overweight children’s cognitive functioning. A +randomized controlled trial. Res. Q. Exerc. Sport. 2007; 78: 510-519. +6. World health organization. Expert committee on physical states: The +use and interpretation of anthropometry. World Health Organization +Technical Report Series. 1995; 854. +7. Malin AJ. Malin’s intelligence scale for Indian Children (MISIC). +Indian Journal of Mental Retardation. 1971; 4. +8. Leger LA, Lambert J. A maximal multistage 20-m shuttle run test to +predict VO2 max. Eur. J. Appl. Physiol. Occup. Physiol. 1982; 49: 1-12. +9. Liu NY, Plowman SA, Looney MA. The reliability and validity of the +20-meter shuttle test in American students 12 to 15 years old. Res. Q. +Exerc. Sport. 1992; 63: 360-365. +10. Castelli DM, Hillman CH, Buck SM, Erwin HE. Physical fitness and +academic achievement in third- and fifth-grade students. J. Sport +Exerc. Psychol. 2007; 29: 239-52. +11. Tomporowski PD, Davis CL, Miller PH, Naglieri JA. Exercise and +Children’s Intelligence, Cognition, and Academic Achievement. Educ. +Psychol. Rev. 2008; 20: 111-131. +12. Etnier JL, Salazar W, Landers DM, Petruzello SJ, et al. The influence +of physical fitness and exercise upon cognitive functioning. A meta +analysis. J. Sport Exerc. Psychol. 1997; 19: 249-277. +13. Taras H. Physical activity and student performance at school. J. Sch. +Health. 2005; 75: 214-218. +14. Etnier JL, Landers DM. Motor performance and motor learning as a +function of age and fitness. Res. Q. Exerc. Sport. 1998; 69: 136-146. +15. Lu B, Chow A. Neurotrophic and hippocampal synaptic transmission +and plasticity. J. Neurosci. Res. 1999; 58: 76-87. +16. Van Praag H, Shubert T, Zhao C, Gage FH. Exercise enhances learn- +ing and hippocampalneurogenesis in aged mice. J. Neurosci. 2005; 25: +8680-8685. +17. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, et al. Inter- +national Child Development Steering Group. Developmental potential +in the first 5 years for children in developing countries. Lancet. 2007; +369: 60-70. diff --git a/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 b/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 new file mode 100644 index 0000000000000000000000000000000000000000..788699475269bf4a3e20db6d4fc1f473a94643fb --- /dev/null +++ b/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 @@ -0,0 +1,564 @@ +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 +0 +READS +38 +3 authors, including: +Some of the authors of this publication are also working on these related projects: +Waist circumference View project +APACHE II; SOFA; Diabetes View project +Jintu Kurian +SVYASA Yoga University +7 PUBLICATIONS   7 CITATIONS    +SEE PROFILE +Shivaramakrishna Sri +Salient Visionary Publications LLC +5 PUBLICATIONS   0 CITATIONS    +SEE PROFILE +All content following this page was uploaded by Shivaramakrishna Sri on 17 November 2022. +The user has requested enhancement of the downloaded file. +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 + +REFERENCES +1. Patel S, Tyagi A, Waran M, Gagre A, Garudkar S, Bedi M. Evaluation of Risk for Type 2 Diabetes +Mellitus in 1 st Degree Relatives Using Indian Diabetes Risk Score (IDRS). The Indian Practitioner. +2015;68(11):32-6. +2. Middelbeek RJ, Abrahamson MJ. Diabetes, prediabetes, and glycemic control in the United States: +challenges and opportunities. Ann Intern Med. 2014;160(8):517-25. +3. Ramaiah R, Jayarama S. Assessment of risk of type 2 diabetes mellitus among rural population in +Karnataka by using Indian diabetes risk score. International Journal Of Community Medicine And Public +Health. 2017;28;4(4):1056-9. +4. Ramachandran A, Snehalatha C. Current scenario of diabetes in India. J Diabetes. 2009;1(1):18-28. +5. Vijayakumar G, Manghat S, Vijayakumar R, Simon L, Scaria LM, Vijayakumar A, et al. Incidence of type +2 diabetes mellitus and prediabetes in Kerala, India: results from a 10-year prospective cohort. BMC Public +Health. 2019;19(1):140. +6. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes care. +2014;37(Supplement 1):S81-90. +7. Ford ES, Kohl III HW, Mokdad AH, Ajani UA. Sedentary behavior, physical activity, and the metabolic +syndrome among US adults. Obes Res. 2005;13(3):608-14. +8. Mohan V, Anbalagan VP. Expanding role of the Madras diabetes research foundation-Indian diabetes risk +score in clinical practice. Indian journal of endocrinology and metabolism. 2013;17(1):31 +9. Joshi SR. Indian diabetes risk score. JAPI. 2005;53:755. +International Clinical and Medical Case Reports Journal + +Research Article (ISSN: 2832-5788) + +Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 + +10. Gupta RK, Shora TN, Verma AK, Raina SK. Utility of MDRF-IDRS (Madras Diabetes Research +Foundation-Indian Diabetes Risk Score) as a tool to assess risk for diabetes—a study from north-west +India. International Journal of Diabetes in Developing Countries. 2015;35(4):570-2. +11. William C Knowler, Elizabeth Barrett-Connor, Sarah E Fowler, Richard F Hamman, John M Lachin, +Elizabeth A Walker, David M Nathan, et al. Reduction in the incidence of type 2 diabetes with lifestyle +intervention or metformin. N Engl J Med. 2002;346(6):393-403. +12. De Nardi AT, Tolves T, Lenzi TL, Signori LU, da Silva AM. High-intensity interval training versus +continuous training on physiological and metabolic variables in prediabetes and type 2 diabetes: A meta- +analysis. Diabetes Res Clin Pract . 2018;137:149-159. +13. Cantley J, Ashcroft FM. Q&A: insulin secretion and type 2 diabetes: why do β-cells fail?. BMC Biology. +2015;13: 33. +14. Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol . +2012;2(2):1143-211. +15. Middelbeek RJ, Abrahamson MJ. Diabetes, prediabetes, and glycemic control in the United States: +challenges and opportunities. Ann Intern Med. 2014;160(8):572-3. +16. Haghighatdoost F, Amini M, Feizi A, Iraj B. Are body mass index and waist circumference significant +predictors of diabetes and prediabetes risk: Results from a population based cohort study. World J Diabetes. +2017;8(7):365-373. +17. Alam DS, Talukder SH, Chowdhury MA, Siddiquee AT, Ahmed S, Pervin S, et al. Overweight and +abdominal obesity as determinants of undiagnosed diabetes and pre-diabetes in Bangladesh. BMC Obesity. +2016;3:19. +18. Wu J, Gong L, Li Q, Hu J, Zhang S, Wang Y, et al. A Novel Visceral Adiposity Index for Prediction of +Type 2 Diabetes and Pre-diabetes in Chinese adults: A 5-year prospective study. Scientific reports. +2017;7(1):13784. +19. Kelley DE, Goodpaster BH. Effects of exercise on glucose homeostasis in Type 2 diabetes mellitus. Med +Sci Sports Exerc. 2001;33(6 Suppl):S495-501;discussion S528-9. +20. Pradeepa R, Mohan V. Prevalence of type 2 diabetes and its complications in India and economic costs to +the nation. Eur J Clin Nutr. 2017;71(7):816-824. +21. Little M, Humphries S, Patel K, Dodd W, Dewey C. Factors associated with glucose tolerance, pre- +diabetes, and type 2 diabetes in a rural community of south India: a cross-sectional study. Diabetol Metab +Syndr. 2016;8:21. +22. Chandrakar O, Saini JR. Development of Indian weighted diabetic risk score (IWDRS) using machine +learning techniques for type-2 diabetes. InProceedings of the 9th Annual ACM India Conference 2016: +125-128. + +23. Whelan J. When diabetes strikes twice. New Scientist. 2007;196(2627):48-51. +24. Vijayakumar V, Balakundi M, Metri KG. Challenges faced in diabetes risk prediction among an indigenous +South Asian population in India using the Indian Diabetes Risk Score. Public health. 2019;176:114-7. +International Clinical and Medical Case Reports Journal + +Research Article (ISSN: 2832-5788) + +Int Clinc Med Case Rep Jour (ICMCRJ) 2022 | Volume 1 | Issue 8 + +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. + +View publication stats diff --git a/subfolder_0/CHANGES IN MIDDLE LATENCY AUDITORY EVOKED POTENTIALS DURING.txt b/subfolder_0/CHANGES IN MIDDLE LATENCY AUDITORY EVOKED POTENTIALS DURING.txt new file mode 100644 index 0000000000000000000000000000000000000000..d4a668ac00d406183a2cbe1bb175bdaeb3386638 --- /dev/null +++ b/subfolder_0/CHANGES IN MIDDLE LATENCY AUDITORY EVOKED POTENTIALS DURING.txt @@ -0,0 +1,32 @@ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/COMPARISON OF CHANGES IN AUTONOMIC AND RESPIRATORY PARAMETERS OF.txt b/subfolder_0/COMPARISON OF CHANGES IN AUTONOMIC AND RESPIRATORY PARAMETERS OF.txt new file mode 100644 index 0000000000000000000000000000000000000000..2a17f29efa72b2824eaa3e32dc5e939e785b5a28 --- /dev/null +++ b/subfolder_0/COMPARISON OF CHANGES IN AUTONOMIC AND RESPIRATORY PARAMETERS OF.txt @@ -0,0 +1,30 @@ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts.txt b/subfolder_0/Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts.txt new file mode 100644 index 0000000000000000000000000000000000000000..c2f9e1e84ae32a05ea503ff36935380209d6a9be --- /dev/null +++ b/subfolder_0/Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts.txt @@ -0,0 +1,489 @@ +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: shirleytelles@gmail.com +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 +1 +2,3 +2 +4 +5 +6 +7 +8 +9 +10 +11 +12 +12a +12b +8/11/2014 +Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/ +3/10 +Go to: +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 +13a +13b +14 +15 +8/11/2014 +Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/ +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 +16 +17 +8/11/2014 +Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/ +6/10 +Go to: +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 +18 +17 +19 +20 +8/11/2014 +Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/ +7/10 +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 +21 +22 +23 +24 +25 +10 +9 +7,26 +27 +28 +29 +8/11/2014 +Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/ +8/10 +Go to: +Go to: +Go to: +Go to: +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. +[PubMed] +3. Wallace RK. Physiological effects of Transcendental Meditation. Science. 1970;167:1751–1754. [PubMed] +4. Orme-Johnson DW. Autonomic stability and Transcendental Meditation. Psychosom Med. 1973;35:341–349. +[PubMed] +5. Dillbeck MC. Orme-Johnson DW. Physiological differences between Transcendental Meditation and rest. American +Psychologist. 1987;42:879–881. +6. Lang R. Dehof K. Meurer KA, et al. Sympathetic activity and Transcendental meditation. J Neural Transm. +1979;44:117–135. [PubMed] +7. Hirai T. Electroencephalographic study on the Zen meditation (ZAZEN)-EEG changes during concentrated relaxation. +Jpn J Psychiatry Neurol. 1960;62:76–105. +8. Sugi Y. Akatsu K. Studies on respiration and energy metabolism during sitting in Zazen. Res J Phys Educ. +1968;12:190–206. +9. Corby JC. Roth WT. Zarcone VP, Jr, et al. Physiological correlates of the practice of Tantric Yoga meditation. Arch +Gen Psychiatry. 1978;35:571–577. [PubMed] +30 +31 +8/11/2014 +Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/ +9/10 +10. Elson BD. Hauri P. Cunis D. Physiological changes in yoga meditation. Psychophysiology. 1977;14:52–57. +[PubMed] +11. Travis F. Shear J. Focused attention, open monitoring and automatic self-transcending: categories to organize +meditations from Vedic, Buddhist and Chinese traditions. Consciousness and Cognition. 2010;19:1110–1118. +[PubMed] +12. Taimini IK. The science of yoga. Madras: The Theosophical Publishing House; 2005. pp. 275–278. (a) (b) 278– +280. +13. Sarasvati M. Swami G. Bhagavad Gita. Calcutta: Advaita Ashrama; 1998. pp. 459–461. (a) (b) 393–394. +14. Kumar S. Telles S. Meditative states based on yoga texts and their effects on performance of a cancellation task. +Percept Mot Skills. 2009;109:679–689. [PubMed] +15. Yildirir A. Kabakci G. Akgul E, et al. Effects of menstrual cycle on cardiac autonomic innervation as assessed by +heart rate variability. Ann Noninvasive Electrocardiol. 2002;7:60–63. [PubMed] +16. Niskanen JP. Tarvainen MP. Ranta-aho PO, et al. Software for advanced HRV analysis. Comput Methods +Programs Biomed. 2004;76:73–81. [PubMed] +17. Task Force of the European Society of Cardiology the North American Society of Pacing Electrophysiology. Heart +rate variability: standards of measurement, physiological interpretation, and clinical use. Eur Heart J. 1996;17:354–381. +[PubMed] +18. Andreassi JL. Mahwah, NJ: Lawrence Earl Baum Associates; 2000. Psychophysiology: human behavior and +physiological response. +19. Malliani A. Julien C. Billman GE, et al. Cardiovascular variability is not an index of autonomic control of circulation. J +Appl Physiol. 2006;101:684–688. [PubMed] +20. Randall DC. Brown DR. Raisch RM, et al. SA nodal parasympathectomy delineates autonomic control of heart rate +power spectrum. Am J Physiol. 1991;260:H985–988. [PubMed] +21. Wennerblom B. Lurje L. Tygesen H, et al. Patients with uncomplicated coronary artery disease have reduced heart +rate variability mainly affecting vagal tone. Heart. 2000;83:290–294. [PMC free article] [PubMed] +22. Shields SA. MacDowell KA. Fairchild SB, et al. Is mediation of sweating cholinergic, adrenergic, or both? A +comment on the literature. Psychophysiology. 1987;24:312–319. [PubMed] +23. Fowles DC. Porges SW. The eccrine system and electrodermal activity. In: Coles MGH, editor; Donchin E, editor; +Psychophysiology: Systems, Processes and Applications. New York: Guilford Press; 1986. pp. 51–96. +24. Delius W. Kellerová E. Reactions of arterial and venous vessels in the human forearm and hand to deep breath or +mental strain. Clin Sci. 1971;40:271–282. [PubMed] +25. Stevenson I. Ripley HS. Variations in respiration and in respiratory symptoms during changes in emotion. Psychosom +Med. 1952;14:476–490. [PubMed] +26. Kasamatsu A. Hirai T. An electroencephalographic study on the Zen meditation (Zazen) Folia Psychiatr Neurol Jpn. +1966;20:315–336. [PubMed] +27. Travis FT. Autonomic and EEG patterns distinguish transcending from other experiences during Transcendental +Meditation practice. Int J Psychophysiol. 2001;42:1–9. [PubMed] +28. Wallace RK. The neurophysiology of enlightenment. Fairfield, IA: MIU Press; 1986. +8/11/2014 +Changes in Autonomic Variables Following Two Meditative States Described in Yoga Texts +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546358/ +10/10 +29. Travis F. Wallace RK. Autonomic patterns during respiratory suspensions: possible markers of Transcendental +Consciousness. Psychophysiology. 1997;34:39–46. [PubMed] +30. Farrow JT. Hebert JR. Breath suspension during the transcendental meditation technique. Psychosom Med. +1982;44:133–153. [PubMed] +31. Badawi K. Wallace RK. Orme-Johnson D. Rouzere AM. Electrophysiologic characteristics of respiratory +suspension periods occurring during the practice of the Transcendental Meditation Program. Psychosom Med. +1984;46:267–276. [PubMed] +Articles from Journal of Alternative and Complementary Medicine are provided here courtesy of Mary Ann Liebert, +Inc. diff --git a/subfolder_0/Changes in Midlatency Auditory Evoked Potentials Following Two Yoga-Based Relaxation Techniques.txt b/subfolder_0/Changes in Midlatency Auditory Evoked Potentials Following Two Yoga-Based Relaxation Techniques.txt new file mode 100644 index 0000000000000000000000000000000000000000..e69de29bb2d1d6434b8b29ae775ad8c2e48c5391 diff --git a/subfolder_0/Changes in lung function measures following Bhastrika Pranayama (bellows breath) and running in healthy individuals..txt b/subfolder_0/Changes in lung function measures following Bhastrika Pranayama (bellows breath) and running in healthy individuals..txt new file mode 100644 index 0000000000000000000000000000000000000000..1e9205d9b73fbadb8ec9e9cd9373dd012af2be15 --- /dev/null +++ b/subfolder_0/Changes in lung function measures following Bhastrika Pranayama (bellows breath) and running in healthy individuals..txt @@ -0,0 +1,463 @@ +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: budhi.rana@gmail.com +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. +References +1. Iyengar BK. New Delhi: Harper Collins Publishers India; 1997. The Illustrated Light on Yoga: Yoga +Dipika. [Google Scholar] +2. Pike G, Pike P. Ch'i: The power within. Boston: Charles E. Tuttle Co; 1996. [Google Scholar] +3. Muktibodhananda S. 4th ed. Munger, Bihar: Bihar School of Yoga; 1999. Hatha Yoga Pradipika. +[Google Scholar] +4. Schünemann HJ, Dorn J, Grant BJ, Winkelstein W, Jr, Trevisan M. Pulmonary function is a long- +term predictor of mortality in the general population: 29-year follow-up of the buffalo health study. +Chest. 2000;118:656–64. [PubMed] [Google Scholar] +5. Pramanik T, Sharma HO, Mishra S, Mishra A, Prajapati R, Singh S, et al. Immediate effect of slow +pace bhastrika pranayama on blood pressure and heart rate. J Altern Complement Med. 2009;15:293–5. +[PubMed] [Google Scholar] +6. Raju PS, Madhavi S, Prasad KV, Reddy MV, Reddy ME, Sahay BK, et al. Comparison of effects of +yoga and physical exercise in athletes. Indian J Med Res. 1994;100:81–6. [PubMed] [Google Scholar] +7. Singh Bal B. Effect of anulom vilom and bhastrika pranayama on the vital capacity and maximal +ventilatory volume. J Phys Educ Sport Manag. 2010;1:11–5. [Google Scholar] +8. Prakash S, Meshram S, Ramtekkar U. Athletes, yogis and individuals with sedentary lifestyles; do +their lung functions differ? Indian J Physiol Pharmacol. 2007;51:76–80. [PubMed] [Google Scholar] +9. Joshi LN, Joshi VD, Gokhale LV. Effect of short term “Pranayam” practice on breathing rate and +ventilatory functions of lung. Indian J Physiol Pharmacol. 1992;36:105–8. [PubMed] [Google Scholar] +10. Shankarappa V, Prashanth P, Nachal A, Varunmalhotra The short term effect of pranayama on the +lung parameters. J Clin Diagn Res. 2012;6:27–30. [Google Scholar] +11. Dinesh T, Gaur G, Sharma V, Madanmohan T, Harichandra Kumar K, Bhavanani A, et al. +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;8:22–6. [PMC free article] +[PubMed] [Google Scholar] +12. Thangavel D, Gaur GS, Sharma VK, Bhavanani AB, Rajajeyakumar M, Syam SA, et al. Effect of +slow and fast pranayama training on handgrip strength and endurance in healthy volunteers. J Clin +Diagn Res. 2014;8:BC01–3. [PMC free article] [PubMed] [Google Scholar] +13. Sharma VK, Rajajeyakumar M, Velkumary S, Subramanian SK, Bhavanani AB, Madanmohan, et +al. Effect of fast and slow pranayama practice on cognitive functions in healthy volunteers. J Clin +Diagn Res. 2014;8:10–3. [PMC free article] [PubMed] [Google Scholar] +14. Bhavanani AB, Madanmohan, Udupa K. Acute effect of mukh bhastrika (a yogic bellows type +breathing) on reaction time. Indian J Physiol Pharmacol. 2003;47:297–300. [PubMed] +[Google Scholar] +15. Salinero JJ, Soriano ML, Ruiz-Vicente D, Gonzalez-Millan C, Areces F, Gallo-Salazar C, et al. +Respiratory function is associated to marathon race time. J Sports Med Phys Fitness. 2016;56:1433–8. +[PubMed] [Google Scholar] +16. Harms CA. Does gender affect pulmonary function and exercise capacity? Respir Physiol +Neurobiol. 2006;151:124–31. [PubMed] [Google Scholar] +17. Vedala SR, Mane AB, Paul CN. Pulmonary functions in yogic and sedentary population. Int J Yoga. +2014;7:155–9. [PMC free article] [PubMed] [Google Scholar] +18. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: Tests for +correlation and regression analyses. Behav Res Methods. 2009;41:1149–60. [PubMed] +[Google Scholar] +19. Research Randomizer. [Last accessed on 2018 Mar 16]. Available from: https://www.randomizer. +org/ +20. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, et al. Standardisation of +spirometry. Eur Respir J. 2005;26:319–38. [PubMed] [Google Scholar] +21. Pal GK, Pal P. Hyderabad: Orient Longman; 2001. Textbook of Practical Physiology. +[Google Scholar] +22. Patil RY, Sawant RS. Study of effect of bhastrika pranayama on pulmonary function. Int Res J +Pharm. 2012;3:204–7. [Google Scholar] +23. Sayyed A, Patil J, Chavan V, Patil S, Charugulla S, Sontakke A, et al. Study of lipid profile and +pulmonary functions in subjects participated in Sudarshan Kriya Yoga. Al Ameen J Med Sci. +2010;3:42–9. [Google Scholar] +24. Joshi LN, Joshi VD. Effect of forced breathing on ventilatory functions of the lung. J Postgrad +Med. 1998;44:67–9. [PubMed] [Google Scholar] +25. Burney PG, Hooper R. Forced vital capacity, airway obstruction and survival in a general +population sample from the USA. Thorax. 2011;66:49–54. [PubMed] [Google Scholar] +26. Kondam A, Chandrasekhar M, Karthik S, Ambareesha Kondam C. Combined effects of pranayama +and suryanamaskar on dynamic spirometric values in normal young subjects. Natl J Physiol Pharm +Pharmacol. 2015;5:79–84. [Google Scholar] +27. Chanavirut R, Khaidjapho K, Jaree P, Pongnaratorn P. Yoga exercise increases chest wall expansion +and lung volumes in young healthy Thais. Thai J Physiol Sci. 2006;19:1–7. [Google Scholar] +28. Manoj J, Vyankatesh R. Effect of integrated yoga module on respiratory pressures and pulmonary +functions in children. Int J Res Med Sci. 2015;33:3548–52. [Google Scholar] +29. Yadav RK, Das S. Effect of yogic practice on pulmonary functions in young females. Indian J +Physiol Pharmacol. 2001;45:493–6. [PubMed] [Google Scholar] +30. Tantucci C, Duguet A, Giampiccolo P, Similowski T, Zelter M, Derenne JP, et al. The best peak +expiratory flow is flow-limited and effort-independent in normal subjects. Am J Respir Crit Care Med. +2002;165:1304–8. [PubMed] [Google Scholar] +31. Singh S, Soni R, Singh KP, Tandon OP. Effect of yoga practices on pulmonary function tests +including transfer factor of lung for carbon monoxide (TLCO) in asthma patients. Indian J Physiol +Pharmacol. 2012;56:63–8. [PubMed] [Google Scholar] +32. Yadav A, Singh S, Singh K, Pai P. Effect of yoga regimen on lung functions including diffusion +capacity in coronary artery disease patients: A randomized controlled study. Int J Yoga. 2015;8:62–7. +[PMC free article] [PubMed] [Google Scholar] +33. Karthik PS, Chandrasekhar M, Ambareesha K, Nikhil C. Effect of pranayama and suryanamaskar +on pulmonary functions in medical students. J Clin Diagn Res. 2014;8:BC04–6. [PMC free article] +[PubMed] [Google Scholar] +34. Navoday RNR, Deepika S, Kulkarni P, Kekuda PTR. Effects of pranayama on respiratory system. +Unique J Ayurvedic Herb Med. 2015;03:79–82. [Google Scholar] +35. Murthy KJ, Sahay BK, Sitaramaraju P, Sunita M, Yogi R, Reddy V, et al. Effect of pranayama +(Rechaka, Puraka and Kumbaka) on bronchial asthma – An open study. Lung India. 2017;2:187–91. +[Google Scholar] +36. Saxena T, Saxena M. The effect of various breathing exercises (pranayama) in patients with +bronchial asthma of mild to moderate severity. Int J Yoga. 2009;2:22–5. [PMC free article] [PubMed] +[Google Scholar] +37. Ranjita R, Hankey A, Nagendra HR, Mohanty S. Yoga-based pulmonary rehabilitation for the +management of dyspnea in coal miners with chronic obstructive pulmonary disease: A randomized +controlled trial. J Ayurveda Integr Med. 2016;7:158–66. [PMC free article] [PubMed] [Google Scholar] +38. Gupta A, Gupta R, Sood S, Arkham M. Pranayam for treatment of chronic obstructive pulmonary +disease: Results from a randomized, controlled trial. Integr Med (Encinitas) 2014;13:26–31. +[PMC free article] [PubMed] [Google Scholar] +Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow +Publications diff --git a/subfolder_0/Complimentary effect of yogic sound resonance relaxation technique in patients with common neck pain.txt b/subfolder_0/Complimentary effect of yogic sound resonance relaxation technique in patients with common neck pain.txt new file mode 100644 index 0000000000000000000000000000000000000000..98f537669fe0d72503662465356dc4f2d1e88cdc --- /dev/null +++ b/subfolder_0/Complimentary effect of yogic sound resonance relaxation technique in patients with common neck pain.txt @@ -0,0 +1,982 @@ +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: baliyogitha@gmail.com +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 +of a non-selected material of 1200 workers in different occupations with +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 +of the stiff neck-brachialgia and lumbago-sciatica syndromes, as well as +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 +International Journal of Yoga  Vol. 3  Jan-Jun-2010 +of neck pain in the general population: A population-based cohort study. +Pain2004;112:267-73. +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 +Author Help: Reference checking facility +The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks +the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal. +• +The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a +single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference. +• +Example of a correct style + +Sheahan P +, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy. +Otolaryngol Head Neck Surg 2002;127:294-8. +• +Only the references from journals indexed in PubMed will be checked. +• +Enter each reference in new line, without a serial number. +• +Add up to a maximum of 15 references at a time. +• +If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct +article in PubMed will be given. +• +If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to +possible articles in PubMed will be given. diff --git a/subfolder_0/Decoding the integrated approach to Yoga therapy.txt b/subfolder_0/Decoding the integrated approach to Yoga therapy.txt new file mode 100644 index 0000000000000000000000000000000000000000..6d618c0eed4ae05bf33035dfe7ba6ac905d30219 --- /dev/null +++ b/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: jaganaarti@gmail.com +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 diff --git a/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 b/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 new file mode 100644 index 0000000000000000000000000000000000000000..a8f59e0ba42879630f8d6329351c13ba5da815de --- /dev/null +++ b/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 @@ -0,0 +1,515 @@ +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: jaganaarti@gmail.com +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. +References +1. Leff J. Working with the families of schizophrenic patients. Br J Psychiatry Suppl. 1994;23:71–6. [PubMed] [Google Scholar] +2. Pascoe MC, Thompson DR, Ski CF. Yoga, mindfulness-based stress reduction and stress-related physiological measures: A meta- +analysis. Psychoneuroendocrinology. 2017;86:152–68. [PubMed] [Google Scholar] +3. Jagannathan A, Hamza A, Thirthalli J, Nagendra HR, Kare M, Yadav M, et al. Efficacy of yoga and psychosocial training programme for +caregivers of persons with schizophrenia. Natl J Prof Soc Work. 2012;13:3–15. [Google Scholar] +4. Varambally S, Vidyendaran S, Sajjanar M, Thirthalli J, Hamza A, Nagendra HR, et al. Yoga-based intervention for caregivers of +outpatients with psychosis: A randomized controlled pilot study. Asian J Psychiatr. 2013;6:141–5. [PubMed] [Google Scholar] +5. Jagannathan A, Hamza A, Thirthalli J, Nagendra H, Nagarathna R, Gangadhar BN, et al. 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. [PMC free article] [PubMed] +[Google Scholar] +6. Thara R, Padmavati R, Kumar S, Srinivasan L. Instrument to assess burden on caregivers of chronic mentally ill. Indian J Psychiatry. +1998;40:21–9. [PMC free article] [PubMed] [Google Scholar] +7. Szabo S. The World Health Organization quality of life (WHOQOL) assessment instrument. In: Spilker B, editor. Quality of Life and +Pharmaeconomics in Clinical Trials. 2nd ed. Philadelphia, New York: Lippincott-Raven Publishers; 1996. [Google Scholar] +8. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–96. [PubMed] +[Google Scholar] +9. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–70. [PubMed] [Google Scholar] +10. Beusenberg M, Orley J. A User's Guide to Self Reporting Questionnaire (SRQ) Geneva: Division of Mental Health, World Health +Organization; 1994. [Google Scholar] +11. Baspure S, Jagannathan A, Kumar S, Varambally S, Thirthalli J, Venkatasubramanain G, et al. Barriers to yoga therapy as an add-on +treatment for schizophrenia in India. Int J Yoga. 2012;5:70–3. [PMC free article] [PubMed] [Google Scholar] +12. Angadi P, Jagannathan A, Thulasi A, Kumar V, Umamaheshwar K, Raghuram N. Adherence to yoga and its resultant effects on blood +glucose in type 2 diabetes: A community-based follow-up study. Int J Yoga. 2017;10:29–36. [PMC free article] [PubMed] [Google Scholar] +13. Chaya MS, Kurpad AV, Nagendra HR, Nagarathna R. The effect of long term combined yoga practice on the basal metabolic rate of +healthy adults. BMC Complement Altern Med. 2006;6:28. [PMC free article] [PubMed] [Google Scholar] +14. Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN. Yoga therapy as an add-on treatment in the management of patients with +schizophrenia – a randomized controlled trial. Acta Psychiatr Scand. 2007;116:226–32. [PubMed] [Google Scholar] +15. Varambally S, Gangadhar BN, Thirthalli J, Jagannathan A, Kumar S, Venkatasubramanian G, et al. Therapeutic efficacy of add-on +yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled comparison with exercise and waitlist. Indian J +Psychiatry. 2012;54:227–32. [PMC free article] [PubMed] [Google Scholar] +16. Umadevi P, Ramachandra S, Varambally S, Philip M, Gangadhar BN. Effect of yoga therapy on anxiety and depressive symptoms and +quality-of-life among caregivers of in-patients with neurological disorders at a tertiary care center in India: A randomized controlled trial. +Indian J Psychiatry. 2013;55(Suppl S3):385–9. [PMC free article] [PubMed] [Google Scholar] +17. Guy W, editor. ECDEU Assessment Manual for Psychopharmacology. Rockville, MD: U.S. Department of Health, Education, and +Welfare; 1976. [Google Scholar] +Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow Publications diff --git a/subfolder_0/Development and Validation of a Need-Based Integrated yoga program for cancer patients_unlocked.txt b/subfolder_0/Development and Validation of a Need-Based Integrated yoga program for cancer patients_unlocked.txt new file mode 100644 index 0000000000000000000000000000000000000000..a18f4ec2183472b42d9d455cd5c94c1336627b01 --- /dev/null +++ b/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: amritram@gmail.com +** Correspondence Email: rnagaratna@gmail.com +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. + + +References + +[1] +World Health Organization. World health Report +factsheet [Internet]. Factsheet. 2012 [cited 2012 Apr +24]. Available from http://www.who.int/mediacentre/ +factsheets/fs297/en/index.html +[2] +Cancer IA for R in. No Title [Internet]. 2008. Available +from: http://globocan.iarc.fr/ +[3] +Gupta M, Shafiq N, Kumari S, Pandhi P. Patterns and +perceptions of complementary and alternative medicine +(CAM) among leukaemia patients visiting haematology +clinic of a north Indian tertiary care hospital. +Pharmacoepidemiology and drug safety [Internet]. 2002 +Dec [cited 2012 Apr 16];11(8):671–6. Available from: +http://www.ncbi.nlm.nih.gov/pubmed/12512243. +[4] +Heddleston JM, Li Z, Lathia JD, Bao S, Hjelmeland +AB, Rich JN. Hypoxia inducible factors in cancer stem +cells. British journal of cancer [Internet]. 2010 Mar 2 +[cited 2012 Jul 16];102(5):789–95. Available from: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?ar +tid=2833246&tool=pmcentrez&rendertype=abstract +[5] +Mimeault M, Batra SK. Concise review: recent +advances on the significance of stem cells in tissue +regeneration and cancer therapies. Stem cells (Dayton, +Ohio) +[Internet]. +2006 +Nov +[cited +2012 +Aug +4];24(11):2319–45. Available from: http://www.ncbi. +nlm.nih.gov/pubmed/16794264 +[6] +Kulkarni DD, Bera TK. Yogic exercises and health--a +psycho-neuro immunological approach. Indian journal +of physiology and pharmacology [Internet]. [cited 2012 +Aug 4];53(1):3–15. Available from: http://www. +ncbi.nlm.nih.gov/pubmed/19810571 +[7] +Bhargav H, Raghuram N, Nagendra HR, Tekur P, Koka +PS. +Potential +yoga +modules +for +treatment +of +hematopoietic inhibition in HIV-1 infection. Journal of +stem cells [Internet]. 2010 Jan [cited 2012 Aug +4];5(3):129–48. +Available +from: +http://www. +ncbi.nlm.nih.gov/pubmed/22314829 +[8] +Ross A, Thomas S. The health benefits of yoga and +exercise: a review of comparison studies. Journal of +alternative and complementary medicine (New York, +N.Y.) [Internet]. 2010 Jan [cited 2012 Aug 4];16(1):3– +Amritanshu Ram, Nagarathna Raghuram, Raghavendra M. Rao et al. + +280 +12. +Available +from: +http://www.ncbi.nlm.nih.gov/ +pubmed/20105062 +[9] +Black DS, Cole SW, Irwin MR, Breen E, St Cyr NM, +Nazarian N, et al. Yogic meditation reverses NF-κB and +IRF-related transcriptome dynamics in leukocytes of +family dementia caregivers in a randomized controlled +trial. Psychoneuroendocrinology [Internet]. 2012 Jul 13 +[cited 2012 Aug 4]; Available from: http://www.ncbi. +nlm.nih.gov/pubmed/22795617 +[10] +Carlson LE. Mindfulness-Based Stress Reduction in +Relation to Quality of Life, Mood, Symptoms of Stress, +and Immune Parameters in Breast and Prostate Cancer +Outpatients. Psychosomatic Medicine [Internet]. 2003 +Jul 1 [cited 2011 Jul 11];65(4):571–81. Available from: +http://www.psychosomaticmedicine.org/cgi/doi/10.1097 +/01.PSY.0000074003.35911.41. +[11] +Yadav RK, Magan D, Mehta N, Sharma R, Mahapatra +SC. Efficacy of a short-term yoga-based lifestyle +intervention in reducing stress and inflammation: +preliminary +results. +Journal +of +alternative +and +complementary medicine (New York, N.Y.) [Internet]. +2012 Jul [cited 2012 Aug 4];18(7):662–7. Available +from: http://www.ncbi.nlm.nih.gov/pubmed/22830969 +[12] +Rao RM, Telles S, Nagendra HR, Nagarathna R, +Gopinath K, Srinath S, et al. Effects of yoga on natural +killer cell counts in early breast cancer patients +undergoing conventional treatment. Comment to: +recreational music-making modulates natural killer cell +activity, cytokines, and mood states in corporate +employees Masatada Wachi. Medical science monitor: +international medical journal of experimental and +clinical research [Internet]. 2008 Feb [cited 2012 Aug +4];14(2):LE3–4. +Available +from: +http://www.ncbi. +nlm.nih.gov/pubmed/18227770 +[13] +Nagarathna R, Vinay C, Chandrashekara S, Gopinath +KS, Srinath BS, Rao RM, et al. Influence of yoga on +postoperative outcomes and wound healing in early +operable breast cancer patients undergoing surgery. +International +journal +of +yoga +[Internet]. +2008 +Jan;1(1):33–41. Available from: http://www.ncbi.nlm. +nih.gov/pubmed/21829279 +[14] +Gopal A, Mondal S, Gandhi A, Arora S, Bhattacharjee +J. Effect of integrated yoga practices on immune +responses in examination stress - A preliminary study. +International journal of yoga [Internet]. 2011 Jan [cited +2012 +Aug +4];4(1):26–32. +Available +from: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?ar +tid=3099098&tool=pmcentrez&rendertype=abstract +[15] +Kiecolt-Glaser JK, Christian L, Preston H, Houts CR, +Malarkey WB, Emery CF, et al. Stress, inflammation, +and yoga practice. Psychosomatic medicine [Internet]. +2010 Feb [cited 2012 Mar 4];72(2):113–21. Available +from: http://www.pubmedcentral.nih.gov/articlerender. +fcgi?artid=2820143&tool=pmcentrez&rendertype=abstr +act +[16] +Culos-Reed SN, Carlson LE, Daroux LM, Hately- +Aldous S. A pilot study of yoga for breast cancer +survivors: physical and psychological benefits. Psycho- +oncology [Internet]. 2006 Oct;15(10):891–7. Available +from: http://www.ncbi.nlm.nih.gov/pubmed/16374892 +[17] +Lin K-Y, Hu Y-T, Chang K-J, Lin H-F, Tsauo J-Y. +Effects of yoga on psychological health, quality of life, +and physical health of patients with cancer: a meta- +analysis. +Evidence-based +complementary +and +alternative medicine: eCAM [Internet]. 2011 Jan [cited +2011 +Jul +27];2011:659876. +Available +from: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?ar +tid=3062158&tool=pmcentrez&rendertype=abstract +[18] +Carlson LE, Speca M, Faris P, Patel KD. One year pre- +post intervention follow-up of psychological, immune, +endocrine and blood pressure outcomes of mindfulness- +based stress reduction (MBSR) in breast and prostate +cancer outpatients. Brain, behavior, and immunity +[Internet]. 2007 Nov [cited 2012 Mar 14];21(8):1038– +49. +Available +from: +http://www.ncbi.nlm.nih.gov/ +pubmed/17521871 +[19] +Cohen L, Warneke C, Fouladi RT, Rodriguez MA, +Chaoul-Reich A. Psychological adjustment and sleep +quality in a randomized trial of the effects of a Tibetan +yoga intervention in patients with lymphoma. Cancer +[Internet]. +2004 +May +15 +[cited +2012 +Mar +28];100(10):2253–60. +Available +from: +http://www.ncbi.nlm.nih.gov/pubmed/15139072 +[20] +Monti DA, Peterson C, Kunkel EJS, Hauck WW, +Pequignot E, Rhodes L, et al. A randomized, controlled +trial of mindfulness-based art therapy (MBAT) for +women with cancer. Psycho-oncology [Internet]. 2006 +May [cited 2012 Aug 4];15(5):363–73. Available from: +http://www.ncbi.nlm.nih.gov/pubmed/16288447 +[21] +Danhauer SC, Tooze JA, Farmer DF, Campbell CR, +Mcquellon RP, Barrett R, et al. Restorative Yoga for +Women with Ovarian or Breast Cancer: Findings from a +Pilot Study. Journal of the Society for Integrative +Oncology. 2008;6(2):47–58. +[22] +Moadel AB, Shah C, Wylie-Rosett J, Harris MS, Patel +SR, Hall CB, et al. Randomized controlled trial of yoga +among a multiethnic sample of breast cancer patients: +effects on quality of life. Journal of clinical oncology: +official journal of the American Society of Clinical +Oncology [Internet]. 2007 Oct 1 [cited 2011 Jan +23];25(28):4387–95. Available from: http://www.ncbi. +nlm.nih.gov/pubmed/17785709 +[23] +Rao RM, Nagendra RH, Nagarathna R, C V, S C, S GK, +et al. Influence of yoga on mood states, distress, quality +of life and immune outcomes in early stage breast +cancer patients undergoing surgery. International +journal of yoga [Internet]. 2008 Jan;1(1):11–20. +Available +from: +http://www.ncbi.nlm.nih.gov/ +pubmed/21829279 +[24] +Rao RM, Nagarathna R, Nagendra RH, Gopinath KS, +Srinath BS, Ravi BD, et al. Effects of an integrated yoga +Development and Validation of a Need-Based Integrated Yoga Program for Cancer Patients + +281 +programme on chemotherapy- induced nausea and +emesis in breast cancer patients. European Journal of +Cancer Care [Internet]. 2006 Nov;16(6):462–74. +Available +from: +http://www.ncbi.nlm.nih.gov/ +pubmed/17944760 +[25] +Rao RM, Nagarathna R, Nagendra RH, Gopinath KS, +Srinath BS, Diwakar RB, et al. Anxiolytic effects of a +yoga program in early breast cancer patients undergoing +conventional treatment: a randomized controlled trial. +Complementary therapies in medicine [Internet]. 2009 +Jan [cited 2011 Jul 27];17(1):1–8. Available from: +http://dx.doi.org/10.1016/j.ctim.2008.05.005 +[26] +Banerjee B, Vadiraj HS, Ram A, Rao RM, Jayapal M, +Gopinath KS, et al. Effects of an integrated yoga +program in modulating psychological stress and +radiation-induced genotoxic stress in breast cancer +patients undergoing radiotherapy. Integrative cancer +therapies [Internet]. 2007 Sep [cited 2010 Dec +22];6(3):242–50. Available from: http://ict.sagepub.com +/cgi/content/abstract/6/3/242 +[27] +Vadiraja HS, Raghavendra RM, Nagarathna R, +Nagendra HR, Rekha M, Vanitha N, et al. Effects of a +yoga program on cortisol rhythm and mood states in +early breast cancer patients undergoing adjuvant +radiotherapy: a randomized controlled trial. Integrative +cancer therapies [Internet]. 2009 Mar [cited 2012 Mar +16];8(1):37–46. +Available +from: +http://online. +sagepub.com +[28] +Vadiraja HS, Rao RM, Nagarathna R, Nagendra RH, +Rekha M, Vanitha N, et al. Effects of yoga program on +quality of life and affect in early breast cancer patients +undergoing adjuvant radiotherapy: a randomized +controlled trial. Complementary therapies in medicine +[Internet]. 2010 [cited 2011 Jan 23];17(5-6):274–80. +Available +from: +http://www.ncbi.nlm.nih.gov/ +pubmed/19942107 +[29] +Vadiraja SH, Rao MR, Nagendra RH, Nagarathna R, +Rekha M, Vanitha N, et al. Effects of yoga on symptom +management in breast cancer patients: A randomized +controlled trial. International journal of yoga [Internet]. +2009 Jul [cited 2012 Apr 16];2(2):73–9. Available +from: http://www.pubmedcentral.nih.gov/articlerender. +fcgi?artid=2933732&tool=pmcentrez&rendertype=abstr +act +[30] +Gambhirananda S. Taittiriya Upanishad. 1st ed. +Kolkata: Advaithashrama; 2010. +[31] +Easwaran E. Three Upanishads: Isha, Mandukya, and +Shvetashvatara. 1st ed. California: Nilgiri Press; 1973. +[32] +Sankaracharya. Tattva Bodha. 1st ed. Bangalore: +Chinmaya Mission Trust; 1986. +[33] +Tapasyananda S. Bhagavat Gita. Economy Ed. +Mylapore: Math, Sri Ramakrishna; +[34] +Taimni IK. The Yoga Sutras of Patanjali. 1st ed. Quest +Books; 1999. +[35] +Sharma RK, Dash VB. Caraka Samhita. Varanasi: +Chowkhamba Sanskrit Series Office; 2007. p. 342 and +577. +[36] +Mankad ZM. Clinical study of role of Rasayana as a pre +adjuvant and post treatment of Chemotherapy in the +management +of +Carcinoma. +Jamnagar, +Gujarat +Ayurveda University; 2007. +[37] +Acharya VJT. Sushrutha Samhita by Sri Dalhanacharya. +Varanasi: Chowkhamba Krishnadas academy; 2008. +[38] +Mehta CS, Joshi VR. Anti-Ageing drungs in Ayurveda. +IJGHC. 2012;1(1):61–74. +[39] +Raghuram N, Nagendra HR. Yoga and Cancer. +Bangalore: SVYP; 1997. +[40] +Spiegel D, Bloom JR, Yalom I. Group Support for +Patients With Metastatic Cancer: A Randomized +Prospective Outcome Study. Archives of General +Psychiatry [Internet]. 1981 May 1 [cited 2012 Apr +23];38(5):527–33. Available from: http://archpsyc.ama- +assn.org/cgi/content/abstract/38/5/527 +[41] +Carlson LE, Garland SN. Impact of mindfulness-based +stress reduction (MBSR) on sleep, mood, stress and +fatigue symptoms in cancer outpatients. International +journal of behavioral medicine [Internet]. 2005 Jan +[cited 2012 Apr 18];12(4):278–85. Available from: +http://www.ncbi.nlm.nih.gov/pubmed/16262547 +[42] +Lengacher CA, Johnson-mallard V, Post-white J, +Moscoso MS, Jacobsen PB, Klein TW, et al. +Randomized controlled trial of mindfulness-based stress +reduction ( MBSR ) for survivors of breast cancer. +Psycho-Oncology. 2009;1272(February):1261–72. +[43] +Carson JW, Carson KM, Porter LS, Keefe FJ, Seewaldt +VL. Yoga of Awareness program for menopausal +symptoms in breast cancer survivors: results from a +randomized trial. Supportive care in cancer: official +journal of the Multinational Association of Supportive +Care in Cancer [Internet]. 2009 Oct [cited 2011 Jul +27];17(10):1301–9. Available from: http://www.ncbi. +nlm.nih.gov/pubmed/19214594 +[44] +Carson JW, Carson KM, Porter LS, Keefe FJ, Shaw H, +Miller JM. Yoga for women with metastatic breast +cancer: results from a pilot study. Journal of pain and +symptom management [Internet]. 2007 Mar [cited 2012 +Mar 28];33(3):331–41. Available from: http://www. +ncbi.nlm.nih.gov/pubmed/17349503 +[45] +Mustian KM, Morrow GR, Carroll JK, Figueroa- +Moseley CD, Jean-Pierre P, Williams GC. Integrative +nonpharmacologic behavioral interventions for the +management of cancer-related fatigue. The oncologist +[Internet]. 2007 Jan [cited 2012 Feb 29];12 Suppl 1:52– +67. +Available +from: +http://www.ncbi.nlm.nih.gov/ +pubmed/17573456 +[46] +TACON AM. Mindfulness effects on symptoms of +distress in women with cancer. Journal of cancer pain +& symptom palliation [Internet]. Haworth Medical +Press; 2006 [cited 2012 Apr 18];2(2):17–22. Available +Amritanshu Ram, Nagarathna Raghuram, Raghavendra M. Rao et al. + +282 +from: +http://cat.inist.fr/?aModele=afficheN&cpsidt +=18736964 +[47] +Duncan MD, Leis A, Taylor-Brown JW. Impact and +outcomes of an Iyengar yoga program in a cancer +centre. Current oncology [Internet]. 2008 Aug;5(2):72– +8. Available from: http://www.pubmedcentral.nih.gov/ +articlerender.fcgi?artid=2528557&tool=pmcentrez&ren +dertype=abstract +[48] +Tacón AM, Caldera YM, Ronaghan C. Mindfulness- +Based Stress Reduction in Women With Breast Cancer. +Families, Systems, & Health [Internet]. 2004 [cited +2012 +Mar +9];22(2):193–203. +Available +from: +http://doi.apa.org/getdoi.cfm?doi=10.1037/1091- +7527.22.2.193 +[49] +Duijts SFA, Faber MM, Oldenburg HSA, Beurden MV. +Effectiveness of behavioral techniques and physical +exercise on psychosocial functioning and health-related +quality of life in breast cancer patients and survivors — +a meta-analysis. Psycho-Oncology. 2011;20:115–26. +[50] +Lemieux J, Goodwin PJ, Bordeleau LJ, Lauzier S, +Théberge +V. +Quality-of-life +measurement +in +randomized clinical trials in breast cancer: an updated +systematic review (2001-2009). Journal of the National +Cancer Institute [Internet]. 2011 Feb 2 [cited 2011 Jul +27];103(3):178–231. Available from: http://jnci.oxford +journals.org/cgi/content/abstract/103/3/178 +[51] +Beachy PA, Karhadkar SS, Berman DM. Tissue repair +and stem cell renewal in carcinogenesis. Nature +[Internet]. +2004 +Nov +18 +[cited +2012 +Jul +28];432(7015):324–31. +Available +from: +http://www.ncbi.nlm.nih.gov/pubmed/15549094 +[52] +Bao S, Wu Q, McLendon RE, Hao Y, Shi Q, +Hjelmeland AB, et al. Glioma stem cells promote +radioresistance by preferential activation of the DNA +damage response. Nature [Internet]. 2006 Dec 7 [cited +2012 Jul 15];444(7120):756–60. Available from: +http://www.ncbi.nlm.nih.gov/pubmed/17051156 +[53] +Zhang M, Dias P, Minev B, Koka PS. Induction, +isolation +and +characterization +human +fetal +hematopoietic cancer stem cells in vivo. J Stem Cells +2010; 5(1): 1-7. +[54] +Cipolleschi MG, Dello Sbarba P, Olivotto M. The role +of hypoxia in the maintenance of hematopoietic stem +cells. Blood [Internet]. 1993 Oct 1 [cited 2012 Aug +6];82(7):2031–7. Available from: http://www.ncbi.nlm. +nih.gov/pubmed/8104535. +[55] +Gupta RK, Telles S, Balkrishna A. Effect of Two Yogic +Breathing Techniques on Oxygen Saturation. Indian +journal +of +physiology +and +pharmacology. +2011;5(5):Supplementary. + + + + + + diff --git a/subfolder_0/Development and feasibility of need based yoga program for.txt b/subfolder_0/Development and feasibility of need based yoga program for.txt new file mode 100644 index 0000000000000000000000000000000000000000..7c22f18835cb1b6f032be3e69523f51ae52281d6 --- /dev/null +++ b/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: jaganaarti@gmail.com +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. +3. +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 +Complement Alternat Med 2007;4:519-29. +5. +Waelde LC, Thompson L, Gallagher-Thompson D. A pilot study of a yoga +and meditation intervention for dementia caregiver stress. J Clin Psychol +2004;60:677-87. +6. +Peeters JM, Van Beek AP, Meerveld JH, Spreeuwenberg PM, Francke AL. +Informal caregivers of persons with dementia, their use of and needs for +specific professional support: A survey of the National Dementia Program. +BMC Nurs 2010;9:9. +7. +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 +Geriatr 2010;51:54-8. +8. +Lai CK, Chung JC. Caregivers’ informational needs on dementia and dementia +care. Asian J Gerontol Geriatr 2007;2:78-87. +9. +Colantonio A, Cohen C, Pon M. Assessing support needs of caregivers +of persons with dementia: Who wants what? Community Ment Health J +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. +11. +Iyengar BK. Light on the yoga sutras of patanjali. London: Harper Collins +Publishers; 1993. +12. Sontakke NS, Rājvade VK, Vāsudevaśāstri MM, Varadarājaśarmā TS. +Rigveda-Samhitā: Śrimat-Sāyanāchārya virachita-bhāṣya-sametā (First ed.). +Pune, India: Vaidika Samśodhana Mandala; 1933. +13. Swami Digambarji, Gharote ML. Gheranda Samhita. 1st ed. Lonavala (India): +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. +2) +RSS feeds + +Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal’s website. +You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. +RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add +www.ijoy.org.in/rssfeed.asp as one of the feeds. diff --git "a/subfolder_0/Development and validation of yoga module for Parkinson\342\200\231s Disease.txt" "b/subfolder_0/Development and validation of yoga module for Parkinson\342\200\231s Disease.txt" new file mode 100644 index 0000000000000000000000000000000000000000..e496e3bdd42b18a339b343f03b253a05ce393852 --- /dev/null +++ "b/subfolder_0/Development and validation of yoga module for Parkinson\342\200\231s 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 +167 PUBLICATIONS   1,637 CITATIONS    +SEE PROFILE +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: +noops1412@gmail.com, kgmhetre@gmail.com +2 Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS] Bangalore, Bangalore, India, +E-mail: drvarambally@gmail.com +3 Holistic Health Centre, S-VYASA Bangalore, Bangalore, India, E-mail: rnagaratna@gmail.com +4 S-VYASA University, Bangalore, Bangalore, India, E-mail: hrn1943@gmail.com +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 | kgmhetre@gmail.com 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 | kgmhetre@gmail.com 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 | kgmhetre@gmail.com 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 | kgmhetre@gmail.com 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 | kgmhetre@gmail.com 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 | kgmhetre@gmail.com 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. +References +[1] Ramaker C, Marinus J, Stiggelbout AM, Van Hilten BJ. Systematic evaluation of rating scales for impairment and disability in Parkinson’s +disease. Mov Disord. 2002;17:867–876. +[2] Jankovic J. Parkinson’s disease: Clinical features and diagnosis. J Neurol Neurosurg Psychiatry. 2008;79:368–376. +[3] Gupta BM, Bala A. Parkinson’s disease in India: An analysis of publications output during 2002-2011. Int J Nutr Pharmacol Neurol Dis. +2013;3:254. +[4] Rajendran PR, Thompson RE, Reich SG. The use of alternative therapies by patients with Parkinson’s disease. Neurology. +2001;57:790–794. +[5] Benito-León J, Bermejo-Pareja F, Rodríguez J, Molina JA, Gabriel R, Morales JM. Prevalence of PD and other types of parkinsonism in three +elderly populations of central Spain. Mov Disord. 2003;18:267–274. +[6] Whetten-Goldstein K, Sloan F, Kulas E, Cutson T, Schenkman M. The burden of Parkinson’s disease on society, family, and the individual. J +Am Geriatr Soc. 1997;45:844–849. +[7] Williams A, Gill S, Varma T, Jenkinson C, Quinn N, Mitchell R, et al. Deep brain stimulation plus best medical therapy versus best medical +therapy alone for advanced Parkinson’s disease (PD SURG trial): A randomised, open-label trial. Lancet Neurol. 2010;9:581–591. +[8] Rascol O, Payoux P +, Ory F, Ferreira JJ, Brefel-Courbon C, Montastruc JL. Limitations of current Parkinson’s disease therapy. Ann Neurol. +2003;53:3–15 S. +[9] Vedanthan PK, Kesavalu LN, Murthy KC, Duvall K, Hall MJ, Baker S, et al. Clinical study of yoga techniques in university students with +asthma: A controlled study. Allergy and asthma proceedings. Providence: Ocean Side Publications, Inc., 1998:3–9. +[10] Bijlani RL, Vempati RP +, Yadav RK, Ray RB, Gupta V, Sharma R, et al. A brief but comprehensive lifestyle education program based on yoga +reduces risk factors for cardiovascular disease and diabetes mellitus. J Altern Complement Med. 2005;11:267–274. +[11] 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;16:216–220. +[12] Visweswaraiah NK, Telles S. Randomized trial of yoga as a complementary therapy for pulmonary tuberculosis. Respirology. +2004;9:96–101. +[13] Naveen GH, Sinha S, Girish N, Taly AB, Varambally S, Gangadhar BN. Yoga and epilepsy: What do patients perceive?. Indian J Psychiatry. +2013;55:390. +[14] Carson JW, Carson KM, Jones KD, Bennett RM, Wright CL, Mist SD. A pilot randomized controlled trial of the yoga of awareness program +in the management of fibromyalgia. Pain. 2010;151:530–539. +[15] Oken BS, Kishiyama S, Zajdel D, Bourdette D, Carlsen J, Haas M, et al. Randomized controlled trial of yoga and exercise in multiple sclero- +sis. Neurology. 2004;62:2058–2064. +[16] Garfinkel MS, Singhal A, Katz WA, Allan DA, Reshetar R, Schumacher HR. Yoga-based intervention for carpal tunnel syndrome: A ran- +domized trial. Jama. 1998;280:1601–1603. +[17] John PJ, Sharma N, Sharma CM, Kankane A. E昀fectiveness of yoga therapy in the treatment of migraine without aura: A randomized con- +trolled trial. Headache. 2007;47:654–661. +[18] Schmid AA, Van Puymbroeck M, Altenburger PA, Schalk NL, Dierks TA, Miller KK, et al. Poststroke balance improves with yoga. Stroke. +2012;43:2402–2407. +[19] Tran MD, Holly RG, Lashbrook J, Amsterdam EA. E昀fects of Hatha yoga practice on the health-related aspects of physical fitness. Prev +Cardiol. 2001;4:165–170. +[20] Oken BS, Zajdel D, Kishiyama S, Flegal K, Dehen C, Haas M, et al. Randomized, controlled, six-month trial of yoga in healthy seniors: +E昀fects on cognition and quality of life. Altern Ther Health Me. 2006;12:40. +[21] DiBenedetto M, Innes KE, Taylor AG, Rodeheaver PF, Boxer JA, Wright HJ, et al. E昀fect of a gentle Iyengar yoga program on gait in the +elderly: An exploratory study. Arch Phys Med Rehabil. 2005;86:1830–1837. +[22] Bastille JV, Gill-Body KM. A yoga-based exercise program for people with chronic poststroke hemiparesis. Phys Ther. 2004;84:33. +[23] Mishra SK, Singh P +, Bunch SJ, Zhang R. The therapeutic value of yoga in neurological disorders. Ann Indian Acad Neurol. 2012;15:247. +[24] Velikonja O, Čurić K, Ožura A, Jazbec SŠ. Inflluence of sports climbing and yoga on spasticity, cognitive function, mood and fatigue in +patients with multiple sclerosis. Clin Neurol Neurosurg. 2010;112:597–601. +[25] Ahmadi A, Nikbakh M, Arastoo A, Habibi AH. The e昀fects of a yoga intervention on balance, speed and endurance of walking, fatigue and +quality of life in people with multiple sclerosis. J Hum Kinet. 2010;23:71–78. +[26] Lynton H, Kligler B, Shifllett S. Yoga in stroke rehabilitation: A systematic review and results of a pilot study. Top Stroke Rehabil. +2007;14:1–8. +[27] Colgrove YS, Sharma N, Kluding P +, Potter D, Imming K, VandeHoef J. E昀fect of yoga on motor function in people with Parkinson’s disease: +A randomized, controlled pilot study. J Yoga Phys Ther. 2012;2:112. +[28] Roland KP +. Applications of yoga in Parkinson’s disease: A systematic literature review. J Perkins Rests Legs Syndr. 2014;4:1–8. +[29] Lee L. The e昀fect of yoga exercises on balance, lower-extremity function and gait in people with Parkinson’s disease. Arch Physical Med +Rehabil. 2006;87. +[30] Scott M, Masterson M, Elmer L, et al. P2.160 The e昀fects of a yoga program on Parkinson’s disease. Parkinsonism Relat Disord. +2009;15:133 S. +[31] Roland KP +. Applications of yoga in Parkinson’s disease: A systematic literature review. J Parkinsonism Restless Legs Synd. 2014;4:1–8. +Authenticated | kgmhetre@gmail.com author's copy +Download Date | 6/16/17 1:17 PM +Kakde et al. +DE GRUYTER +[32] Moriello G, Denio C, Abraham M, DeFrancesco D, Townsley J. Incorporating yoga into an intense physical therapy program in someone +with Parkinson’s disease: A case report. J Bodyw Mov Ther. 2013;17:408–417. +[33] Uhrbrand A, Stenager E, Pedersen MS, Dalgas U. Parkinson’s disease and intensive exercise therapy–a systematic review and meta- +analysis of randomized controlled trials. J Neurol Sci. 2015;353:9–19. +[34] Manyam BV, Sanchez-Ramos JR. Traditional and complementary therapies in Parkinson’s disease. Adv Neurol. 1998;80:565–574. +[35] Katzenschlager R, Evans A, Manson A, Patsalos PN, Ratnaraj N, Watt H, et al. Mucuna pruriens in Parkinson’s disease: A double blind +clinical and pharmacological study. J Neurol Neurosurg Psychiatry. 2004;75:1672–1677. +[36] Digamberji S, Gharote ML. Gheranda Samhita. Lonavala, India: Kaivalyadhama S.M.Y.M Samiti, 1997. +[37] Digambarji S, Kokaje RS. Hathapradipika of Svatmarama. Lonavala, India: Kaivalyadhama, S.M.Y.M. Samiti, 1998. +[38] Gharote ML, Devnath P +, Jha VK. Hathatatvakaumudi: A treatise on HathaYoga by Sundaradeva. Lonavla, India: The Lonavla Yoga Insti- +tute (India), 2007. +[39] Gharote ML, Devnath P +, Jha VK. Hatharatnavali of Srinivasayogi. Lonavla: The Lonavla Yoga Institute (India), 2002. +[40] Desikachar TK, Krishnamacharya T. Nathamuni’s yoga rahasya. Chennai, India: Krishnamacharya Yoga Mandiram, 1998. +[41] Taimni IK. The science of yoga: A commentary on the yoga sutras of patanjali in the light of modern thought, 5th ed. Illinois: Theosophi- +cal Publishing House, 1992. +[42] Svatmarama. Hatha Yoga Pradipika of Svatmarama, 4th ed. Madras: Adyar Library and Research Centre, 1994. +[43] Cohen AD, Tillerson JL, Smith AD, Schallert T, Zigmond MJ. Neuroprotective e昀fects of prior limb use in 6-hydroxydopamine-treated rats: +Possible role of GDNF. J Neurochem. 2003;85:299–305. +[44] Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction +intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry. 1995;17:192–200. +[45] Hall E, Verheyden G, Ashburn A. E昀fect of a yoga programme on an individual with Parkinson’s disease: A single-subject design. Disabil +Rehabil. 2011;33:1483–1489. +[46] Lawshe CH. A quantitative approach to content validity. Pers Psychol. 1975;28:563–575. +[47] Taylor M. Yoga therapeutics in neurological physical therapy: Application to a patient with Parkinson’s disease. Jnpt. 2001;25:55–62. +Authenticated | kgmhetre@gmail.com author's copy +Download Date | 6/16/17 1:17 PM +View publication stats +View publication stats diff --git a/subfolder_0/Diet enriched with fresh coconut decreases blood glucose levels and body weight in normal adults.txt b/subfolder_0/Diet enriched with fresh coconut decreases blood glucose levels and body weight in normal adults.txt new file mode 100644 index 0000000000000000000000000000000000000000..62957d093b8cd04b47c5b6152984b499a0638b24 --- /dev/null +++ b/subfolder_0/Diet enriched with fresh coconut decreases blood glucose levels and body weight in normal adults.txt @@ -0,0 +1,453 @@ +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: dr.mooventhan@gmail.com +3 Division of Yoga and Life Sciences,Department of Research and Development,S-VYASA University,Bengaluru,Karnataka, +India,E-mail: dr.mooventhan@gmail.com +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 +Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd +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 +Brought to you by | University of California - Santa Barbara +Authenticated +Download Date | 2/27/18 5:46 PM +Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd +DE GRUYTER +Vijayakumar et al. +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 +Brought to you by | University of California - Santa Barbara +Authenticated +Download Date | 2/27/18 5:46 PM +Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd +Vijayakumar et al. +DE GRUYTER +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]. +4 +Brought to you by | University of California - Santa Barbara +Authenticated +Download Date | 2/27/18 5:46 PM +Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd +DE GRUYTER +Vijayakumar et al. +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. +References +[1] Dash B,Sharma R.Caraka Samhita.Varanasi,Uttar Pradesh,India: Chowkhamba Sanskrit Series Office,2009. +[2] Mehta P +.Shushrutha Samhita.Varanasi,Uttar Pradesh,India: Chowkhamba Sanskrit Series Office,1997. +5 +Brought to you by | University of California - Santa Barbara +Authenticated +Download Date | 2/27/18 5:46 PM +Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd +Vijayakumar et al. +DE GRUYTER +[3] Bakhru HK.The complete hand book of Nature Cure,5th ed.Delhi: Jaico Publishing House,2010. +[4] Gala DR,Gala D,Gala S.Nature Cure for common diseases.17th ed.Ahmadanbad: Navneet publications,2012. +[5] Sabitha P +,Vasudevan DM.Lipid profile and antioxidant enzymes in coconut oil consumers.Indian Coconut J.2010;72:3–6. +[6] Hu FB,Van Dam RM,Liu S.Diet and risk of Type II diabetes: the role of types of fat and carbohydrate.Diabetologia.2001;44:805–17. +[7] WHO.Global status report on noncommunicable diseases 2014.World Health,2014. +[8] Mohan V,Sandeep S,Deepa R,Shah B,Varghese C.Epidemiology of type 2 diabetes: Indian scenario.Indian J Med Res.2007;125:217–30. +[9] Nevin KG,Rajamohan T.Beneficial effects of virgin coconut oil on lipid parameters and in vitro LDL oxidation.Clin Biochem. +2004;37:830–35. +[10] Pehowich DJ,Gomes AV,Barnes JA.Fatty acid composition and possible health effects of coconut constituents.West Indian Med J. +2000;49:128–33. +[11] Astrup A,Dyerberg J,Elwood P +,Hermansen K,Hu FB,Jakobsen MU,et al.The role of reducing intakes of saturated fat in the prevention of +cardiovascular disease : where does the evidence stand in 2010? Am J Clin Nutr.2011;93:684–88. +[12] Kumar PD.The role of coconut and coconut oil in coronary heart disease in Kerala,south India.Trop Doct.1997;27:215–17. +[13] Siri-Tarino PW,Sun Q,Hu FB,Krauss RM.Meta-analysis of prospective cohort studies evaluating the association of saturated fat with +cardiovascular disease.Am J Clin Nutr.2010;91:535–46. +[14] Gopalan C,Sastri BVR,Balasubramanian SC.Nutritive value of Indian foods,1st ed.Hyderabad: National Institute of Nutrition,ICMR. +2012. +[15] Mozaffarian D,Appel LJ,Van Horn L.Components of a cardioprotective diet: new insights.Circulation.2011;123:2870–91. +[16] Ley SH,Hamdy O,Mohan V,Hu FB.Prevention and management of type 2 diabetes: dietary components and nutritional strategies. +Lancet.2014;383:1999–2007. +[17] Blundell J,Burley V Satiation,satiety and the action of fibre on food intake Int J Obes.1987;11:Suppl 1:9–25. +[18] Burton-Freeman B.Do we need to look beyond dietary fat?.J Nutr.2000;130:272–75. +[19] Slavin J.Dietary fiber and body weight.Nutrition.2005;21:411–18. +[20] Howarth NC.Dietary fiber & weight regulation.Nutr Rev.2009;59:129–39. +[21] Delzenne NM,Cani PD.A place for dietary fibre in the management of the metabolic syndrome.Curr Opin Clin Nutr Metab Care. +2005;8:636–40. +[22] Raghavarao KSMS,Raghavendra SN,Rastogi NK.Potential of coconut dietary fiber.Indian Coconut J.2008;51:2–7. +[23] Slavin J,Lloyd B.Health benefits of fruits and vegetables.Adv Nutr.2012;3:506–16. +[24] Torre M,Rodriguez AR,Saura-Calixto F.Effects of dietary fiber and phytic acid on mineral availability.Crit Rev Food Sci Nutr J. +1991;30:1–22. +[25] Kritchevsky D.Dietary fiber and disease.Bull N Y Acad Med.1982;58:230–41. +[26] ICMR.Nutrient requirements & recommended dietary allowance for Indians.2010. +[27] Andre BBV.Medium-chain triglycerides: an update.Am J Clin Nutr.1982;36:950–62. +[28] Clegg ME.Medium-chain triglycerides are advantageous in promoting weight loss although not beneficial to exercise performance.Int J +Food Sci Nutr.2010;61:653–79. +[29] St-Onge M-P +,Jones PJH.Recent advances in nutritional sciences physiological effects of medium- chain triglycerides : potential of obe- +sity.Clin Trials.2002;132:329–32. +[30] Krotkiewski M.Value of very low calorie diet (VLCD) supplementation with medium chain triglycerides.Int J Obes Relat Metab Disord. +2001;25:1393–400. +[31] Babio N,Balanza R,Basulto J,Bulló M,Salas-Salvadó J.Dietary fibre: influence on body weight,glycemic control and plasma cholesterol +profile.Nutr Hosp.2010;25:327–40. +[32] Lattimer JM,Haub MD.Effects of dietary fiber and its components on metabolic health.Nutrients.2010;2:1266–89. +[33] Brand C.Importance of glycemic index in diabetes3.Am J Nutr.1994;59:7475–525. +[34] Fujii H,Iwase M,Ohkuma T,Ogata-Kaizu S,Ide H,Kikuchi Y,et al.Impact of dietary fiber intake on glycemic control,cardiovascular risk +factors and chronic kidney disease in Japanese patients with type 2 diabetes mellitus: the Fukuoka diabetes registry.Nutr J.2013;12:159. +[35] Kendall CWC,Esfahani A,Jenkins DJA.The link between dietary fibre and human health.Food Hydrocoll.2010;24:42–48. +[36] Chanalia M.Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus.N Engl J Med.2015;342:1392–98. +[37] Salil G,Kg N,Rajamohan T.Coconut kernel-derived proteins enhance hypolipidemic and antioxidant activity in alloxan-induced diabetic +rats.Int J Food Sci Nutr.2013;64:327–32. +[38] Rosa S.Soluble fibre (Plantagoovata husk) reduces plasma low-density lipoprotein (LDL) cholesterol,triglycerides,insulin.Atherosclero- +sis.2010;211:630–37. +[39] Nagao K,Yanagita T.Medium-chain fatty acids: functional lipids for the prevention and treatment of the metabolic syndrome.Pharma- +col Res.2010;61:208–12. +[40] Shankar NR,Manjunath NK,Mavathur R,Venugopal V,Sreedhar P +,Sood A,et al.Impact of fresh coconut on dietary intake: a random- +ized comparative trial.Int J Educ Res Health Sci.2016;2:64–68. +[41] Hamsi MA,Othman F,Das S,Kamisah Y,Thent ZC,Qodriyah HMS,et al.Effect of consumption of fresh and heated virgin coconut oil +on the blood pressure and inflammatory biomarkers: an experimental study in Sprague–Dawley rats.Alexandria Journal of Medicine. +2015;51:53–63. +[42] Beegom R,Singh RB Association of higher saturated fat intake with higher risk of hypertension in an urban population of Trivandrum in +south India.Int J Cardiol.1997 Jan 3;58:63–70. +[43] Lindeberg S,Lundh B.Apparent absence of stroke and ischaemic heart disease in a traditional Melanesian island: a clinical study in Ki- +tava.J Intern Med.1993;233:269–75. +[44] Misra A,Singhal N,Sivakumar B,Bhagat N,Jaiswal A,Khurana L.Nutrition transition in India: secular trends in dietary intake and their +relationship to diet-related non-communicable diseases.J Diabetes.2011;3:278–92. +6 +Brought to you by | University of California - Santa Barbara +Authenticated +Download Date | 2/27/18 5:46 PM +Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd +DE GRUYTER +Vijayakumar et al. +[45] DebMandal M,Mandal S.Coconut (Cocosnucifera L.: arecaceae): in health promotion and disease prevention.Asian Pac J Trop Med. +2011;4:241–47. +[46] Renjith RS,Chikku AM,Rajamohan T Cytoprotective,antihyperglycemic and phytochemical properties of Cocosnucifera (L.) inflorescence. +Asian Pac J Trop Med.2013 Oct;6:804–10. +[47] Fernando WM,Martins IJ,Goozee KG,Brennan CS,Jayasena V,Martins RN The role of dietary coconut for the prevention and treatment +of Alzheimer’s disease: potential mechanisms of action.Br J Nutr.2015 Jul 14;114:1–14. +7 +Brought to you by | University of California - Santa Barbara +Authenticated +Download Date | 2/27/18 5:46 PM diff --git a/subfolder_0/Distribution of glycated haemoglobin and its determinants in Indian young adults.txt b/subfolder_0/Distribution of glycated haemoglobin and its determinants in Indian young adults.txt new file mode 100644 index 0000000000000000000000000000000000000000..aae4ada394ff11597d724d73f76870d8f946ea78 --- /dev/null +++ b/subfolder_0/Distribution of glycated haemoglobin and its determinants in Indian young adults.txt @@ -0,0 +1,1679 @@ +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: rnagaratna@gmail.com (R. Nagarathna), akshay1anand@rediffmail.com (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. +R E F E R E N C E S +[1] Lascar N, Brown J, Pattison H, Barnett AH, Bailey CJ, Bellary S. +Type 2 diabetes in adolescents and young adults. Lancet Diab +Endocrinol 2018;6(1):69–80. +[2] Arathi DNM. Risk of developing diabetes mellitus among +medical students in South India. J Evol Med Dental Sci-JEMDS +2015;55(4):9534–44. +[3] Shashank RJ, Das A, Vijay V, Mohan V. Challenges in diabetes +care in India: sheer numbers, lack of awareness and +inadequate control. J Assoc Phys India 2008;56(6):443–50. +[4] Feigin VL, Roth GA, Naghavi M, Parmar P, Krishnamurthi R, +Chugh S, et al. Global burden of stroke and risk factors in 188 +countries, during 1990–2013: a systematic analysis for the +Global Burden of Disease Study 2013. Lancet Neurol 2016;15 +(9):913–24. +[5] Dudeja P, Singh G, Gadekar T, Mukherji S. Performance of +Indian diabetes risk score (IDRS) as screening tool for +diabetes in an urban slum. Medical J Armed Forces India +2017;73(2):123–8. +[6] Lindstro +¨m J, Tuomilehto J. The diabetes risk score: a practical +tool to predict type 2 diabetes risk. Diabetes Care 2003;26 +(3):725–31. +[7] Wilson PW, Meigs JB, Sullivan L, Fox CS, Nathan DM, +D’Agostino RB. Prediction of incident diabetes mellitus in +middle-aged adults: the Framingham Offspring Study. Arch +Intern Med 2007;167(10):1068–74. +[8] Chen L, Magliano DJ, Balkau B, Colagiuri S, Zimmet PZ, +Tonkin AM, et al. AUSDRISK: an Australian Type 2 Diabetes +Risk Assessment Tool based on demographic, lifestyle and +simple anthropometric measures. Med J Aust 2010;192 +(4):197–202. +[9] Buijsse B, Simmons RK, Griffin SJ, Schulze MB. Risk +assessment tools for identifying individuals at risk of +developing type 2 diabetes. Epidemiol Rev 2011;33(1):46–62. +[10] Adhikari P, Pathak R, Kotian S. Validation of the mdrf-indian +diabetes risk score (idrs) in another south indian population +through the boloor diabetes study (bds). J Assoc Phys India +2010;58(434):6. +[11] Khan MM, Sonkar GK, Alam R, Mehrotra S, Khan MS, Kumar +A, et al. Validity of Indian Diabetes Risk Score and its +association with body mass index and glycosylated +hemoglobin for screening of diabetes in and around areas of +Lucknow. J Family Med Primary Care 2017;6(2):366. +[12] Awasthi A, Rao CR, Hegde DS. Association between type 2 +diabetes mellitus and anthropometric measurements–a case +control study in South India. J Preventive Med Hygiene +2017;58(1):E56. +[13] Nsiah-Kumi P, Lasley S, Whiting M, Brushbreaker C, Erickson +J, Qiu F, et al. Diabetes, pre-diabetes and insulin resistance +screening in Native American children and youth. Int J +Obesity 2013;37(4):540. +[14] Kaler SN, Ralph-Campbell K, Pohar S, King M, Laboucan CR, +Toth E. High rates of the metabolic syndrome in a First +Nations Community in western Canada: prevalence and +determinants in adults and children. Int J Circumpolar +Health 2006;65(5):389–402. +[15] Albers JJ, Marcovina SM, Imperatore G, Snively BM, Stafford J, +Fujimoto WY, et al. Prevalence and determinants of elevated +apolipoprotein B and dense low-density lipoprotein in youths +with type 1 and type 2 diabetes. J Clin Endocrinol Metab +2008;93(3):735–42. +[16] Association AD. Diagnosis and classification of diabetes +mellitus. Diabetes Care 2013;36(Suppl 1):S67–74. +[17] Pandey SK, Sharma V. World diabetes day 2018: battling the +emerging epidemic of diabetic retinopathy. Indian J +Ophthalmol 2018;66(11):1652. +[18] Nagendra H, Nagarathna R, Rajesh S, Amit S, Telles S, Hankey +A. Niyantrita Madhumeha Bharata 2017, methodology for a +nationwide diabetes prevalence estimate: Part 1. Int J Yoga +2019;12(3):179. +[19] Nagarathna R, Rajesh S, Amit S, Patil S, Anand A, Nagendra H. +Methodology of Niyantrita Madhumeha Bharata Abhiyaan- +2017, a nationwide multicentric trial on the effect of a +validated culturally acceptable lifestyle intervention for +primary prevention of diabetes: Part 2. Int J Yoga 2019;12 +(3):193. +[20] Pan J, Jia W. Early-onset diabetes: an epidemic in China. +Frontiers of medicine 2018;12(6):624–33. +[21] Suastika K, Dwipayana P, Semadi MS, Kuswardhani RT. Age is +an important risk factor for type 2 diabetes mellitus and +cardiovascular diseases. Glucose Tolerance 2012:67–80. +[22] Al-Saeed AH, Constantino MI, Molyneaux L, D’Souza M, +Limacher-Gisler F, Luo C, et al. An inverse relationship +between age of type 2 diabetes onset and complication risk +and mortality: the impact of youth-onset type 2 diabetes. +Diabetes Care 2016;39(5):823–9. +[23] Gutch M, Razi SM, Kumar S, Gupta KK. Diabetes mellitus: +Trends in northern India. Indian J Endocrinol Metab 2014;18 +(5):731. +[24] MacKay MF, Haffner SM, Wagenknecht LE, D’Agostino RB, +Hanley AJ. Prediction of type 2 diabetes using alternate +anthropometric measures in a multi-ethnic cohort: the +insulin resistance atherosclerosis study. Diabetes Care +2009;32(5):956–8. +[25] Seo J-Y, Hwang S-s, Kim JH, Lee YA, Lee SY, Shin CH, et al. +Distribution of glycated haemoglobin and its determinants in +Korean youth and young adults: a nationwide population- +based study. Sci Rep 2018;8(1):1962. +[26] Saaddine JB, Fagot-Campagna A, Rolka D, Narayan KV, Geiss +L, Eberhardt M, et al. Distribution of HbA1c levels for children +and young adults in the US: Third National Health and +Nutrition Examination Survey. Diabetes Care 2002;25 +(8):1326–30. +[27] Eldeirawi K, Lipton RB. Predictors of hemoglobin A1c in a +national sample of nondiabetic children: the Third National +Health and Nutrition Examination Survey, 1988–1994. Am J +Epidemiol 2003;157(7):624–32. +[28] Lipska KJ, Inzucchi SE, Van Ness PH, Gill TM, Kanaya A, +Strotmeyer ES, et al. Elevated HbA1c and fasting plasma +glucose in predicting diabetes incidence among older adults: +are two better than one?. Diabetes Care 2013;36(12):3923–9. +[29] Vijayakumar P, Nelson RG, Hanson RL, Knowler WC, Sinha M. +HbA1c and the prediction of type 2 diabetes in children and +adults. Diabetes Care 2017;40(1):16–21. +[30] Song B, Kim H, Lee J, Lee JM, Kim D, Lee YH, et al. +Performance of HbA1c for the prediction of diabetes in a rural +community in Korea. Diabet Med 2015;32(12):1602–10. +[31] Mohan V, Mathur P, Deepa R, Deepa M, Shukla D, Menon GR, +et al. Urban rural differences in prevalence of self-reported +diabetes in India—The WHO–ICMR Indian NCD risk factor +surveillance. Diabetes Res Clin Pract 2008;80(1):159–68. +[32] Anjana R, Pradeepa R, Deepa M, Datta M, Sudha V, +Unnikrishnan R, et al. Prevalence of diabetes and prediabetes +(impaired fasting glucose and/or impaired glucose tolerance) +in urban and rural India: Phase I results of the Indian Council +of Medical Research–INdia DIABetes (ICMR–INDIAB) study. +Diabetologia 2011;54(12):3022–7. +10 +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 +[33] Benrahma H, Arfa I, Charif M, Bounaceur S, Eloualid A, +Boulouiz R, et al. Maternal effect and familial aggregation in a +type 2 diabetic Moroccan population. J Community Health +2011;36(6):943–8. +[34] Mahajan S, Kaur P. Diabetes mellitus type II in school +children: risk evaluation and its genetic correlation. Int J Oral +Health Sci 2017;7(1):4. +[35] Gale EA, Gillespie KM. Diabetes and gender. Diabetologia +2001;44(1):3–15. +[36] Weerarathna T, Dissanayake A. Value of assessing post +prandial blood glucose as a surrogate for fasting blood +glucose in an outpatient medical clinic: a descriptive study. +Galle Med J 2009;11(1). +[37] Ketema EB, Kibret KT. Correlation of fasting and postprandial +plasma glucose with HbA1c in assessing glycemic control; +systematic review and meta-analysis. Arch Public Health +2015;73(1):43. +[38] Mooradian AD. Dyslipidemia in type 2 diabetes mellitus. Nat +Rev Endocrinol 2009;5(3):150. +[39] Kannel WB. Lipids, diabetes, and coronary heart disease: +insights from the Framingham Study. Am Heart J 1985;110 +(5):1100–7. +[40] Pulungan AB, Afifa IT, Annisa D. T +ype 2 diabetes mellitus in +children and adolescent: an Indonesian perspective. Ann +Pediatric Endocrinol Metab 2018;23(3):119. +[41] Hansel B, Giral P, Gambotti L, Lafourcade A, Peres G, Filipecki +C, et al. A fully automated web-based program improves +lifestyle habits and HbA1c in patients with type 2 diabetes +and abdominal obesity: randomized trial of patient E- +coaching nutritional support (The ANODE Study). J Med +Internet Res 2017;19(11):e360. +[42] Lim S, Meigs JB. Ectopic fat and cardiometabolic and vascular +risk. Int J Cardiol 2013;169(3):166–76. +[43] Khan A, Faheem M, Shah ST, Hadi A, Ullah R, Ahmad S, et al. +Frequency of abdominal obesity and its association with +diabetes mellitus among people of peshawar. J Ayub Med +College Abbottabad 2015;27(3):617–9. +[44] Goedecke JH, Micklesfield LK. The effect of exercise on +obesity, body fat distribution and risk for type 2 diabetes. +Diabetes and Physical Activity. 60: Karger Publishers; 2014. p. +82–93. +[45] Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, +White RD. Physical activity/exercise and type 2 diabetes: a +consensus statement from the American Diabetes +Association. Diabetes Care 2006;29(6):1433–8. +[46] Zinman B, Ruderman N, Campaigne B, Devlin J, Schneider S. +Physical activity/exercise and diabetes mellitus. Diabetes +Care 2003;26:S73. +[47] Jeon CY, Lokken RP, Hu FB, Van Dam RM. Physical activity of +moderate intensity and risk of type 2 diabetes: a systematic +review. Diabetes Care 2007;30(3):744–52. +[48] El-Kader SA, Gari A, El-Den AS. Impact of moderate versus +mild aerobic exercise training on inflammatory cytokines in +obese type 2 diabetic patients: a randomized clinical trial. +African Health Sciences 2013;13(4):857–63. +[49] Seshadri KG, Ananthakrishnan V, Tamilselvan B, Amarabalan +R, Kumar RN. Effect of mild physical activity in obese and +elderly women with type 2 diabetes. Indian J Endocrinol +Metab 2012;16(Suppl 2):S453. +[50] Sato Y, Nagasaki M, Kubota M, Uno T, Nakai N. Clinical +aspects of physical exercise for diabetes/metabolic +syndrome. Diabetes Res Clin Pract 2007;77(3):S87–91. +[51] Angadi P, Jagannathan A, Thulasi A, Kumar V, +Umamaheshwar K, Raghuram N. Adherence to yoga and its +resultant effects on blood glucose in type 2 diabetes: a +community-based follow-up study. Int J Yoga 2017;10(1):29. +[52] Jagannathan A, Narayanan V, Kulkarni I, Jogdand SP, Pailoor +S, Nagarathna R. Prevalence of type 2 diabetes among Yoga +practitioners: a pilot cross-sectional study in two districts in +India. Int J Yoga 2015;8(2):148. +[53] Madanmohan ABB, Dayanidy G, Sanjay Z, Basavaraddi IV. +Effect of yoga therapy on reaction time, biochemical +parameters and wellness score of peri and post-menopausal +diabetic patients. Int J Yoga 2012;5(1):10. +[54] More P, Jagannathan A. Pathways to care in type 2 diabetes +mellitus-Where does yoga find a place?. Int J Yoga 2015;8 +(2):164. +[55] Astrup A. Healthy lifestyles in Europe: prevention of obesity +and type II diabetes by diet and physical activity. Public +Health Nutr 2001;4(2b):499–515. +[56] Bazzano LA, Serdula M, Liu S. Prevention of type 2 diabetes by +diet and lifestyle modification. J Am Coll Nutr 2005;24 +(5):310–9. +[57] Higgins T. HbA1c for screening and diagnosis of diabetes +mellitus. Endocrine 2013;43(2):266–73. https://doi.org/ +10.1007/s12020-012-9768-y. 22907625 In press. +[58] Lovrenc +ˇic +´ M et al. Hemoglobin A1c: Standardization of the +‘‘gold standard”. Biochemia Medica 2006;16(1):25–36. https:// +doi.org/10.11613/BM.2006.004. In press. +[59] Aydın A. Comparison of the Effects of Impaired Fasting +Glucose and Impaired Glucose Tolerance on Diabetic +Development Risks on HbA1c Levels: A Retrospective Study. +Journal of Surgery and Medicine 2017;1(1):1–4. https://doi.org/ +10.28982/josam.337791. +[60] Taba +´k AG et al. Prediabetes: a high-risk state for diabetes +development. The Lancet 2012;379(9833):2279–90. https://doi. +org/10.1016/S0140-6736(12)60283-9. In press. +[61] Alberti G. Type 2 Diabetes in the Young: The Evolving +Epidemic. Diabetes Care 2004;27(7):1798–811. https://doi.org/ +10.2337/diacare.27.7.1798. In press. +[62] Emma WG. Type 2 diabetes in younger adults: the emerging +UK epidemic. Postgraduate Medical Journal 2010;86 +(1022):711–8. https://doi.org/10.1136/pgmj.2010.100917. In +press. +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 +11 diff --git a/subfolder_0/Dyadic yoga program for patients undergoing thoracic radiotherapy and their family caregivers results of a pilot randomized controlled trial.txt b/subfolder_0/Dyadic yoga program for patients undergoing thoracic radiotherapy and their family caregivers results of a pilot randomized controlled trial.txt new file mode 100644 index 0000000000000000000000000000000000000000..0c8c7cad8f0d73b6e391a973c67f1498c12399ec --- /dev/null +++ b/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: kmilbury@mdanderson.org, +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 +REFERENCES +1. Deng G, Liang N, Xie J, et al. Pulmonary toxicity generated from +radiotherapeutic +treatment +of thoracic malignancies. +Oncol +Lett. +2017;14(1):501‐511. +2. Simone CB 2nd. Thoracic radiation normal tissue injury. Semin Radiat +Oncol. 2017;27(4):370‐377. +3. Gopal R, Starkschall G, Tucker SL, et al. Effects of radiotherapy and +chemotherapy on lung function in patients with non‐small‐cell lung +cancer. Int J Radiat Oncol Biol Phys. 2003;56(1):114‐120. +4. Wang XS, Fairclough DL, Liao Z, et al. Longitudinal study of the rela- +tionship between chemoradiation therapy for non‐small‐cell lung +cancer and patient symptoms. J Clin Oncol. 2006;24(27):4485‐4491. +5. Besharat S, Jabbari A, Semnani S, Keshtkar A, Marjani J. Inoperable +esophageal +cancer +and +outcome +of +palliative +care. +World +J +Gastroenterol. 2008;14(23):3725‐3728. +6. Tanaka K, Akechi T, OkuyamaT, Nishiwaki Y, Uchitomi Y. Impact of dys- +pnea, pain, and fatigue on daily life activities in ambulatory patients with +advanced lung cancer. J Pain Symptom Manage. 2002;23(5):417‐423. +7. Bakas T, Lewis RR, Parsons JE. Caregiving tasks among family care- +givers of patients with lung cancer. Oncol Nurs Forum. 2001;28(5): +847‐854. +8. Booth S, Silvester S, Todd C. Breathlessness in cancer and chronic +obstructive pulmonary disease: using a qualitative approach to describe +the +experience +of +patients +and +carers. +Palliat +Support +Care. +2003;1(4):337‐344. +9. Porter LS, Keefe FJ, Garst J, McBride CM, Baucom D. Self‐efficacy for +managing pain, symptoms, and function in patients with lung cancer +and their informal caregivers: associations with symptoms and distress. +Pain. 2008;137(2):306‐315. +10. Jacobs JM, Shaffer KM, Nipp RD, et al. Distress is interdependent in +patients and caregivers with newly diagnosed incurable cancers. Ann +Behav Med. 2017;51(4):519‐531. +11. Kershaw T, Ellis KR, Yoon H, Schafenacker A, Katapodi M, Northouse +L. The interdependence of advanced cancer patients' and their family +caregivers' mental health, physical health, and self‐efficacy over time. +Ann Behav Med. 2015;49(6):901‐911. +620 +MILBURY ET AL. +12. Carmack Taylor CL, Badr H, Lee JH, et al. Lung cancer patients and +their spouses: psychological and relationship functioning within 1 +month of treatment initiation. Ann Behav Med. 2008;36(2):129‐140. +13. Badr H, Smith CB, Goldstein NE, Gomez JE, Redd WH. Dyadic psycho- +social intervention for advanced lung cancer patients and their family +caregivers: results of a randomized pilot trial. Cancer. 2015;121(1): +150‐158. +14. Porter +LS, +Keefe +FJ, +Baucom +DH, +et +al. +Partner‐assisted +emotional disclosure for patients with gastrointestinal cancer: results +from a randomized controlled trial. Cancer. 2009;115(18 Suppl): +4326‐4338. +15. Cramer H, Lange S, Klose P, Paul A, Dobos G. Yoga for breast cancer +patients and survivors: a systematic review and meta‐analysis. BMC +Cancer. 2012;12(1):412. +16. Cramer H, Lauche R, Klose P, Lange S, Langhorst J, Dobos GJ. Yoga for +improving health‐related quality of life, mental health and cancer‐ +related symptoms in women diagnosed with breast cancer. Cochrane +Database +Syst +Rev. +2017;1:CD010802. +https://doi.org/10.1002/ +14651858.CD010802.pub2 +17. Milbury K, Mallaiah S, Lopez G, et al. Vivekananda yoga program for +patients with advanced lung cancer and their family caregivers. Integr +Cancer Ther. 2015;14(5):446‐451. +18. Kasymjanova G, Correa JA, Kreisman H, et al. Prognostic value of the +six‐minute walk in advanced non‐small cell lung cancer. J Thorac Oncol. +2009;4(5):602‐607. +19. Mosher CE, Winger JG, Hanna N, et al. Randomized pilot trial of a +telephone symptom management intervention for symptomatic lung +cancer patients and their family caregivers. J Pain Symptom Manage. +2016;52(4):469‐482. +20. Pocock S, Pocock SJ. Clinical Trials: A Practical Approach. New York: +John Wiley & Sons; 1983. +21. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports +Exerc. 1982;14(5):377‐381. +22. Laboratories ATSCoPSfCPF. ATS statement: guidelines for the six‐ +minute walk test. Am J Respir Crit Care Med. 2002;166(1):111‐117. +23. Granger CL, Holland AE, Gordon IR, Denehy L. Minimal important dif- +ference of the 6‐minute walk distance in lung cancer. Chron Respir Dis. +2015;12(2):146‐154. +24. Mahler DA, Horowitz MB. Perception of breathlessness during +exercise in patients with respiratory disease. Med Sci Sports Exerc. +1994;26(9):1078‐1081. +25. Oxberry SG, Bland JM, Clark AL, Cleland JG, Johnson MJ. Minimally +clinically important difference in chronic breathlessness: every little +helps. Am Heart J. 2012;164(2):229‐235. +26. Radloff LS. The CES‐D scale: a new self‐report depression scale for +research +in +the +general +population. +Appl +Psychol +Measurement. +1977;1(3):385‐401. +27. Ware +JE, +Johnston +SA, +Davies‐Avery +A. +Conceptualization +and +Measurement of Health for Adults in the Health Insurance Study (Mental +Health R‐1987/3‐HEW: 3). +Santa Monica, CA: RAND Corporation; +1994. +28. Kaasa S, Mastekaasa A, Lund E. Prognostic factors for patients with +inoperable non‐small cell lung cancer, limited disease. The importance +of patients' subjective experience of disease and psychosocial well‐ +being. Radiother Oncol. 1989;15(3):235‐242. +29. Blanchon F, Grivaux M, Asselain B, et al. 4‐year mortality in patients +with non‐small‐cell lung cancer: development and validation of a prog- +nostic index. Lancet Oncol. 2006;7(10):829‐836. +30. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. +Hillsdale, NJ: Lawrence Earlbaum Associates; 1988. +31. Whitehead AL, Julious SA, Cooper CL, Campbell MJ. Estimating the +sample size for a pilot randomised trial to minimise the overall trial +sample size for the external pilot and main trial for a continuous out- +come variable. Stat Methods Med Res. 2016;25(3):1057‐1073. +32. Wallace JP, Raglin JS, Jastremski CA. Twelve month adherence of +adults who joined a fitness program with a spouse vs without a spouse. +J Sports Med Phys Fitness. 1995;35(3):206‐213. +33. Martire LM, Schulz R, Keefe FJ, et al. Feasibility of a dyadic intervention +for management of osteoarthritis: a pilot study with older patients and +their spousal caregivers. Aging Ment Health. 2003;7(1):53‐60. +34. Nezu AM, Nezu CM, Felgoise SH, McClure KS, Houts PS. Project +genesis: +assessing +the +efficacy +of +problem‐solving +therapy +for +distressed adult cancer patients. J Consult Clin Psychol. 2003;71(6): +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 diff --git a/subfolder_0/EFFECT OF FOUR VOLUNTARY REGULATED YOGA BREATHING TECHNIQUES ON GRIP STRENGTH.txt b/subfolder_0/EFFECT OF FOUR VOLUNTARY REGULATED YOGA BREATHING TECHNIQUES ON GRIP STRENGTH.txt new file mode 100644 index 0000000000000000000000000000000000000000..b0cf2a415cd3ec099733011535362242af524c79 --- /dev/null +++ b/subfolder_0/EFFECT OF FOUR VOLUNTARY REGULATED YOGA BREATHING TECHNIQUES ON GRIP STRENGTH.txt @@ -0,0 +1,1038 @@ + + + + + + + +P +PS +SY +YC +CH +HO +OL +LO +OG +GI +IC +CA +AL +L + R +RE +EP +PO +OR +RT +TS +S + + + + + + + + + + + + + + P +PE +ER +RC +CE +EP +PT +TU +UA +AL +L + A +AN +ND +D + M +MO +OT +TO +OR +R + S +SK +KI +IL +LL +LS +S + + + + + + + + Box 9229 Missoula, Montana 59807 + + www.AmmonsScientific.com + + + + + + + +June 3, 2009 + +Dr. Shirley Telles +Patanjali Yogpeeth +Maharishi Dayananda Gram +New Delhi--Haridwar Highway +Bahadrabad, Haridwar +Uttarakhand 249402 +INDIA + + +Dear Dr. Telles: + +This PDF contains the edited manuscript and a copy of the proof of your paper, “Effect of four voluntarily +regulated yoga breathing techniques on grip strength.” + +Please read the proof carefully. Author’s corrections are charged to the author. This refers to any changes in +the copy which are not due to printer’s error. Such changes are expensive and increase the time necessary for +handling. + +You will receive 50 preprints without covers. If you wish to order additional preprints or covers, please fill in +the amounts of each on the enclosed form. Be sure to indicate the correct mailing address for the preprints. + +Please note that we were able to get the piece into an 8-page signature rather than the estimated 12 pages. +Please advise us whether you wish the $110.00 credit to be returned to you, held until you wish to publish a +paper in the future, or applied to additional reprints or covers. Note that in the 8-page signature you will have +one blank page which you may use in the future by submitting a 1- to 2-page note-sized manuscript. + +Please be sure to courier back to us or e-mail a copy of the corrected proof and any changes to the preprint +order form within 72 hours of receipt. We cannot accept faxed documents. Courier services will require our +street address—1917 South Higgins Avenue, Missoula, MT 59801—and telephone number, (406)-728-1702. + + + +Sincerely, + + + +Carol H. Ammons, Ph.D. + +Senior Editor +CHA/tws +Enclosures + + + + + +ORDER FORM + +PERCEPTUAL & MOTOR SKILLS +Box 9229, Missoula, Montana 59807 + + +RATES FOR ADDITIONAL PREPRINTS & COVERS: + + +Length of Article + Additional preprints +1-4 pages +5-8 pages +9-12 pages +13-16 pages +_____ pages* + First Additional 50 +$15.00 +$20.00 +$25.00 +$30.00 + + Shipping*: to USA +$ 1.00 +$ 2.00 +$ 2.00 +$ 2.00 + + to Canada/Mexico +$ 5.00 +$ 5.00 +$10.00 +$10.00 + + to All Other Countries +$ 3.00 +$ 6.00 +$12.00 +$12.00 + + Further Additional 50s +$12.00 +$15.00 +$15.00 +$15.00 + + Shipping*: to USA +$ 1.00 +$ 1.00 +$ 1.00 +$ 2.00 + + to Canada/Mexico +$ 4.00 +$ 5.00 +$ 7.00 +$10.00 + + to All Other Countries +$ 3.00 +$ 6.00 +$11.00 +$12.00 + + Covers* + + + First 50 (or 25 for a note) +$15 + + Further 50s +$12 + +*E-mail us for fees for: (1) signatures of 17 pages or more, (2) ordering covers, or (3) delivery via courier (shipping@AmmonsScientific.com). + + +I wish to order the following preprints and covers. I am enclosing either a purchase order or a personal check for extra +preprints and covers, if applicable. + + +Preprints (free) 50 + + +$ 00.00 + + +Additional preprints + + + + + + +Number of covers + + + + + + +Shipping + + + + + + + +TOTAL ENCLOSED + + +$ + + +For payment options, visit our website +(http://ammons.ammonsscientific.com/homepage/pdf/Payment- +Options.pdf ). + + +Please send proof to: +Please send preprints to: +(street address and phone number +( + required) +street address and phone number required) + + +Dr. Shirley Telles +Same +Patanjali Yogpeeth, Marharishi + Gayanand Gram + +New Delhi – Haridwar Highway + +Bahadrabad, Haridwar + +Uttarakhand 249408 + +INDIA + + + + + +Phone No. ______________________ +Phone No. ______________________ +_____ + + + +If box is X’d, please complete, sign, and promptly return the enclosed Copyright Assignment form. + +This is your ONLY OFFICIAL ORDER for additional preprints and covers. +Please fill it out carefully and return it + + with your corrected proof. + + + +Joshi, & Telles, PMS, 2009, 108, June 1 +For Office Use Only + +Author Payment Rec’d: _ wire transfer + +____________ +Decrease Signature: $110.00 +Credit / Refund / Charge +_________________________ + +Author Alteration Fee: $_________________________ + +Other: __________________________________________ +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 (shirleytelles@gmail.com). + + + +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 diff --git a/subfolder_0/EFFECT OF PRANIC HEALING IN CHRONIC MUSCULOSKELETAL PAIN- A SINGLE BLIND CONTROL STUDY.txt b/subfolder_0/EFFECT OF PRANIC HEALING IN CHRONIC MUSCULOSKELETAL PAIN- A SINGLE BLIND CONTROL STUDY.txt new file mode 100644 index 0000000000000000000000000000000000000000..4a50480fa60d550fa8a04c2331541270813681e8 --- /dev/null +++ b/subfolder_0/EFFECT OF PRANIC HEALING IN CHRONIC MUSCULOSKELETAL PAIN- A SINGLE BLIND CONTROL STUDY.txt @@ -0,0 +1,4 @@ + + + + diff --git a/subfolder_0/EFFECT OF YOGA ON SOMATIC INDICATERS OF STRESS IN HEALTHY.txt b/subfolder_0/EFFECT OF YOGA ON SOMATIC INDICATERS OF STRESS IN HEALTHY.txt new file mode 100644 index 0000000000000000000000000000000000000000..0e70f9eb88442d42936df5a1a91baa77e8de3222 --- /dev/null +++ b/subfolder_0/EFFECT OF YOGA ON SOMATIC INDICATERS OF STRESS IN HEALTHY.txt @@ -0,0 +1,15 @@ + + + + + + + + + + + + + + + diff --git a/subfolder_0/EFFECT OF YOGA TRAINING ON MAZE LEARNING.txt b/subfolder_0/EFFECT OF YOGA TRAINING ON MAZE LEARNING.txt new file mode 100644 index 0000000000000000000000000000000000000000..30b472ee69f49462cdeacbd4e58583c3ff14cc29 --- /dev/null +++ b/subfolder_0/EFFECT OF YOGA TRAINING ON MAZE LEARNING.txt @@ -0,0 +1,13 @@ + + + + + + + + + + + + + diff --git a/subfolder_0/Effect of 12 Weeks of Yogic Training on Neurocognitive Variables A Quasi-Experimental Study.txt b/subfolder_0/Effect of 12 Weeks of Yogic Training on Neurocognitive Variables A Quasi-Experimental Study.txt new file mode 100644 index 0000000000000000000000000000000000000000..8ff1e1217e63cdcaa81642a99e5fa6cd6ea3e6c8 --- /dev/null +++ b/subfolder_0/Effect of 12 Weeks of Yogic Training on Neurocognitive Variables A Quasi-Experimental Study.txt @@ -0,0 +1,527 @@ +© 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: sridipchatterjee.ped@jadavpuruniversity.in +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: WKHLRPMedknow_reprints@wolterskluwer.com +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. +References +1. Klimova B, Valis M, Kuca K. Cognitive decline in normal aging and its +prevention: A review on non‑pharmacological lifestyle strategies. Clin +Interv Aging 2017;12:903‑10. +2. Gajewski  PD, Falkenstein  M. Physical activity and neurocognitive +functioning in aging‑a condensed updated review. Eur Rev Aging Phys +Act 2016;13:1. +3. Sharma VK, Rajajeyakumar M, Velkumary S, Subramanian SK, +Bhavanani AB, Madanmohan, et al. Effect of fast and slow pranayama +practice on cognitive functions in healthy volunteers. J Clin Diagn Res +2014;8:10-3. +4. Sogaard  I, Ni  R. Mediating age‑related cognitive decline through +lifestyle activities: A brief review of the effects of physical exercise and +sports‑playing on older adult cognition. Acta Psychopathol 2018;4:22. +5. Gothe NP, Khan I, Hayes J, Erlenbach E, Damoiseaux JS. Yoga effects +on brain health: A systematic review of the current literature. Brain Plast +2019;5:105‑22. +6. Mohan A, Sharma R, Bijlani RL. Effect of meditation on stress‑induced +changes in cognitive functions. J  +Altern Complement Med 2011;17:207‑12. +7. Erdfelder  E, Faul  F, Buchner A. Gpower: A  general power analysis +program. Behav Res Methods Instruments Comput 1996;28:1‑11. +8. Chatterjee S, Mondal S. Effect of regular yogic training on growth +hormone and dehydroepiandrosterone sulfate as an endocrine marker of +aging. Evid Based Complement Alternat Med. 2014;2014:240581. doi: +10.1155/2014/240581. Epub 2014 May 8. PMID: 24899906; PMCID: +PMC4034508. +9. Chatterjee S, Mondal S. Effect of combined yoga programme on blood +levels of thyroid hormones: A quasi‑experimental study. Indian J Tradit +Knowledge 2017;16 Suppl: S9‑16. +10. Kramer  AF, Colcombe  SJ, McAuley  E, Scalf  PE, Erickson  KI. +Fitness, aging and neurocognitive function. Neurobiol Aging +2005;26 Suppl 1:124‑7. +11. Öhman H, Savikko N, Strandberg TE, Pitkälä KH. Effect of physical +exercise on cognitive performance in older adults with mild cognitive +impairment or dementia: A  systematic review. Dement Geriatr Cogn +Disord 2014;38:347‑65. +12. Malathi A, Parulkar VG. Effect of yogasanas on the visual and auditory +reaction time. Indian J Physiol Pharmacol 1989;33:110‑2. +13. Gallego J, Perruchet P. The effect of voluntary breathing on reaction +time. J Psychosom Res 1993;37:63‑70. +14. Bhavanani  AB, Madanmohan , Udupa  K. Acute effect of Mukh +bhastrika (a yogic bellows type breathing) on reaction time. Indian J +Physiol Pharmacol 2003;47:297‑300. +15. Telles S, Pal S, Gupta RK, Balkrishna A. Changes in reaction time after +yoga bellows‑type breathing in healthy female volunteers. Int J Yoga +2018;11:224‑30. +16. Madanmohan , Udupa K, Bhavanani AB, Vijayalakshmi P, Surendiran A. +Effect of slow and fast pranayams on reaction time and cardiorespiratory +variables. Indian J Physiol Pharmacol 2005;49:313‑8. +17. Borker AS, Pednekar JR. Effect of pranayama on visual and auditory +reaction time. Indian J Physiol Pharmacol 2003;47:229‑30. +18. Das S, Gandhi A, Mondal S. Effect of premenstrual stress on audiovisual +reaction time and audiogram. Indian J Physiol Pharmacol 1997;41:67‑70. +19. Thompson Schill  SL. Neuro imaging studies of symatic memory +interring how from “where. Neuropsychologia 2003;41:280‑92. +20. Naveen  KV, Nagarathna  R, Nagendra  HR, Telles  S. Yoga breathing +through a particular nostril increases spatial memory scores without +lateralized effects. Psychol Rep 1997;81:555‑61. +21. Sharma VK, Das S, Mondal S, Goswami U, Gandhi A. Effect of Sahaj +Yoga on neuro‑cognitive functions in patients suffering from major +depression. Indian J Physiol Pharmacol 2006;50:375‑83. +22. Joshi M, Telles S. Immediate effects of right and left nostril breathing on +verbal and spatial scores. Indian J Physiol Pharmacol 2008;52:197‑200. +23. Subramanya P, Telles S. Effect of two yoga‑based relaxation techniques +on memory scores and state anxiety. Biopsychosoc Med 2009;3:8. +24. Rangan R, Nagendra H, Bhat GR. Effect of yogic education system and +modern education system on memory. Int J Yoga 2009;2:55‑61. +25. Dhansoia  V, Bhargav  H, Metri  K. Immediate effect of mind sound +resonance technique on state anxiety and cognitive functions in patients +suffering from generalized anxiety disorder: A  self‑controlled pilot +study. Int J Yoga 2015;8:70‑3. diff --git a/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 b/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 new file mode 100644 index 0000000000000000000000000000000000000000..e1297331044507bd180a0ce95a398ac05b0f89b1 --- /dev/null +++ b/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: monaliyoga@gmail.com +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. + + +References + +Botterell EH, Jousse AT, Kraus AS, Thompson MG, Wynne +Jones M, Geisler WO. A model for the future care of +acute spinal cord injuries. Ann R Coll Phys Surg Can. +1975;8:193-218. +De Vivo MJ. Epidemiology of traumatic spinal cord injury. In: +Kirshblum S, Campagnolo DI, De Lisa JA, eds. Spinal +Cord Medicine. Baltimore, Md: Lippincott Williams & +Wilkins;2002:69-81. +Dean CM, Richards CL, Malouin F. Task-related circuit +training improves performance of locomotor tasks in +chronic stroke: A randomized, controlled pilot trial. Arch +Phys Med Rehabil. 2000;81:409–17. +Ditunno PL, Patrick M, Stineman M, B Morganti, Townson AF +and Ditunno JF, Cross-cultural differences in preference +for recovery of mobility among spinal cord injury +rehabilitation professionals, Spinal Cord. 2006;44, 567- +575. +Garland SJ, Stevenson TJ, Ivanova T. Postural responses to +unilateral arm perturbation in young, elderly, and +hemiplegic subjects. Arch Phys Med Rehabil. 1997;78: +1072–7. +Monali Madhusmita, T. M. Srinivasan, John Ebnezar et al. +66 +Gjone R, Nordlie L. Incidence of traumatic paraplegia and +tetraplegia in Norway: a statistical survey of the years +1974 and1975. Paraplegia 1978;16:88-93. +Go BK, De Vivo MJ, Richards JS. The epidemiology of spinal +cord injury. In: Stover SL, De Lisa JA, Whiteneck GG, +eds. Spinal Cord Injury. Gaithersburg, Md: Aspen; 1995: +21-55. +Harvey, Lisa A, Adrian J Byak, Marsha Ostrovskaya, Joanne +Glinsky, Lyndall Katte and Robert Herbert, Randomised +trial of the effects of four weeks of daily stretch on +extensibility of ham string muscles in people with spinal +cord injuries, Australian Journal of Physiotherapy. 2003 +Vol. 49, 176– 181. +Kahn NN, Feldman SP, Bauman WA. Lower extremity +functional +electrical +stimulation +decreases +platelet +aggregation and blood coagulation in persons with chronic +spinal cord injury: a pilot study. J Spinal Cord Med. 2010; +33(2):150-8. +Katiyar SK, Bihari S. Role of pranayama in rehabilitation of +COPD patients a randomized controlled study. Indian J +Allergy Asthma Immunol 2006;20:98e104. (Katiyar, +Bihari, 2006). +Kim E. Innes, Heather K. Vincent. The Influence of Yoga- +Based Programs on Risk Profiles in Adults with Type 2 +Diabetes Mellitus: A Systematic Review. Evid Based +Complement Alternat Med. 2007 Dec;4(4):469-86. doi: +10.1093/ecam/nel103. +Kraus JF. Injury of the head and spinal cord: the epidemiology +relevance of the medical literature published from 1960 +to1978. J Neurosurg 1980;53:3-10. +Krause JS, Sternberg M, Lottes S, et al. Mortality after spinal +cord injury: an 11 year prospective study. Arch Phys Med +Rehabil. Aug1997;78(8):815-21. +Kurtzke JF. Epidemiology of spinal cord injury. Exp Neurol +1975;48:163-236. +Li M, Yang CW. Current situation and prospect in treatment of +spine and spinal cord injuries. Chin J Traumatol. +2009Jun;12(3):131-2. +Lundgren T, Dahl J, Yardi N, Melin L. Acceptance and +Commitment Therapy and yoga for drug-refractory +epilepsy: A randomized controlled trial. Epilepsy Behav. +2008;13:102–8. +Lynskey James V., Adam Belanger, and Ranu Jung, Activity- +dependent plasticity in spinal cord injury, J Rehabil Res +Dev. 2008;45(2):229-240. +Minaire P, Castanier M, Girard R, Berard E, Deidier C, Bourret +L. Epidemiology of spinal cord injury in the Rhône-Alpes +region, France, 1970-1975. Paraplegia 1978;16:76-87. +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. +Pearson KG, Topical Review: Could enhanced reflex function +contribute to improving locomotion after spinal cord +repair?. Journal of Physiology. 2001, 533. 1, pp. 75-81. +Rajashree +Ranjita, +Alex +Hankey, +HR. +Nagendra, +Soubhagyalaxmi +Mohanty. +Yoga-based +pulmonary +rehabilitation for the management of dyspnea in coal +miners with chronic obstructive pulmonary disease: A +randomised controlled trial. J Ayurveda Integr Med. 2016 +Jul - Sep;7(3):158-166. doi: 10.1016/j.jaim.2015.12.001. +Epub 2016 Aug 18. +Rhee P, Kuncir EJ, Johnson L, et al. Cervical spine injury is +highly dependent on the mechanism of injury following +blunt and penetrating assault. J Trauma. Nov 2006;61(5): +1166-70. +Santo Tomas LH. Emphysema and chronic obstructive +pulmonary disease in coal miners. Curr Opin Pulm Med +2011;17:123e5. (Tomas, 2011). +Schwab ME. Repairing the injured spinal cord. Science. 2002; +295:1029-1031 (review). +Tandon OP, Tripathi Y, editors. Best and Taylor’s +physiological basis of medical practice. 13th ed. Gurgaon: +Wolters Kluwer Health/Lippincott Williams and Wilkins +Publishers; 2012. (Tandon, Tripathi, 2012). +Velikonja O, Curic K, Ozura A, Jazbec SS. Influence of sports +climbing and yoga on spasticity, cognitive function, mood +and fatigue in patients with multiple sclerosis. Clin Neurol +Neurosurg. 2010;112:597–601. +Water RL, Adkins RH, Yakura JS. Definition of complete +spinal cord injury. Paraplegia. Nov. 1991;29(9):573-81. +Waters RL, Meyer PR, Adkins RH, Felton D. Emergency, +acute, and surgical management of spinal trauma. Arch +Phys Med Rehabil 1999;80:1383-1390. +Winterholler M, Erbguth F, Neundörfer B. The use of +alternative medicine by multiple sclerosis patients--patient +characteristics and patterns of use. Fortschr Neurol +Psychiatr. 1997;65:555–61. +Zwick D. Integrated Iyengar Yogain to rehab for spinal cord +injury. Nursing. 2006Oct;36. SupplPT:18– 22. + + +Received: 1/27/18. Revised: 3/12/18. Accepted: +3/30/18. + +Reproduced with permission of copyright owner. Further reproduction +prohibited without permission. diff --git a/subfolder_0/Effect of Naturopathy and Yoga Intervention on Patients with Type II Diabetes Mellitus.txt b/subfolder_0/Effect of Naturopathy and Yoga Intervention on Patients with Type II Diabetes Mellitus.txt new file mode 100644 index 0000000000000000000000000000000000000000..d5df21604f8b9e1358d3b9d647f19d0742035e78 --- /dev/null +++ b/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 + diff --git a/subfolder_0/Effect of Yoga and Physiotherapy on Pulmonary Functions in Children with Duchenne Muscular Dystrophy A Comparative Study.txt b/subfolder_0/Effect of Yoga and Physiotherapy on Pulmonary Functions in Children with Duchenne Muscular Dystrophy A Comparative Study.txt new file mode 100644 index 0000000000000000000000000000000000000000..9dc7bef91bb53728f04d2da46e1357e6976f14ae --- /dev/null +++ b/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. +References +1. +Servais  L, Straathof  CS, Schara  U, Klein  A, Leinonen  M, +Hasham  S, et  al. Long‑term data with idebenone on respiratory +function outcomes in patients with Duchenne muscular +dystrophy. Neuromuscul Disord 2020;30:5‑16. +2. +Machado DL, Silva EC, Resende MB, Carvalho CR, Zanoteli E, +Reed  UC. Lung function monitoring in patients with Duchenne +muscular dystrophy on steroid therapy. BMC Res Notes +2012;5:435. +3. +Bushby  K, Finkel  R, Birnkrant  DJ, Case  LE, Clemens  PR, +Cripe L, et al. Diagnosis and management of Duchenne muscular +dystrophy, part  2: Implementation of multidisciplinary care. +Lancet Neurol 2010;9:177‑89. +4. +McDonald  CM, Abresch  RT, Carter  GT, Fowler WM Jr., +Johnson  ER, Kilmer  DD, et  al. Profiles of neuromuscular +diseases. Duchenne muscular dystrophy. Am J Phys Med Rehabil +1995;74:S70‑92. +5. +Hahn  A, Bach  JR, Delaubier  A, Irani  RA, Guillou  C, +Rideau Y. Clinical implications of maximal respiratory pressure +determinations +for +individuals +with +Duchenne +muscular +dystrophy. Arch Phys Med Rehabil 1997;78:1‑6. +6. +Tangsrud S, Petersen IL, Lødrup Carlsen KC, Carlsen KH. Lung +function in children with Duchenne’s muscular dystrophy. Respir +Med 2001;95:898‑903. +7. +Gayraud J, Ramonatxo M, Rivier F, Humberclaude V, Petrof B, +Matecki  S. Ventilatory parameters and maximal respiratory +pressure changes with age in Duchenne muscular dystrophy +patients. Pediatr Pulmonol 2010;45:552‑9. +8. +Dhargave  P, Nalini  A, Adoor  M, Nagarathna  R, Raju  TR, +Thennarasu  K, et  al. Respiratory dysfunctions in children +with Duchenne muscular dystrophy. Int J Physiother Res +2016;4:1365‑69. +9. +Angliss  ME, Sclip  KD, Gauld  L. Early NIV is associated +with accelerated lung function decline in Duchenne muscular +dystrophy treated with glucocorticoids. BMJ Open Resp Res +2020;7:e000517. +10. Yeldan  I, Gurses  HN, Yuksel  H. Comparison study of chest +physiotherapy +home +training +programmes +on +respiratory +functions in patients with muscular dystrophy. Clin Rehabil +2008;22:741‑8. +11. Saper RB, Eisenberg DM, Davis RB, Culpepper L, Phillips RS. +Prevalence and patterns of adult yoga use in the United +States: Results of a national survey. Altern Ther Health Med +2004;10:44‑9. +12. Pradnya D, Nalini A, Nagarathna R, Raju TR, Sendhilkumar R, +Meghana A, et  al. Effect of yoga as an add‑on therapy in the +modulation of heart rate variability in children with Duchenne +muscular dystrophy. Int J Yoga 2019;12:55‑61. +13. Rodrigues MR, Carvalho CR, Santaella DF, Filho LG, Marie SK. +Effects of yoga breathing exercises on pulmonary function in +patients with Duchenne muscular dystrophy: An exploratory +analysis. J Bras Pneumol 2014;40:128‑33. +14. Swaminathan  B, Shubha  GN, Shubha  D, Murthy  AR, +Kiran Kumar  HB, Shylashree  S, et  al. Duchenne muscular +dystrophy: A  clinical, histopathological and genetic study at a +neurology tertiary care center in Southern India. Neurol India +2009;57:734‑8. +15. Ciafaloni  E, Fox  DJ, Pandya  S, Westfield  CP, Puzhankara  S, +Romitti  PA, et  al. Delayed diagnosis in Duchenne muscular +dystrophy: Data from the muscular dystrophy surveillance, +tracking, and research network  (MD STARnet). J  Pediatr +2009;155:380‑5. +16. Gosselin LE, McCormick KM. Targeting the immune system to +improve ventilatory function in muscular dystrophy. Med Sci +Sports Exerc 2004;36:44‑51. +17. Toussaint  M, Chatwin  M, Soudon  P. Mechanical ventilation in +Duchenne patients with chronic respiratory insufficiency: Clinical +implications of 20 years published experience. Chron Respir Dis +2007;4:167‑77. +18. Lo Mauro A, D’Angelo  MG, Romei  M, Motta  F, Colombo  D, +Comi GP, et al. Abdominal volume contribution to tidal volume +as an early indicator of respiratory impairment in Duchenne +muscular dystrophy. Eur Respir J 2010;35:1118‑25. +19. Kurz LT, Mubarak SJ, Schultz P, Park SM, Leach J. Correlation +of scoliosis and pulmonary function in Duchenne muscular +dystrophy. J Pediatr Orthop 1983;3:347‑53. +20. Kravitz RM. Airway clearance in Duchenne muscular dystrophy. +Pediatrics 2009;123 Suppl 4:S231‑5. +21. Ekici  B, Ergül Y, Tatlı B, Bilir  F, Binboğa F, Süleyman A, +et al. Being ambulatory does not secure respiratory functions of +Duchenne patients. Ann Indian Acad Neurol 2011;14:182‑4. +22. Kakulas  BA. Problems and solutions in the rehabilitation of +patients with progressive muscular dystrophy. Scand J Rehabil +Med Suppl 1999;39:23‑37. +23. Eagle  M, Baudouin  SV, Chandler  C, Giddings  DR, Bullock  R, +Bushby  +K. +Survival +in +Duchenne +muscular +dystrophy: +Improvements in life expectancy since 1967 and the impact of +home nocturnal ventilation. Neuromuscul Disord 2002;12:926‑9. +24. Topin N, Matecki S, Le Bris S, Rivier F, Echenne B, Prefaut C, +et  al. Dose‑dependent effect of individualized respiratory +muscle training in children with Duchenne muscular dystrophy. +Neuromuscul Disord 2002;12:576‑83. +25. LoMauro  A, D’Angelo  MG, Aliverti  A. Assessment and +Dhargave, et al.: Yoga with physiotherapy in DMD +140 +140 +International Journal of Yoga | Volume 14 | Issue 2 | May-August 2021 +management of respiratory function in patients with Duchenne +muscular dystrophy: Current and emerging options. Ther Clin +Risk Manag 2015;11:1475‑88. +26. Netz  Y, Lidor  R. Mood alterations in mindful versus aerobic +exercise modes. J Psychol 2003;137:405‑19. +27. Joshi LN, Joshi VD, Gokhale LV. Effect of short term ‘Pranayam’ +practice on breathing rate and ventilatory functions of lung. +Indian J Physiol Pharmacol 1992;36:105‑8. +28. Makwana  K, Khirwadkar  N, Gupta  HC. Effect of short term +yoga practice on ventilatory function tests. Indian J Physiol +Pharmacol 1988;32:202‑8. +29. Pal  GK. Yoga and heart rate variability. Int J Clin Exp Physiol +2015;2:2‑9. +30. Jerath  R, Edry  JW, Barnes  VA, Jerath  V. Physiology of long +pranayamic breathing: Neural respiratory elements may provide +a mechanism that explains how slow deep breathing shifts the +autonomic nervous system. Med Hypotheses 2006;67:566‑71. +31. Sendhilkumar  R, Gupta  A, Nagarathna  R, Taly  AB. Effect of +pranayama and meditation as an add‑on therapy in rehabilitation +of patients with Guillain‑Barré syndrome – A randomized control +pilot study. Disabil Rehabil 2013;35:57‑62. +32. Telles S, Nagarathna R, Nagendra HR, Desiraju T. Physiological +changes in sports teachers following 3 months of training in +Yoga. Indian J Med Sci 1993;47:235‑8. +33. Lee  DG. Biomechanics of the thorax‑research evidence and +clinical expertise. J Man Manip Ther 2015;23:128‑38. diff --git a/subfolder_0/Effect of Yoga on Immune Parameters, Cognitive Functions, and Quality of Life among HIV-Positive Children_Adolescents_ A Pilot Study.txt b/subfolder_0/Effect of Yoga on Immune Parameters, Cognitive Functions, and Quality of Life among HIV-Positive Children_Adolescents_ A Pilot Study.txt new file mode 100644 index 0000000000000000000000000000000000000000..7a381dc03f434dbad13477a1f67fffecf9eb8e4d --- /dev/null +++ b/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: harisnehadaana@gmail.com +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 +1. Kumar A, Girish H, Nawaz A, Balu P, Kumar B. Determinants of quality of life among people living +with HIV/AIDS: A cross sectional study in central Karnataka, India. Int J Med Sci Public Health. +2014;3:1413. [Google Scholar] +2. Holzemer WL, Human S, Arudo J, Rosa ME, Hamilton MJ, Corless I, et al. Exploring HIV stigma +and quality of life for persons living with HIV infection. J Assoc Nurses AIDS Care. 2009;20:161–8. +[PubMed] [Google Scholar] +3. Aranda-Naranjo B. Quality of life in the HIV-positive patient: Implications and consequences. J +Assoc Nurses AIDS Care. 2004;15:20S–27S. [PubMed] [Google Scholar] +4. Masiello A, De Guglielmo C, Giglio S, Acone N. Beyond depression: Assessing personality +disorders, alexithymia and socio-emotional alienation in patients with HIV infection. Infez Med. +2014;22:193–9. [PubMed] [Google Scholar] +5. Goldberg RE, Short SE. What do we know about children living with HIV-infected or AIDS-ill +adults in sub-saharan africa? A systematic review of the literature. AIDS Care. 2016;28(Suppl 2):130– +41. [PMC free article] [PubMed] [Google Scholar] +6. Chaponda M, Aldhouse N, Kroes M, Wild L, Robinson C, Smith A, et al. Systematic review of the +prevalence of psychiatric illness and sleep disturbance as co-morbidities of HIV infection in the UK. +Int J STD AIDS. 2018;29:704–13. [PubMed] [Google Scholar] +7. Nichols SL, Montepiedra G, Farley JJ, Sirois PA, Malee K, Kammerer B, et al. Cognitive, academic, +and behavioral correlates of medication adherence in children and adolescents with perinatally acquired +HIV infection. J Dev Behav Pediatr. 2012;33:298–308. [PMC free article] [PubMed] [Google Scholar] +8. Tymchuk S, Gomez D, Koenig N, Gill MJ, Fujiwara E, Power C, et al. Associations between +depressive symptomatology and neurocognitive impairment in HIV/AIDS. Can J Psychiatry. +2018;63:329–36. [PMC free article] [PubMed] [Google Scholar] +9. Bhargav H, Huilgol V, Metri K, Sundell IB, Tripathi S, Ramagouda N, et al. Evidence for extended +age dependent maternal immunity in infected children: Mother to child transmission of HIV infection +and potential interventions including sulfatides of the human fetal adnexa and complementary or +alternative medicines. J Stem Cells. 2012;7:127–53. [PubMed] [Google Scholar] +10. Falkenberg RI, Eising C, Peters ML. Yoga and immune system functioning: A systematic review of +randomized controlled trials. J Behav Med. 2018;41:467–82. [PubMed] [Google Scholar] +11. Bhargav H, Raghuram N, Rao NH, Tekur P, Koka PS. Potential yoga modules for treatment of +hematopoietic inhibition in HIV-1 infection. J Stem Cells. 2010;5:129–48. [PubMed] [Google Scholar] +12. Field T. Yoga clinical research review. Complement Ther Clin Pract. 2011;17:1–8. [PubMed] +[Google Scholar] +13. Naoroibam R, Metri KG, Bhargav H, Nagaratna R, Nagendra HR. Effect of integrated yoga (IY) on +psychological states and CD4 counts of HIV-1 infected patients: A randomized controlled pilot study. +Int J Yoga. 2016;9:57–61. [PMC free article] [PubMed] [Google Scholar] +14. Koar WH. Meditation, T-cells, anxiety, depression and HIV infection. Subtle Energies Energy Med +J Arch. 1995;6:89–97. [Google Scholar] +15. Telles S, Singh N, Bhardwaj AK, Kumar A, Balkrishna A. Effect of yoga or physical exercise on +physical, cognitive and emotional measures in children: A randomized controlled trial. Child Adolesc +Psychiatry Ment Health. 2013;7:37. [PMC free article] [PubMed] [Google Scholar] +16. Kovacs M. (CDI 2) Technical Manual. 2nd ed. Multi-Health Systems Inc.; 2012. Children's +Depression Inventory. [Google Scholar] +17. Mayer A. Yoga for Skin Diseases. Mysore. 2014. [Last accessed on 2018 Jul 10]. Available from: +https://www.yogaindea.wordpress.com/2014/01/14/yoga-for-skin-diseases/ +18. Bosire EM, Nyamache AK, Gicheru MM, Khamadi SA, Lihana RW, Okoth V, et al. Population +specific reference ranges of CD3, CD4 and CD8 lymphocyte subsets among healthy Kenyans. AIDS +Res Ther. 2013;10:24. [PMC free article] [PubMed] [Google Scholar] +19. Pradhan B, Nagendra HR. Normative data for the letter-cancellation task in school children. Int J +Yoga. 2008;1:72–5. [PMC free article] [PubMed] [Google Scholar] +20. Giofrè D, Stoppa E, Ferioli P, Pezzuti L, Cornoldi C. Forward and backward digit span difficulties +in children with specific learning disorder. J Clin Exp Neuropsychol. 2016;38:478–86. [PubMed] +[Google Scholar] +21. Christopher G, MacDonald J. The impact of clinical depression on working memory. Cogn +Neuropsychiatry. 2005;10:379–99. [PubMed] [Google Scholar] +Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow +Publications diff --git a/subfolder_0/Effect of a Residential Integrated Yoga Program on Blood Glucose Levels, Physiological Variables, and Anti-Diabetic Medication Score of Patients wi.txt b/subfolder_0/Effect of a Residential Integrated Yoga Program on Blood Glucose Levels, Physiological Variables, and Anti-Diabetic Medication Score of Patients wi.txt new file mode 100644 index 0000000000000000000000000000000000000000..c24c8d3206210cb3222d750a3da48fef3c04940c --- /dev/null +++ b/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 + 1 +World Health Organization (WHO): Global health risks – mortality and burden of disease attributable to +selected major risks. Cancer. 2017 Feb 3. + 2 +Hu G, Qiao Q, Silventoinen K, Eriksson JG, Jousilahti P, Lindström J, Valle TT, Nissinen A, Tuomilehto J: Occu­ +pational, commuting, and leisure-time physical activity in relation to risk for type 2 diabetes in middle-aged +Finnish men and women. Diabetologia 2003; 46: 322–329. + 3 +Santaguida PL, Balion C, Hunt D, Morrison K, Gerstein H, Raina P, Yazdi H: Diagnosis, prognosis, and treatment +of impaired glucose tolerance and impaired fasting glucose. Evid Rep Technol Assess (Summ) 2005; 128: 1–11. + 4 +International Society for Pediatric and Adolescent Diabetes: IDF/ISPAD 2011 Global Guideline for Diabetes in +Childhood and Adolescence. Berlin, International Society for Pediatric and Adolescent Diabetes, 2011. + 5 +Misra P, Upadhyay RP, Misra A, Anand K: A review of the epidemiology of diabetes in rural India. Diabetes Res +Clin Pract 2011; 92: 303–311. + 6 +Mohan V, Sandeep S, Deepa R, Shah B, Varghese C: Epidemiology of type 2 diabetes: Indian scenario. Indian J +Med Res 2007; 125: 217. + 7 +Temelkova-Kurktschiev T, Stefanov T: Lifestyle and genetics in obesity and type 2 diabetes. Exp Clin Endo­ +crinol Diabetes 2012; 120: 1–6. + 8 +Dorababu M, Prabha T, Priyambada S, Agrawal VK, Aryya NC, Goel RK: Effect of Bacopa monniera and Azadi­ +rachta indica on gastric ulceration and healing in experimental NIDDM rats. Indian J Exp Biol 2004; 42: 389– +397. + 9 +Halim M: Lowering of blood sugar by water extract of Azadirachta indica and Abroma augusta in diabetes rats. +Indian J Exp Biol 2003; 41: 636–640. +186 +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 +10 +Zia T, Hasnain SN, Hasan SK: Evaluation of the oral hypoglycaemic effect of Trigonella foenum-graecum L. +(methi) in normal mice. J Ethnopharmacol 2001; 75: 191–195. +11 +Ribes G, Sauvaire Y, Costa CD, Baccou JC, Loubatieres-Mariani MM: Antidiabetic effects of subtractions from +fenugreek seeds in diabetic dogs. Proc Soc Exp Biol Med 1986; 182: 159–166. +12 +Chimkode SM, Kumaran SD, Kanhere VV, Shivanna R: Effect of yoga on blood glucose levels in patients with +type 2 diabetes mellitus. J Clin Diagn Res 2015; 9:CC01. +13 +Garfinkel MS, Singhal A, Katz WA, Allan DA, Reshetar R, Schumacher HR Jr: Yoga-based intervention for carpal +tunnel syndrome: a randomized trial. JAMA 1998; 280: 1601–1603. +14 +Miller JJ, Fletcher K, Kabat-Zinn J: Three-year follow-up and clinical implications of a mindfulness meditation- +based stress reduction intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry 1995; 17: +192–200. +15 +Nagarathna R, Nagendra HR: Yoga for bronchial asthma: a controlled study. Br Med J (Clin Res Ed) 1985; 291: +1077–1079. +16 +Metri KG, Pradhan B, Nagendra HR: Impact of short-term residential yoga-based lifestyle intervention on +cognitive function in hypertensive patients. J Stem Cells 2017; 12: 33. +17 +Manchanda SC, Narang R, Reddy KS, Sachdeva U, Prabhakaran D, Dharmanand S, Bijlani R: Retardation of +coronary atherosclerosis with yoga lifestyle intervention. J Assoc Physicians India 2000; 48: 687–694. +18 +Nagarathna R, Usharani MR, Rao AR, Chaku R, Kulkarni R, Nagendra HR: Efficacy of yoga-based life style modi­ +fication program on medication score and lipid profile in type 2 diabetes – a randomized control study. Int J +Diabetes Dev Ctries 2012; 32: 122–130. +19 +Yang L, Brozovic S, Xu J, Long Y, Kralik PM, Waigel S, Epstein PN: Inflammatory gene expression in OVE26 +diabetic kidney during the development of nephropathy. Nephron 2011; 119:e8. +20 +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. +21 +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– +220. diff --git a/subfolder_0/Effect of high-frequency yoga breathing on pulmonary functions in patients with asthma..txt b/subfolder_0/Effect of high-frequency yoga breathing on pulmonary functions in patients with asthma..txt new file mode 100644 index 0000000000000000000000000000000000000000..b264dbaa92984ff758d71df9ee479b016d22a38c --- /dev/null +++ b/subfolder_0/Effect of high-frequency yoga breathing on pulmonary functions in patients with asthma..txt @@ -0,0 +1,304 @@ +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 +aparsaoji@gmail.com +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 diff --git a/subfolder_0/Effect of integrated Yoga and Physical therapy on audiovisual reaction time, anxiety and depression in patients with chronic multiple sclerosis.txt b/subfolder_0/Effect of integrated Yoga and Physical therapy on audiovisual reaction time, anxiety and depression in patients with chronic multiple sclerosis.txt new file mode 100644 index 0000000000000000000000000000000000000000..82f654cb788f1027259ce77ef31f0b4404f9d1b6 --- /dev/null +++ b/subfolder_0/Effect of integrated Yoga and Physical therapy on audiovisual reaction time, anxiety and depression in patients with chronic multiple sclerosis.txt @@ -0,0 +1,2714 @@ +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 +Journal of Complementary and Integrative Medicine +Journal of Complementary and Integrative Medicine +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +60 +For Review Only +Email: drshivajichobe06@gmail.com +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 +Journal of Complementary and Integrative Medicine +Journal of Complementary and Integrative Medicine +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +60 +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 +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 +Journal of Complementary and Integrative Medicine +Journal of Complementary and Integrative Medicine +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +60 +For Review Only + + +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 +Journal of Complementary and Integrative Medicine +Journal of Complementary and Integrative Medicine +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +60 +For Review Only + + + +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 +Journal of Complementary and Integrative Medicine +Journal of Complementary and Integrative Medicine +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +60 +For Review Only + + +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 +Journal of Complementary and Integrative Medicine +Journal of Complementary and Integrative Medicine +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +60 +For Review Only + + +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 EDSS0.05 +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 +Unauthenticated +Download Date | 7/26/18 3:11 AM +Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd +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 diff --git a/subfolder_0/Effect of trataka (Yogic Visual Concentration) on the performance in the corsi-block tapping task A repeated measures study.txt b/subfolder_0/Effect of trataka (Yogic Visual Concentration) on the performance in the corsi-block tapping task A repeated measures study.txt new file mode 100644 index 0000000000000000000000000000000000000000..7137f52aa2c1dac6ebd8a89ca9adbe1479f08df8 --- /dev/null +++ b/subfolder_0/Effect of trataka (Yogic Visual Concentration) on the performance in the corsi-block tapping task A repeated measures study.txt @@ -0,0 +1,671 @@ +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 +aparsaoji@gmail.com +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. +REFERENCES +Anusuya, U. S., Mohanty, S., and Saoji, A. A. (2021). Effect of mind +sound resonance technique (MSRT–A yoga-based relaxation technique) on +psychological variables and cognition in school children: a randomized +controlled trial. Complement. Ther. Med. 56:102606. doi: 10.1016/j.ctim.2020. +102606 +Basso, J. C., McHale, A., Ende, V., Oberlin, D. J., and Suzuki, W. A. (2019). Brief, +daily meditation enhances attention, memory, mood, and emotional regulation +in non-experienced meditators. Behav. Brain Res. 356, 208–220. doi: 10.1016/j. +bbr.2018.08.023 +Brunetti, R., Del Gatto, C., and Delogu, F. (2014). eCorsi: implementation and +testing of the Corsi block-tapping task for digital tablets. Front. Psychol. 5:939. +doi: 10.3389/fpsyg.2014.00939 +Chattha, R., Nagarathna, R., Padmalatha, V., and Nagendra, H. R. (2008). Effect +of yoga on cognitive functions in climacteric syndrome: a randomised control +study. BJOG 115, 991–1000. doi: 10.1111/j.1471-0528.2008.01749.x +Field, T. (2016). Yoga research review. Complement. Ther. Clin. Pract. 24, 145–161. +doi: 10.1016/j.ctcp.2016.06.005 +Garg, R., Malhotra, V., Tripathi, Y., and Agarawal, R. (2016). Effect of left, right and +alternate nostril breathing on verbal and spatial memory. J. Clin. Diagn. Res. 10, +CC01–CC03. doi: 10.7860/JCDR/2016/12361.7197 +Gothe, N. P., and McAuley, E. (2015). Yoga and cognition: a meta-analysis of +chronic and acute effects. Psychosom. Med. 77, 784–797. doi: 10.1097/PSY. +0000000000000218 +Gothe, N. P., Khan, I., Hayes, J., Erlenbach, E., and Damoiseaux, J. S. (2019). +Yoga effects on brain health: a systematic review of the current literature. Brain +Plasticity 5, 105–122. doi: 10.3233/BPL-190084 +Guariglia, C. C. (2007). Spatial working memory in Alzheimer’s disease: a study +using the Corsi block-tapping test. Dement. Neuropsychol. 1, 392–395. doi: +10.1590/S1980-57642008DN10400011 +Gupta, R., Agnihotri, S., Telles, S., and Balkrishna, A. (2019). Performance in a +Corsi block-tapping task following high-frequency yoga breathing or breath +awareness. Int. J. Yoga 12:247. doi: 10.4103/ijoy.ijoy_55_18 +Jarraya, S., Wagner, M., Jarraya, M., and Engel, F. A. (2019). 12 weeks of +Kindergarten-based yoga practice increases visual attention, visual-motor +precision and decreases behavior of inattention and hyperactivity in 5-year-old +children. Front. Psychol. 10:796. doi: 10.3389/fpsyg.2019.00796 +Joshi, M., and Telles, S. (2008). Immediate effects of right and left nostril breathing +on verbal and spatial scores. Indian J. Physiol. Pharmacol. 52, 197–200. +Kessels, R. P. C., Van Den Berg, E., Ruis, C., and Brands, A. M. A. (2008). +The backward span of the corsi block-tapping task and its association with +the WAIS-III digit span. Assessment 15, 426–434. doi: 10.1177/107319110831 +5611 +Kessels, R. P. C., Van Zandvoort, M. J. E., Postma, A., Kappelle, L. J., and De Haan, +E. H. F. (2000). The corsi block-tapping task: standardization and normative +data. Appl. Neuropsychol. 7, 252–258. doi: 10.1207/S15324826AN0704_8 +Mallick, T., and Kulkarni, R. (2010). The effect of Trataka, a yogic visual +concentration practice, on critical flicker fusion. J. Altern. Complement. Med. +16, 1265–1267. doi: 10.1089/acm.2010.0012 +Marciniak, R., Sheardova, K., ˇ +Cermáková, P., Hudeˇ +cek, D., Šumec, R., and Hort, +J. (2014). Effect of meditation on cognitive functions in context of aging and +neurodegenerative diseases. Front. Behav. Neurosci. 8:17. doi: 10.3389/fnbeh. +2014.00017 +Miller, E. K. (2000). The prefrontal cortex and cognitive control. Nat. Rev. Neurosci. +1, 59–65. doi: 10.1038/35036228 +Monaco, M., Costa, A., Caltagirone, C., and Carlesimo, G. A. (2013). Forward and +backward span for verbal and visuo-spatial data: standardization and normative +data from an Italian adult population. Neurol. Sci. 34, 749–754. doi: 10.1007/ +s10072-012-1130-x +Muktibodhananda, S. (1999). Hatha Yoga Pradipika. Munger: Yoga Publications +trust. +Namratha, H. G., George, V. M., Bajaj, G., Mridula, J., and Bhat, J. S. (2017). Effect +of yoga and working memory training on cognitive communicative abilities +among middle aged adults. Complement. Ther. Clin. Pract. 28, 92–100. doi: +10.1016/J.CTCP.2017.05.007 +Naveen, K. V., Nagarathna, R., Nagendra, H. R., and Telles, S. (1997). Yoga +breathing through a particular nostril increases spatial memory scores without +lateralized effects. Psychol. Rep. 81, 555–561. doi: 10.2466/pr0.1997.81.2.555 +Raghavendra, B. R., and Ramamurthy, V. (2014). Changes in heart rate variability +following yogic visual concentration (Trataka). Heart India 2:15. +Raghavendra, B. R., and Singh, P. (2016). Immediate effect of yogic visual +concentration on cognitive performance. J. Tradit. Complement. Med. 6, 34–36. +doi: 10.1016/j.jtcme.2014.11.030 +Rajesh, S., Ilavarasu, J., and Srinivasan, T. (2014). Effect of bhramari pranayama +on response inhibition: evidence from the stop signal task. Int. J. Yoga 7:138. +doi: 10.4103/0973-6131.133896 +Sherlee, J. I., and David, A. (2020). Effectiveness of yogic visual concentration +(Trataka) +on +cognitive +performance +and +anxiety +among +adolescents. +J. Complement. Integr. Med 17. doi: 10.1515/jcim-2019-0055 [Epub ahead +of print]. +Siddi, S., Preti, A., Lara, E., Brébion, G., Vila, R., Iglesias, M., et al. (2020). +Comparison of the touch-screen and traditional versions of the Corsi block- +tapping test in patients with psychosis and healthy controls. BMC Psychiatry +20:329. doi: 10.1186/s12888-020-02716-8 +Stoffers, D., Berendse, H. W., Deijen, J. B., and Wolters, E. C. (2003). Deficits on +Corsi’s block-tapping task in early stage Parkinson’s disease. Parkinsonism Relat. +Disord. 10, 107–111. doi: 10.1016/s1353-8020(03)00106-8 +Subramanya, P., and Telles, S. (2009). Effect of two yoga-based relaxation +techniques on memory scores and state anxiety. Biopsychosoc. Med. 3:8. doi: +10.1186/1751-0759-3-8 +Swathi, P. S., Raghavendra, B. R., and Saoji, A. A. (2020). Health and therapeutic +benefits of shatkarma: a narrative review of scientific studies. J. Ayurveda Integr. +Med. 12, 206–212. doi: 10.1016/j.jaim.2020.11.008 +Frontiers in Psychology | www.frontiersin.org +6 +December 2021 | Volume 12 | Article 773049 +Swathi et al. +Trataka and Cognition +Swathi, P. S., Saoji, A. A., and Raghavendra, B. (2021). Role of Trataka in +ameliorating visual strain and promoting psychological well-being during +prolonged use of digital displays: randomized controlled trial. Work A J. Prev. +Assess. Rehabil. (in press). +Taimni, I. K. (2010). The Science of Yoga: The Yoga-sutras of Patanjali +in Sanskrit with Transliteration in Roman, Translation in English and +Commentary. Quest Books Available online at: https://books.google.com/ +books?id=q9kenQEACAAJ&pgis=1 (accessed April 4, 2016). +Talwadkar, S., Jagannathan, A., and Raghuram, N. (2014). Effect of trataka on +cognitive functions in the elderly. Int. J. Yoga 7, 96–103. doi: 10.4103/0973- +6131.133872 +Vhavle, S., Rao, R., and Manjunath, N. (2019). Comparison of yoga versus physical +exercise on executive function, attention, and working memory in adolescent +schoolchildren: a randomized controlled trial. Int. J. Yoga 12:172. doi: 10.4103/ +ijoy.ijoy_61_18 +Yamaya, N., Tsuchiya, K., Takizawa, I., Shimoda, K., Kitazawa, K., and +Tozato, F. (2021). Effect of one-session focused attention meditation on the +working memory capacity of meditation novices: a functional near-infrared +spectroscopy study. Brain Behav. 11:e2288. doi: 10.1002/brb3.2288 +Zakaria, R., Ahmad, A. H., and Othman, Z. (2016). The potential role of melatonin +on memory function: lessons from rodent studies. Folia Biol. 62, 181–187. +Zisapel, N. (2018). New perspectives on the role of melatonin in human sleep, +circadian rhythms and their regulation. Br. J. Pharmacol. 175, 3190–3199. doi: +10.1111/BPH.14116 +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 diff --git a/subfolder_0/Effect of yoga on musculoskeletal discomfort and motor functions in professional computer users.txt b/subfolder_0/Effect of yoga on musculoskeletal discomfort and motor functions in professional computer users.txt new file mode 100644 index 0000000000000000000000000000000000000000..2a8c5efb795b0baa9f7da404992b8d97788b2702 --- /dev/null +++ b/subfolder_0/Effect of yoga on musculoskeletal discomfort and motor functions in professional computer users.txt @@ -0,0 +1,959 @@ +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: shirleytelles@gmail.com. +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. +References +[1] +T.J. Armstrong, Ergonomics and Cumulative Trauma Disor- +ders of the Hand and Wrist, in: Rehabilitation of the Hand: +Surgery and Therapy, (3rd ed.), J.M. Hunter, L.H. Schneider, +E.J. Mackin and A.D. Callahan, eds, Mosby, St. Louis, 1990. +[2] +T.J. Armstrong, P. Buckle, L.J. Fine et al., A conceptual model +for work-related neck and upper-limb musculoskeletal disor- +ders, Scand J Work Environ Health 19(2) (1993), 73–84. +[3] +B. Bernard, S.L. Sauter, L.J. Fine, M.R. Peterson and T.R. +Hales, Psychosocial and work organization risk factors for cu- +mulative trauma disorders in the hands and wrists of newspa- +per employees, Scand J Work Environ Health 18(2) (1992), +119–120. +[4] +M. Dash and S. Telles, Yoga training and motor speed based +on a finger tapping task, Indian J Physiol Pharmacol 43(4) +(1999), 458–462. +[5] +M. Dash and S. Telles, Improvement in hand grip strength in +normal volunteers and rheumatoid arthritis patients following +yoga training, Indian J Physiol Pharmacol 45(3) (2001), 355– +360. +[6] +T. Delbanco, The healing roles of doctor and patient, in: Heal- +ing and the Mind, B. Moyers, ed., David Grubin Productions, +New York, 1993, pp. 7–23. +[7] +M.J. Duncan, L. Woodfield and Y. al-Nakeeb, Anthropomet- +ric and physiological characteristics of junior elite volleyball +players, Br J Sports Med 40(7) (2006), 649–651. +[8] +A.B. Erez and K.N. Lindgren, Psychosocial factors in work- +related musculoskeletal disorders, in: Ergonomics for Thera- +pists, K. Jacobs, ed., Butterworth-Heinemann, Boston, 1999. +[9] +M.S. Garfinkel, A. Singhal, W.A. Katz, D.A. Allan, R. +Reshetar and H.R. Schumacher, Yoga-based intervention for +carpal tunnel syndrome: a randomized trial, JAMA 280(18) +(1998), 1601–1603. +[10] +F. Goodyear-Smith and B. Arroll, What can family physicians +offer patients with carpal tunnel syndrome other than surgery? +A systematic review of nonsurgical management, Ann Fam +Med 2(3) (2004), 267–273. +[11] +I. Haslock, R. Monro, R. Nagarathna, H.R Nagendra and N.V. +Raghuram, Measuring the effects of yoga in rheumatoid arthri- +tis, Br J Rheumatol 33(8) (1994), 787–788. +[12] +A. Hedge, S. Morimoto and D. McCrobie, Effects of keyboard +tray geometry on upper body posture and comfort, Ergonomics +42 (10) (1999), 1333–1349. +[13] +A. Hopkins, Stress, the quality of work and repetitive strain +injury in Australia, Work Stress 4(2) (1990), 129–138. +[14] +M.A. +Hutson, +Work +Related +Upper +Limb +Disorders, +Butterworth-Heinemann, Oxford, 1997. +[15] +B.R. Jensen, M. Pilegaard and A. Momsen, Vibrotactile sense +and mechanical functional start of the arm and hand among +computer users compared with a control group, Int Arch Occup +Environ Health 75(5) (2002), 332–340. +306 +S. Telles et al. / Yoga and motor functions in computer professionals +[16] +E. Kierklo and S. Jones, Stop repetitive injuries before they +start, Safety Health 150 (1994), 68–69 +[17] +L.O. Mikkelson, H. Nupponen, J. Kaprio, H. Kautiainen, +M. Mikkelsson and U.M. Kujala, Adolescent flexibility, en- +durance strength, and physical activity as predictors of adult +tension neck, low back pain, and knee injury: a 25 year follow +up study, Br J Sports Med 40(2) (2006), 107–113. +[18] +C.S. Pan, and L.M. Schleifer, An exploratory study of the re- +lationship between biomechanical factors and right-arm mus- +culoskeletal discomfort and fatigue in a VDT data-entry task, +Appl Ergon 27(3) (1996), 195–200 +[19] +M. Parkash and S.L. Malik, Effect of smoking on anthropo- +metric somatotype and grip strength, Indian J Med Res 87 +(1988), 494–499. +[20] +NIOSH, Musculoskeletal disorders and workplace factors, US +Department of Health and Human Services, Public Health Ser- +vice, Centers for Disease Control and Prevention, National In- +stitute for Occupational Safety and Health, Washington, D.C., +1997. +[21] +R.C. Oldfield, The assessment and analysis of handedness: the +Edinburgh inventory, Neuropsychologia 9(1) (1971), 97–113. +[22] +E.F. Pascarelli and J.J. Kella, Soft- tissue injuries related to +use of the computer key- board. A clinical study of 53 severely +injured persons, J Occup Med 35(5) (1993), 522–532. +[23] +M.S. Pesco, E. Chosa, N. Tajima, Comparative study of hands- +on therapy with active exercises vs education with active exer- +cises for the management of upper back pain, J Manipulative +Physiol Ther 29(3) (2006), 228–235. +[24] +C.R. Ratzlaff, J.H. Gillies and M.W. Koehoorn, Work-related +repetitive strain injury and leisure-time physical activity, +Arthritis Rheum 57(3) (2007), 495–500. +[25] +S. Chandra, Repetitive strain injuries: the modern epidemic. +Indian J Clin Practice 13(11) (2003), 12–15. +[26] +I. Shimoyama, T. Ninchoji and K. Uemura, The finger tapping +test: a quantitative analysis, Arch Neurol 47(6) (1990), 681– +684. +[27] +D.S. Stetson, W.M. Keyserling, B.A. Silverstein and J.A. +Leonard, Observational analysis of the hand and wrist: a pilot +study, Appl Occup Environ Hyg 6(11) (1991), 927–937. +[28] +S. Telles, R. Nagarathna, H.R. Nagendra and T. Desiraju, +Physiological changes in sports teachers following 3 months +of training in yoga, Indian J Med Sci 47(10) (1993), 235–238. +[29] +S. Telles, K.V. Naveen, M. Dash, R. Deginal and N.K. Man- +junath, Effect of yoga on self-rated visual discomfort in com- +puter users, Head Face Med 3(2) (2006), 46. +[30] +A. Toomingas, T. Theorell, H. Michelsen and R. Nordemar, +Association between self-rated psychosocial work conditions +and musculoskeletal symptoms and signs. Stockholm MUSIC +I Study Group, Scand J Work Environ Health 23(2) (1997), +130–139. +[31] +F. Tremblay, A.C. Mireault, J. L´ +etourneau, A. Pierrat and S. +Bourrassa, Tactile perception and manual dexterity in com- +puter users, Somatosens Mot Res 19(2) (2002), 101–108. +[32] +J.R. Wilson and E.N. Corlett, Evaluation of Human Work, (2nd +ed.), Taylor and Francis, London, 1995. +[33] +K.S. Wright and D.S. Wallach, CTD Resource Network (www. +tifaq.com), 1998. +[34] +Z.H. Zar, Biostatistical Analysis, Prentice-Hall, Inc., New Jer- +sey, 1999. diff --git a/subfolder_0/Effect of yoga on plasma glucose, lipid profile, blood pressure and insulin requirement in a patient with type 1 diabetes mellitus..txt b/subfolder_0/Effect of yoga on plasma glucose, lipid profile, blood pressure and insulin requirement in a patient with type 1 diabetes mellitus..txt new file mode 100644 index 0000000000000000000000000000000000000000..e69de29bb2d1d6434b8b29ae775ad8c2e48c5391 diff --git a/subfolder_0/Effect of yoga on symptom management in breast cancer patient A randomized controled trial.txt b/subfolder_0/Effect of yoga on symptom management in breast cancer patient A randomized controled trial.txt new file mode 100644 index 0000000000000000000000000000000000000000..f16f0077f5ca9b6815e6cd1e78799b1ee8ef7fb2 --- /dev/null +++ b/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: rnagaratna@gmail.com +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. +Stehlin JS, Beach KH. Psychological aspects of cancer therapy: A surgeon’s +viewpoint. JAMA 1966;197:100-4. +2. +Thomas BC, Pandey M, Ramdas K, Nair MK. Psychological distress in cancer +patients: Hypothesis of a distress model. Eur J Cancer Prev 2002;11:179-85. +3. +Hughes J. Emotional reactions to diagnosis and treatment of early breast +cancer. J Psychosom Res 1982;26:277-83. +4. +Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F, et al. +Postoperative radiotherapy in high-risk premenopausal women with breast +cancer who receive adjuvant chemotherapy Danish Breast Cancer Cooperative +Group 82b Trial. N Engl J Med 1997;337:949-55. +5. +Ragaz J, Jackson SM, Le N, Plenderleith IH, Spinelli JJ, Basco VE, et al +Adjuvant radiotherapy and chemotherapy in node-positive premenopausal +women with breast cancer. N Engl J Med 1997;337:956-62. +6. +Patrick DL, Ferketich SL, Frame PS, Harris JJ, Hendricks CB, Levin B, et al +National Institutes of Health State-of-the-Science Panel. National Institutes +of Health State-of-the-Science Conference Statement: Symptom management +in cancer: Pain, depression, and fatigue, July 15-17, 2002. J Natl Cancer Inst +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] diff --git a/subfolder_0/Effect of yoga on visual perception and visual strain.txt b/subfolder_0/Effect of yoga on visual perception and visual strain.txt new file mode 100644 index 0000000000000000000000000000000000000000..c4c02190eceae5f8432850f5274844e1043a0725 --- /dev/null +++ b/subfolder_0/Effect of yoga on visual perception and visual strain.txt @@ -0,0 +1,14 @@ + + + + + + + + + + + + + + diff --git a/subfolder_0/Effects of ice massage of the head and spine on heart rate variability in healthy volunteers.txt b/subfolder_0/Effects of ice massage of the head and spine on heart rate variability in healthy volunteers.txt new file mode 100644 index 0000000000000000000000000000000000000000..42e6b692fe0c343418303f982bb9b5ca875bb552 --- /dev/null +++ b/subfolder_0/Effects of ice massage of the head and spine on heart rate variability in healthy volunteers.txt @@ -0,0 +1,532 @@ +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: dr.mooventhan@gmail.com +● 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. diff --git a/subfolder_0/Effects of yoga on natural killer cell counts in early breast cancer patients undergoing conventional treatment.txt b/subfolder_0/Effects of yoga on natural killer cell counts in early breast cancer patients undergoing conventional treatment.txt new file mode 100644 index 0000000000000000000000000000000000000000..3e144967824d77d6d2f110fd286e88eb6d06147e --- /dev/null +++ b/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: shirleytelles@gmail.com +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 diff --git a/subfolder_0/Efficacy of Naturopathy And Yoga In Bronchial Asthma..txt b/subfolder_0/Efficacy of Naturopathy And Yoga In Bronchial Asthma..txt new file mode 100644 index 0000000000000000000000000000000000000000..e1a8e287ae7725876182d0188ff17378d4365580 --- /dev/null +++ b/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: jaganaarti@gmail.com +(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 +Rao, Kadam, Jagannathan, Babina, Rao and Nagendra +Indian J Physiol Pharmacol 2014; 58(3) +1. +Pretorius E. The role of alternative and complementary +treatments in asthma. Acupunct Electrother 2009; 34(1- +2): 15–26. +2. +Posadzki P, Ernst E. Yoga for asthma ? A systematic +review of randomized clinical trials. J Asthma 2011; 48(6): +632–639. +3. +Nagendra HR Nagarathna R. An integrated approach of +yoga therapy for bronchial asthma: A 3-54 month +prospective study. J Asthma 1986; 23(3): 123–137. +4. +Khalsa SB. Yoga as a therapeutic intervention: a +bibliometric analysis of published research studies; Indian +J Physiol Pharmacol 2004; 48(3): 269–285. +5. +Birdee GS, Legedza AT, Saper RB, Bertisch SM, Eisenberg +DM, Phillips RS. Characteristics of yoga users: results of +a national survey. J Gen Intern Med 2008; 23(10): 1653– +1658. +6. +Tokem Y. The use of complementary and alternative +treatment in patients with asthma. Tuberk Toraks 2006; +54(2): 189–196. +7. +Mark JD. Pediatric Asthama – an integrative approach to +care. Nutrition in Clinical Practice 2009; 24(5): 578– +588. +8. +Saxena T, Saxena M. The effect of various breathing +exercises (pranayama) in patients with bronchial asthma +of mild to moderate severity. Int J Yoga 2009; 2(1): 22–5. +9. +Sodhi C, Singh S, Dandona PK. A study of the effect of +yoga training on pulmonary functions in patients with +bronchial asthma. Indian J Physiol Pharmacol 2009; 53(2): +169–174. +10. Panda AK, Doddanagali SR. Clinical efficacy of herbal +Padmapatradi yoga in bronchial asthma (Tamaka Swasa). +J Ayurveda Integr Med 2011; 2: 85–90. +11. Satyaprabha TN, Murthy H, Murthy BTC. Efficacy of +naturopathy and yoga in Bronchial asthma–A self-controlled +matched scientific study. Indian J Physiol Pharmacol 2001; +45(1): 80–86. +12. Vempati R, Bijlani RL, Deepak KK. The efficacy of a +comprehensive lifestyle modification programme based on +yoga in the management of bronchial asthma: a randomized +controlled trial; BMC Pulmonary Medicine 2009; 9: 37. +13. Chen TL, Mao HC, Lai CH, Li CY, Kuo CH. The effect of +yoga exercise intervention on health related physical +fitness in school-age asthmatic children. Hu Li Za Zhi +2009; 56(2): 42–52. +14. Cotton S, Luberto CM, Yi MS, Tsevat J. Complementary +and alternative medicine behaviors and beliefs in urban +adolescents with asthma; J Asthma 2011; 48(5): 531– +538. +15. Kligler B, Homel P, Blank AE, Kenny J, Levenson H, Merrell +W. Randomized trial of the effect of an integrative +medicine approach to the management of asthma in adults +on disease-related quality of life and pulmonary function. +Altern Ther Health Med 2011; 17(1): 10–5. +16. Manocha S, Walley KR, Russell JA. Severe Acute +Respiratory Distress Syndrome (SARS): a critical care +perspective. Crit Care Med 2003; 31(11): 2684–2692. +17. Slader CA, Reddel HK, Spencer LM, Belousova EG, Armour +CL, Bosnic-Anticevich SZ, Thien FCK, Jenkins CR. Double +blind randomised controlled trial of two different breathing +techniques in the management of asthma. Thorax 2006; +61: 651–656. +18. Nagarathna R and Nagendra HR. Yoga for bronchial +asthma: A controlled study. British Medical Journal 1985; +291: 1077–1079. +19. Steriti R. Nutritional support for chronic myelogenous and +other leukemias; a review of the scientific literature. Altern +Med Rev 2002; 7(5): 404–409. +20. Dunn, O.J. (1961). Multiple Comparisons among Means. +Journal of the American Statistical Association 56: 52– +64. +21. Strassburger K, Bretz Frank. Compatible simultaneous +lower confidence bounds for the Holm procedure and +other Bonferroni-based closed tests. Statistics in Medicine, +2008; 27(24); 4914–4927. +22. Agrawal B, Mehta A. Antiasthmatic activity of Moringa +oleifera Lam: A clinical study. Indian Journal of +Pharmacology 2008; 40(1): 28–31. +23. Wood MR, Bolyard DJ. Making Education Count: The Nurse’s +Role in Asthma Education. J Asthma 2010; 26(6): 552– +558. +References diff --git a/subfolder_0/Efficacy of Yoga as an add-on to Physiotherapy in the management of Patients with Paraplegia Randomized Controlled Trial.txt b/subfolder_0/Efficacy of Yoga as an add-on to Physiotherapy in the management of Patients with Paraplegia Randomized Controlled Trial.txt new file mode 100644 index 0000000000000000000000000000000000000000..eddeb12788e39cdb652c126f12142d5d9b900b46 --- /dev/null +++ b/subfolder_0/Efficacy of Yoga as an add-on to Physiotherapy in the management of Patients with Paraplegia Randomized Controlled Trial.txt @@ -0,0 +1,1013 @@ +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 +CITATION +1 +READS +722 +6 authors, including: +Some of the authors of this publication are also working on these related projects: +Cerebral autoregulation and autonomic nervous system activity while performing yoga practices View project +Effect of Yoga Practices on Cognitive functions in Type2 Diabetes Mellitus View project +Deepeshwar Singh +SVYASA Yoga University +31 PUBLICATIONS   92 CITATIONS    +SEE PROFILE +All content following this page was uploaded by Deepeshwar Singh on 14 March 2019. +The user has requested enhancement of the downloaded file. +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 +REFERENCEs + Cieza A, Sabariego C, Bickenbach J, Chatterji S. Rethinking Disability. BMC +[1] +Med. 2018;16(1):10-14. + Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of +[2] +acute spinal cord injury. Spine (Phila Pa 1976). 2001;26(24 Suppl):S2-12. + Singh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings MG. Global Prevalence and +[3] +incidence of traumatic spinal cord injury. Clin Epidemiol. 2014;6:309-31. + Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic +[4] +spinal cord injury epidemiology: update 2011, global incidence rate. +2013;52(2):110-16. + Weidner N, Rupp R, Tansey KE, editors. Neurological Aspects of Spinal Cord +[5] +Injury. Cham: Springer International Publishing; 2017. + Ness LL, Field-Fote EC. Whole-body vibration improves walking  function +[6] +in  individuals with spinal cord injury: a pilot study. Gait Posture. +2009;30(4):436-40. + Nicotra A, Critchley HD, Mathias CJ, Dolan RJ. Emotional and autonomic +[7] +consequences of spinal cord injury explored using functional brain imaging. +Brain. 2006;129(Pt 3):718-28. + Gibson AE, Buchholz AC, Martin Ginis KA, Latimer AE, Bray SR, Craven C, et +[8] +al. C-reactive protein in adults with chronic spinal cord injury: Increased chronic +inflammation in tetraplegia vs paraplegia. Spinal Cord. 2008;46(9):616-21. + Buchholz AC, Bugaresti JM. A review of body mass index and waist circumference +[9] +as markers of obesity and coronary heart disease risk in persons with chronic +spinal cord injury. Spinal Cord. 2005;43(9):513-18. + Gorgey AS, Gater DR, Jr. Prevalence of obesity after spinal cord injury. Top Spinal +[10] +Cord Inj Rehabil. 2007;12(4):1-7. + Meyer HB, Katsman A, Sones AC, Auerbach DE, Ames D, Rubin RT. Yoga as +[11] +an ancillary treatment for neurological and psychiatric disorders: a review. J +Neuropsychiatry Clin Neurosci. 2012;24(2):152-64. + Bhargav H, Nagendra HR, Gangadhar BN, Nagarathna R. Frontal hemodynamic +[12] +responses to high frequency yoga breathing in schizophrenia: a functional near- +infrared spectroscopy study. Front Psychiatry. 2014;5:29. + Curtis K, Hitzig SL, Bechsgaard G, Stoliker C, Alton C, Saunders N, et al. +[13] +Evaluation of a specialized yoga program for persons with a spinal cord injury: a +pilot randomized controlled trial. J Pain Res. 2017;10:999-1017. + Telles S, Sayal N, Nacht C, Chopra A, Patel K, Wnuk A, et al. Yoga: Can it be +[14] +integrated with treatment of neuropathic pain? Integr Med Int. 2017;4:69-84. + Zwick D. Integrating Iyengar yoga into rehab for spinal cord injury. Nursing (Lond). +[15] +2006;36 Suppl P:18-22. + Raju T. Yoga induced brain plasticity- role of neurotrophic factors. Open access +[16] +J Neurol Neurosurg. 2017;6(1):10-12. + Smith EN, Boser A. Yoga, vertebral fractures, and osteoporosis: research and +[17] +recommendations. Int J Yoga Therap. 2013;23(1):17-23. + Norrbrink C, Löfgren M. Needs and requests – patients and physicians voices +[18] +about improving the management of spinal cord injury neuropathic pain. Disabil +Rehabil. 2016;38(2):151-58. + Patil NJ, Nagaratna R, Garner C, Raghuram NV, Crisan R. Effect of +[19] +integrated Yoga on neurogenic bladder dysfunction in patients with multiple +sclerosis-A prospective observational case series. Complement Ther Med. +2012;20(6):424-30. + Kirshblum SC, Burns SP +, Biering-Sorensen F, Donovan W, Graves DE, Jha A, +[20] +et al. International standards for neurological classification of spinal cord injury +(revised 2011). J Spinal Cord Med. 2011;34(6):535-46. + Goldstein RL, Walia P +, Teylan M, Lazzari AA, Tun CG, Hart JE, et al. Clinical +[21] +factors associated with C-reactive protein in chronic spinal cord injury. Spinal +Cord. 2017 Aug; + Kono T, Otsuka M, Ito M, Misawa M, Hoshioka A, Suzuki M, et al. Negative C-reactive +[22] +protein in children with bacterial infection. Pediatr Int. 1999;41(5):496-99. + Catz A, Itzkovich M, Agranov E, Ring H TA. No TitleSCIM--spinal cord +[23] +independence measure: a new disability scale for patients with spinal cord +lesions. Spinal Cord. 1997;35(12):850-56. + Overholser, James C., Schubert, Daniel S., Foliart, Roland, Frost F. No +[24] +TitleAssessment of emotional distress following a spinal cord injury. Rehabil +Psychol. 1993;38(3):187-98. + Estwing Ferrans C, Powers MJ. Quality Of Life Index - Spinal Cord Injury Version +[25] +III. 1998;01-04. + Nuttall FQ. Body Mass Index: Obesity, BMI, and Health: A critical review. Nutr +[26] +Today. 2015;50(3):117-28. + Froehlich-Grobe K, Nary DE, Van Sciver A, Lee J, Little TD. Measuring height +[27] +without a stadiometer: empirical investigation of four height estimates among +wheelchair users. Am J Phys Med Rehabil. 2011;90(8):658-66. + Narasimhan L, Nagarathna R, Nagendra H. Effect of integrated yogic practices on +[28] +positive and negative emotions in healthy adults. Int J Yoga. 2011;4(1):13-19. + Rajesh SK, Ilavarasu J V, Srinivasan TM, Nagendra HR. Stress and its expression +[29] +according to contemporary science and ancient Indian wisdom: perseverative +cognition and the Pañca kosas. Mens Sana Monogr. 2014;12(1):139-52. + Rakhshani A, Maharana S, Raghuram N, Nagendra HR, Venkatram P +. Effects +[30] +of integrated yoga on quality of life and interpersonal relationship of pregnant +women. Qual Life Res. 2010;19(10):1447-55. + Nagendra HR. Integrated yoga therapy for mental illness. Indian J Psychiatry. +[31] +2013;55(Suppl 3):S337-39. + Math SB, Srinivasaraju R. Indian Psychiatric epidemiological studies: Learning +[32] +from the past. Indian J Psychiatry. 2010;52(Suppl 1):S95-103. + Manzoni GM, Pagnini F, Castelnuovo G, Molinari E. Relaxation training for anxiety: +[33] +a ten-years systematic review with meta-analysis. 2008; + Deshpande S, Nagendra HR, Raghuram N. A randomized control trial of the +[34] +effect of yoga on verbal aggressiveness in normal healthy volunteers. Int J Yoga. +2008;1(2):76-82. + Streeter CC, Whitfield TH, Owen L, Rein T, Karri SK, Yakhkind A, et al. Effects +[35] +of yoga versus walking on mood, anxiety, and brain GABA levels: a randomized +controlled MRS study. J Altern Complement Med. 2010;16(11):1145-52. + Streeter CC, Gerbarg PL, Saper RB, Ciraulo DA, Brown RP +. Effects of yoga +[36] +on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis +in epilepsy, depression, and post-traumatic stress disorder. Med Hypotheses. +2012;78(5):571-79. + Wang T-D, Wang Y-H, Huang T-S, Su T-C, Pan S-L, Chen S-Y. Circulating levels +[37] +of markers of inflammation and endothelial activation are increased in men with +chronic spinal cord injury. J Formos Med Assoc. 2007;106(11):919-28. + Frost F, Roach MJ, Kushner I, Schreiber P +. Inflammatory C-reactive protein and +[38] +cytokine levels in asymptomatic people with chronic spinal cord injury. Arch Phys +Med Rehabil. 2005;86(2):312-17. + Rao MR, Raghuram N, Nagendra HR, Gopinath KS, Srinath BS, Diwakar RB, et +[39] +al. Anxiolytic effects of a yoga program in early breast cancer patients undergoing +conventional treatment: A randomized controlled trial. Complement Ther Med. +2009;17(1):01-08. + Bower JE, Greendale G, Crosswell AD, Garet D, Sternlieb B, Ganz PA, et al. Yoga +[40] +reduces inflammatory signaling in fatigued breast cancer survivors: a randomized +controlled trial. Psychoneuroendocrinology. 2014;43:20-29. + Gopal A, Mondal S, Gandhi A, Arora S, Bhattacharjee J. Effect of integrated yoga +[41] +practices on immune responses in examination stress-A preliminary study. Int J +Yoga. 2011;4(1):26-32. + Madhusmita M, Srinivasan TM, Ebnezar J, Nagendra HR, Mohanty PP +. Effect of +[42] +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. J Stem Cells. 2018;13(1):57-66. + Woodyard C. Exploring the therapeutic effects of yoga and its ability to increase +[43] +quality of life. Int J Yoga. 2011;4(2):49-54. + Denham J, Marques FZ, O’Brien BJ CF. “Exercise: putting action into our +[44] +epigenome.” Sport Med. 2014;44(2):189-209. + Steinmann L. Elaborate interactions between the immune and nervous systems. +[45] +Nat Immunol. 2004;5(6):575-81. + Sengupta P +. Health impacts of yoga and pranayama: a state-of-the-art review. Int +[46] +J Prev Med. 2012;3(7):444-58. +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: monaliyoga@gmail.com +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 diff --git a/subfolder_0/Evaluation of cardiovascular functions during the practice of different types of yogic breathing techniques.txt b/subfolder_0/Evaluation of cardiovascular functions during the practice of different types of yogic breathing techniques.txt new file mode 100644 index 0000000000000000000000000000000000000000..ca621564cb4633e960cf03b98ab4a265af5f9f88 --- /dev/null +++ b/subfolder_0/Evaluation of cardiovascular functions during the practice of different types of yogic breathing techniques.txt @@ -0,0 +1,677 @@ +© 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. +15. Nivethitha  L, Manjunath  NK, Mooventhan  A. Heart rate +variability changes during and after the practice of Bhramari +pranayama. Int J Yoga 2017;10:99‑102. +16. Stancák A Jr., Kuna  M, Srinivasan, Vishnudevananda  S, +Dostálek +C. +Kapalabhati‑‑yogic +cleansing +exercise. +I. +Cardiovascular and respiratory changes. Homeost Health Dis +1991;33:126‑34. +[Downloaded free from http://www.ijoy.org.in on Tuesday, June 15, 2021, IP: 136.232.192.146] diff --git a/subfolder_0/Evidence based effects of yoga practice on various health related problems of elderly people A review.txt b/subfolder_0/Evidence based effects of yoga practice on various health related problems of elderly people A review.txt new file mode 100644 index 0000000000000000000000000000000000000000..9c1ea142428187c066101725eb7a3a6776182d83 --- /dev/null +++ b/subfolder_0/Evidence based effects of yoga practice on various health related problems of elderly people A review.txt @@ -0,0 +1,586 @@ +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: dr.mooventhan@gmail.com (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. +References +Alexander, G.K., Innes, K.E., Selfe, T.K., Brown, C.J., 2013. “More than I expected”: +perceived benefits of yoga practice among older adults at risk for cardiovascular +disease. +Complement. +Ther. +Med. +21, +14e28. +http://dx.doi.org/10.1016/ +j.ctim.2012.11.001. +Bankar, M.A., Chaudhari, S.K., Chaudhari, K.D., 2013. Impact of long term Yoga +practice on sleep quality and quality of life in the elderly. J. Ayurveda Integr. +Med. 4, 28e32. http://dx.doi.org/10.4103/0975-9476.109548. +Barbieri, M., Ouellette, N., 2012. The demography of Canada and the United States +from the 1980s to the 2000s a summary of changes and a statistical assessment. +Population 67, 177e280. +Bezerra, L.A., de Melo, H.F., Garay, A.P., et al., 2014. Do 12-week yoga program in- +fluence respiratory function of elderly women? J. Hum. Kinet. 43, 177e184. +http://dx.doi.org/10.2478/hukin-2014-0103. +Bonura, K.B., Tenenbaum, G., 2014. Effects of yoga on psychological health in older +adults. J. Phys. Act. Health 11, 1334e1341. http://dx.doi.org/10.1123/jpah.2012- +0365. +Bowman, A.J., Clayton, R.H., Murray, A., et al., 1997. Effects of aerobic exercise +training and yoga on the baroreflex in healthy elderly persons. Eur. J. Clin. +Investig. 27, 443e449. +Cebri +a I Iranzo, M., Arnall, D.A., et al., 2014. Effects of inspiratory muscle training +and yoga breathing exercises on respiratory muscle function in institutionalized +frail older adults: a randomized controlled trial. J. Geriatr. Phys. Ther. 37, 65e75. +http://dx.doi.org/10.1519/JPT.0b013e31829938bb. +Cheung, C., Wyman, J.F., Resnick, B., Savik, K., 2014. Yoga for managing knee oste- +oarthritis in older women: a pilot randomized controlled trial. BMC Comple- +ment. Altern. Med. 14, 160. http://dx.doi.org/10.1186/1472-6882-14-160. +Di Benedetto, M., Innes, K.E., Taylor, A.G., et al., 2005. Effect of a gentle Iyengar yoga +program on gait in the elderly: an exploratory study. Arch. Phys. Med. Rehabil. +86, 1830e1837. +Fan, J.T., Chen, K.M., 2011. Using silver yoga exercises to promote physical and +mental health of elders with dementia in long-term care facilities. Int. Psy- +chogeriatr. 23, 1222e1230. http://dx.doi.org/10.1017/S1041610211000287. +Farinatti, P.T., Rubini, E.C., Silva, E.B., Vanfraechem, J.H., 2014. Flexibility of the +elderly after one-year practice of yoga and calisthenics. Int. J. Yoga Ther. 24, +71e77. +Field, T., 2016. Knee osteoarthritis pain in the elderly can be reduced by massage +therapy, yoga and tai chi: a review. Complement. Ther. Clin. Pract. 22, 87e92. +http://dx.doi.org/10.1016/j.ctcp.2016.01.001. +Galantino, M.L., Green, L., Decesari, J.A., et al., 2012. Safety and feasibility of +modified chair-yoga on functional outcome among elderly at risk for falls. Int. J. +Yoga 5, 146e150. http://dx.doi.org/10.4103/0973-6131.98242. +Gard, T., Noggle, J.J., Park, C.L., Vago, D.R., Wilson, A., 2014. Potential self-regulatory +mechanisms of yoga for psychological health. Front. Hum. Neurosci. 8, 770. +http://dx.doi.org/10.3389/fnhum.2014.00770. +Gonçalves, L.C., Vale, R.G., Barata, N.J., et al., 2011. Flexibility, functional autonomy +and quality of life (QoL) in elderly yoga practitioners. Arch. Gerontol. Geriatr. 53, +158e162. http://dx.doi.org/10.1016/j.archger.2010.10.028. +Gothe, N.P., Kramer, A.F., McAuley, E., 2014. The effects of an 8-week Hatha yoga +intervention on executive function in older adults. J. Gerontol. Ser. A Biol. Sci. +Med. Sci. 69, 1109e1116. http://dx.doi.org/10.1093/gerona/glu095. +Halpern, J., Cohen, M., Kennedy, G., et al., 2014. Yoga for improving sleep quality and +quality of life for older adults. Altern. Ther. Health Med. 20, 37e46. +Hariprasad, V.R., Sivakumar, P.T., Koparde, V., et al., 2013a. Effects of yoga inter- +vention on sleep and quality-of-life in elderly: a randomized controlled trial. +Indian +J. +Psychiatry +55 +(3), +S364eS368. +http://dx.doi.org/10.4103/0019- +5545.116310. +Hariprasad, V.R., Varambally, S., Varambally, P.T., et al., 2013b. Designing, validation +and feasibility of a yoga-based intervention for elderly. Indian J. Psychiatry 55 +(3), S344eS349. http://dx.doi.org/10.4103/0019-5545.116302. +Hariprasad, V.R., Koparde, V., Sivakumar, P.T., et al., 2013c. Randomized clinical trial +of yoga-based intervention in residents from elderly homes: effects on cogni- +tive function. Indian J. Psychiatry 55 (3), S357eS363. http://dx.doi.org/10.4103/ +0019-5545.116308. +Hariprasad, V.R., Varambally, S., Shivakumar, V., et al., 2013d. Yoga increases the +volume of the hippocampus in elderly subjects. Indian J. Psychiatry 55 (3), +S394eS396. http://dx.doi.org/10.4103/0019-5545.116309. +Hunter, S.D., Dhindsa, M.S., Cunningham, E., et al., 2013a. The effect of Bikram yoga +on arterial stiffness in young and older adults. J. Altern. Complement. Med. 19, +930e934. http://dx.doi.org/10.1089/acm.2012.0709. +Hunter, S.D., Dhindsa, M., Cunningham, E., et al., 2013b. Improvements in glucose +tolerance with Bikram Yoga in older obese adults: a pilot study. J. Bodyw. Mov. +Ther. 17, 404e407. http://dx.doi.org/10.1016/j.jbmt.2013.01.002. +Kelley, K.K., Aaron, D., Hynds, K., et al., 2014. The effects of a therapeutic yoga +program on postural control, mobility, and gait speed in community-dwelling +older adults. J. Altern. Complement. Med. 20, 949e954. http://dx.doi.org/ +10.1089/acm.2014.0156. +Krishnamurthy, M.N., Telles, S., 2007. Assessing depression following two ancient +Indian interventions: effects of yoga and ayurveda on older adults in a resi- +dential home. J. Gerontolog. Nurs. 33, 17e23. +Lindahl, E., Tilton, K., Eickholt, N., Ferguson-Stegall, L., 2016. Yoga reduces perceived +stress and exhaustion levels in healthy elderly individuals. Complement. Ther. +Clin. Pract. 24, 50e56. http://dx.doi.org/10.1016/j.ctcp.2016.05.007. +A. Mooventhan, L. Nivethitha / Journal of Bodywork & Movement Therapies 21 (2017) 1028e1032 +1031 +Manjunath, N.K., Telles, S., 2005. Influence of Yoga and Ayurveda on self-rated sleep +in a geriatric population. Indian J. Med. Res. 121, 683e690. +McCaffrey, R., Park, J., Newman, D., Hagen, D., 2014. The effect of chair yoga in older +adults with moderate and severe Alzheimer's disease. Res. Gerontolog. Nurs. 7, +171e177. http://dx.doi.org/10.3928/19404921-20140218-01. +Murthy, V., Sibbritt, D., Adams, J., et al., 2014. Self-prescribed complementary and +alternative medicine use for back pain amongst a range of care options: results +from a nationally representative sample of 1310 women aged 60-65 years. +Complement. +Ther. +Med. +22, +133e140. +http://dx.doi.org/10.1016/ +j.ctim.2013.11.013. +Ni, M., Mooney, K., Richards, L., Balachandran, A., et al., 2014. Comparative impacts +of tai chi, balance training, and a specially-designed yoga program on balance in +older fallers. Arch. Phys. Med. Rehabil. 95, 1620e1628. http://dx.doi.org/ +10.1016/j.apmr.2014.04.022 e30. +Ni, M., Signorile, J.F., Mooney, K., Balachandran, A., et al., 2016. Comparative effect of +power training and high-speed yoga on motor function in older patients with +parkinson disease. Arch. Phys. Med. Rehabil. 97, 345e354. http://dx.doi.org/ +10.1016/j.apmr.2015.10.095 e15. +Oken, B.S., Zajdel, D., Kishiyama, S., et al., 2006. Randomized, controlled, six-month +trial of yoga in healthy seniors: effects on cognition and quality of life. Altern. +Ther. Health Med. 12, 40e47. +Patel, N.K., Newstead, A.H., Ferrer, R.L., 2012. The effects of yoga on physical func- +tioning and health related quality of life in older adults: a systematic review +and meta-analysis. J. Altern. Complement. Med. 18, 902e917. http://dx.doi.org/ +10.1089/acm.2011.0473. +Patil, S.G., Aithala, M.R., Das, K.K., 2015. Effect of yoga on arterial stiffness in elderly +subjects with increased pulse pressure: a randomized controlled study. Com- +plement. Ther. Med. 23, 562e569. http://dx.doi.org/10.1016/j.ctim.2015.06.002. +Patil, S.G., Dhanakshirur, G.B., Aithala, M.R., Naregal, G., Das, K.K., 2014. Effect of +yoga on oxidative stress in elderly with grade-I hypertension: a randomized +controlled study. J. Clin. Diagn. Res. JCDR 8, BC04eBC07. http://dx.doi.org/ +10.7860/JCDR/2014/9498.4586. +Ramos-Jim +enez, A., Hern +andez-Torres, R.P., Wall-Medrano, A., et al., 2009. Cardio- +vascular and metabolic effects of intensive Hatha yoga training in middle-aged +and older women from northern Mexico. Int. J. Yoga 2, 49e54. http://dx.doi.org/ +10.4103/0973-6131.60044. +Santaella, D.F., Devesa, C.R., Rojo, M.R., et al., 2011. Yoga respiratory training im- +proves respiratory function and cardiac sympathovagal balance in elderly +subjects: a randomised controlled trial. BMJ Open 1, e000085. http://dx.doi.org/ +10.1136/bmjopen-2011-000085. +Shahidi, M., Mojtahed, A., Modabbernia, A., et al., 2011. Laughter yoga versus group +exercise program in elderly depressed women: a randomized controlled trial. +Int. J. Geriatr. Psychiatry 26, 322e327. http://dx.doi.org/10.1002/gps.2545. +Singh, S., Kyizom, T., Singh, K.P., et al., 2008. Influence of pranayamas and yoga- +asanas on serum insulin, blood glucose and lipid profile in type 2 Diabetes. +Indian J. Clin. Biochem. 23, 365e368. http://dx.doi.org/10.1007/s12291-008- +0080-9. +Siu, P.M., Yu, A.P., Benzie, I.F., Woo, J., 2015. Effects of 1-year yoga on cardiovascular +risk factors in middle-aged and older adults with metabolic syndrome: a ran- +domized trial. Diabetol. Metabol. Syndr. 7, 40. http://dx.doi.org/10.1186/s13098- +015-0034-3. +Sprod, L.K., Fernandez, I.D., Janelsins, M.C., et al., 2015. Effects of yoga on cancer- +related fatigue and global side-effect burden in older cancer survivors. +J. Geriatr. Oncol. 6, 8e14. http://dx.doi.org/10.1016/j.jgo.2014.09.184. +Talwadkar, S., Jagannathan, A., Raghuram, N., 2014. Effect of trataka on cognitive +functions in the elderly. Int. J. Yoga 7, 96e103. http://dx.doi.org/10.4103/0973- +6131.133872. +Tiedemann, A., O'Rourke, S., Sesto, R., Sherrington, C., 2013. A 12-week Iyengar yoga +program improved balance and mobility in older community-dwelling people: +a pilot randomized controlled trial. J. Gerontol. Ser. A Biol. Sci. Med. Sci. 68, +1068e1075. http://dx.doi.org/10.1093/gerona/glt087. +Vinchurkar, S.A., Arankalle, D.V., 2015. Integrating yoga therapy in the management +of urinary incontinence: a case report. J. Evid. Based Complement. Altern. Med. +20, 154e156. http://dx.doi.org/10.1177/2156587214563311. +Wang, M.Y., Yu, S.S., Hashish, R., et al., 2013. The biomechanical demands of +standing yoga poses in seniors: the Yoga empowers seniors study (YESS). BMC +Complement. Altern. Med. 13, 8. http://dx.doi.org/10.1186/1472-6882-13-8. +Wang, Y.Y., Chang, H.Y., Lin, C.Y., 2014. Systematic review of yoga for depression and +quality of sleep in the elderly. J. Nurs. 61, 85e92. http://dx.doi.org/10.6224/ +JN.61.1.85. Hu Li Za Zhi. +Wu, W.W., Kwong, E., Lan, X.Y., Jiang, X.Y., 2015. The effect of a meditative move- +ment intervention on quality of sleep in the elderly: a systematic review and +meta-analysis. J. Altern. Complement. Med. 21, 509e519. http://dx.doi.org/ +10.1089/acm.2014.0251. +Yagli, N.V., Ulger, O., 2015. The effects of yoga on the quality of life and depression in +elderly breast cancer patients. Complement. Ther. Clin. Pract. 21, 7e10. http:// +dx.doi.org/10.1016/j.ctcp.2015.01.002. +Youkhana, S., Dean, C.M., Wolff, M., et al., 2016. Yoga-based exercise improves +balance and mobility in people aged 60 and over: a systematic review and +meta-analysis. Age Ageing 45, 21e29. http://dx.doi.org/10.1093/ageing/afv175. +Zettergren, K.K., Lubeski, J.M., Viverito, J.M., 2011. Effects of a yoga program on +postural control, mobility, and gait speed in community-living older adults: a +pilot +study. +J. +Geriatr. +Phys. +Ther. +34, +88e94. +http://dx.doi.org/10.1519/ +JPT.0b013e31820aab53. +A. Mooventhan, L. Nivethitha / Journal of Bodywork & Movement Therapies 21 (2017) 1028e1032 +1032 diff --git a/subfolder_0/Feasibility study of integrated yoga module in overweight & obese adolescents..txt b/subfolder_0/Feasibility study of integrated yoga module in overweight & obese adolescents..txt new file mode 100644 index 0000000000000000000000000000000000000000..121b7d0cd042f7c197050d947e970a4f680ded30 --- /dev/null +++ b/subfolder_0/Feasibility study of integrated yoga module in overweight & obese adolescents..txt @@ -0,0 +1,643 @@ +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 +1. +World health Organization (WHO). Obesity and overweight Fact sheet. +Geneva: World health Organization; 2015. +2. +Batch JA, Baur LA. Management and prevention of obesity and its +complications in children and adolescents. Med J Aust. 2005;182(3):130– +135. +3. +http://www.vlib.us/amdocs/texts/prichard37.html +4. +Yazdi FT, Clee SM, Meyre D . Obesity genetics in mouse and human: back +and forth, and back again. Peer J. 2015;3:856. +5. +Dibaise JK, Foxx-Orenstein AE. Role of the gastroenterologist in managing +obesity. Expert Rev Gastroenterol Hepatol. 2013;7(5):439–451. +6. +World Health Organization (WHO). Obesity: preventing and managing the +global epidemic. World Health Organ Tech Rep Ser. Geneva; World Health +Organization; 2000. p. 894. +7. +Telles S, Bhardwaj AK. Fight against the challenges during adolescence +adopting yogic life-style. Yog Sandesh. pp. 20–23. +8. +Must A, Strauss RS. Risks and consequences of childhood and adolescent +obesity. Int J Obes Relat Metab Disord. 1999;23 (Suppl 2):S2–S11. +9. +de Onis M, Onyango AW, Borghi E, et al. Development of a WHO growth +reference for school-aged children and adolescents. Bull World Health +Organ. 2007;85(9):660–667. +10. Birdee GS, Yeh GY, Wayne PM, et al. Clinical applications of yoga for the +paediatric population: a systematic review. Acad Pediatr. 2009;9(4):212. +11. Galantino ML, Galbavy R, Quinn L. Therapeutic effects of yoga for +children: a systematic review of the literature. Pediatr Phys Ther. +2008;20(1):66–80. +12. Kaley-Isley LC, Peterson J, Fischer C, et al. Yoga as a complementary +therapy for children and adolescents: a guide for clinicians. Psychiatry +(Edgemont). 2010;7(8):20–32. +13. Shannahoff-Khalsa DS. Patient perspectives: Kundalini yoga meditation +techniques for psycho-oncology and as potential therapies for cancer. +Integr Cancer Ther. 2005;4(1):87–100. +14. Moadel AB, Shah C, Wylie-Rosett J, et al. Randomized controlled trial +of yoga among a multi-ethnic sample of breast cancer patients: Effects on +quality of life. J Clin Oncol. 2007;25(28):4387–4395. +15. Wren AA, Wright MA, Carson JW. Yoga for persistent pain: New findings +and directions for an ancient practice. Pain. 2011;152(3):477–480. +16. Taimni IK. The Science of Yoga: A Commentary on the Yoga Sutras of +Patanjali in the Light of Modern Thought. 5th edn. Illinois: Theosophical +Publishing House; 1992. +Feasibility study of integrated yoga module in overweight & obese adolescents +133 +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 +17. Justis RT, Kreigsmann B. The feasibility study as a tool for venture +analysis. 1979;17(1):35–42. +18. Svatmarama. Hatha Yoga Pradipika of Svatmarama. 4th edn. Madras: +Adyar Library and Research Centre; 1994. +19. Digambarji S, Gharote ML. Gheranda Samhita. 1st edn. Lonavala: +Kaivalyadhama S.M.Y.M Samiti; 1978. +20. Lawshe CH. A quantitative approach to content validity. Pers Psychol. +1975;28:563–575. diff --git a/subfolder_0/Health and therapeutic benefits of Shatkarma A narrative review of scientific studies.txt b/subfolder_0/Health and therapeutic benefits of Shatkarma A narrative review of scientific studies.txt new file mode 100644 index 0000000000000000000000000000000000000000..9108adb6737eb2beb4d0abbea7920aaa8ae146e5 --- /dev/null +++ b/subfolder_0/Health and therapeutic benefits of Shatkarma A narrative review of scientific studies.txt @@ -0,0 +1,952 @@ +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: swathisanketh@gmail.com +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 41C +for 20 min, and simple jala neti at 39C 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. +References +[1] Muktibodhananda S. Hatha yoga Pradipika. Munger: Yoga Publications trust; +1999. +[2] Saraswati SN. Gheranda samhita -: commentary on the yoga teachings of +maharshi Gheranda. Munger: Yoga Publications trust; 2012. +[3] Gharote M, Parimal D. Hatharatnavali (A treatise on Hathayoga of sriniva- +sayogi). Motilal Banarsidass; 2003. +[4] Yogeshwar G. Kunjara - the yogic stomach wash. Ancient Sci Life 1992;12: +261e3. +[5] Balakrishnan R, Nanjundaiah RM, Manjunath NK. Voluntarily induced vomiting - +a yoga technique to enhance pulmonary functions in healthy humans. J Ayurveda +Integr Med 2018;9:213e6. https://doi.org/10.1016/j.jaim.2017.07.001. +[6] Kiran S, Sapkota S, Shetty P, Honnegowda T. Effect of yogic colon cleansing +(laghu sankhaprakshalana kriya) on bowel health in normal individuals. Yoga +Mimamsa 2019;51:26. https://doi.org/10.4103/ym.ym_4_19. +[7] Tekur P, Nagarathna R, Nagendra H, Haldavnekar R. Effect of yogic colon +cleansing +(Laghu +Sankhaprakshalana +Kriya) +on +pain, +spinal +flexibility, +disability and state anxiety in chronic low back pain. Int J Yoga 2014;7:111. +https://doi.org/10.4103/0973-6131.133884. +[8] Meshramkar R, Patil SB, Patil NP. A case report of patient practising yoga +leading to dental erosion. Int Dent J 2007;57:184e6. https://doi.org/10.1111/ +j.1875-595X.2007.tb00123.x. +[9] Patra S. Physiological effect of kriyas: cleansing techniques. Int J Yoga - Philos +Psychol Parapsychol 2017;5:3. https://doi.org/10.4103/ijny.ijoyppp_31_17. +[10] Heatley DG, McConnell KE, Kille TL, Leverson GE. Nasal irrigation for the +alleviation of sinonasal symptoms. Otolaryngol Head Neck Surg 2001;125: +44e8. https://doi.org/10.1067/mhn.2001.115909. +[11] Shoseyov D, Bibi H, Shai P, Shoseyov N, Shazberg G, Hurvitz H. Treatment with +hypertonic saline versus normal saline nasal wash of pediatric chronic +sinusitis. J Allergy Clin Immunol 1998;101:602e5. https://doi.org/10.1016/ +S0091-6749(98)70166-6. +[12] Lin SY, Baugher KM, Brown DJ, Ishman SL. Effects of nasal saline lavage on +pediatric sinusitis symptoms and disease-specific quality of life: a case series +of 10 patients. Ear Nose Throat J 2015;94:E13. https://doi.org/10.1177/ +014556131509400212. +[13] Georgitis JW. Nasal hyperthermia and simple irrigation for perennial rhinitis: +changes +in +inflammatory +mediators. +Chest +1994;106:1487e92. +https:// +doi.org/10.1378/chest.106.5.1487. +[14] Leydon +GM, +McDermott +L, +Thomas +T, +Halls +A, +Holdstock-Brown +B, +Petley S, et al. “Well, it literally stops me from having a life when it’s +really bad”: a nested qualitative interview study of patient views on the +use of self-management treatments for the management of recurrent +sinusitis (SNIFS trial). BMJ Open 2017;7. https://doi.org/10.1136/bmjopen- +2017-017130. +[15] Little P, Mullee M, Stuart B, Thomas T, Johnson S, Leydon G, et al. Effec- +tiveness of steam inhalation and nasal irrigation for chronic or recurrent +sinus symptoms in primary care: a pragmatic randomized controlled trial. +CMAJ +(Can +Med +Assoc +J) +2016;188:940e9. +https://doi.org/10.1503/ +cmaj.160362. +[16] Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R. Efficacy of +daily hypertonic saline nasal irrigation among patients with sinusitis: a ran- +domized controlled trial. J Fam Pract 2002;51:1049e55. +[17] Luo HH, Fu ZC, Cheng HH, Liao SG, Li DS, Cheng LP. Clinical observation and +quality of life in terms of nasal sinusitis after radiotherapy for nasopharyngeal +carcinoma: long-term results from different nasal irrigation techniques. Br J +Radiol 2014;87. https://doi.org/10.1259/bjr.20140043. +[18] Liang K-L, Kao T-C, Lin J-C, Tseng H-C, Su M-C, Hsin C-H, et al. Nasal irrigation +reduces postirradiation rhinosinusitis in patients with nasopharyngeal carci- +noma. Am J Rhinol 2008;22:258e62. https://doi.org/10.2500/ajr.2008.22.3166. +[19] Tiwana H, Virk RS, Gautam V. The ancient practice of sutra neti leading to +velopharyngeal stenosis: case report. J Laryngol Otol 2019;133:730e2. +https://doi.org/10.1017/S0022215119001142. +[20] Ramalingam KK, Smith MCF. Simple treatment for snoring also a means of +prediction of uvulopalatopharyngoplasty success? J Laryngol Otol 1990;104: +428e9. https://doi.org/10.1017/S0022215100158633. +[21] Mallick T, Kulkarni R. The effect of trataka, a yogic visual concentration +practice, on critical flicker fusion. J Alternative Compl Med 2010;16:1265e7. +https://doi.org/10.1089/acm.2010.0012. +[22] Raghavendra BR, Singh P. Immediate effect of yogic visual concentration on +cognitive performance. J Tradit Complement Med 2016;6:34e6. https:// +doi.org/10.1016/j.jtcme.2014.11.030. +[23] Talwadkar S, Jagannathan A, Raghuram N. Effect of trataka on cognitive +functions in the elderly. Int J Yoga 2014;7:96e103. https://doi.org/10.4103/ +0973-6131.133872. +[24] Raghavendra B, Ramamurthy V. Changes in heart rate variability following +yogic visual concentration (Trataka). Hear India 2014;2:15. https://doi.org/ +10.4103/2321-449X.127975. +[25] Gopinathan G, Dhiman KS, Manjusha R. A clinical study to evaluate the effi- +cacy of Trataka Yoga Kriya and eye exercises (non-pharmacological methods) +in the management of Timira (Ammetropia and Presbyopia). Ayu 2012;33: +543e6. https://doi.org/10.4103/0974-8520.110534. +[26] Tiwari KK, Shaik R, Aparna B, Brundavanam R. A comparative study on the +effects of vintage nonpharmacological techniques in reducing myopia (bates +eye exercise therapy vs. Trataka yoga kriya). Int J Yoga 2018;11:72e6. https:// +doi.org/10.4103/ijoy.IJOY_59_16. +[27] Saoji AA, Raghavendra BR, Manjunath NK. Effects of yogic breath regulation: a +narrative review of scientific evidence. J Ayurveda Integr Med 2019;10:50e8. +https://doi.org/10.1016/j.jaim.2017.07.008. +[28] Desai BP, Gharote ML. Effect of Kapalabhati on blood urea, creatinine and +tyrosine. Act Nerv Super (Praha) 1990;32:95e8. +P.S. Swathi, B.R. Raghavendra and A.A. Saoji +Journal of Ayurveda and Integrative Medicine 12 (2021) 206e212 +211 +[29] Stanc +ak A, Kuna M, Nov +ak P, Srinivasan MA, Dost +alek C, Vishnudevananda S. +Observations on respiratory and cardiovascular rhythmicities during yogic +high-frequency respiration. Physiol Res 1991;40:345e54. +[30] Stanc +ak A, Kuna M, Srinivasan, Dost +alek C, Vishnudevananda S. Kapalabhati– +yogic cleansing exercise. II. EEG topography analysis. Homeost Health & Dis +1991;33:182e9. +[31] Stanc +ak A, Kuna M, Srinivasan, Vishnudevananda S, Dost +alek C. Kapalabhati– +yogic cleansing exercise. I. Cardiovascular and respiratory changes. Homeost +Health & Dis 1991;33:126e34. +[32] Joshi M, Telles S. A nonrandomized non-naive comparative study of the effects +of kapalabhati and breath awareness on event-related potentials in trained +yoga practitioners. J Alternative Compl Med 2009;15:281e5. https://doi.org/ +10.1089/acm.2008.0250. +[33] Telles S, Gupta RK, Gandharva K, Vishwakarma B, Kala N, Balkrishna A. Im- +mediate effect of a yoga breathing practice on attention and anxiety in pre- +teen children. Child (Basel, Switzerland) 2019;6:84. https://doi.org/10.3390/ +children6070084. +[34] Telles S, Sharma SK, Yadav A, Singh N, Balkrishna A. Immediate changes in +muscle strength and motor speed following yoga breathing. Indian J Physiol +Pharmacol 2014;58:22e9. +[35] Telles S, Singh N, Balkrishna A. Finger dexterity and visual discrimination +following two yoga breathing practices. Int J Yoga 2012;5:37e41. https:// +doi.org/10.4103/0973-6131.91710. +[36] Gupta R, Agnihotri S, Telles S, Balkrishna A. Performance in a Corsi block- +tapping task following high-frequency yoga breathing or breath awareness. +Int J Yoga 2019;12:247. https://doi.org/10.4103/ijoy.ijoy_55_18. +[37] 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;42:467e72. +[38] Telles S, Singh N, Balkrishna A. Heart rate variability changes during high +frequency yoga breathing and breath awareness. Biopsychosoc Med 2011;5:4. +https://doi.org/10.1186/1751-0759-5-4. +[39] Telles S, Singh N, Balkrishna A. Metabolic and ventilatory changes during and +after high-frequency yoga breathing. Med Sci Monit Basic Res 2015;21: +161e71. https://doi.org/10.12659/MSMBR.894945. +[40] Telles S, Gupta RK, Singh N, Balkrishna A. A functional near-infrared spectroscopy +study of high-frequency yoga breathing compared to breath awareness. Med Sci +Monit Basic Res 2016;22:58e66. https://doi.org/10.12659/MSMBR.899516. +[41] Pradhan B. Effect of kapalabhati on performance of six-letter cancellation and +digit letter substitution task in adults. Int J Yoga 2013;6:128e30. https:// +doi.org/10.4103/0973-6131.113415. +[42] Nivethitha L, Mooventhan A, Manjunath NK, Bathala L, Sharma VK. Cerebro- +vascular hemodynamics during the practice of bhramari pranayama, kapalb- +hati +and +bahir-kumbhaka: +an +exploratory +study. +Appl +Psychophysiol +Biofeedback 2018;43:87e92. https://doi.org/10.1007/s10484-017-9387-8. +[43] Raghavendra P, Shetty P, Shetty S, Manjunath NK, Saoji AA. Effect of high- +frequency yoga breathing on pulmonary functions in patients with asthma: +a randomized clinical trial. Ann Allergy Asthma Immunol 2016;117:550e1. +https://doi.org/10.1016/j.anai.2016.08.009. +[44] Johnson DB, Tierney MJ, Sadighi PJ. Kapalabhati pranayama: breath of fire or +cause of pneumothorax? A case report. Chest 2004;125:1951e2. https:// +doi.org/10.1378/chest.125.5.1951. +P.S. Swathi, B.R. Raghavendra and A.A. Saoji +Journal of Ayurveda and Integrative Medicine 12 (2021) 206e212 +212 diff --git a/subfolder_0/Heart rate variability during sleep following the practice of cyclic meditation and supine rest..txt b/subfolder_0/Heart rate variability during sleep following the practice of cyclic meditation and supine rest..txt new file mode 100644 index 0000000000000000000000000000000000000000..f7ac01f6cc672579fb88f3a27c3247a47a6c648a --- /dev/null +++ b/subfolder_0/Heart rate variability during sleep following the practice of cyclic meditation and supine rest..txt @@ -0,0 +1,658 @@ +Heart Rate Variability During Sleep Following the Practice +of Cyclic Meditation and Supine Rest +Sanjib Patra • Shirley Telles +Published online: 17 October 2009 + Springer Science+Business Media, LLC 2009 +Abstract +Day time activities are known to influence the +sleep on the following night. Cyclic meditation (CM) has +recurring cycles. Previously, the low frequency (LF) power +and the ratio between low frequency and high frequency +(LF/HF ratio) of the heart rate variability (HRV) decreased +during and after CM but not after a comparable period of +supine rest (SR). In the present study, on thirty male vol- +unteers, CM was practiced twice in the day and after this +the HRV was recorded (1) while awake and (2) during 6 h +of sleep (based on EEG, EMG and EGG recordings). This +was similarly recorded for the night’s sleep following the +day time practice of SR. Participants were randomly +assigned to the two sessions and all of them practiced both +CM and SR on different days. During the night following +day time CM practice there were the following changes; a +decrease in heart rate, LF power (n.u.), LF/HF ratio, and an +increase in the number of pairs of Normal to Normal RR +intervals differing by more than 50 ms divided by total +number of all NN intervals (pNN50) (P \ 0.05, in all +cases, comparing sleep following CM compared with sleep +following SR). No change was seen on the night following +SR. Hence yoga practice during the day appears to shift +sympatho-vagal +balance +in +favor +of +parasympathetic +dominance during sleep on the following night. +Keywords +Sleep  HRV  Meditation +Introduction +The recovery experiences during leisure time, sleep, and +affect the next morning are inter-related (Sonnetag et al. +2008). Psychological detachment from work on the pre- +ceding day predicted negative activation and fatigue the +next morning, whereas mastery experiences during the +evening predicted positive activation, while relaxation +predicted serenity. Also, the quality of sleep showed a +relation with all affective variables. The results hence +suggest that events on a particular day impact the quality of +sleep at night and the affect the following day. Various +factors of diverse behavioral and chemical origins are +known to influence sleep (Jurkowski and Bobek-Billwicz +2007). Among the well recognized factors are sleep depri- +vation and high intensity exercise (Dworak et al. 2007). +Yoga is an ancient science, originating in India, which +has components of physical activity, instructed relaxation +and interoception (Vivekananda Kendra 2005). Yoga +includes a number of practices such as physical postures +(asanas), regulated breathing (pranayama), meditation, and +lectures on philosophical aspects of yoga (Taimini 1986). In +persons with sleep-onset and/or sleep-maintenance insom- +nia, as well as those with primary or secondary insomnia, +8 weeks of yoga practice improved the sleep efficiency, +total sleep time, total wake time, sleep onset latency, and the +wake time after sleep onset (Khalsa 2004). +Also, a combination of yoga practices (i.e., physical +postures, voluntarily regulated breathing, relaxation tech- +niques, and lectures on yoga philosophy), improved the self- +rated quality of sleep in older persons, compared to a group +receiving an ayurveda poly-herbal preparation and another +wait-list control group (Manjunath and Telles 2005). The +following benefits were self-rated by the older participants +after 6 months of yoga practice viz., a decrease in the time +S. Patra +Indian Council of Medical Research Center for Advanced +Research in Yoga and Neurophysiology, SVYASA, Bangalore, +India +S. Telles (&) +Patanjali Yogpeeth, Maharishi Dayanand Gram, Bahadrabad, +Haridwar, Uttarakhand 249408, India +e-mail: shirleytelles@gmail.com +123 +Appl Psychophysiol Biofeedback (2010) 35:135–140 +DOI 10.1007/s10484-009-9114-1 +taken to fall asleep, an increase in the total number of hours +slept and in the feeling of being rested in the morning. +Among yoga techniques, meditation particularly has +been shown to reduce stress and increase feelings of calm +(Oman et al. 2008). However our unpublished observations +were that many individuals, particularly those with high +baseline levels of stress, find it difficult to begin their +practice of yoga with meditation (Nagendra and Naga- +rathna 1997). In fact, in traditional yoga texts meditation is +described as the seventh, out of eight stages required to +reach a stage of final mental liberation (Taimini 1986). +Some people find it easier to practice those techniques +which are described as earlier stages, such as yoga postures +(asanas). Based on this a technique was evolved, called +cyclic meditation, which combines yoga postures with +periods of supine rest when the person is given instructions +to help them reach a meditative state (Telles et al. 2000). +In +normal +volunteers +practicing +cyclic +meditation +reduced psychophysiological arousal based on a decrease +in oxygen consumption (Telles et al. 2000; Sarang and +Telles 2006a); and changes in the heart rate variability +suggestive of a shift towards vagal dominance (Sarang and +Telles 2006b). In another study correlating cyclic medita- +tion and heart rate variability, a 2-day cyclic meditation +program decreased occupational stress levels and baseline +autonomic arousal (Vempati and Telles 2000). This was +more apparent when participants were categorized based +on the occupational stress index (OSI) at baseline. Those +with high OSI levels showed a change in heart rate vari- +ability suggestive of vagal dominance, while those with +low OSI levels to begin with showed no change. +There have been studies which have shown that day time +stress influences the sympathetic/parasympathetic balance +during +sleep. +For +example, +reduced +parasympathetic +activity, based on the heart rate variability was recorded +during sleep in the symptomatic phase of severe premen- +strual syndrome (Baker et al. 2008). +Hence, considering that (1) day time activities influence +sleep, including the level of parasympathetic activity during +sleep, and (2) cyclic meditation is a relatively easy to learn +technique which influences the heart rate variability, with +specific changes associated with the levels of mental stress, +the present study was designed to compare the effects of +practicing cyclic meditation in theday time with theeffects of +supine rest practice, on the heart rate variability during sleep. +Methods +Participants +Thirty male volunteers with ages ranging from 20 to +33 years +(group +mean +age ± SD, +22.3 ± 4.6 years) +participated in the study. Autonomic and respiratory vari- +ables have been shown to vary with the phases of the +menstrual cycle (Yildirir et al. 2002), hence the study was +restricted to males. All of them were undergoing training at +a residential yoga center in the south of India and had a +minimal experience of practicing cyclic meditation and +relaxation in a position of supine rest (shavasana, the +corpse posture), which was the ‘control’ intervention, at +least once a day for 4 days in a week, for a year. All of +them were in normal health based on a routine clinical +examination and none of them had a history of smoking or +consuming alcohol or caffeinated beverages. Also none of +them were taking medication and they did not use any other +wellness strategy. The electrocardiogram (EKG) recording +of all volunteers was free of extra systoles. The design of +the study was explained to the participants and their signed +consent was taken. The study was approved by the Insti- +tution’s Ethical Committee. +Design of the Study +Participants were assessed on three separate nights in the +sleep laboratory. The first night was for acclimatization to +the laboratory environment. Electrodes and transducers +were connected as for a standard recording but no recording +was taken. The other two recording sessions were 3 days +apart. On 1 day participants were asked to practice cyclic +meditation two times a day, i.e., at 06:00 h and 18:45 h. +Their practice was supervised by a trained yoga instructor. +After that they were asked to report to the sleep laboratory +at 21:00 h and a whole night recording was taken. On the +other day of recording participants were asked to practice +unguided supine rest in shavasana (SR), as a control for +cyclic meditation, twice in the day, and at the same time and +for the same duration as the cyclic meditation sessions. This +practice was also supervised by the same yoga instructor, +though no instructions were given. Each session lasted for +22 min 30 s. For this session also, participants reported to +the sleep laboratory at 21:00 h and a whole night poly- +somnography recording was taken. A minimum duration of +6 h of recording was made for all the participants even if +they continued to sleep for longer than that. The 6 h of +recording did not include ‘wakefulness before sleep onset’ +but may have included periods of wakefulness in between. +Throughout the night standard polysomnography measures +(EEG, EOG, EMG) were recorded but in the present study +they were used to distinguish between wakefulness and +sleep, not between the different stages of sleep. All readings +for heart rate variability taken during sleep were averaged +into one value for analysis. +For all participants on each recording day there were +two separate recordings. The first recording was for 10 min +while the participants lay supine but awake. After this the +136 +Appl Psychophysiol Biofeedback (2010) 35:135–140 +123 +lights were switched off and participants were told that +they could go to sleep. The order of the sessions was +randomized using a random number table. On both +recording days [i.e., cyclic meditation (CM) and supine rest +(SR)], participants were asked to avoid all other physical +activity (e.g., walking, jogging, or other yoga practices). +However they continued with the rest of their routine (e.g., +listening to lectures on yoga). Since all of them were +residing in the same yoga center, the rest of their routine +was relatively comparable. As described above, for each of +the two recordings the average of all readings taken during +sleep was obtained as one value. +Assessments +Autonomic and respiratory variables were acquired using a +four channel polygraph (Medicaid, Chandigarh, India). The +EKG was recorded using Ag/AgCI electrodes with con- +ducting gel (Electrode Gel, Medicaid Systems, Chandigarh, +India) and recording was made using standard limb lead II +configuration. Data were acquired at the sampling rate of +1,024 Hz and were analyzed offline. Noise free data were +included for analysis. Records of six participants had +artifact and these recordings were excluded but repeat +recordings were taken on the same participants and inclu- +ded for analysis. The R waves were detected to obtain a +point event series of successive response-response inter- +vals, from which the beat-to-beat heart series was com- +puted. The data were analyzed with an HRV analysis +program developed by the Biomedical Signal Analysis +Group, University of Kuopio, Finland (Niskanen et al. +2004). The respiration was recorded using a stethograph +connected to an AC amplifier and fixed around the trunk +approximately 8 cm below the lower costal margin when +the participants stood erect. +Intervention +Cyclic Meditation (CM) +CM lasted for 22 min 30 s. Throughout the practice, par- +ticipants kept their eyes closed and followed pre-recorded +instructions from an audiotape. The instructions empha- +sized carrying out the practice slowly, with awareness and +relaxation. The five phases of CM consisted of the fol- +lowing practices. +Phase 1 (5 min): The practice began by repeating a verse +(1 min) from the yoga text, the Mandukya Upanishad +(Chinmayananda 1984); followed by isometric contraction +of the muscles of the body ending with SR (1 min, 30 s); +slowly coming up from the left side and standing at ease, +called tadasana, and balancing the weight on both feet, +called centering (2 min, 30 s). +Phase 2 (5 min): Then the first actual posture, bending +to the right (ardhakaticakrasana, 1 min, 20 s); a gap of +1 min, 10 s in tadasana with instructions about relaxation +and awareness; bending to the left (ardhakaticakrasana, +1 min, 20 s); and a gap of 1 min, 10 s in tadasana. +Phase 3 (5 min): Forward bending (padahastasana, +1 min, 20 s); another gap (1 min, 10 s); backward bending +(ardhacakrasana, 1 min, 20 s); and a gap of 1 min, 10 s in +tadasana. +Phase 4 (5 min): Slowly coming down to a supine +posture for rest with instructions to relax different parts of +the body in sequence. +Phase 5 (5 min): Supine relaxation and a prayer for +2 min, 30 s; followed by SR for 2 min, 30 s. +Supine Rest (SR) +During the supine rest session, the participants lay supine +in the corpse posture (shavasana) with eyes closed, legs +apart and arms away from the body. This practice also +lasted for 22 min 30 s. +Data Extraction +The heart rate in beats per minute (bpm) was obtained by +continuously counting QRS complexes in successive 60 s +periods. The breath rate (in cycles per minute) was cal- +culated by counting the breath cycles in 60 s epochs, +continuously. +Heart rate and heart rate variability spectrum (HRV) as +well as breath rate were recorded for 6 h during sleep and +the first 5 min and the last 5 min of each hour was included +for analysis. Hence in each 6-h sleep recording there were +twelve epochs each of 5 min, for analysis. For the pre-sleep +recording the first 5 min out of a 10 min period was used. +Following the European Guidelines of the Task Force of +the European Society of Cardiology (18), the following +components of time domain HRV were analyzed viz., the +number of pairs of Normal to Normal RR intervals dif- +fering by more than 50 ms (NN50), NN50 divided by total +number of all NN intervals (pNN50), and total index of NN +intervals (TINN). In addition, the HRV power spectrum +was obtained using Fast Fourier Transform analysis (FFT). +The energy in the HRV series in the following specific +frequency bands was studied viz., the very low frequency +band (0.0–0.05 Hz), low frequency band (0.5–0.15 Hz), +and high frequency band (0.15–0.50 Hz). The low fre- +quency and high frequency band values were expressed as +normalized units (Task Force of the European Society of +Cardiology 1996). +Hence the HRV data were analyzed to obtain both time +domain and frequency domain measures. +Appl Psychophysiol Biofeedback (2010) 35:135–140 +137 +123 +Data Analysis +Data were analyzed using SPSS version 16.0. Repeated +measures analyses of variance (ANOVA) were performed +with two Within Subjects factors, i.e., (1) Sessions with +two levels; Cyclic meditation (CM) and Supine rest (SR) +and (2) States with two levels; i.e., Pre-sleep and During- +sleep. +Post hoc tests with Bonferroni adjustment for multiple +comparisons were used to detect significant differences +between mean values recorded pre-sleep and during-sleep +(for both ‘CM Sessions’ and ‘SR sessions’ separately). +Also, comparisons were made with values recorded during +sleep following CM compared with those recorded during +sleep following SR. +Results +The group mean values ± SD for heart rate, breath rate, +time domain and frequency domain measures of HRV +spectrum are given in Table 1. Time domain measures are +given in rows 3–5 and frequency domain measures in rows +6–8. +Repeated Measures Analysis of Variance (ANOVA) +There was a significant difference between Sessions for (1) +heart rate [F = 3.90, for df = 3.89, 71.89, P \ 0.05; +Huynh–Feldt e = 0.983]; (2) the square root of the mean of +the sum of squares of differences between adjacent NN +intervals +[RMSSD; +F = 4.06, +for +df = 1.00, +79.41, +P \ 0.05; Huynh–Feldt e = 0.875]; (3) low frequency +power [F = 4.06, for df = 1.00, 73.09, P \ 0.05; Huynh– +Feldt e = 0.934]; and (4) the ratio between low frequency +and high frequency power [F = 3.47, for df = 1.00, 68.5, +P \ 0.05; Huynh–Feldt e = 0.835]. +No significant changes were observed between States +for any measures of HRV, heart rate or breath rate. +There was a significant interaction between Sessions and +States for (1) the square root of the mean of the sum of +squares of differences between adjacent NN intervals +[RMSSD; F = 4.42, for df = 1.10, 140.25, P \ 0.05; +Huynh–Feldt +e = 0.951]; +and +(2) +low +frequency +[F = 3.78, for df = 3.79, 88.25, P \ 0.05; Huynh–Feldt +e = 0.864], suggesting that the two factors were not +independent of each other for these variables. +Post Hoc Tests for Multiple Comparisons +Post hoc tests for multiple comparisons were performed +with Bonferroni adjustment. Comparisons were made +between During-sleep following CM with During-sleep +following SR, Pre sleep CM with During-sleep CM, and +Pre-sleep SR with During-sleep SR sessions. +A significant decrease in heart rate, LF and LF/HF power +and an increase in the number of pairs of Normal to Normal +RR intervals differing by more than 50 ms divided by total +number of all NN intervals (pNN50) was observed when a +comparison was made between During-sleep following CM +with During-sleep following SR sessions (P \ 0.05 in all +the cases). No significant change was noticed in the com- +parison of Pre-Sleep with the respective During-Sleep. +Discussion +In the present study, practicing cyclic meditation twice in +the day time reduced the heart rate and breath rates during +sleep, the following night, and also influenced time and +Table 1 Heart rate, breath rate and measures of heart rate variability recorded pre and during-sleep following cyclic meditation (CM) practice +and following supine rest (SR) +Variables +Sessions +Cyclic meditation (CM) +Supine rest (SR) +Pre-sleep +During-sleep +Pre-sleep +During-sleep +Heart rate (bpm) +62.17 ± 5.74 +60.98 ± 7.22* +66.48 ± 7.68 +65.92 ± 6.24 +Breath rate (cpm) +19.67 ± 6.28 +17.93 ± 3.50 +18.48 ± 2.61 +18.26 ± 2.91 +NN50 (count) +91.64 ± 41.56 +108.84 ± 43.44 +101.77 ± 55.13 +106.53 ± 53.47 +pNN50 (%) +41.60 ± 25.11 +52.44 ± 26.51* +42.90 ± 22.43 +46.27 ± 23.81 +TINN (ms) +570.31 ± 302.49 +571.26 ± 285.63 +413.83 ± 229.60 +573.85 ± 263.43 +Low frequency (LF) power (n.u.) +48.76 ± 21.43 +45.23 ± 18.03* +55.11 ± 15.23 +55.19 ± 16.83 +High frequency (HF) power (n.u.) +49.38 ± 19.45 +53.20 ± 19.87 +51.09 ± 20.65 +50.45 ± 18.01 +LF/HF ratio +1.28 ± 0.80 +1.06 ± 0.68* +1.38 ± 0.84 +1.36 ± 0.93 +Values are group mean ± SD; * P \ 0.05, using repeated measures analysis of variance (ANOVA), post hoc tests with Bonferroni adjustment, +comparing During-sleep (CM) with During-sleep (SR) +138 +Appl Psychophysiol Biofeedback (2010) 35:135–140 +123 +frequency domain measures of the heart rate variability +recorded during sleep. Similar changes were not seen +during sleep following the practice of supine rest twice a +day on another day. The changes during sleep following +CM were suggestive of reduced arousal and a shift in the +autonomic balance towards parasympathetic dominance. +These changes were a decrease in the low frequency power +(normalized units) and a decrease in the LF/HF ratio +among frequency domain measures. The LF band of the +HRV is mainly related to sympathetic modulation when +expressed in normalized units (Task Force of the European +Society of Cardiology 1996), whereas efferent vagal +activity is a major contributor to the HF band. However +changes in autonomic tone are not the only factors which +can vary LF. +Respiratory sinus arrhythmia is a commonly used non- +invasive measure of cardiac vagal control (Wilhelm et al. +2004). Hence concurrent monitoring of respiration along +with heart rate variability increases the accuracy of the HRV +to predict autonomic control. This supposition is supported +by an acute increase in LF and total spectrum HRV as well +as vagal baroflex gain corrected with slow breathing during +biofeedback periods (Lehrer et al. 2003). It was earlier +shown that bio-feedback training to increase the amplitude +of respiratory sinus arrhythmia maximally increases the +amplitude of heart rate oscillations only at approximately +0.1 Hz (Lehrer et al. 2000). To achieve this, breathing is +slowed to a point at which resonance occurs between +respiratory-induced oscillations and oscillations that natu- +rally occur at this rate. In the present study there was no +change in the breathing rate during sleep following either +CM or SR. This suggests that the change in LF activity was +related to autonomic activity and not to the breath rate. +The LF/HF ratio is correlated with sympatho-vagal bal- +ance (Malliani et al. 1991). Apart from these changes in +frequency domain measures of the HRV, there was an +increase in the pNN50 among the time domain measures of +the HRV measured during sleep following CM. The pNN50 +is a time domain measure which is highly correlated with +frequency domain measures and recognized to be strongly +dependent on vagal tone (Massin et al. 1999). +Hence, these changes in frequency and time domain +measures of the HRV suggest that the night sleep following +day time practice of CM is associated with increased +parasympathetic activity and a corresponding shift in the +sympatho-vagal balance. +Cyclic meditation is best described as a moving medi- +tation, in which physical postures are interspersed with +supine rest (Sarang and Telles 2006a). In a previous study +the frequency domain measures of the HRV were recorded +in 42 volunteers before, during and after the practice of CM +and SR. The results are relevant to the results of the present +study (Sarang and Telles 2006b). During and after CM the +LF power and LF/HF ratio decreased whereas HF power +increased. However, while actually practicing yoga pos- +tures during CM, the LF power increased. Hence, it +appeared +that +predominantly +sympathetic +activation +occurred while practicing yoga postures during CM +whereas parasympathetic dominance increased after CM. +The changes following CM suggesting a shift towards +vagal dominance are similar to the HRV changes following +a low velocity, low impact technique involving move- +ments, called Wai Tan Kung, which is a traditional Tai- +wanese conditioning exercise (Lu and Kuo 2003). The +study was conducted in elderly volunteers and suggested +enhanced vagal activity and lower sympathetic activity +associated with Wai Tan Kung. +In the present study changes in VLF have not been +described though the VLF power accounts for more than +90% of the total power in the 24 h of the heart rate power +spectrum. The physiological mechanism underlying the +VLF power has not been conclusively identified (Hadase +et al. 2004). The VLF power in part reflects thermoregu- +latory mechanisms and fluctuation in the activity of the +renin-angiotensin function and the function of chemore- +ceptors (Malliani et al. 1991; Parati et al. 1995). +The exact mechanism by which CM leads to a state of +physiological relaxation needs to be understood. Apart +from the changes in the HRV, the practice of CM was +associated with a decrease in the oxygen consumption, +breath rate and breath volume which exceeded the decrease +in the same variables after a comparable period of SR +(Sarang and Telles 2006a). The benefits may be related to +the fact that CM practice includes yoga postures (which +involve stretching) and guided relaxation. In an earlier +study by different authors when a body and mind program +which included meditative stretching and guided relaxa- +tion, was practiced by persons with chronic toxic enceph- +alopathy for 8 weeks, they showed improved physical and +mental relaxation indicated by lower electromyography +activity, higher alpha percentage and reduced state anxiety. +Also in another study, guided relaxation was shown to be +more effective in reducing physiological arousal than a +control session in SR (Vempati and Telles 2002). Specifi- +cally yoga based guided relaxation which is a part of CM +decreased LF power and increased HF power. This was not +seen during a period of SR of the same duration. Guided +relaxation includes visual imagery and muscle relaxation +which may have contributed to the effect. However, the +exact mechanism is not known. CM practice also includes +interoception with awareness of internal body sensations. +During the breath awareness phase of Vipassana mindful- +ness meditation, the LF/HF ratio decreased (Telles et al. +2005). Hence the changes associated with CM practice may +be related to the fact that the practice includes mental +imagery, muscle relaxation and internal awareness. The +Appl Psychophysiol Biofeedback (2010) 35:135–140 +139 +123 +fact that the changes occurred during sleep following the +practice of CM on the preceding day may be related to the +fact that day time activities influence sleep in the night. +While attempts were made to control the other activities +of the participants during the day, a further study in which +participants’ daily activities and diet are individually noted. +These variations in the subjects’ routine as well as inherent +differences between individuals may have accounted for +the fact the participants’ baseline values differed widely, +which is a limitation of the study. Accounting for these +individual variations would be expected to substantiate the +present findings. Also in the present study no attempt was +made to correlate the HRV with the stages of sleep; as this +presented certain technical difficulties. A future study with +such a correlation would overcome this limitation and +provide additional information. +Acknowledgments +The +Authors +gratefully +acknowledge +H.R. +Nagendra, Ph.D. who derived the cyclic meditation technique from +ancient yoga texts. The funding from the Indian Council of Medical +Research, Government of India, as part of a grant (Project No. 2001- +05010) towards the Center for Advanced Research in Yoga and +Neurophysiology is also gratefully acknowledged. +References +Baker, F. C., Colrain, I. M., & Trinder, J. (2008). Reduced +parasympathetic activity during sleep in the symptomatic phase +of severe premenstrual syndrome. Journal of Psychosomatic +Research, 65(1), 13–22. +Chinmayananda, S. (1984). Mandukya Upanishad. Bombay: Sachin +Publishers. +Dworak, M., Diel, P., Voss, S., Hollmann, W., & Struder, H. K. +(2007). Intense exercise increases adenosine concentrations in +rat brain: Implications for a homeostatic drive. Neuroscience, +150(4), 789–795. +Hadase, M., Azuma, A., Zen, K., Asada, S., Kawasaki, T., Kamitani, +T., et al. (2004). Very low frequency power of heart rate +variability is a powerful predictor of clinical prognosis in +patients with congestive heart failure. Circulation, 6, 343–347. +Jurkowski, M. K., & Bobek-Billwicz, B. (2007). Natural factors +influencing sleep. Prezegl Lek, 64(9), 572–582. +Khalsa, S. B. (2004). Treatment of chronic insomnia with yoga: A +preliminary study with sleep—wake diaries. Applied Psycho- +physiology and Biofeedback, 29(4), 269–278. +Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonance +frequency biofeedback training to increase cardiac variability: +Rationale and manual for training. Applied Psychophysiology +and Biofeedback, 25(3), 177–191. +Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. E., Eckberg, D. L., +Edelberg, R., et al. (2003). Heart rate variability biofeedback +increases baroflex gain and peak expiratory flow. Psychosomatic +Medicine, 65(5), 796–805. +Lu, W. A., & Kuo, C. D. (2003). The effect of Wai Tan Kung on +autonomic nervous modulation in elderly. Journal of Biomedical +Science, 10(6 Pt 2), 697–705. +Malliani, A., Pagani, M., Lombardi, F., & Cerutti, S. (1991). +Cardiovascular neural regulation explore in the frequency +domain. Circulation, 84, 482–492. +Manjunath, N. K., & Telles, S. (2005). Influence of Yoga & Ayurveda +on self-rated sleep in a geriatric population. Indian Journal of +Medical Research, 121, 683–690. +Massin, M. M., Derkenne, B., & Bernuth, G. (1999). Correlations +between heart rate variability in healthy children and children +with congenital heart disease. Cardiology, 91(2), 109–113. +Nagendra, H. R., & Nagarathna, R. (1997). New perspectives in stress +management. Bangalore: Swami Vivekananda Yoga Prakashan. +Niskanen, J. P., Tarvainen, M. P., Ranta-aho, P. O., & Karjalainen, +P. A. (2004). Software for advanced HRV analysis. Computer +Methods and Programs in Biomedicine, 76, 73–81. +Oman, D., Shapiro, S. L., Thoresen, C. E., Plante, T. G., & Flinders, +T. (2008). Meditation lowers stress and supports forgiveness +among college students: A randomized controlled trial. Journal +of American College Health, 56(5), 69–78. +Parati, G., Saul, J. P., Di Rieuzo, M., & Mancia, G. (1995). Spectral +analysis of blood pressure and heart rate variability in evaluating +cardiovascular regulation: A critical appraisal. Hypertension, 25, +1276–1286. +Sarang, P. S., & Telles, S. (2006a). Oxygen consumption and +respiration during and after two yoga relaxation techniques. +Applied Psychophysiology and Biofeedback, 31(2), 143–151. +Sarang, P., & Telles, S. (2006b). Effects of two yoga based relaxation +techniques on heart rate variability (HRV). International Journal +of Stress Management, 13(4), 01–16. +Sonnetag, S., Binnewies, C., & Mojza, E. J. (2008). ‘‘Did you have +nice evening?’’ Day-level studies on recovery experiences, sleep, +and affect. Journal of Applied Psychology, 93(3), 674–684. +Taimini, I. K. (1986). The science of yoga. Madras: The Theosophical +Publishing House. +Task Force of the European Society of Cardiology. (1996). North +American Society of Pacing and Electrophysiology: Heart rate +variability standards of measurement, physiological interpreta- +tion and clinical use. Circulation, 93, 1043–1065. +Telles, S., Mohapatra, R. S., & Naveen, K. V. (2005). Heart rate +variability spectrum during Vipassana mindfulness meditation. +Journal of Indian Psychology, 22(2), 215–219. +Telles, S., Reddy, S. K., & Nagendra, H. R. (2000). Oxygen +consumption and respiration following two yoga relaxation +techniques. Applied Psychophysiology and Biofeedback, 25(4), +221–227. +Vempati, R. P., & Telles, S. (2000). Baseline occupational stress +levels and physiological responses to a two day stress manage- +ment program. Journal of Indian Psychology, 18(1–2), 33–37. +Vempati, R. P., & Telles, S. (2002). Yoga-based guided relaxation +reduces sympathetic activity judged from baseline levels. +Psychological Reports, 90, 487–494. +Vivekananda Kendra. (2005). Yoga the science of holistic living. +Chennai: Vivekananda Kendra Prakashan Trust. +Wilhelm, F. H., Grossman, P., & Coyle, M. A. (2004). Improving +estimation of cardiac vagal tone during spontaneous breathing +using a paced breathing calibration. +Biomedical +Sciences +Instrumentation, 40, 317–324. +Yildirir, A., Kabakei, G., Akgul, E., Tokgozoglu, L., & Oto, A. (2002). +Effects of menstrual cycle on cardiac autonomic innervation as +assessed by heart rate variability. Annals of Noninvasive Electro- +cardiology, 7(1), 60–63. +140 +Appl Psychophysiol Biofeedback (2010) 35:135–140 +123 diff --git a/subfolder_0/IMMEDIATE EFFECT OF THREE YOGA BREATHING TECHNIQUES ON.txt b/subfolder_0/IMMEDIATE EFFECT OF THREE YOGA BREATHING TECHNIQUES ON.txt new file mode 100644 index 0000000000000000000000000000000000000000..de50d46d547164b08bdaacc80303b7f8cac1ae14 --- /dev/null +++ b/subfolder_0/IMMEDIATE EFFECT OF THREE YOGA BREATHING TECHNIQUES ON.txt @@ -0,0 +1,36 @@ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/IMPROVEMENT IN HAND GRIP STRENGTH IN NORMAL VOLUNTEERS AND RHEUMATOID.txt b/subfolder_0/IMPROVEMENT IN HAND GRIP STRENGTH IN NORMAL VOLUNTEERS AND RHEUMATOID.txt new file mode 100644 index 0000000000000000000000000000000000000000..e8c102be8ee96b9035aeb81b65b5e496aabf363f --- /dev/null +++ b/subfolder_0/IMPROVEMENT IN HAND GRIP STRENGTH IN NORMAL VOLUNTEERS AND RHEUMATOID.txt @@ -0,0 +1,25 @@ + + + + + + + + + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/Immediate effect of high frequency yoga breathing on attention.txt b/subfolder_0/Immediate effect of high frequency yoga breathing on attention.txt new file mode 100644 index 0000000000000000000000000000000000000000..f7d46d277bc4e4579c49f65239dbffdcc94c6a79 --- /dev/null +++ b/subfolder_0/Immediate effect of high frequency yoga breathing on attention.txt @@ -0,0 +1,264 @@ +Indian J Med Sci, Vol. 62, No. 1, January 2008 +VOLUME +62 +NUMBER +1 +JANUARY +2008 +EDICAL +CIENCES +M +S +INDIAN JOURNAL +OF +INDIAN JOURNAL +OF +Published by +Medknow Publications +A-109, Kanara Business Center, Off Link Road, Ghatkopar (E), Mumbai - 400075, India +ORIGINAL CONTRIBUTIONS +Psychological distress and associated risk factors in bronchial asthma patients in Kuwait +N. R. Panicker, P. N. Sharma, A. R. Al-Duwaisan + ........... + +........... +1 +Identifi + cation of enteroaggregative escherichia coli in infants with acute diarrhea based on biofi + lm +production in Manipal, South India +Raju Bangar, Ballal Mamatha + ........... + +........... +8 +A study of bone marrow failure syndrome in children +V. Gupta, S. Tripathi, T. B. Singh, V. Tilak, B. D. Bhatia + ........... + +........... +13 +LETTERS TO EDITOR +Chylothorax after childbirth in a mother +Mohammad Hossein Rahimi-Rad + ........... + +........... +19 +Immediate effect of highfrequency yoga breathing on attention +Shirley Telles, P. Raghuraj, Dhananjay Arankalle, K. V. Naveen + ........... + +........... +20 +PRACTITIONERS’ SECTION +Metabolic comorbidity in schizophrenia +Rajesh Jacob, Arabinda Narayan Chowdhury + ........... + +........... +23 +Indian J Med Sci, Vol. 62, No. 1, January 2008 +or parenchymal involvement were seen in +CT scan after 3 years. +With chylothorax, the main dangers to the +patient are malnutrition and a compromised +immunologic status caused by the removal of +large amounts of protein, fat, electrolytes and +lymphocytes.[1,2] Chyle is bacteriostatic, so +complication by empyema is rare. However, +the presence of chyle causes a gross pleural +reaction, which becomes greatly thickened and +covered by exudates. This can lead to loss of +chest-wall and lung-parenchymal function.[2] +Management strategies of chylothoraces are +(1) maintaining nutrition and reducing the +chyle fl + ow with parenteral hyperalimentation +and low-fat diet (Octreotide, a somatostatin +analogue, has been reported to be effective +in hastening the closure of thoracic duct leak); +(2) relieving dyspnea by removing the chyle by +repeated thoracentesis or tube thoracostomy +and pleuroperitoneal shunts; (3) closure of the +defect with chemical pleurodesis, lymphatic +embolization and blockade and video-assisted +thoracoscopic surgery (VATS).[1,5] +In summary, this is a report of chylothorax after +childbirth, with its relatively benign course. +MOHAMMAD HOSSEIN RAHIMI-RAD +Department of Respiratory Medicine, Urmia University +of Medical Sciences, Urmia, Iran +Correspondence: +Dr. Mohammad Hossein Rahimi-Rad, Bronchoscopy Unit, +Imam-Khomeini Hospital, 57157-81351, Urmia, West +Azerbaijan, Iran. E-mail: rahimirad@umsu.ac.ir +REFERENCES +1. Light RW, Garry Lee YC. Pneumothorax, +chylothorax, hemothorax and fibrothorax. In: +Mason RJ, Broaddus VC, Murray JF, et al., +editors. Murray and Nadel’s textbook of respiratory +medicine. Elsievier Saunders: Philadelphia; 2005. +p. 1961-88. +2. Banerjee D. Nontraumatic chylothorax: Revisited. +J Indian Assoc Pediatr Surg 2007;12:96-8. +3. Kairamkonda VR. A rare cause of chylo- +pneumothorax in a preterm neonate. Indian J +Med Sci 2007;61:476-7. +4. Tornling G, Axelsson G, Peterffy A. Chylothorax as +a complication after delivery. Acta Obstet Gynecol +Scand 1987;66:381-2. +5. Honguero Martinez AF, Arnau Obrer A, Perez +Alonso D, Estors Guerrero M, Cortes Alcaide CM, +Canto Armengod A. Bilateral Chylothorax +after delivery: An infrequent case treated with +videothoracoscopic talc pleurodesis. Cir Esp +2006;80:400-2. +IMMEDIATE EFFECT OF +HIGH-FREQUENCY YOGA +BREATHING ON ATTENTION +Sir, +Kapalabhati (KPB) is a yoga breathing +technique characterized by forceful exhalation +and high-frequency breathing, whose name +(kapala = forehead, bhati = shining, in Sanskrit) +suggests that it stimulates the brain.[1] KPB +is being practiced throughout India for health +promotion and disease prevention.[2] +The alpha- and beta-1 activity in the EEG +increased during the first 5 minutes of a +15 minute KPB session in 11 advanced + +yoga practitioners.[3] When practiced at high +frequencies (i.e., approximately 120 breaths per +min), autonomic changes, based on the heart +rate variability spectrum, suggested increased +sympathetic and reduced vagal activity.[4] +However, despite the supposed effect on the +LETTERS TO EDITOR +20 +LETTERS TO EDITOR +brain, the effects of KPB on attention and +cognition have not been reported. +Forty-six medical students (11 males; mean +age ± SD, 20.9 ± 2.3 years; mean experience +of KPB, 3.3 ± 1.0 years) took part in the trial. +The attention task was administered before and +after KPB on one day and before and after an +alternate intervention, i.e., breath awareness +(BAW) on another day. BAW was chosen as it +is believed to improve attention. +To understand whether similar results would be +seen in different age groups, a similar trial was +conducted in middle-aged adults (30-59 years, +n = 48) with comparable gender distribution +and experience of KPB (±1 month). There +was also a smaller number (n = 16) of older +adults, over the age of 60 years (all males; +comparable experience of KPB, ±1 month). +Both groups were studied as described for +medical students. +A standard six-letter cancellation test was used. +The worksheet specifi + es six target letters to +be cancelled and has a working section, with +letters of the alphabet arranged randomly in +22 rows and 14 columns. Participants were +asked to cancel as many of the six target +letters as possible in 90 s. The sheets were +blind scored. The ‘before’ and ‘after’ values for +(i) KPB and (ii) BAW were compared separately +with Wilcoxon paired signed-ranks test. +For the medical students, total errors before +KPB (group mean ± SD, 11.4 ± 8.2) and +before BAW (9.6 ± 6.2) were not different. +However, after KPB, total errors decreased +(5.0 ± 4.0; P < 0.001); with no change after +BAW (8.7 ± 7.2). For the adults and older +persons, there were no changes in total errors +after both sessions. However, for both groups +of adults, the net scores (i.e., total letters +cancelled minus errors) were higher after +KPB. For middle-aged adults, the net scores +after KPB were higher (37.5 ± 13.3, P < 0.001, +32.5% increase) compared to those before KPB +(28.3 ± 8.7). Also, the older persons showed +higher net scores after KPB (33.4 ± 10.4, +P < 0.05, 16.4% increase) compared to those +before KPB (28.6 ± 10.5). The net scores did +not change in medical students. +Hence in all three age groups (medical students, +middle-aged adults and older persons), the +changes in cancellation scores (either total +errors or net scores) after KPB suggested +improvement. This task requires selective and +sustained attention, as well as the ability to +shift attention. The mechanism underlying the +improvement is not known. It may be related to +the fact that KPB is associated with increased +sympathetic activity, and increased sympathetic +tone is associated with better vigilance.[5] The +study is limited by the small sample sizes +and the fact that the study did not attempt to +assess how long the effect of KPB on attention +lasted. Further research is required with larger +numbers and with reassessments to understand +how long the effects last so as to understand +the therapeutic possibilities. +SHIRLEY TELLES, P. RAGHURAJ1, +DHANANJAY ARANKALLE1, K. V. NAVEEN +Patanjali Yogpeeth, Haridwar, and 1JSS College of +Naturopathy and Yogic Sciences, +Utagamund, India +Correspondence: +Dr. Shirley Telles, Patanjali Yogpeeth, Maharishi +Dayanand Gram, New Delhi-Haridwar Highway, Bahadrabad, +Haridwar - 249 402, India. E-mail: shirleytelles@gmail.com +REFERENCES +1. Niranjananda SS. Prana, Pranayama, Pranavidya. +Yoga Publications Trust: Munger, India; 2002. +2. Balkrishna A. Yog in synergy with medical science. +Divya Prakashan: Haridwar, India; 2007. +3. Stancák A Jr, Kuna M, Srinivasan, Dostálek C, +Vishnudevananda S. Kapalabhati--yogic cleansing +exercise: II, EEG topography analysis. Homeost +Health Dis 1991;33:182-9. +4. 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. +5. Fredrikson M, Engel BT. Cardiovascular and +electrodermal adjustments during a vigilance +task in patients with borderline and established +hypertension. J Psychosom Res 1985;29:235-46. +21 +22 +Indian J Med Sci, Vol. 62, No. 1, January 2008 +Indian J Med Sci, Vol. 62, No. 1, January 2008 +INDIAN JOURNAL OF MEDICAL SCIENCES +Author Help: Reference checking facility +The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of +references. The tool checks the references with PubMed as per a predefined style. Authors are encouraged to use +this facility before submitting articles to the journal. +• +The style as well as bibliographic elements should be 100% accurate to get the references verified from +the system. A single spelling error or addition of issue number / month of publication will lead to error to +verifying the reference. +• +Example of a correct style + +Sheahan P +, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine +needle aspiration biopsy. Otolaryngol Head Neck Surg 2002;127:294-8. +• +Only the references from journals indexed in PubMed would be checked. +• +Enter each reference in new line, without a serial number. +• +Add up to a maximum 15 reference at time. +• +If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT +and a link to the correct article in PubMed will be given. +• +If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be +shown as INCORRECT and link to possible articles in PubMed will be given. diff --git a/subfolder_0/Immediate effect of needling at CV-12 (Zhongwan) acupuncture point on blood glucose level in patients with type 2 diabetes mellitus A pilot randomi.txt b/subfolder_0/Immediate effect of needling at CV-12 (Zhongwan) acupuncture point on blood glucose level in patients with type 2 diabetes mellitus A pilot randomi.txt new file mode 100644 index 0000000000000000000000000000000000000000..345dd7cfb5597b437b2dba881bedc77bea3858a6 --- /dev/null +++ b/subfolder_0/Immediate effect of needling at CV-12 (Zhongwan) acupuncture point on blood glucose level in patients with type 2 diabetes mellitus A pilot randomi.txt @@ -0,0 +1,606 @@ +Accepted Manuscript +Immediate Effect of Needling at CV-12 (Zhongwan) Acupuncture Point on Blood +Glucose Level in Patients with Type 2 Diabetes Mellitus: A Pilot Randomized Placebo +Controlled Trial +Ranjan Kumar, A. Mooventhan, MD, Naturopathy, N.K. Manjunath, Professor and +Head +PII: +S2005-2901(17)30052-3 +DOI: +10.1016/j.jams.2017.06.003 +Reference: +JAMS 356 +To appear in: +Journal of Acupuncture and Meridian Studies +Received Date: 21 March 2017 +Revised Date: +2 June 2017 +Accepted Date: 6 June 2017 +Please cite this article as: Kumar R, Mooventhan A, Manjunath NK, Immediate Effect of Needling at +CV-12 (Zhongwan) Acupuncture Point on Blood Glucose Level in Patients with Type 2 Diabetes Mellitus: +A Pilot Randomized Placebo Controlled Trial, Journal of Acupuncture and Meridian Studies (2017), doi: +10.1016/j.jams.2017.06.003. +This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to +our customers we are providing this early version of the manuscript. The manuscript will undergo +copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please +note that during the production process errors may be discovered which could affect the content, and all +legal disclaimers that apply to the journal pertain. +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +Immediate Effect of Needling at CV-12 (Zhongwan) Acupuncture Point on Blood +Glucose Level in Patients with Type 2 Diabetes Mellitus: A Pilot Randomized Placebo +Controlled Trial +Ranjan Kumar,1 A. Mooventhan,2 N.K. Manjunath3 + +1 Department of Yoga and Naturopathy, S-VYASA University, Bengaluru, Karnataka, India +2MD (Naturopathy), Department of Research and Development, S-VYASA University, +Bengaluru, Karnataka, India +3Professor and Head, Department of Research and Development, S-VYASA University, +Bengaluru, Karnataka, India + +Number of Tables: 01 +Number of Figure: 02 +Word Counts: Abstract: 198; Manuscript 1442 +Corresponding contributor: +Dr. A. Mooventhan, +MD (Naturopathy), +Department of Research and Development, +S-VYASA University, #19, Eknath Bhavan, Kavipuram Circle, Kempegowda Nagar, +Bengaluru 560019, Karnataka, India. +Mobile: +91 9844457496 +E-mail: dr.mooventhan@gmail.com + + +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +1 + +Immediate Effect of Needling at CV-12 (Zhongwan) Acupuncture Point on Blood Glucose +1 +Level in Patients with Type 2 Diabetes Mellitus: A Pilot Randomized Placebo Controlled +2 +Trial +3 +ABSTRACT: +4 +Introduction: Diabetes mellitus is a major global health problem. Needling at CV-12 has +5 +reported to reduce blood glucose level in diabetic rats. Aim of this study was to evaluate the +6 +effect of needling at CV-12 (Zhongwan) on blood glucose level in patients with type-2-diabetes +7 +mellitus (T2DM). +8 +Materials and Methods: Forty T2DM subjects were recruited and randomized into either the +9 +acupuncture group or the placebo control group. The participants in the acupuncture group were +10 +needled at CV-12 (4-cun above the center of the umbilicus), and those in the placebo control +11 +group were needled at a placebo point on the right side of the abdomen (1-cun beside the CV- +12 +12). For both groups, the needle was retained for 30 minutes. Assessments were performed prior +13 +to and after the intervention. Statistical analysis was performed using the Statistical Package for +14 +the Social Sciences, version 16. +15 +Results: Result of this study showed a significant reduction in random blood glucose level in +16 +Acupuncture group compared to its baseline. But no such significant change was observed in +17 +placebo control group. +18 +Conclusion: The result of this study suggests that 30 minutes of needling at CV-12 might be +19 +useful in reducing blood glucose level in patients with T2DM. +20 +Keywords: Acupuncture; Blood glucose; CV-12; Type 2 Diabetes Mellitus +21 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +2 + +INTRODUCTION: +1 +Diabetes mellitus is a group of metabolic disorders characterized by chronic hyperglycemia due +2 +to relative insulin deficiency or resistance or both. Type 2 diabetes mellitus (T2DM) is a major +3 +global health problem with a prevalence of 366 million in 2011 and that is projected to increase +4 +by 51%, reaching 552 million by 2030. India follows this global trend with a prevalence of 31 +5 +million diabetics in 2000, 60 million in 2011 and that is projected to increase by 63%, reaching +6 +98 million by 2030. Use of drugs has its own drawbacks, such as drug dependency, drug +7 +resistance and adverse effects, if used for a long time. Hence, in recent years there has been an +8 +intense search for non-medical measures not only to manage the T2DM, but also to prevent its +9 +complications[1]. +10 +The traditional Chinese medicine (TCM) offers a complete medical system that has been used to +11 +diagnose, treat, and prevent illnesses for more than 2,000 years. One of the most commonly used +12 +therapies of TCM is acupuncture, which consists in stimulating specific points on the body +13 +(acupoints), by inserting thin metal needles into superficial structures such as skin, subcutaneous +14 +tissue, or muscles, in order to remove blockages in the flow of vital energy or life force called +15 +“qi” that circulates throughout the body through a system of pathways called channels[2]. +16 +Acupuncture has been used for thousands of years for the treatment of diabetes and its associated +17 +medical conditions[3]. Needling at CV-12 (Zhongwan) has been widely used to relieve +18 +symptoms of diabetes[4]. In a previous study, CV-12 in combination with other acupuncture +19 +points such as CV-4 (Guanguan), CV-6 (Qihai), CV-10 (Xiawan), ST-24 (Huaroumen), ST-25 +20 +(Tianshu), TE-5 (Wailing), SP-15 (Daheng), and KI-13 (Qixue) has shown to decrease blood +21 +glucose level and improve insulin resistance with no adverse effects in obese T2DM[5]. +22 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +3 + +Even though needling at CV-12 alone has shown to produce a significant reduction in blood +1 +glucose level in diabetic rats[4], it did not produce a significant reduction in blood glucose level +2 +of healthy individuals[6]. There are various studies reporting the hypoglycemic effect of single +3 +acupuncture point therapy including electroacupuncture at CV-12[4], ST-36 (Zusanli)[7], and +4 +GB 26 (Daimai)[8]; and laser acupuncture at only BL20 (Pishu) in diabetic rats[9]. But to the +5 +best of our knowledge, there is no known study reporting the effect of single needling at CV-12 +6 +in patients with diabetes. Hence, the aim of this study was to evaluate the effect of needling CV- +7 +12 on blood glucose level in patients with T2DM. +8 +MATERIALS AND METHODS +9 +Subjects: +10 +A total of forty subjects who were diagnosed as having T2DM with the mean ± standard +11 +deviation age of 56.20±11.00 were recruited from a holistic health care center, South India, +12 +India. Male subjects with the history of T2DM, under stable medication for the past 3 months +13 +and willing to participate in the study were included and subjects with the history of T2DM +14 +complications, needle phobia, mental illness were excluded from the study. Study protocol was +15 +approved by institutional ethics committee and a written informed consent was obtained from +16 +each subject. +17 +Design of the Study: +18 +A randomized placebo controlled trail was adopted for this pilot study. All the subjects were +19 +randomly assigned into either the acupuncture group or the placebo control group. The +20 +acupuncture group received needling at CV-12 and the placebo control group received needling +21 +at a non-acupuncture point for 30 minutes. Data assessment was performed prior to and after the +22 +intervention [Figure 1]. +23 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +4 + +Randomization: +1 +All the subjects were randomly assigned into either the acupuncture group or the placebo control +2 +group using computerized randomization. Randomization was performed by one of the authors +3 +who was not involved in any part of assessment. +4 +Blinding/masking +5 +All participants were blind to the acupuncture (CV-12) and the placebo control points. The +6 +investigator who assessed the blood glucose was blind to the acupuncture and placebo control +7 +groups. +8 +Assessments: +9 +Random blood glucose (RBG): It was assessed using a portable ACCU-CHEK Active, Performa +10 +Nano machine (Roche Diagnostics India Pvt. Ltd, Mumbai, India). Assessments were performed +11 +prior to and after the intervention for both groups. +12 +Intervention +13 +Acupuncture group: The participants received traditional Chinese medicine style of +14 +acupuncture. Needling was performed at CV-12 (4-cun above the center of the umbilicus) at a +15 +depth of 0.5-cun. The participants were informed about the procedure, sensations of needle +16 +insertion, and response sought[6]. Manual stimulation was given by lifting the needle ups and +17 +down for 5 minutes. We used 0.5-cun filiform locally manufactured cupper needle with 0.38 mm +18 +diameter and 13 mm length. The participants received only one session of acupuncture for a +19 +duration of 30 minutes. The participants did not receive any treatments other than acupuncture. +20 +Needling was administered by one of the authors who is institutionally qualified with 2 years’ +21 +experience in clinical acupuncture. +22 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +5 + +Placebo control group: The participants in this group received needling in the right side of the +1 +abdomen 1-cun lateral to CV-12 where there is no known acupuncture point with manual +2 +stimulation same like Acupuncture group. +3 +Data Analysis: +4 +Data were check for normality using kolmogorov smirnov. Statistical analysis of within group +5 +was performed using paired samples-t-test and between groups analysis was performed using +6 +independent samples-t-test (Data that were normally distributed) and Mann Whitney-U-test +7 +(Data that were not normally distributed) with the use of Statistical Package for the Social +8 +Sciences (SPSS) for Windows, Version 16.0, Chicago, SPSS Inc. +9 +RESULT +10 +Of 51 subjects, 11 subjects did not fulfill the criteria and thus not included in the study. +11 +Recruited 40 subjects were divided into either Acupuncture group or placebo control group. +12 +Demographic variables and baseline values of both Acupuncture and placebo control groups +13 +were comparable and there were no significant differences between the groups [Table 1]. Result +14 +of this study showed a significant reduction in RBG in Acupuncture group compared to its +15 +baseline. But no such significant change was observed in placebo control group. However, there +16 +was no statistical significant difference in between the groups [Figure 2]. +17 +DISCUSSION: +18 +In the last decade, there is an increasing interest for alternative medicine, including Acupuncture +19 +(one of the common TCM)[2]. In Korean medicine, CV-12 is known as the stomach control +20 +point and is located on the abdominal wall associated with the pancreas. Although it is located on +21 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +6 + +the Conception Vessel Meridian, it is considered a therapeutic point for diseases of the digestive +1 +organs such as the stomach, pancreas, and spleen[6,10]. +2 +Even though the result of this study showed no significant difference between the groups, a +3 +significant reduction in RBG level was observed 30 minutes after the needling at CV-12 +4 +(Acupuncture group), while no such significant change was observed 30 minutes after the +5 +needling at placebo point (placebo control group) compared to its respective baselines. It +6 +suggests that needling at CV-12 with manual stimulation might be effective in reducing blood +7 +glucose level in patients with T2DM. +8 +This result supports the hypoglycemic effect of CV-12 that was reported in the previous studies +9 +on needling at CV-12 alone in diabetic rats[4] as well as in combination with other points in +10 +diabetic patients[5]. Result of the present study confirm the statement of a previous study that +11 +needling at CV-12 might be more effective in patients with high blood glucose levels (i.e. +12 +diabetes) than in healthy individuals[6], The reduction in the blood glucose level in patient with +13 +T2DM might be possibly through an increase in plasma insulin-like immunoreactivity or +14 +secretion of endogenous beta-endorphin due to needling at CV-12 as reported in the previous +15 +study on electroacupuncture in diabetic rats[4]. But, future studies are required to warrant this +16 +mechanism. +17 +Strength of the study: This is the first randomized placebo controlled study to evaluate the effect +18 +of a single needling at CV-12 on RBG levels in T2DM. Both the participants and the investigator +19 +were blind to the acupuncture and placebo control groups. Limitations of this study: The present +20 +study evaluated only the immediate effect with manual stimulation and did not evaluate its short- +21 +term or long-term effect with or without stimulation. Small sample size and it was not calculated +22 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +7 + +based on the previous study. Only male subjects were included, hence generalization of the +1 +finding of this study to the female subjects is limiting the scope of this study. Assessments of +2 +variables such as fasting blood glucose, postprandial blood glucose, glycosylated hemoglobin, +3 +and insulin levels were not performed. Hence, long-term studies with various other methods of +4 +stimulation using electrical, moxa, laser, embedding are required in a larger sample size +5 +including both male and female genders, and more variables as mentioned above for the better +6 +understanding. +7 +CONCLUSION: +8 +The result of this present study suggests that 30 minutes of needling at CV-12 with manual +9 +stimulation might be considered as an effective method in reducing blood glucose level in +10 +patients with T2DM. +11 +DISCLOSURE STATEMENT +12 +The authors declare that they have no conflicts of interest and no financial interests related to the +13 +material of this manuscript. +14 + +15 + +16 + +17 + +18 + +19 + +20 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +8 + +REFERENCES: +1 +1. Mooventhan A. A narrative review on role of Yoga as an adjuvant in the management of +2 +risk factor, disease progression and the complications of type 2 diabetes mellitus. +3 +Diabetes Metab Syndr. 2017.pii: S1871-4021(16)30314-9. +4 +2. Garcia-Vivas JM, Galaviz-Hernandez C, Becerril-Chavez F, Lozano-Rodriguez F, +5 +Zamorano-Carrillo A, Lopez-Camarillo C, et al. Acupoint catgut embedding therapy with +6 +moxibustion reduces the risk of diabetes in obese women. J Res Med Sci. 2014;19:610-6. +7 +3. Peplow PV. Topical Issue: Acu-obesity and Diabetes. J Acupunct Meridian Stud. +8 +2016;9:107-8. +9 +4. Chang SL, Lin JG, Chi TC, Liu IM, Cheng JT. An insulin dependent hypoglycaemia +10 +induced by electroacupuncture at the Zhongwan (CV12) acupoint in diabetic rats. +11 +Diabetologia. 1999;42:250e255. +12 +5. Yang Y, Liu Y. BO’s abdominal acupuncture for obese type-2 diabetes mellitus. +13 +Zhongguo Zhen Jiu. 2015;35:330e334. +14 +6. Mohanty S, Mooventhan A, Manjunath NK. Effect of Needling at CV-12 (Zhongwan) on +15 +Blood Glucose Levels in Healthy Volunteers: A Pilot Randomized Placebo Controlled +16 +Trial. J Acupunct Meridian Stud. 2016;9:307-310. +17 +7. Lee YC, Li TM, Tzeng CY, Chen YI, Ho WJ, Lin JG, et al. Electroacupuncture at the +18 +zusanli (ST-36) acupoint induces a hypoglycemic effect by stimulating the cholinergic +19 +nerve in a rat model of streptozotocine-induced insulin-dependent diabetes mellitus. Evid +20 +Based Complement Alternat Med. 2011;2011:650263. +21 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +9 + +8. Li YY, Hu H, Liang CM, Wang H. Effects of electroacupuncture stimulation of “Daimai” +1 +(GB 26) on body weight, blood glucose and blood lipid levels in rats with metabolism +2 +syndrome. Zhen Ci Yan Jiu. 2014;39:202e206. +3 +9. Cornejo-Garrido J, Becerril-Cha´vez F, Carlı´n-Vargas G, Ordon ˜ez-Rodrı´guez JM, +4 +Abrajan-Gonza´lez Mdel C, de la Cruz- Ramı´rez R, et al. Antihyperglycaemic effect of +5 +laser acupuncture treatment at BL20 in diabetic rats. Acupunct Med. 2014;32:486e494. +6 +10. Kim MS, Sung B, Ogay V, Choi CJ, Kim MS, Kang DI, et al. Novel circulatory +7 +connection from the acupoint Zhong Wan (CV12) to pancreas. J Korean Pharmacopunct +8 +Inst. 2008;11:13e19. +9 + +10 + +11 + +12 +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT + +12 + +TABLES: + +Table 1: Demographic variables of both Acupuncture (n = 20) and placebo control group (n = 20) +Variables +Acupuncture Group Placebo Control Group +t/z value +p value +Age (Years)¶ +53.55±10.50 +58.85±11.12 +-1.504 +0.133 +Gender +20 Males +20 Males +- +- +Height (meters)* +1.68±0.07 +1.64±0.07 +-0.996 +0.326 +Weight (kg)* +74.18±10.53 +72.30±17.00 +0.419 +0.677 +Body mass index (kg/m2)* 26.54±4.52 +26.86±6.20 +-0.183 +0.857 +Note: All values are in mean ± standard deviation except values of gender. ¶ = Mann Whitney-U- +test; * = Independent samples-t-test. + + + + + + + + + + + + + + + +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +10 + +FIGURES: +Figure 1: Trial Profile + + + + + + + + + + + + + + + + + + + + + + +*CV: Conception Vessel + + +Assessed for eligibility (n = 51) +Randomization (n = 40) +Subjects excluded (n = 11) due to +1. Needle phobia (n = 4) +2. Not willing to participate (n = 7) +Recruited subject (n = 40) +Placebo control group (n = 20) +Acupuncture group (n = 20) +Baseline assessment (n = 20) +Baseline assessments (n = 20) +Needling at CV-12 (n = 20) +Needling at 1-cun beside CV-12(n = 20) + +Post assessment (n = 20) +Post assessment (n = 20) +Data analysis (n = 40) +MANUSCRIPT + +ACCEPTED +ACCEPTED MANUSCRIPT +11 + +Figure 2: Baseline and post-test assessments of Acupuncture group (n= 20) and placebo +control group (n= 20) + + + + + + +146.1 +139.15 +133.85 +138.8 +Acupuncture Group +Placebo Control Group +Random Blood Glucose Levels (mg/dl) +Baseline +Post-test +* =p value <0.001 +* diff --git a/subfolder_0/Impact of Yoga on cognition and mental health among elderly A systematic review..txt b/subfolder_0/Impact of Yoga on cognition and mental health among elderly A systematic review..txt new file mode 100644 index 0000000000000000000000000000000000000000..e69de29bb2d1d6434b8b29ae775ad8c2e48c5391 diff --git a/subfolder_0/Impact of pranayama and vedic mathematics on math anxiety and cognitive skills.txt b/subfolder_0/Impact of pranayama and vedic mathematics on math anxiety and cognitive skills.txt new file mode 100644 index 0000000000000000000000000000000000000000..b6c3aad0fff6f894569cdd3e10969f78b321f246 --- /dev/null +++ b/subfolder_0/Impact of pranayama and vedic mathematics on math anxiety and cognitive skills.txt @@ -0,0 +1,381 @@ +ORIGINAL ARTICLE +Year : 2017 | Volume : 49 | Issue : 2 | Page : 53--62 +Impact of pranayama and vedic mathematics on math anxiety and cognitive +skills +Vasant Venkatraman Shastri1, Alex Hankey1, Bhawna Sharma2, Sanjib Patra3, +1 Division of Yoga and Physical Sciences, S-VYASA University, Bengaluru, Karnataka, India +2 Department of Biology, Sri Sai Angels PU College, Chikkamagaluru, Karnataka, India +3 Division of Yoga and Life Sciences, S-VYASA University, Bengaluru, Karnataka, India +Correspondence Address: +Vasant Venkatraman Shastri +S-VYASA, No. 19, Eknath Bhawan, Gavipuram Circle, K.G. Nagar, Bengaluru - 560 019, Karnataka +India +Abstract +Context: Many children have low self-confidence in mathematics, leading to math anxiety, disturbed cognitive skills, and reduction +of the quality of their educational experience. Aims: This study aimed to compare methods of reducing such anxiety and improving +cognitive skills using pranayama; and second, introducing pattern recognition in problem solving, using methods of Vedic +Mathematics. These methods were chosen because pranayamas are well-established, standardized means of anxiety reduction +for any stressful condition, offering a precise standard for comparison, while, Vedic Mathematics shortens and facilitates +calculations. Settings and Design: The study design was a randomized controlled trial with three groups: Yoga pranayama (YP), +Vedic Mathematics (VM), and controls (CG) taking 12th grade students from a private preuniversity college in India. Method: +Intervention was 15 days each of 30 min daily instruction in either selected YP or VM for the two experimental groups. All the three +groups received conventional math training every day. Exclusion criteria were major psychological problems. Assessments used +the Mathematics Anxiety Rating Scale Revised and Children's Cognitive Assessment Questionnaire. Statistical Analysis Used: +SPSS 19.0 was used for statistical analysis. Results: The experimental groups improved on all subscales of both tests, p < 0.001: +the VM group improving more on the first test and the pranayama group performing better on the second test. Controls showed no +improvements. Conclusion: Introducing pranayama and VM methods as teaching aids would improve cognitive skills and reduce +math anxiety and offer a means to improve examination results, as later demonstrated. +How to cite this article: +Shastri VV, Hankey A, Sharma B, Patra S. Impact of pranayama and vedic mathematics on math anxiety and cognitive +skills.Yoga Mimamsa 2017;49:53-62 +How to cite this URL: +Shastri VV, Hankey A, Sharma B, Patra S. Impact of pranayama and vedic mathematics on math anxiety and cognitive skills. +Yoga Mimamsa [serial online] 2017 [cited 2021 Jan 27 ];49:53-62 +Available from: https://www.ym-kdham.in/text.asp?2017/49/2/53/220183 +Full Text + Introduction +Many children have less interest in mathematics (Frenzel, Goetz, Pekrun & Watt, 2010), and find learning mathematics very +difficult. Why this is may not be clear, because many children find well-presented mathematical ideas inspiring (Hohenwarter, +Hohenwarter & Lavicza, 2008; Tatar, 2013). Demands of science and mathematics can turn school into an unpleasant experience +(Kihwele, 2014). Anxiety caused by daily mathematics lessons starts in elementary school (Ramirez, Gunderson, Levine & Beilock, +2013) and becomes a dominant feature of their school experience (Maloney, Risko, Ansari & Fugelsang, 2010), causing math +anxiety (Taylor & Fraser, 2013) and leading to poor performance in mathematics. A specific anxiety rating scale for math anxiety +developed by Richardson & Suinn (1972) was revised and validated (Plake & Parker, 1982). One problem it causes is decrease in +working memory (Maloney et al., 2010), a skill important for performing calculations in class exercises, tests, and examinations +(Ashcraft & Krause, 2007). Of many papers on math anxiety (Ashcraft & Krause, 2007; Ashcraft & Moore, 2009; Maloney & +Beilock, 2012; Wang et al., 2014), few show how to reduce it (Bellinger, DeCaro & Ralston, 2015; Brunyé et al., 2013). +How to remedy these problems? This study compares two methods of reducing math anxiety and improving cognitive skills: Vedic +Mathematics (VM), a system offering students choice of ways to carry out calculations (Ismail & Sivasubramniam, 2010), and yoga +pranayama (YP), a well-researched means of anxiety reduction (Khalsa, Hickey-Schultz, Cohen, Steiner & Cope, 2012; Nemati, +2013; Sharma & Haider, 2013) and benchmark for doing so. +Yoga Pranayama +The first method investigated to reduce student's overall anxiety was YP (Cramer, Lauche, Langhorst & Dobos, 2016; Goldstein et +al., 2016), already well researched at many different institutions (Cramer, Lauche & Dobos, 2014) and shown to be highly effective +against anxiety (Varambally & Gangadhar, 2016; Uebelacker & Broughton, 2016). +Traditionally, pranayama (Nagendra, 2005) is used as preparation for meditation (Brown & Gerbarg, 2009) because it has a +delightful settling influence on mind and body, while at the same time enlivening certain levels of “subtle energy” within the tissues +(Sharma, Hankey, Meenakshy & Nagendra, 2014). Its settling influence has been much studied, including test anxiety reduction, +test performance(Nemati, 2013), perceived stress reduction, and cardiovascular and respiratory parameters (Bhavanani, Raj, +Ramanathan & Trakroo, 2016; Sharma et al., 2013). +Universally, high levels of stress, elevating levels of disease, make application of pranayama to decrease the effects of stressful +situations an acute need of our times. Learning its practice in school offers children a life skill with lifelong benefits. It was of central +interest here because competitive examination systems providing elimination procedures for those entering professional education +have put new pressures on schoolchildren (Kadapatti & Vijayalaxmi, 2012). Also, more countries today are seeking to become +knowledge-based societies (Gilbert, 2005), offering citizens more interesting work than drudgery of employment in mines and +factories. However, some argue that examination-oriented education systems pressure children unnecessarily. +Introducing children to stress-reducing techniques of yoga offers great potential benefit. By steadying the breathing process, +pranayama steadies the mind itself. Everything passing through the mind can be “seen” and understood more clearly (Jerath & +Barnes, 2009). Conversely, when a person performs a steadying series of yoga breathings, their emotions are steadied (Gilbert, +1999), negative thoughts tend to decrease (Arch & Craske, 2006), and their thinking patterns become clearer and more positive. +Problem-solving abilities and mental efficiency improve (Sharma et al., 2014). YP also promotes positive health among +adolescents (Singh, 2015). +Vedic Mathematics +VM gives students a choice of method to solve problems by selecting specific patterns of calculation (Muehlman, 1998). It shortens +many calculations, directly improving examination results. Previously, mediocre students start scoring 90% or higher. Various +researchers have demonstrated the intuitive and holistic nature of VM (Muehlman, 1998). +VM (Tirthaji Maharaja & Agarwala, 1992) seems to have been developed by Bharathi Krishna Tirtha (1884–1960) and by +Shankaracharya of Puri, who said that it effectively formed an appendix to Atharva Veda. Previously, a teacher of high school +mathematics demonstrated many applications at that level which have since been greatly expanded (Nicholas, Williams & Pickles, +2010). +The Shankaracharya's methods prove popular with children learning them (Ismail & Sivasubramniam, 2010). They develop abilities +to visualize patterns of calculation for solving problems. Imagining hidden pictorial or algebraic patterns leads to enjoying the +process (Zazkis & Liljedahk, 2002). Performing calculations becomes more like a game. +Professional mathematicians use similar powers of mental cognition in understanding and creating mathematics. VM methods +have been applied professionally, for example, to shorten algorithms for multiplier circuits and decrease chip areas (Anjana, +Pradeep & Samuel, 2015; Bansal & Madhu, 2016). +This led to the choice of tests employed in this study; the Mathematics Anxiety Rating Scale-Revised (MARS-R) aims to assess +benefits of learning VM, while the Children's Cognitive Assessment Questionnaire (CCAQ) was chosen to demonstrate benefits of +the chosen sequence of pranayamas and related yoga breathing as summarized in [Table 1].{Table 1} + Method +Participants +A total of 168 students, aged 17.0–18.5 years, studying in 12th standard at a Pre-University College in Chikkmagaluru, Karnataka, +India, were randomly assigned to: YP (59 students, 34 male, 25 female), VM (59 students, 16 male, 43 female), and controls (CG – +50 students, 22 male, 28 female). +Design +The three groups employed pre-post randomized controlled design [Figure 1]. Randomization used an online random number +generator (Psychic Science, n.d.). G*Power analysis on a pilot study yielded n = 23.{Figure 1} +Informed consent +The study purpose and design were explained to parents/guardians who signed informed consent forms. +Interventions +Students in the experimental groups attended workshops lasting 30 min/day for 15 days during their regular mathematics +classroom periods. The YP group received instruction in yoga breathing while the VM group received instruction and exercises in +VM. Controls continued their usual maths classwork during the same classroom periods. Thirty minutes daily instruction was given +to all the three groups at different times by the first author who is expert in YP, VM, and conventional mathematics teaching +methods. The YP and VM groups also attended conventional mathematics classes after the 30 min intervention class. +The YP intervention consisted of a sequence of yoga breathing listed in the right column of [Table 2]. The first two (Kapalabhati +and Bhastrika) are yoga kriyas and cleansing techniques, the third is deep breathing technique, while the last three are forms of +pranayama. Each technique was first demonstrated, and then the class imitated the demonstrator, each member being carefully +corrected for mistakes. After mastery of the first technique, instruction moved to the second technique, etc., until all were confident +in performing the techniques in sequence. In each workshop, verbal instructions were given to start each technique and students +with difficulties were helped. After each allotted 5 min time period, the group began performance of the next technique. Each +workshop ended with Bhramari pranayama, the 6th technique listed in [Table 2] (right column).{Table 2} +The VM intervention comprised instruction in 12th standard mathematics, taught by standard procedures for VM instruction. +Examples are given in [Table 2], with details of three explained in Appendix, for example, solutions to simultaneous equations were +demonstrated using VM sutras, “vertically and crosswise,” “transpose and apply,” and “addition and subtraction,” offering +alternative strategies to solve equations related to specific examples. Example 1 solves two simultaneous equations using +“vertically and crosswise.” Example 2 demonstrates the use of “transpose and apply” to simplify integration of the reciprocal of a +factorable quadratic function. Both problems cause less gifted students conceptual problems, time loss, and errors. Example 3 +presents a multiple choice question on integration of nonfactorizable quadratic functions, the most difficult problem in Indian +preuniversity maths, requiring understanding functions less familiar to the student [Appendix 1]. +These examples show how VM methods shorten 12th grade maths calculations used in differential and integral calculus, +coordinate geometry, algebra, trigonometry, vectors, and 3D geometry. The above topics were taught to all the three groups +participating in the study, but only the VM group learned to solve problems by VM procedures. +Assessments +Mathematics Anxiety Rating Scale-Revised (Plake & Parker, 1982) +This 24-item instrument is designed to measure anxiety incurred in maths and statistics courses. It is a revised version of a 98-item +scale by Richardson & Suinn (1972), and is more focused on situation-specific (state) anxiety, general (trait) anxiety, and test +anxiety. It contains two subscales: learning mathematics anxiety (LMA) concerning processes of learning of maths and statistics +and evaluation maths anxiety (EMA) measuring anxiety from maths and statistics tests. LMA plus EMA form the total maths anxiety +(TMA). +Scoring: Respondents rate each item on a 5-point scale from “low” to “high anxiety.” +Scores are the sum of item ratings, ranging from 24 to 120 for the total scale. +Children's Cognitive Assessment Questionnaire (Zatz & Chassin, 1983) +This 40-item instrument measures self-defeating and self-enhancing cognitions associated with test anxiety. It focuses on negative +self-evaluations and positive self-evaluations, reflecting self-defeating and self-enhancing cognitions. It also assesses distracting, +“off-task thoughts,” and “on-task thoughts,” focusing attention on task. These four constitute CCAQ subscales. +Scoring: Each item is answered true or false. Scores on the four subscales are the number of items answered “true,” ranging from +0 to 10. The first two subscales more reflect thoughts associated with test anxiety, while the last two subscales reflect less test +anxiety. +Data analysis +IBM SPSS Statistics for Windows, Version 19.0, manufactured by IBM Corporation, Armonk, NY (IBM Corp., 2010) software was +used, and Kruskal–Wallis, Mann–Whitney, and Wilcoxon tests were also used for data analysis. + Results +Seven students in the VM group and eight in YP group failed to give postintervention data, and were listed as dropouts. Data were +therefore analyzed for the remaining 52 students in VM, 51 in YP group, and 50 in CG. Baseline demographic data were not +significantly different between the three groups. +Test results are presented in [Table 1] and [Table 3], [Table 4], [Table 5]. [Table 3] presents means and standard deviations of the +scores on MARS-R for the three groups, pre- and postinterventions, while [Table 4] and [Figure 2] summarize pre-post differences, +giving statistical significances of differences between experimental and CGs. The VM group showed consistent improvements on +both LMA and EMA subscales, p < 0.001, while the YP group showed consistent improvements on both subscales at p < 0.01. +Controls showed no change in scores.{Table 3}{Table 4}{Table 5}{Figure 2} +For CCAQ results, [Table 5] presents pre-post values of means and standard deviations for the three groups, pre- and +postintervention period. As hypothesized, both experimental groups showed significant pre-post differences, p < 0.001. +Significance was less for the On Task subscale, where the YP group attained p < 0.05, while the difference for the VM group was +only p = 0.06 only, showing a trend; interestingly, values for controls improved on every scale, but did not reach significance on +any. +[Table 1] and [Figure 3] compare the groups' pre-post differences showing that relative improvements between CG and the YP +groups were significant for the first three subscales, reaching p < 0.01 for the Off Task subscale and p < 0.05 for negative and +positive evaluation subscales, but not for the fourth subscale, On Task. Pre-post differences were significantly different for positive +evaluation between VM and CGs (p < 0.05).{Figure 3} + Discussion +Results confirm experimental hypotheses with good statistical significance, math anxiety reduces most in the VM group (Cohen's d += 0.57 for TMA in VM), and seemingly less in the YP group, though between-group differences were not significant. Scores on +CCAQ improved most in the YP group, less in the VM group, but not in CG – with a similar caveat (Cohen's d varies from 0.35 to +0.95 for various CCAQ parameters for YP). The immediate scientific question is why should such results obtain? +Systematic reviews of randomized controlled trials (RCTs) of yoga provide much evidence for benefits of YP for anxiety (Sharma & +Haider, 2013; Weaver & Darragh, 2015). Changes observed in the YP group are consistent with such predictions and G*Power +analysis. Changes observed in the VM group may be attributed to the intervention. Similarly, studies comparing yogic practices to +eyes-closed rest obtain different results for experimental and CGs: eyes-closed rest showing little change (Travis & Wallace, 1999). +Positive effects observed in the YP group are therefore due to the intervention. +Reasons for using YP comparison group may still require comment. YP practices can be taken as a benchmark with which to +compare other methods of anxiety reduction. They are effective for any kind of stressful condition. Evaluation of their comparative +ability to reduce math anxiety is therefore relevant. +This study represents the first full study of effects of using the VM approach to maths teaching, though a single case study has +recently been published (Pagedar, 2015). Many studies concern effects of regular practice of yoga in the classroom (Ferreira- +Vorkapic et al., 2015). In India, introducing yogic practices is intended to improve the quality of life of schoolchildren, as well as, +help decreasing anxiety and depression generated by emphasis on exam performance. Any study providing evidence for benefits +to schoolchildren of particular yoga practices is therefore of potential value. +Another angle of investigation is provided by a study of 1345 Filipino engineering students aged 15–25, which showed that, when +learning trigonometry, anxiety measured by the Academic Emotion Questionnaire – Mathematics correlates negatively with positive +emotions, pride, and enjoyment (Villavicencio & Bernardo, 2016). Findings from our data are parallel to those Spearman's rho +between the three subscales of MARS-R and the four subscales of CCAQ ranged from ρ = 0.273 to ρ = 0.450, with all highly +significant (p < 0.0001). Although the correlations may be expected, since both tests concern quality of emotion experienced by +participants, it is of value to see the extent of the correlations. + Conclusion +This study obtained good statistical significance in all subscales of both tests except the fourth subscale of CCAQ, On Task. These +observed pre-post improvements were significant at p < 0.05, but did not reach significance between groups. Improvements on +other subscales for both VM and YP groups suggest considering VM as a potential teaching aid and yogic breathing as an activity +to improve cognitive skills in schoolchildren. +Strengths +The study was a RCT with 59 in VM, 59 in YP, and 50 in CGs. It obtained significant results on all subscales of both tests except +CCAQ's 4th subscale. +Weaknesses +The first author is an experienced teacher of both VM and YP. Whether reported results depend on teacher's personal qualities +may require further study. However, he also conducted mathematics classes for controls; their lack of improvement tends to +discount teacher's personal qualities as the cause of improvements in experimental groups. +Future research +Being the first quantitative study of the effects of VM on math anxiety, results need to be verified by further research. Follow-up +studies including more test variables have been planned. +The first author introduced VM as a means to improve mindfulness (Shastri, Hankey, Sharma & Patra, 2017) and student +performance on final-year professional examinations. A 6-year assessment is being made of examination results at the school +where the study was performed. +Financial support and sponsorship +Nil. +Conflicts of interest +There are no conflicts of interest.[51] +References +1 +Anjana, S., Pradeep, C., & Samuel, P. (2015). Synthesize of high speed floating-point multipliers based on vedic +mathematics. Procedia Computer Science, 46, 1294-1302. +2 +Arch, J. J., & Craske, M. G. (2006). Mechanisms of mindfulness: Emotion regulation following a focused breathing +induction. Behaviour Research and Therapy, 44 (12), 1849-1858. +3 +Ashcraft, M. H., & Krause, J. A. (2007). Working memory, math performance, and math anxiety. Psychonomic Bulletin & +Review, 14 (2), 243-8. +4 +Ashcraft, M. H., & Moore, A. M. (2009). Mathematics anxiety and the affective drop in performance. Journal of +Psychoeducational Assessment, 27 (3), 197-205. +5 +Bansal, Y., & Madhu, C. (2016). A novel high-speed approach for 16 × 16 Vedic multiplication with compressor adders. +Computers & Electrical Engineering, 49, 39-49. +6 +Bellinger, D. B., DeCaro, M. S., & Ralston, P. A. (2015). Mindfulness, anxiety, and high-stakes mathematics performance in +the laboratory and classroom. Consciousness and Cognition, 37, 123-132. +7 +Bhavanani, A. B., Raj, J. B., Ramanathan, M., & Trakroo, M. (2016). Effect of different pranayamas on respiratory sinus +arrhythmia. Journal of Clinical and Diagnostic Research, 10 (3), CC04-CC06. +8 +Brown, R. P., & Gerbarg, P. L. (2009). Yoga breathing, meditation, and longevity. Annals of the New York Academy of +Sciences, 1172, 54-62. +9 +Brunyé, T. T., Mahoney, C. R., Giles, G. E., Rapp, D. N., Taylor, H. A., & Kanarek, R. B. (2013). Learning to relax: Evaluating +four brief interventions for overcoming the negative emotions accompanying math anxiety. Learning and Individual +Differences, 27, 1-7. +10 +Cramer, H., Lauche, R., & Dobos, G. (2014). Characteristics of randomized controlled trials of yoga: A bibliometric analysis. +BMC Complementary and Alternative Medicine, 14 (1), 1-20. +11 +Cramer, H., Lauche, R., Langhorst, J., & Dobos, G. (2016). Is one yoga style better than another? A systematic review of +associations of yoga style and conclusions in randomized yoga trials. Complementary Therapies in Medicine, 25, 178-187. +12 +Ferreira-Vorkapic, C., Feitoza, J. M., Marchioro, M., Simões, J., Kozasa, E., & Telles, S. (2015). Are there benefits from +teaching yoga at schools? A systematic review of randomized control trials of yoga-based interventions. Evidence-Based +Complementary and Alternative Medicine, 2015, 1-17. +13 +Frenzel, A. C., Goetz, T., Pekrun, R., & Watt, H. M. (2010). Development of mathematics interest in adolescence: Influences +of gender, family, and school context. Journal of Research on Adolescence, 20 (2), 507-537. +14 +Gilbert, C. (1999). Yoga and breathing. Journal of Bodywork and Movement Therapies, 3 (1), 44-54. +15 +Gilbert, J. (2005). Catching the knowledge wave: The knowledge society and the future of public education in New Zealand. +In J. Codd & K. Sullivan (Eds.), Education Policy Directions in Aotearoa/New Zealand. (pp. 53-70). South Bank, Australia: +Thomson Dunmore Press. +16 +Goldstein, M. R., Lewis, G. F., Newman, R., Brown, J. M., Bobashev, G., & Kilpatrick, L., … Meleth, S. (2016). +Improvements in well-being and vagal tone following a yogic breathing-based life skills workshop in young adults: Two +open-trial pilot studies. International Journal of Yoga, 9 (1), 20-26. +17 +Hohenwarter, J., Hohenwarter, M., & Lavicza, Z. (2008). Introducing dynamic mathematics software to secondary school +teachers: The case of GeoGebra. Journal of Computers in Mathematics and Science Teaching, 28 (2), 135-146. +18 +IBM Corp. (2010). IBM SPSS statistics for windows. Armonk, NY: IBM Corp. +19 +Ismail, S., & Sivasubramniam, P. (2010). Multiplication with the vedic method. Procedia-Social and Behavioral Sciences, 8 +(5), 129-133. +20 +Jerath, R., & Barnes, V. A. (2009). Augmentation of mind-body therapy and role of deep slow breathing. Journal of +Complementary and Integrative Medicine, 6 (1). doi: 10.2202/1553-3840.1299. +21 +Kadapatti, M. G., & Vijayalaxmi, A. H. (2012). Stressor of academic stress – A study on pre-university students. Indian +Journal of Scientific Research, 3 (1), 171-175. +22 +Khalsa, S. B., Hickey-Schultz, L., Cohen, D., Steiner, N., & Cope, S. (2012). Evaluation of the mental health benefits of yoga +in a secondary school: A Preliminary Randomized Controlled Trial. The Journal of Behavioral Health Services & Research, +39 (1), 80-90. +23 +Kihwele, J. E. (2014). Students' perception of science subjects and their attitude in Tanzanian secondary schools. World +Journal of Educational Research, 1 (1), 1-8. +24 +Maloney, E. A., & Beilock, S. L. (2012). Math anxiety: Who has it, why it develops, and how to guard against it. Trends in +Cognitive Sciences, 16 (8), 404-406. +25 +Maloney, E. A., Risko, E. F., Ansari, D., & Fugelsang, J. (2010). Mathematics anxiety affects counting but not subitizing +during visual enumeration. Cognition, 114 (2), 293-297. +26 +Muehlman, J. M. (1998). Maharishi's vedic mathematics in elementary education : Developing all knowingness to improve +affect, achievement, and mental computation. Modern Science and Vedic Science, 8 (1), 36-107. Retrieved from +https://www.mum.edu/pdf_msvs/v08/muehlman.pdf. [Last accessed on 2017 Apr 01]. +27 +Nagendra, H. R. (2005). Pranayama. Bangalore: Swami Vivekananda Yoga Prakashana. +28 +Nemati, A. (2013). The effect of pranayama on test anxiety and test performance. International Journal of Yoga, 6 (1), 55- +60. +29 +Nicholas, A. P., Williams, K. R., & Pickles, J. (2010). Vertically and Crosswise (3rd Rev.). Castle Douglas, Scotland: +Inspiration Books. +30 +Pagedar, S. (2015). A study of mathematics anxiety remediated with the vedic math program. The International Journal of +Humanities & Social Studies, 3 (10), 195-200. +31 +Plake, B. S., & Parker, C. S. (1982). The development and validation of a revised version of the mathematics anxiety rating +scale. Educational and Psychological Measurement, 42 (2), 551-557. +32 +Psychic +Science. +(n.d.). +Random +Number +Generator +& +Checker. +Retrieved +March +23, +2014, +from +http://www.psychicscience.org/random.aspx. [Last accessed on 2014 Mar 23]. +33 +Ramirez, G., Gunderson, E. A., Levine, S. C., & Beilock, S. L. (2013). Math anxiety, working memory, and math +achievement in early elementary school. Journal of Cognition and Development, 14 (2), 187-202. +34 +Richardson, F. C., & Suinn, R. M. (1972). The mathematics anxiety rating scale: Psychometric data. Journal of Counseling +Psychology, 19 (6), 551-554. +35 +Sharma, B., Hankey, A., Meenakshy, K. B., & Nagendra, H. R. (2014). Can yoga practices benefit health by improving +organism regulation? Evidence from electrodermal measures of acupuncture meridians. International Journal of Yoga, 7, +32-40. +36 +Sharma, M., & Haider, T. (2013). Yoga as an alternative and complementary therapy for patients suffering from anxiety: A +systematic review. Journal of Evidence-Based Complementary & Alternative Medicine, 18 (1), 15-22. +37 +Sharma, V. K., Rajajeyakumar, M., Velkumary, S., Subramanian, S. K., Bhavanani, A. B., & Madanmohan, … Thangavel, D. +(2014). Effect of fast and slow pranayama practice on cognitive functions in healthy volunteers. Journal of Clinical and +Diagnostic Research, 8 (1), 10-13. +38 +Sharma, V., Trakroo, M., Subramaniam, V., Sahai, A., Bhavanani, A., & Rajajeyakumar, M. (2013). Effect of fast and slow +pranayama on perceived stress and cardiovascular parameters in young health-care students. International Journal of +Yoga, 6 (2), 104-110. +39 +Shastri, V. V., Hankey, A., Sharma, B., & Patra, S. (2017). Investigation of yoga pranayama and vedic mathematics on +mindfulness, aggression and emotion regulation. International Journal of Yoga, 10 (3), 138-144. +40 +Singh, A. (2015). Efficacy of a 4-week yogic lifestyle education for promoting holistic health in Indian school adolescents. +Yoga Mimamsa, 47 (1), 22. +41 +Tatar, E. (2013). The effect of dynamic software on prospective mathematics teachers' perceptions regarding information +and communication technology. Australian Journal of Teacher Education, 38 (12), 1-16. +42 +Taylor, B. A., & Fraser, B. J. (2013). Relationships between learning environment and mathematics anxiety. Learning +Environments Research, 16 (2), 297-313. +43 +Tirthaji Maharaja, B. K., & Agrawala, V. S. (1992). Vedic Mathematics. Delhi, India: Motilal Banarsidass. +44 +Travis, F., & Wallace, R. K. (1999). Autonomic and EEG patterns during eyes-closed rest and transcendental meditation +(TM) practice: the basis for a neural model of TM practice. Consciousness and cognition, 8(3), 302-318. +45 +Uebelacker, L. A., & Broughton, M. K. (2016). Yoga for depression and anxiety: A review of published research and +implications for healthcare providers. Rhode Island Medical Journal (2013), 99 (3), 20. +46 +Varambally, S., & Gangadhar, B. N. (2016). Yoga-based interventions for the management of psychiatric disorders. In L. C. +Lam & M. Riba (Eds.), Physical Exercise Interventions for Mental Health. (1st ed., pp. 124-146). Cambridge: Cambridge +University Press. +47 +Villavicencio, F. T., & Bernardo, A. B. (2016). Beyond math anxiety: Positive emotions predict mathematics achievement, +self-regulation, and self-efficacy. Asia-Pacific Education Researcher, 25 (3), 415-422. +48 +Wang, Z., Hart, S. A., Kovas, Y., Lukowski, S., Soden, B., & Thompson, L. A., … Petrill, S. A. (2014). Who's afraid of math? +Two sources of genetic variance for mathematical anxiety. Journal of Child Psychology and Psychiatry, 55 (9), 1056-1064. +49 +Weaver, L. L., & Darragh, A. R. (2015). Systematic review of yoga interventions for anxiety reduction among children and +adolescents. American Journal of Occupational Therapy, 69 (6), 6906180070p1-9. +50 +Zatz, S., & Chassin, L. (1983). Cognitions of test-anxious children. Journal of Consulting and Clinical Psychology, 51 (4), +526-34. +51 +Zazkis, R., & Liljedahk, P. (2002). Generalization of patterns: The tension between algebraic thinking and algebraic notation. +Educational Studies in Mathematics, 49 (3), 379-402. + + +Wednesday, January 27, 2021 + Site Map | Home | Contact Us | Feedback | Copyright and Disclaimer diff --git a/subfolder_0/Improved performance in the tower of london test following yoga.txt b/subfolder_0/Improved performance in the tower of london test following yoga.txt new file mode 100644 index 0000000000000000000000000000000000000000..4a50480fa60d550fa8a04c2331541270813681e8 --- /dev/null +++ b/subfolder_0/Improved performance in the tower of london test following yoga.txt @@ -0,0 +1,4 @@ + + + + diff --git a/subfolder_0/Insulin sensitivity and cardiac autonomic function in young male practioner of yoga.txt b/subfolder_0/Insulin sensitivity and cardiac autonomic function in young male practioner of yoga.txt new file mode 100644 index 0000000000000000000000000000000000000000..ecee719588e359e008287a95517572c3dfd1fe5d --- /dev/null +++ b/subfolder_0/Insulin sensitivity and cardiac autonomic function in young male practioner of yoga.txt @@ -0,0 +1,680 @@ +217 +Original Articles +Insulin sensitivity and cardiac autonomic function in young +male practitioners of yoga +M. S. CHAYA, G. RAMAKRISHNAN, S. SHASTRY, R. P. KISHORE, H. NAGENDRA, +R. NAGARATHNA, T. RAJ, T. THOMAS, M. VAZ, A. V. KURPAD +ABSTRACT +Background. While yoga is thought to reduce the risk of +chronic non-communicable diseases such as diabetes, there +are no studies on insulin sensitivity in long term practitioners +of yoga. We assessed insulin sensitivity and cardiac autonomic +function in long term practitioners of yoga. +Methods. Fifteen healthy, young, male practitioners of +yoga were compared with 15 young, healthy males who did +not practice yoga matched for body–mass index. Fasting +insulin sensitivity was measured in the fasting state by the +hyperinsulinaemic–euglycaemic clamp. +Results. +There were no significant differences between the +groups +in +their +anthropometry +or +body +composition. +However, +the fasting plasma insulin was significantly lower in the yoga +group. The yoga group was also more insulin sensitive (yoga +7.82 [2.29] v. control 4.86 [1.97] (mg/[kg.min])/(μU/ml), +p<0.001). While the body weight and waist circumference +were negatively correlated with glucose disposal rate in the +controls, there were no similar correlations in the yoga group. +The yoga group had significantly higher low-frequency power +and lower normalized high-frequency power. +Conclusion. Long term yoga practice (for 1 year or more) +is associated with increased insulin sensitivity and attenuates the +negative +relationship +between +body +weight +or +waist +circumference +and insulin sensitivity. +Natl Med J India 2008;21:217–21 +INTRODUCTION +Obesity, type 2 diabetes and cardiovascular disease are major +public health problems globally1–3 in which insulin resistance (IR) +has a central role. Prospective studies have shown that IR is an +important predictor of whether or not an individual will develop +diabetes later.2,3 There is an interest in the potential role that non- +pharmacological interventions may play to prevent the onset of IR +at an early age. +Exercise and daily physical activity is generally accepted as a +part of the non-pharmacological approach to IR. For example, +dynamic strength training improves insulin sensitivity (IS) in men +with IR, independent of weight loss.4 Low intensity and low +volume exercise training has been found to be effective in reducing +IR in healthy elderly subjects, due mainly to exercise-induced +improvement in fitness levels.5 The effect of exercise is also +graded, in that an exercise prescription of 170 minutes/week +improved IS in sedentary, overweight or obese subjects more +substantially than a programme of 115 minutes of exercise/week, +regardless of the intensity of exercise.6 +In India, yoga is widely claimed to be effective in the prevention, +management and cure of many diseases. Yoga modules have, for +instance, been found to be effective in the management of +hypertension, diabetes and IR.7–11 These may be related to +reductions in stress and arousal, since the basal metabolic rate +(BMR) has been found to be reduced in practitioners of yoga,12 as +have diurnal metabolic rates;13 the reduced metabolic rate of +transcendental meditation (TM) has been called ‘alert rest’.14 The +reduction in arousal has been attributed to a diminished cardiac +sympathetic tone and enhanced vagal activity.15,16 Further, an +increase in baroreflex sensitivity has been documented with the +practice of yoga including meditation or prayers.17 Plasma +norepinephrine levels have been shown to be reduced in patients +with cardiac failure after yoga training18 and urinary catecholamines +have been shown to be significantly reduced in long term +practitioners of yogic asanas.19 Finally, yoga has been found to be +useful in reducing IR-related risk factors.20 These studies have +mainly been done on older, obese, frankly hypertensive or diabetic +subjects; moreover, many studies have used surrogate measures +of IR such as the homeostatic model assessment (HOMA) or +fasting plasma insulin or glucose levels. +Careful studies that measure IS in young adults who routinely +practice yoga are necessary because (i) type 2 diabetes mellitus in +India is increasingly being reported in young adults and children,21,22 +and (ii) this brings a prevention-oriented, culturally acceptable, +lifestyle paradigm to bear on the problem. While there are no +detailed interventional studies using yoga to test the hypothesis +that yoga improves IS, we undertook a pilot study to measure IS +in normal young healthy volunteers who routinely practised yoga +for more than 12 months in comparison with BMI-matched non- +© The National Medical Journal of India 2008 +Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), +Bangalore, Karnataka, India +M. S. CHAYA, H. NAGENDRA, R. NAGARATHNA +St John’s Research Institute, St John’s National Academy of Health +Sciences, Bangalore 560034, Karnataka, India +G. RAMAKRISHNAN, S. SHASTRY, R. P. KISHORE, T. RAJ, +T. THOMAS, M. VAZ, A. V. KURPAD +Correspondence to A. V. KURPAD; a.kurpad@iphcr.res.in +THE NATIONAL MEDICAL JOURNAL OF INDIA +VOL. 21, NO. 5, 2008 +218 +THE NATIONAL MEDICAL JOURNAL OF INDIA +VOL. 21, NO. 5, 2008 +yoga practitioners, using the hyperinsulinaemic–euglycaemic +clamp (HEC) technique. +METHODS +Subjects +The yoga group consisted of 15 male volunteers in the age range +of 20–32 years, who were enrolled for various yoga courses in a +residential yoga school, and had a minimum of 12 months of +experience of practising yoga. The general daily practice of yoga +followed was an asana (physical posture) for 37 minutes, +pranayama (breathing techniques) for 18 minutes and meditation +for 23 minutes; a total of about 70 minutes a day for 6 days a week. +The control group consisted of 15 male volunteers; the entire +group was matched for BMI, in the age range of 18–35 years, who +had never practised yoga. The control group was recruited through +advertisements in and around St John’s Medical College campus. +None of the subjects smoked or drank alcohol, and usually had less +than 3–4 caffeinated beverages per day. Food intake was assessed +using a food diary for 3 days, and physical activity level (PAL) +was calculated using 3-day physical activity diaries with activities +filled in blocks of 10 minutes. PAL was computed as the estimated +total 24-hour energy expenditure from the physical activity diary +divided by the estimated BMR (from standard regression +equations).23 Subjects on a high meat protein diet and high PAL +were excluded. PAL values obtained by the diary recall method +have been validated with PAL values derived using doubly +labelled water method in Indians in our laboratory.24 Both groups +reported that their weight was stable during the past 6 months. The +study protocol and potential risks involved were explained to each +subject and written informed consent was obtained. All were in +good health as determined by the medical history, physical +examination, analysis for blood cell counts, routine blood +biochemical profile and urinalysis. Subjects with a family history +of diabetes, high resting blood pressure, fasting plasma blood +glucose >110 mg/dl, abnormal liver function tests and on any +medication were excluded from the study. The Institutional +Ethical Review Board of St John’s Medical College and Swami +Vivekananda Yoga Anusandhana Samsthana (SVYASA) approved +the research protocol. +Anthropometry +The subjects reported to the laboratory in the evening before the +start of the study and stayed overnight in the laboratory after being +provided a standard dinner, without any caffeinated beverages. +Anthropometric and skin-fold thickness measurements were done +on the day of the experiment, early in the morning after an +overnight fast of 10 hours. Subjects were weighed in minimal +clothing to the nearest 0.1 kg and their height was measured to the +nearest 0.1 cm. Their skin-folds (biceps, triceps, subscapular and +supra-iliac) were measured to the nearest 0.2 mm using a skin-fold +caliper (Holtain, Crymych, UK) and their body density predicted +from age- and gender-specific equations; body fat proportion was +calculated from body density.25–27 Since most of the muscle mass +is appendicular, and earlier studies have shown that the limb girth +corrected for skin-fold appears to correlate best with total body +skeletal mass,28 whole body muscle mass was predicted from an +Indian equation based on skin-fold corrected arm muscle area +(CAMA).29 Waist and hip circumferences were measured using a +standard non-stretchable tape measure, at the narrowest point +between the iliac crest and ribcage (waist) and at the level of the +greater trochanter (hip). +Hyperinsulinaemic–euglycaemic clamp technique +The experiment was performed after the subjects had emptied +their urinary bladder. Soon after anthropometric measurements, +an intravenous catheter (Jelco, 22 G, Medex Medical Ltd., +Lancashire, UK) was inserted, under sterile precautions, into the +antecubital vein for infusion of insulin and 25% dextrose solutions, +while another catheter was inserted in an anti-flow direction into +the dorsal vein of the contralateral hand for arterialized venous +blood sampling (using a warm box into which the hand was +placed, maintained between 60 °C and 65 °C). The latter catheter +was kept patent using a slow intravenous drip of isotonic saline. +The insulin infusate was prepared in 100 ml isotonic saline to +which 4 ml of the subject’s whole blood (previously drawn) was +added, to prevent insulin adsorption onto the plastic surfaces of +the syringe and tubing. Regular human insulin (Eli Lilly & Co, +Gurgaon, India) was diluted with this isotonic saline to a +concentration of 2083.5 µM/L (300 mU/ml). A sterile 25% +dextrose solution was used to prevent hypoglycaemia during the +HEC as described below. Insulin and glucose infusions began 30 +minutes after cannulation, after blood samples were collected for +baseline glucose and insulin measurements, and the basal heart +rate and blood pressure were recorded. +The protocol for performing the clamp was as described +earlier.30 Briefly, a 10-minute priming insulin infusion was followed +by a constant infusion at the rate of 277.80 pmol/m2 surface area/ +minute (40 mU/m2 surface area/minute) by a calibrated infusion +pump (Harvard Infusion Pump, model 55-2222, Holliston, MA), +for the next 110 minutes, to increase the plasma insulin +concentration to about 694.5 pmol/L (100 µU/ml).30 The glucose +infusion, also delivered by a Harvard infusion pump, was begun +at the fourth minute, and the glucose infusion rate up to the tenth +minute was empirically set at 0.01 mmol/kg/minute (2 mg/kg/ +minute). Plasma glucose concentration was maintained at an +average basal value of 5 mmol/L (90 mg/dl). Subsequent glucose +infusion rates were based on arterialized venous plasma glucose +values obtained every 5 minutes. These were drawn into ethylene +diamine tetra acetate (EDTA) tubes (Becton Dickinson, Franklin +Lakes, NJ) and the separated plasma analysed by the glucose +oxidase method on a bedside glucose analyser (GM9D, Analox +instruments, London, UK). The intra-assay coefficient of variation +for this method (using 8 mmol/L [144.1 mg/dl] standards) was +<1%, while the interassay coefficient of variation was <5%. +Blood samples for insulin measurements were collected every +20 minutes in heparinized tubes (Becton Dickinson, Franklin +Lakes, NJ) and centrifuged at 4 °C. The plasma was stored at +–80 °C until analysis by an electrochemiluminescent method +(Roche Diagnostics, Mannheim, Germany). The intra-assay +coefficient of variation for this method (using tri-level lyophilized +serum controls, level 1: 68.76–113.20 pmol/L [9.9–16.3 µU/ml]; +level 2: 215.30–444.48 pmol/L [31–64 µU/ml]; level 3: 791.73– +1173.71 pmol/L [114–169 µU/ml], Biorad, Irvine, CA) was <5% +while the interassay coefficient of variation was <10%. The +method and formula used for the calculation of the glucose +disposal rate as the glucose infusion rate required for maintenance +of the plasma glucose concentration at the nominated fasting level +throughout the clamp procedure, was as previously described.30 IS +was calculated as the ratio of the glucose disposal rate and plasma +insulin concentration for nominated periods of the clamp. Both +glucose disposal rate and IS were calculated over 20–120 minutes +of the clamp, as previously described.30 +219 +Cardiac autonomic function +After a 30-minute rest period following i.v. catheterization +described above, a continuous lead II ECG was obtained (Nihon +Kohden RM-6000, Japan) for 10 minutes, before the start of the +insulin infusion, during which the subjects were awake, lay supine +and breathed normally. Subjects were asked to avoid unnecessary +movements during this period. Spectral analysis of heart rate +variability was performed as described earlier.31 Briefly, data +segments of 128-second duration were sampled at 2 Hz to create +256-point datasets. Thus, for each 10-minute recording, 6 datasets +of 256 points, overlapping by 50%, were created. Linear trends +were removed from each dataset to avoid its contribution to low +frequency (LF) power and a Hanning window was used to attenuate +spectral leakage. Spectral analysis to calculate LF and high frequency +(HF) power (reflecting cardiac sympathetic and parasympathetic +nerve activity, respectively) was done using a Fast Fourier +Transform. In addition to the absolute power, these data were also +normalized for total power minus power of the very low frequency +(VLF) band (0.0–0.04 Hz).32 The LF/HF ratio, which is regarded +as an index of sympathovagal balance, was also computed. +Statistical analysis +A minimum sample size of 8 subjects in each group was calculated +based on the published clamp IS values,30 to detect a difference of +10% in IS between groups, with a level of significance of 5% and +power of 80%. We recruited 15 subjects in both the groups. +Normality of data was assessed by evaluating the ratio of skewness +to the standard error of skewness. Almost all the parameters were +normally distributed. All data are expressed as mean and standard +deviation (SD). The studied variables were IS, glucose disposal +rate, metabolic clearance rate (MCR) of insulin, basal glucose and +insulin, weight, BMI, percentage body fat (%BF) and waist +circumference. Differences in the anthropometric, spectral and +clamp variables between groups were assessed by independent +sample t test. Pearson correlations were performed between IS, +glucose disposal rate and anthropometric variables such as weight, +BMI, %BF and waist circumference. Regression analyses were +also performed between IS and glucose disposal rate with +anthropometric variables. Differences in slopes between groups +were assessed using ANCOVA. Results were considered significant +if p<0.05. All statistical analyses were performed using SPSS +(v13.0, SPSS, Chicago, Ill, USA). +RESULTS +There were no significant differences between the groups in +terms of their anthropometry or PALs. However, subjects in the +yoga group were slightly but significantly older by about 4 years +(Table I). There were no significant differences between the +groups in calculated arm muscle area or muscle mass. The yoga +subjects had practised yoga for a mean of 39 (28) months (range +12–120 months). +While there was no significant difference between the groups +in basal glucose levels, the yoga group’s fasting plasma insulin +level was lower than that of controls by about 50% (Table II). +During the HEC, the glucose disposal rate and IS of the yoga +group was significantly higher, as was the MCR of insulin (Table +II). The difference in IS between the groups persisted after +adjusting for age in an analysis of covariance model (p<0.001). +There was a significant correlation between various anthropometric +parameters and IS in the control group (weight: r = –0.76, p=0.003; +BMI: r = –0.72, p=0.002; %BF: r = –0.59, p=0.021; and waist +circumference: r = –0.70, p=0.004, respectively) while in the yoga +group, these correlations were low and not significant (weight +r = –0.04, BMI r = –0.40, %BF r = –0.26 and waist circumference +r = –0.20). The slope of regression of IS on weight was close to +being significantly different between the groups at p=0.07; and +the regression of glucose disposal rate by weight was significantly +different between the 2 groups (p=0.03, Fig. 1, upper panel). The +slope of waist circumference on IS between groups was not +significant (p=0.147). However, there was a significant difference +between groups in the slope of waist circumference on glucose +disposal rate (p<0.05, Fig. 1, lower panel). There were no significant +differences between the slopes of BMI or %BF on IS (p=0.451, +0.497) or glucose disposal rate (p=0.173, 0.365) between the +groups. Within the yoga group, there was no correlation between +the duration of yoga practice and IS (r = –0.1, p>0.05), although +the age of the subjects and duration of yoga practice were +significantly and positively correlated (r = 0.4, p<0.05). +Resting heart rates were comparable between the groups. At +baseline, the yoga group had a significantly higher LF power in +absolute terms as well as when normalized for total power. +Normalized HF power was significantly lower in the yoga group. +The differences in LF and HF power between the groups translated +into a higher LF/HF ratio in the yoga group compared with that in +controls (Table III). Further, the significant differences in all +reported parameters between the groups persisted even after +adjusting for age. +DISCUSSION +The principal finding of our study is that the practice of yoga over +a period of at least 1 year is associated with greater IS in healthy +young men compared with anthropometrically similar men who +TABLE I. Anthropometric parameters of the yoga and control groups +Parameter +Yoga group +Control group +(n=15) +(n=15) +Age (years) +26.6 (3.2)* +22.6 (3.9) +Height (m) +1.65 (0.06) +1.69 (0.05) +Weight (kg) +58.4 (7.1) +61.9 (6.3) +Body mass index (kg/m2) +21.4 (1.8) +21.7 (1.8) +Per cent body fat +15.0 (4.3) +16.4 (4.5) +Fat mass (kg) +8.9 (3.2) +10.3 (3.5) +Fat-free mass (kg) +50.0 (5.8) +51.6 (4.5) +Muscle mass (kg) +28.8 (2.8) +30.2 (2.3) +Waist–hip ratio +0.82 (0.04) +0.82 (0.03) +Physical activity level +1.50 (0.08) +1.44 (0.23) +Mid-upper arm circumference (cm) +24.5 (1.6) +25.7 (1.9) +Corrected arm muscle area (cm) +28.4 (4.7) +30.3 (4.5) +Waist circumference (cm) +71.2 (5.5) +72.9 (4.4) +Hip circumference (cm) +87.2 (4.1) +88.4 (4.0) +All values are mean (SD) +* p<0.05, independent Student t test +TABLE II. Hyperinsulinaemic–euglycaemic clamp parameters in +both groups +Parameter +Yoga group +Control group +(n=15) +(n=15) +Glucose disposal rate (mg/(kg.min) +6.0 (1.6)* +4.8 (1.6) +Insulin sensitivity (mg/(kg.min))/(µU/ml) +7.8 (2.3)† +4.9 (1.2) +Steady state plasma insulin (pmol/L) +539.6 (65.3)† +707.7 (120.1) +Metabolic clearance rate of insulin +559.6 (70.3)† +451.6 (84.8) +(ml/m2.min) +Basal glucose (mmol/L) +5.1 (0.3) +5.2 (0.5) +Basal insulin (pmol/L) +35.4 (13.1)† +73.6 (33.3) +All values are mean (SD) +* p<0.05, independent Student t test +† p<0.001, independent Student t test +CHAYA et al. : INSULIN +SENSITIVITY AND +CARDIAC AUTONOMIC +FUNCTION IN +YOGA PRACTITIONERS +220 +THE NATIONAL MEDICAL JOURNAL OF INDIA +VOL. 21, NO. 5, 2008 +been expected to have a lower IS; further, the differences in IS +between the groups persisted after the statistical analysis was +adjusted for age within the model. It was noteworthy that the +duration of yoga practice did not correlate with IS in the yoga +group, suggesting that the beneficial effects on IS may set in +relatively early, but may equally reach a ceiling effect with this +type of yoga practice. On the other hand, the duration of yoga +practice correlated significantly with the age of the subjects, and +the latter is expected to be associated with a reduction in IS. +Therefore, it might be that there are complex interactions between +age, duration of yoga practice and IS. Yoga has been shown to be +beneficial in people with type 2 diabetes with reported +improvements in fasting and postprandial blood glucose as well as +glycosylated haemoglobin levels.10,33 A review of yoga and IR has +indicated that yoga is associated with beneficial effects on the +indices of IR.20 Although our study was on healthy young volunteers +without any IR-related risk factors, the results suggest that yoga +increases IS even in these low risk individuals, and may be a useful +lifestyle modification to prevent IR. +One possible mechanism by which yoga may have operated is +by reducing stress or arousal,16,34 since chronic stress is implicated +in the pathogenesis of the IR syndrome.35,36 There is some evidence +that yoga enhances cardiac vagal activity and reduces sympathetic +activity.16,20 However, in this study, practitioners of yoga had +higher resting sympathetic activity compared with controls, as +evidenced by higher normalized LF values. This may have been +related to the stress of a novel experimental setting, since in +contrast to the yoga group, many of the healthy subjects in the +control group had undergone other experimental procedures such +as protein kinetic studies in the experimental laboratory. While +autonomic nervous function is clearly related to ageing, we are not +aware of studies that have indicated that a small difference in age +(4 years) in young, healthy adults would result in significant +changes, as observed in our study. Indeed, the scale of difference +in autonomic function between the study groups was marginally +larger than what was observed in previously published studies +comparing young adults with older individuals (with a mean age +difference of >40 years).37 Ageing might be expected to decrease +total power and HF power in absolute terms but both of these were +in fact not different between the study groups. What is important +is that enhanced sympathetic activity typically would have resulted +in lower IS and it is conceivable that the differences between the +groups are greater than those described in our study. However, +there were no significant correlations between heart rate variability +and duration of yoga practice as well as age in the pooled dataset, +suggesting that the novelty of the experiment might have been the +dominating factor in these considerations. +Another possible mechanism by which yoga improves IS may be +related to skeletal muscle function, since a large part of the disposal +of glucose in the euglycaemic resting state occurs in skeletal +muscle. Since the muscle mass in both the groups was similar, it may +be that muscle function rather than mass is the critical variable. +Skeletal muscle function improves after yoga, since the asanas used +involve stretching of muscles, which increases flexibility, strength +and metabolic rate, which in turn could improve the muscle uptake +of glucose.11 Yoga has also been shown to improve muscle strength +and isometric muscle endurance, although these were not recorded +by us.38 The stretching of muscles alternating with contraction may +be an important aspect of the effect of yoga, since muscle hypertrophy +due to muscle protein synthesis is known to occur with stretching +in mammalian models.39 The linkage between muscle stretch and +glucose uptake by muscle may be linked to the expression of +had never practised yoga. In addition, the negative relationship +between body weight, fat or waist circumference, which was +evident in the control group, was attenuated in those who practised +yoga. Even though the subjects were not matched for age, the IS +was higher in the yoga group, who were older and would have +TABLE III. Resting heart rate and heart rate variability in the +frequency domain in the study groups +Parameter +Yoga group +Control group +(n=15) +(n=15) +Resting heart rate (beats per minute) +62 (7) +65 (9) +Total power (0–0.4 Hz) ms2 +3406 (1703) +2711 (2251) +Normalized low frequency power +61.9 (15.2)* +45.4 (14.6) +Normalized high frequency power +43.1 (11.6)* +60.6 (13.1) +Low frequency/high frequency ratio +1.59 (0.83)* +0.83 (0.43) +All values are mean (SD) +* p<0.05, independent Student t test comparing +groups at baseline +Glucose disposal rate +(mg/[kg.min]) +Weight (kg) +z (Dashed line) Yoga group: r=0.00, Glucose disposal +rate=(–0.0003*weight)+5.97 +{ (Solid line) Control group: r=0.74, Glucose disposal +rate=(–0.183*weight)+16.08 +Difference between slopes: p=0.03 +z (Dashed line) Yoga group: r=0.14, +Glucose disposal rate=(–0.039*waist circumference)+8.703 +{ (Solid line) Control group: r=0.73, +Glucose disposal rate=(–0.257*waist circumference)+23.50 +Difference between slopes: p=0.049 +FIG 1. Linear regression between glucose disposal rate and weight +(upper panel) and waist circumference (lower panel) in both +groups +Glucose disposal rate +(mg/[kg.min]) +Waist circumference (cm) +221 +neuronal nitric oxide synthase (nNOS) in stretched or loaded +muscle.40 In turn, nitric oxide has been shown to positively modulate +glucose uptake in muscle preparations, and this may be additive to +insulin-stimulated glucose uptake.41 The foregoing discussion does +not discount the possibility that the effects in the yoga group might +be related to an exercise paradigm, although significant exercise +training would have raised the HF power in the yoga group, which +was not observed. Even so, low intensity and low volume exercise +has been shown to improve IR, measured by HOMA-IR, in elderly +subjects independent of loss of body weight.5 Exercise-based +reduction in body weight may also result in improved functional +capacity through greater mitochondrial content in skeletal muscle.42 +Body weight and waist circumference are related to IS, and the +practice of yoga over a period of time has been associated with a +reduction in body weight and an improvement in body composition, +possibly with the loss of body fat.43 However, the lack of correla- +tion between glucose disposal and body weight or waist +circumference in the yoga group in our study is particularly +interesting, suggesting that those who practice yoga over a long +period have better glucose disposal and IS irrespective of their +body weight and composition. None of the subjects in our study +reported changes in body weight, nor were there any differences +in body composition between the groups. The overall daily +physical activity levels in the 2 groups were also comparable. +Therefore, our preliminary cross-sectional study suggests that the +practice of yoga improves IS independent of the usual +anthropometric risk factors for type 2 diabetes. Clearly, more +intervention trials are necessary to strengthen the findings. Also, +the multidimensional mental and physical effects of yoga and its +role in the prevention of the IR syndrome need further study. +ACKNOWLEDGEMENTS +This study was funded by the Ministry of Health, Department of AYUSH, +Government of India. We thank Mrs Deepti Pradhan, Division of Nutrition, +St John’s Research Institute, for her help in anthropometric measurements. +REFERENCES +1 +Seidell JC. Obesity, insulin resistance and diabetes—a worldwide epidemic. Br J +Nutr 2000;83 (Suppl 1):S5–S8. +2 +Grundy SM. Obesity, metabolic syndrome, and coronary atherosclerosis. Circulation +2002;105:2696–8. +3 +Ramachandran A, Snehalatha C, Vishwanathan V. Explosion of type two diabetes +in Indian subcontinent. Int Diabetes Monitor 2003;15:1–6. +4 +Hejnová J, Majercík M, Polák J, Richterová B, Crampes F, deGlisezinski I, et al. +[Effect of dynamic strength training on insulin sensitivity in men with insulin +resistance]. Cas Lek Cesk 2004;143:762–5. +5 +Kodama S, Shu M, Saito K, Murakami H, Tanaka K, Kuno S, et al. Even low- +intensity and low-volume exercise training may improve insulin resistance in the +elderly. Intern Med 2007;46:1071–7. +6 +Houmard JA, Tanner CJ, Slentz CA, Duscha BD, McCartney JS, Kraus WE. Effect +of the volume and intensity of exercise training on insulin sensitivity. J Appl +Physiol 2004;96:101–6. +7 +Telles S, Naveen KV. Yoga for rehabilitation: An overview. Indian J Med Sci +1997;51:123–7. +8 +Pandya DP, Vyas VH, Vyas SH. Mind–body therapy in the management and +prevention of coronary disease. Compr Ther 1999;25:283–93. +9 +Damodaran A, Malathi A, Patil N, Shah N, Suryavansihi, Marathe S. Therapeutic +potential of yoga practices in modifying cardiovascular risk profile in middle aged +men and women. J Assoc Physicians India 2002;50:633–40. +10 Monro R, Power J, Coumar A, Nagarathna R, Dandona P. Yoga therapy for +NIDDM: A controlled trial. Complement Med Res 1992;6:66–8. +11 Raub JA. Psychophysiologic effects of Hatha Yoga on musculoskeletal and cardio- +pulmonary function: A literature review. J Altern Complement Med 2002;8:797–812. +12 Chaya MS, Kurpad AV, Nagendra HR, Nagarathna R. The effect of long term +combined yoga practice on the basal metabolic rate of healthy adults. BMC +Complement Altern Med 2006;6:28. +13 Chaya MS, Nagendra HR. Long-term effect of yogic practices on diurnal metabolic +rates of healthy subjects. Int J Yoga 2008;1:1–4. Available at www.ijoy.org.in +14 Wallace RK, Benson H, Wilson AF. A wakeful hypometabolic physiologic state. +Am J Physiol 1971;221:795–9. +15 Vempati RP, Telles S. Baseline occupational stress levels and physiological responses +to a two day stress management program. J Indian Psychol 2000;18:33–7. +16 Vempati RP, Telles S. Yoga-based guided relaxation reduces sympathetic activity +judged from baseline levels. Psychol Rep 2002;90:487–94. +17 Bernardi L, Sleight P, Bandinelli G, Cencetti S, Fattorini L, Wdowczyc-Szulc J, et +al. Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: +Comparative study. BMJ 2001;323:1446–9. +18 Curiati JA, Bocchi E, Freire JO, Arantes AC, Braga M, Garcia Y, et al. Meditation +reduces sympathetic activation and improves the quality of life in elderly patients +with optimally treated heart failure: A prospective randomized study. J Altern +Complement Med 2005;11:465–72. +19 Schmidt T, Wijga A, Von Zur Mühlen A, Brabant G, Wagner TO. Changes in +cardiovascular risk factors and hormones during a comprehensive residential three +month kriya yoga training and vegetarian nutrition. Acta Physiol Scand Suppl +1997;640:158–62. +20 Innes KE, Bourguignon C, Taylor AG. Risk indices associated with the insulin +resistance syndrome, cardiovascular disease, and possible protection with yoga: A +systematic review. J Am Board Fam Pract 2005;18:491–519. +21 Vikram NK, Tandon N, Misra A, Srivastava MC, Pandey RM, Mithal A, et al. +Correlates of type 2 diabetes mellitus in children, adolescents and young adults in north +India: A multisite collaborative case–control study. Diabet Med 2006;23:293–8. +22 Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Type 2 +diabetes in Asian-Indian urban children. Diabetes Care 2003;26:1022–5. +23 Human energy requirements. Report of a joint FAO/WHO/UNU expert consultation. +FAO Food and Nutrition Tech Rep Ser 1. 2001:92–6. +24 Kurpad AV, Borgonha S, Shetty PS. Measurement of total energy expenditure by +the doubly labelled water technique in free living Indians in Bangalore city. Indian +J Med Res 1997;105:212–19. +25 Harrison GG, Buskirk ER, Carter LGE, Johnston FE, Lohman TG, Pollock ML, et +al. Skinfold thicknesses and measurement technique. In: Lohman GT, Roche AF, +Martorell R (eds). Anthropometric standardization reference manual. Champaign, +IL,USA:Human Kinetics Books; 1988:55–70. +26 Durnin JV, Womersley J. Body fat assessed from total body density and its +estimation from skinfold thickness: Measurements on 481 men and women aged +from 16 to 72 years. Br J Nutr 1974;32:77–97. +27 Siri WE. Body composition from fluid spaces and density: Analysis of methods. In: +Brozek J, Henschel A (eds). Techniques for measuring body composition. +Washington, DC, USA:National Academy of Science, National Research Council; +1961:223–44. +28 Lee RC, Wang Z, Heo M, Ross R, Janssen I, Heymsfield SB. Total-body skeletal +muscle mass: Development and cross-validation of anthropometric prediction +models. Am J Clin Nutr 2000;72:796–803. Erratum in: Am J Clin Nutr 2001;73:995. +29 Kuriyan R, Kurpad AV. Prediction of total body muscle mass from simple +anthropometric measurements in young Indian males. Indian J Med Res +2004;119:121–8. +30 DeFronzo RA, Tobin JD, Andres R. Glucose clamp technique: A method for +quantifying insulin secretion and resistance. Am J Physiol 1979;237:E214–E223. +31 Vaz M, Turner A, Kingwell B, Chin J, Koff E, Cox H, et al. Postprandial sympatho- +adrenal activity: Its relation to metabolic and cardiovascular events and to changes +in meal frequency. Clin Sci (Lond) 1995;89:349–57. +32 Heart rate variability: Standards of measurement, physiological interpretation and +clinical use. Task Force of the European Society of Cardiology and the North +American Society of Pacing and Electrophysiology. Circulation 1996;93: +1043–65. +33 Jain SC, Uppal A, Bhatnagar SO, Talukdar B. A study of response pattern of non- +insulin dependent diabetics to yoga therapy. Diabetes Res Clin Pract 1993;19: +69–74. +34 Nagendra HR, Nagarathna R. New perspectives in stress management. +Bangalore:Vivekananda Kendra Prakashana; 1977. +35 Hjemdahl P. Stress and the metabolic syndrome: An interesting but enigmatic +association. Circulation 2002;106:2634–6. +36 Brunner EJ, Hemingway H, Walker BR, Page M, Clarke P, Juneja M, et al. +Adrenocortical, autonomic, and inflammatory causes of the metabolic syndrome: +Nested case–control study. Circulation 2002;106:2659–65. +37 Srinivasan K, Sucharita S, Vaz M. Effect of standing on short term heart rate +variability across age. Clin Physiol Funct Imaging 2002;22:404–8. +38 Tran MD, Holly RG, Lashbrook J, Amsterdam EA. Effects of Hatha Yoga practice +on the health-related aspects of physical fitness. Prev Cardiol 2001;4:165–70. +39 Goldspink DF. Exercise-related changes in protein turnover in mammalian striated +muscle. J Exp Biol 1991;160:127–48. +40 Tidball JG, Lavergne E, Lau KS, Spencer MJ, Stull JT, Wehling M. Mechanical +loading regulates NOS expression and activity in developing and adult skeletal +muscle. Am J Physiol 1998;275 (1 Pt 1):C260–C266. +41 Balon TW, Nadler JL. Evidence that nitric oxide increases glucose transport in +skeletal muscle. J Appl Physiol 1997;82:359–63. +42 Toledo FG, Menshikova EV, Ritov VB, Azuma K, Radikova Z, DeLany J, et al. +Effects of physical activity and weight loss on skeletal muscle mitochondria and +relationship with glucose control in type 2 diabetes. Diabetes 2007;56:2142–7. +43 Bera TK, Rajapurkar MV. Body composition, cardiovascular endurance and anaerobic +power of yogic practitioner. Indian J Physiol Pharmacol 1993;37:225–8. +CHAYA et al. : INSULIN +SENSITIVITY AND +CARDIAC AUTONOMIC +FUNCTION IN +YOGA PRACTITIONERS diff --git a/subfolder_0/Integrated approach to yoga therapy and autism spectrum disorders.txt b/subfolder_0/Integrated approach to yoga therapy and autism spectrum disorders.txt new file mode 100644 index 0000000000000000000000000000000000000000..22b572d4dbd89877ddc56c4538ace12da9d3cc3f --- /dev/null +++ b/subfolder_0/Integrated approach to yoga therapy and autism spectrum disorders.txt @@ -0,0 +1,494 @@ +120 +Journal of Ayurveda & Integrative Medicine | April 2010 | Vol 1 | Issue 2 +Address for correspondence: +Dr. Shantha Radhakrishna, Sri Ganapathi Sachchidananda (SGS), +Vagdevi Centre for the Rehabilitation of Communication Impaired, +3rd C Main, 7th Cross, Girinagar II Phase, Bangalore-560 085, +Karnataka, India. E-mail: vagdevitrust@rediffmail.com +Received: 02-Mar-2010 +Revised: 21-Mar-2010 +Accepted: 26-Mar-2010 +DOI: 10.4103/0975-9476.65089 +Integrated approach to yoga therapy and autism +spectrum disorders +Shantha Radhakrishna, Raghuram Nagarathna1, H. R. Nagendra1 +Sri Ganapathi Sachchidananda, Vagdevi Centre for the Rehabilitation of Communication Impaired, Bangalore, +1Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana University, India +C L I N I C A L +S H O R T C O M M U N I C A T I O N S +A B S T R A C T +INTRODUCTION +Autism spectrum disorder (ASD) characteristics include +“markedly abnormal or impaired development in social +interaction and communication, and restricted activity +and interest repertoires”.[1] Studies of many risk factors, +neurochemical, genetic, natal, etc., have found no +association with autism. No causative theory exists, but +causative hypotheses have been proposed, and various +interventions based on them. Treatments based on +behavioral models are currently the best validated. Learning +principles applied intensively early in the development +improve socially important behaviors. No treatment fits +all requirements, and no established protocol relates child, +family, and target behaviors to individualized treatment +regimes. +In the matched control study reported here, six children +with ASD practiced a specially formulated Integrated +Approach to Yoga Therapy (IAYT) module, in addition +to their applied behavior analysis (ABA). Changes in +communication, social, cognitive, and adaptive skills were +compared to six matched controls, who only received ABA. +Pre-, mid-, and post-therapy, special educators assessed +subjects on ASD’s nine core targeted behaviors: eye to eye +gaze (EEG), sitting tolerance (ST), body posture (BP), body +awareness (BA), depth perception and balance (DPPB), +imitation skills (IS), self-stimulatory behavior (SSB), +receptive skills related to spatial relationships (RSRSR), +and self-injurious behavior (SI). Results indicate that +IAYT improves imitation skills and social-communicative +behaviors, playing an important role in improving quality +of life. +Many parents of children with ASD use Complimentary +and Alternative medicine (CAM), since no single +intervention has proved effective in alleviating ASD’s +core symptoms.[2] Reports exist of significant recovery +using various combinations of mainstream and alternate +medicine combinations. IAYT, in particular, is noninvasive +and has no side effects. Parents are willing to try it. +Yoga’s traditional knowledge concerns physiological +and psychological processes that change physiological +parameters through respiratory manipulation (breathing +technique), postures (asanas), and cognitive controls +(relaxation and meditation). Yoga is ideally a lifetime +practice, far more than an adjunctive therapy, generally +discontinued after particular conditions have been +corrected. Children with ASD require lifetime Yoga +practice. +The majority require a program with repetition, structure, +and continuity, as established in IAYT sessions, which seem +to increase critical skills. ASD children typically display +decreased co-ordination, body awareness, and sensory +integration; competitive physical outlets are frustrating. +A specially designed Integrated Approach to Yoga Therapy module was applied to Autism Spectrum Disorders over a period +of two academic years. Despite low numbers (six in each arm), consistency and magnitude of effects make the findings +significant. Parental participation, allowing firm guidance to be given to each child, resulted in significant improvements +in imitation and other skills, and in behavior at home and family relationships. We hypothesize that guided imitation of +therapist body positions stimulated mirror neuron activation, resulting in improved sense of self. +Key words: Autism spectrum disorder, communication, integrated approach to yoga therapy, social and imitation skills. +[Downloaded free from http://www.jaim.in on Saturday, January 29, 2011, IP: 110.234.115.114] +Journal of Ayurveda & Integrative Medicine | April 2010 | Vol 1 | Issue 2 +121 +Yoga is noncompetitive, and provides an environment +where risk-taking and self-confidence can increase. +Improvements in sensory integration, attention, sensory +defensiveness, and increased verbal receptivity for +commands related to spatial perception are reported.[3-5] +In one study, heart rate was measured pre- and post-yoga +sessions, and correlated with improved test scores in +certain skill areas: turn taking, receptive language following +verbal directions, body awareness and proximity, following +routines, regulating, and self-monitoring.[6] Another +reported increased concentration, focus, organization, +and relaxation after 25 yoga sessions,[7] consistent with +the hypothesis based on many years observation that ASD +children have frontal lobe deficits involving cortical and +subcortical regions, as suggested by ASD’s pervasive nature. +Working to improve brain function directly through Yoga +may improve behavior better than focusing on the problem. +MATERIALS AND METHODS +Subjects +Admission and medical records of children entering SGS +Vagdevi School, Bangalore, 2000-2007, were examined. +Forty-two children with established ASD were profiled; +six satisfying inclusion/exclusion criteria were selected. +Inclusion/exclusion criteria +Inclusion: Diagnosis of autism according to ICD-10 +criteria.[8] Age 8-14 years; parents’ education - minimum +graduates; socioeconomic background - middleclass; +record of 15-20 hr weekly, 1-to-1 treatment for at least 1 +year at special school. Exclusion: neurological disorders of +known etiology; significant sensory or motor impairment; +major physical abnormalities; history of head injury or +neurological disease. +Demographical details are given in Table 1. +Procedure +All six children attended regular elementary classes, +receiving 15 hr ABA-based training and 5 hr IAYT weekly +for two 10-month academic years with 2 months summer +holiday gap. Teaching sessions involved 1-to-1 instruction +with one parent present. IAYT sessions were conducted +in open, green surroundings; with a serene atmosphere. +Children marked boundaries of operation round their +mats in the same place every day. +Assessment and data collection +Special educators and parents helped data collection +through questionnaires and tests as given in Table 2. +Assessment was conducted pre- (sessions 1-12), mid- +(sessions 200-202), and post- (sessions 389-391) the +intervention. Two special educators completed assessment +and were co-related at every point. Intra- and interobserver +reliability was thus calculated. +The 5×per week, 1 hr, IAYT intervention was conducted +over 82 weeks at SGS Vagdevi School. “Warm-up,” +“strengthening,” “release of tension,” and “calming” +exercises were practiced. In the initial 2 weeks, parents +were trained to guide their child’s full participation. Regular +home practice was emphasized. +Yoga intervention +The IAYT module developed over 35 years experience +with ASD children, with Yogasanas and breathing exercises +selected to improve cognitive, social, and communication +skills. +The sequence, including warm-up, strengthening, +loosening, and calming asanas, yogic breathing practices, +and chanting are listed in Table 3. +Table 1: Demographic details +School +Mean IQ Range +Average Age +Sex M/F +SEB +EB +School - SGS Vagdevi +76.5 +12.7 +5/1 +Middle class +Graduate +SEB, socioeconomic background (minimum Rs. 8000); EB, educational background (graduate mothers) +Radhakrishna, et al.: ASD and efficacy of IAYT +Table 2: Test measures +Behavior check list +Items +Scale +Check list 1: The Autism +Research Institutes’ form +E-2 check list +Eye to eye gaze (EEG), sitting tolerance (ST), body posture (BP), body +awareness (BA), depth perception and balance (DPPB), imitation skills +(IS), self-stimulatory behavior (SSB), receptive skills related to spatial +relationships (RSRSR) and self-injurious behavior (SI) +3-point rating scale (0 = little, 1 = moderate, +2 = a lot) +Check list 2: Imitation test +battery (ITB) +Imitating gross motor actions (IGMA), imitating vocalization (IV), +imitating complex motor actions (ICMA), imitating oral facial +movements (IOFM), imitating breathing exercises (IBE) +3-point rating scale (2 = exact imitation, +1= occasional imitation, 0 = rarely imitated) +Check list 3: Repetitive +stereotyped behavior test +battery (RSBTB) +Stereotyped behavior, self-injurious behavior, restricted behavior, +sameness behavior, and repetitive behavior +4-point rating scale: (3 = behavior occurs +severe, 2 = behavior occurs moderate, +1 = behavior occurs mild, 0 = behavior does not +occur) +[Downloaded free from http://www.jaim.in on Saturday, January 29, 2011, IP: 110.234.115.114] +122 +Journal of Ayurveda & Integrative Medicine | April 2010 | Vol 1 | Issue 2 +RESULTS +Results are presented in three parts: first, baseline +characteristics; second, impact on ASD symptoms and +perceived child outcomes; third, effects on a wide range +of behaviors, nonverbal skills, social interaction, imitation, +and repetitive stereotyped behaviors (RSB). Despite small +sample size, consistency across tests and subjects make the +results significant [Figure 1]. +Behavior characteristics addressed in the research were +significant to parents and staff. Parents find lack of eye +contact, hyperactivity, and resistance to change difficult +to endure; staff emphasize those impacting learning +negatively: lack of eye contact to gain attention, lack of +imitation skills, poor sitting tolerance, and temper tantrums. +Table 4 summarizes results of their qualitative reports at +baseline. +Behaviors manifesting during Yoga and in class were +consistent with baseline reports of parents and staff. +After the first 12 sessions, no observable changes in eye- +to-eye gaze, sitting tolerance, or imitation skills occurred. +Thereafter, subtle changes in behavior were recorded by +observers and parents. Children initially unaware of their +breath gradually learned to breathe in and out, and to deepen +their breathing. Hand held mirrors, blowing toy materials, +candles, soap bubbles, straw to drink water, etc. were used at +this stage. Noticeable changes to slower and quieter breathing +patterns were observed in the last few sessions. +By mid-session assessments, observed behavioral changes +included eye-to-eye gaze (focus retained on objects: lighted +candle, focus circle, color mat); sitting tolerance; and body +posture. Improvements were noted in receptive skills to +verbal commands concerning spatial relationship during +trikonasana (triangle position) and uttanasana; imitation +skills; self-stimulatory activity; and self-injurious behaviors. +Teachers reported increased alertness after sessions. +During the post-assessment, children previously unable +to connect with the therapist started coming closer during +0 +0.2 +0.4 +0.6 +0.8 +1 +1.2 +1.4 +1.6 +1.8 +Eye to eye gaze +Sitting tolerance +Body postures +Body awareness +Depth perception & +balance +Imitation skills +Self stimulatory behaviour +Receptive skills regarding +spatial relation +Self injurious behaviour +Average Rating of Responsiveness on a scale 0 to 2 +Pre +Mid +Post +Figure 1: Graphic representation of observed improvement. Black bars, base-line data; white bars, 1-year +reassessment showing consistent improvements on all variables; gray bars, second year’s reassessment showing +continuing improvements. Note that all children originally with ASD have left the ASD defined range after 2 × +10-month interventions. +Table 3: Yoga intervention +Warm-up practices +Loosening practices +Strengthening +asanas +Calming asanas + Yogic breathing +practices +Chanting +a. Jogging +b. Forward and backward +bending in standing +posture +a. Neck exercises +b. Waist-back +bending exercises +c. Waist forward +bending +a. Trikonasana +(triangle pose) +b. Veerabhadrasana +(warrior pose) +c. Parvathasana +(mountain pose) +d. Sasankasana +(moon pose) +a. Sukhasana(cross +legged pose) +b. Shavasana (corpse +pose) +c. Makarasana +(crocodile posture +a. Preparatory +blowing exercises +b. Sasha swasa +(rabbit) +c. Vyaghra swasa +(tiger) +d. Simha mudra (lion +pose) +e. Hasta prasarita +swasa (hands in +and out breathing) +a. AAAA +b. UUUU +c. MMM +d. OMM +e. Short mantras +Radhakrishna, et al.: ASD and efficacy of IAYT +[Downloaded free from http://www.jaim.in on Saturday, January 29, 2011, IP: 110.234.115.114] +Journal of Ayurveda & Integrative Medicine | April 2010 | Vol 1 | Issue 2 +123 +continuous chanting of mantras; they seemed to enjoy +chants as they encouraged a sense of rhythm and a means +to work on coordination. Slow mantra chanting witnessed +appreciable increases in oral-facial movement imitation +skills. Children who initially sat outside the mat, or span +or jumped on the mat, demonstrated discipline by sitting +in vajrasana when gentle touch was applied on their lower +back. Significant changes occurred in communication, +language, play, and joint attention. Patterns of eye contact +steadily improved, e.g., focusing on the therapist’s counts +by drumbeat. Over the intervention, children started to +trust, share, initiate, and reciprocate. By the 372nd session, +all children showed increased vocal imitation skills by +imitating vowels “a, e, i o, u” and “OM.” They greeted +the therapist with a smile, vocalizing “namaste.” Parents +reported improvement in ability to interact with other +children and family members. +DISCUSSION +Our observations confirm previous reports of qualitative +behavior changes in ASD children following short- +term yoga interventions: increased tolerance of sitting +and adult proximity and subsequent socialization. Our +quantitative results amplify them. Aberrant immune +activity may also be regularized. Interactions between +immune and nervous systems begins in the embryo. +Successful neurodevelopment depends on balanced +immune response. Symptoms consistent with poorly +regulated immune response have been reported in autistic +children.[9] Neurotransmitter abnormalities are reported, +e.g., increased serotonin.[10] Growth factors and hormones +may be unstable; studies see both increase and decrease. +Some genes may be associated with autism but probably +account for fewer cases.[11] +Stress retards neuron growth in the hippocampus, +associated with memory, helping explain why anxious ASD +children have difficulty learning.[5] Stimulation exercises and +environmental enrichment all help increase hippocampus +cells. As IAYT calms the physical body, the child becomes +more focused and organized. Not much research exists on +how early interventions work. The brain can both duplicate +and transfer function, allowing information to go to brain +areas not usually used for that purpose.[12] +Feeling safe is essential for relaxation. Individual mats +help children identify personal space and remain supine. +Combining physical exercises with speech and language +stimulation increased recall ability, imitation skills, verbal +receptive skills, and expression. Ardhasherasanana (half +inverted position), Ardhachakrasana (half wheel position), +and trikonasana (triangular position) stimulate vestibular +and proprioceptive sense. Parivrittatrikonâsana (modified +triangular position) and its variations seem to stimulate +parasympathetic activity, calming the nervous system. With +direct instruction even those with extreme attention deficit +can slow their breath and use breath regulation to control +unwanted movement of body and mind. +ASD children sense input from muscles and joints better +than eyes and ears.[5] Heavy touch pressure often produces +positive responses. This enhanced RSB reduction during +therapy. Some suggest that the central nervous system in +ASD children processes information abnormally, causing +over- or under-arousal. Repetitive stereotyped behavior +may calm over-aroused nervous systems and alert under- +aroused ones.[13,14] Engaging in repetitive IAYT procedures +may thus make ASD children feel more calm and more +awake, becoming a powerful motivator. +An important observation was that slowing down facial, +vocal, motor, and auditory cues would impact children’s +imitative and cognitive performance, particularly when +the environment was changing too fast, agreeing with +the finding that slowing down facial and vocal events +enhances imitative, verbal, and cognitive skills of some +ASD children,[15] and supporting the rapid visual-motion +integration deficit hypothesis.[16] +Comprehension of spatial commands (right, left, front, +back, up, down) may have improved during Yogasana +practice, because subjects could use the therapist’s +body, which remained at their eye level, as a visual aid. +Kinesthetic/tactile stimulation given during asanas helped +children learn them. They thus became aware of imitating +the “Being” aspect of the therapist during each yoga +posture. We hypothesize that reinforcing this experience +slowly brought the children a greater sense of their felt- +self, or identity, enabling them to learn to relate better to +others. Thus, the children slowly progressed to the stage of +being able to interact with others as more normal people. +REFERENCES +1. +American +Psychiatric +Association. +Diagnostic +and +Radhakrishna, et al.: ASD and efficacy of IAYT +Table 4: Qualitative reports of parents and staff +at baseline +All subjects displayed +Poor eye contact and sitting tolerance +Poor balance and awkward body posture +Poor imitation skills +Object, body, and hand stereotypes, e.g., body rocking, hand flapping, +twiddling sticks +Self-injurious behavior, e.g., hitting and biting self, pulling hairs +Poor receptive skills related to spatial relationships +Poor breath awareness +[Downloaded free from http://www.jaim.in on Saturday, January 29, 2011, IP: 110.234.115.114] +124 +Journal of Ayurveda & Integrative Medicine | April 2010 | Vol 1 | Issue 2 +Statistical Manual of Mental Disorders (DSM-IV-TR). 4th +ed. Text revision. Washington, D.C.: American Psychiatric +Association; 2000. p. 78. +2. +Himan, Levy H. When traditional medicine is not enough +contemporary paediatrics. Contemp Pediatr 2000;77:100-14. +3. +Kenny M. Integrated movement therapy. Available from: +http://www.samaryacenter.com/assets/ijyt.pdf. +[cited +on +2002]. +4. +Harrison J. Sahaja Yoga. Clin Child Psychol Psychiatry +2004;9:479-97. +5. +Goldeberg L. Creative relaxation a yoga based program for +regular and exceptional student education. Int J Yoga Ther +2004;14:67-78. +6. +Connor C. So much stress; so little time. Autism News +Orange County 2005;2:18-20. +7. +Oldenberg L. Use of yoga with occupational therapy. Int J +Yoga Ther 2004;12:71-7. +8. +World Health Organization. ICD-10. The ICD-10 classification +of mental and behavioral disorders: Diagnostic criteria for +research. Geneva: World Health Organization; 1993. +9. +Ashwood P, Wills S, van de Water J. The immune response +in autism: A new frontier for autism research. J Leuk Biol +2006;80:1-15. +10. Penn HE. Neurobiological correlates of autism: A review of +recent research. Child Neuropsychol 2006;12:57-79. +11. Manzi B, Loizzo AL, Giana G, Curatolo P. Autism and +metabolic diseases. J Child Neurol 2008;23:307-14. +12. Siegel B. The world of the autistic child. New York: Oxford +University Press; 1996. +13. Guess, D, Carr E. Emergence and maintenance of stereotypy +and self-injury. Am J Ment Retard 1991;96:299-319. +14. Schneck CM. The efficacy of a sensorimotor treatment +approach by occupational therapists. Autism: A sensorimotor +approach to management. In: Huebner RA, editor. Austin: +PRO-ED INC; 2000. p. 139-78. +15. Gepner B, Fe´ron F. Autism: A world changing too fast for a +mis-wired brain? Neurosci Biobehav Rev 2009;33:1227-42. +16. Gepner B, Mestre D. Rapid visual-motion integration deficit in +autism. Trends Cogn Sci 2002;6:455. +Radhakrishna, et al.: ASD and efficacy of IAYT +Source of Support: Nil, Conflict of Interest: None declared. +Author Help: Online submission of the manuscripts +Articles can be submitted online from http://www.journalonweb.com. For online submission, the articles should be prepared in two files (first +page file and article file). Images should be submitted separately. +1) First Page File: + +Prepare the title page, covering letter, acknowledgement etc. using a word processor program. All information related to your identity +should be included here. Use text/rtf/doc/pdf files. Do not zip the files. +2) +Article File: + +The main text of the article, beginning with the Abstract to References (including tables) should be in this file. Do not include any information +(such as acknowledgement, your names in page headers etc.) in this file. Use text/rtf/doc/pdf files. Do not zip the files. Limit the file size +to 1024 kb. Do not incorporate images in the file. If file size is large, graphs can be submitted separately as images, without their being +incorporated in the article file. This will reduce the size of the file. +3) +Images: + +Submit good quality color images. Each image should be less than 2048 kb (2 MB) in size. The size of the image can be reduced by +decreasing the actual height and width of the images (keep up to about 6 inches and up to about 1800 x 1200 pixels). JPEG is the most +suitable file format. The image quality should be good enough to judge the scientific value of the image. For the purpose of printing, always +retain a good quality, high resolution image. This high resolution image should be sent to the editorial office at the time of sending a revised +article. +4) +Legends: + +Legends for the figures/images should be included at the end of the article file. +[Downloaded free from http://www.jaim.in on Saturday, January 29, 2011, IP: 110.234.115.114] diff --git a/subfolder_0/Irritable Bowel Syndrome Yoga as Remedial Therapy.txt b/subfolder_0/Irritable Bowel Syndrome Yoga as Remedial Therapy.txt new file mode 100644 index 0000000000000000000000000000000000000000..8ad0535e7526014f5485b5833a12c2e1fd3776c3 --- /dev/null +++ b/subfolder_0/Irritable Bowel Syndrome Yoga as Remedial Therapy.txt @@ -0,0 +1,1148 @@ +Review Article +Irritable Bowel Syndrome: Yoga as Remedial Therapy +Vijaya Kavuri,1,2 Nagarathna Raghuram,2 Ariel Malamud,3 and Senthamil R. Selvan1 +1Vivekananda Yoga Research Foundation, Norwalk, CA 90650, USA +2Swami Vivekananda Yoga University (SVYASA), Bangalore, Karnataka 560019, India +3White Memorial Medical Center, Los Angeles, CA 90033, USA +Correspondence should be addressed to Senthamil R. Selvan; senthamils59@gmail.com +Received 31 January 2015; Accepted 16 April 2015 +Academic Editor: Waris Qidwai +Copyright © 2015 Vijaya Kavuri et al. This is an open access article distributed under the Creative Commons Attribution License, +which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. +Irritable bowel syndrome (IBS) is a group of symptoms manifesting as a functional gastrointestinal (GI) disorder in which patients +experience abdominal pain, discomfort, and bloating that is often relieved with defecation. IBS is often associated with a host of +secondary comorbidities such as anxiety, depression, headaches, and fatigue. In this review, we examined the basic principles of +Pancha Kosha (five sheaths of human existence) concept from an Indian scripture Taittiriya Upanishad and the pathophysiology of +a disease from the Yoga approach, Yoga Vasistha’s Adhi (originated from mind) and Vyadhi (ailment/disease) concept. An analogy +between the age old, the most profound concept of Adhi-Vyadhi, and modern scientific stress-induced dysregulation of brain-gut +axis, as it relates to IBS that could pave way for impacting IBS, is emphasized. Based on these perspectives, a plausible Yoga module +as a remedial therapy is provided to better manage the primary and secondary symptoms of IBS. +1. Introduction +Irritable bowel syndrome (IBS) is defined as “abdominal +pain or discomfort that occurs in association with altered +bowel habits over a period of at least three months, in the +absence of any detectable organic cause” [1, 2]. It can be clas- +sified as either diarrhea-predominant (IBS-D), constipation- +predominant (IBS-C), or IBS with alternating stool pattern +(IBS-M (mixed)) [3]. IBS is the most prevalent functional +gastrointestinal (GI) disorder in the world [4]. The preva- +lence varies according to country and age, with worldwide +prevalence rates ranging from 9 to 23% and in USA from 10 +to 15% [5]. IBS is the most common disorder diagnosed by +gastroenterologists and accounts for up to 12% of total visits +to primary care providers [4]. It can affect people of all ages +but is more likely to occur between 20 and 45 years of age. +More women suffer from this disorder with an incidence ratio +of 2 : 1 between females and males [6]. It is suspected that +the changing hormones in the female menstrual cycle may +be a reason for this disparity [7]. IBS has a significant impact +on health care use and costs, which is heightened due to the +imprecise nature of its diagnosis and treatment. The aggregate +cost, direct and indirect, of treating IBS in the United States +has been estimated at $21 billion or more annually, excluding +prescription and over the counter drug costs [8, 9]. In this +review, we have made an attempt to compare the viewpoint +of ancient Indian scriptural understanding of IBS with that of +mind-gut model of conventional medical science that offers a +strong basis to combine Yoga as a vital therapeutic modality +in the holistic approach to the management of IBS. +Comorbidities of IBS. IBS is called a functional disorder +because no structural, biochemical, or infectious etiology +has been found and is a disorder of motor and sensory +functions of the GI tract [10]. Whitehead et al. observed +a strong association of psychiatric disorders in 94% of IBS +patients pointing to the role of psychological factors in the +etiology of IBS [11]. Headache, fibromyalgia, and depression +were commonly found in a study of about 100,000 individuals +with IBS [12]. A systematic review found that IBS occurs +in 51% of chronic fatigue syndrome patients and 49% of +fibromyalgia patients [12]. Evidence supports an important +role of stress in IBS patients, particularly in altering brain- +gut interactions, resulting in development or exacerbation of +IBS [13]. Symptoms of IBS seem to worsen during periods +of stressful events [14], as illustrated in Figure 1. Diagnosis +Hindawi Publishing Corporation +Evidence-Based Complementary and Alternative Medicine +Volume 2015, Article ID 398156, 10 pages +http://dx.doi.org/10.1155/2015/398156 +2 +Evidence-Based Complementary and Alternative Medicine +ANS +Imbalanced ANS +BGA dysfunctions +Microbiota- +gut interplay +IBS +GERD +Peptic ulcer +Figure 1: Role of stress in the exacerbation/development of stress. +Stress-induced pathophysiological consequences of the disruption +of brain-gut axis. Exposure to stress affects autonomic nervous +system, causing an imbalance that results in the disturbance of +brain-gut axis (BGA). This leads to the development of different +diseases of the gastrointestinal tract, including gastroesophageal +reflux disease (GERD), peptic ulcer disease, and irritable bowel +syndrome (IBS) (source of various images: stress, http://www.1st- +classmed.com/; brain, http://lifehacker.com/; stomach/intestines, +http://www.rechildrens.org/blog/gut-brain-axis/; +GERD, +http:// +www.highlandersurgicalassociates.com/; holding the stomach, http:// +www.paleoibs.com/). +of IBS also includes identifying key stressors/triggers such +as emotional, physical, or sexual abuse and psychological +distress including anxiety and depression [2]. Thus, it appears +that IBS is a manifestation of “derailing of the brain-gut axis” +[15]. +Conventional Management of IBS and Its Limitations. Con- +ventional management of IBS primarily involves dietary +modifications, medications, and psychotherapy. Medications +may consist of anticholinergics, stool softeners, and laxatives +such as dicyclomine for abdominal cramps, lubiprostone for +IBS-C, and loperamide for IBS-D [16]. Although the conven- +tional modalities of treatments produce favorable outcomes, +there have been reported side effects. Loperamide has been +shown to be effective in slowing down the movement of the +gut, decreasing the number of bowel movements, and makes +the stool less watery, but side effects of nausea, cramping, +and constipation have been reported [17]. Antispasmodics +like dicyclomine improve symptoms of IBS and reduce pain, +but side effects may include drowsiness, dry mouth, blurred +vision, or inability to urinate [1]. Fiber is often recommended +as a dietary change to reduce global IBS symptoms, but the +clinical data to date are less clear. Notably, soluble fiber can +lower GI symptoms in IBS-C but was not able to reduce +pain perception in IBS patients [18, 19]. As the conventional +medical treatments are not always effective in producing a +satisfactory clinical response outcome, more than 50% of +people who suffer from IBS turn to alternative medicine +[20]. Since IBS often results from a combination of physical +and stress-related factors, a treatment approach addressing +both body and mind would be most appropriate. In this +context, IBS sufferers seek alternative remedial approach +such as probiotics, herbal remedies, acupuncture, and Yoga +[20]. Even though psychotherapy like hypnosis and cognitive +behavioral therapy (CBT) have been shown to be effective in +improving quality of life and reduction in pain, IBS patients +have to continue therapy sessions at frequent intervals to +maintain the benefits [19]. This is considered to pose financial +burden and time constraint for the patients. +2. Ancient Indian Approach of Managing IBS +According to Ayurveda, an ancient Indian medical science +developed around 3,500 BC, a disorder called “Grahani” +can be correlated to IBS. Grahani can be a syndrome with +alteration of stool either in solid or in liquid form. The main +causative factor ascribed for this disorder is the malfunction- +ing of Agni (digestive fire). According to Caraka, Agni is the +most important factor and it regulates all metabolic processes +and maintains the overall health and zeal. If Agni is impaired, +body functions are impaired [21]. Agni is deranged by exces- +sive fasting, eating during indigestion, overeating, irregular +eating, and intake of unhealthy and contaminated foods [22]. +Agni is also deranged by emaciation, faulty adaptation to +place, time, and season, and suppression of natural urges. +Stress levels (mano-udvega) influence one’s eating habits and +lifestyle. Treatment in Ayurveda mainly focuses on increasing +Agni that promotes the healthy functioning of the gut, with +various herbal preparations like chitrakadi vati (Plumbago +zeylanica), bilwa adi vati (Aegle Marmelos), and Basti, a +colon cleansing enema, with medicated oil or ghee (clarified +butter) and herbal decoction. Meditation, pranayama, and +Yogasanas are beneficial for the mind in reducing the stress. +Yoga is a prescribed remedy to treat Grahani as a part of +Ayurveda treatment [23]. According to the scriptures of +Ayurveda and Yoga, the health at the physical level can +only be achieved by balanced functioning of all aspects of +an individual (samatolanam/homeostasis) and, hence, it is +important to treat the person as a whole (“mind, body, and +breath”). +3. Yoga +Yoga, a traditional “mind-body-breath” discipline, was deri- +ved from India about 3,500 BC. The word Yoga, in Sanskrit, +is “yuj” meaning to unite the mind, body, and spirit [24]. +Yoga encompasses mental and physical discipline to help +in personal transformation that leads to perfect health as +envisioned by WHO. Yoga practitioners are totally immersed +in the practices with an awareness and command over +every movement of the body and synchronizing it with the +breath. This gives them a feeling of self-control and calmness +leading to relaxation and health. The popularity of Yoga is +evident with a prevalence of 8.7% Yoga practitioners in 2012 +within the USA that is equivalent to 20 million adults, and +women practitioners outweigh males by a ratio of almost 4 : 1 +[25]. There is a vast amount of literature available, listing +Evidence-Based Complementary and Alternative Medicine +3 +the benefits of Yoga, among which, a few studies are alluded +to, including IBS and Yoga, in this review. +3.1. Yoga and Physical Well-Being. Flexibility is an impor- +tant component of health-related physical fitness and well- +being [26]. Adequate range of motion, lower back, and +shoulder flexibility are extremely important for day to day +performance. Several studies have shown that Yoga improves +the flexibility of the body both internal and external. In +1986, Ray et al. [27], have shown that six-month practice +of Yogic asanas increased trunk, hip, neck, and shoulder +flexibility in middle-aged men whereas physical exercises +had no such effect. Two recent studies of chronic lower +back pain patients also concluded that Yoga increased spinal +flexibility and quality of life better than physical exercise +[28, 29]. Yoga’s emphasis on developing body awareness and +physical discipline supports the adoption of healthy dietary +and exercise habits and thus potentially could influence the +management of IBS symptoms. Several research studies have +emphasized that Yoga makes one feel “more connected” to +their bodies (internal and external organs) and promotes a +positive body experience and a sense of well-being [30, 31]. +Ducrott´ +e [32] suggested that Yoga postures targeting the +lower abdomen would help in relieving the symptoms of +IBS by enhancing bioenergy circulation in and around the +intestines. +3.2. Yogic Breathing and Autonomic Balance. Yoga practices +offer the possibility of reducing inappropriate activation of +the autonomic nervous system (ANS). Clinical trials on IBS +patients have shown abnormalities in autonomic function +and psychological profiles. Some studies have shown that +there is an increased sympathetic activity in IBS patients. +Using spectral analysis of heart-rate variability in 54 subjects +(18 IBS patients and 36 healthy controls), it was reported +that IBS patients had significantly increased sympathetic +activity compared to healthy controls, whereas there was +no difference in parasympathetic activity between these two +groups [33]. In a study conducted by Waring et al. [34] on +69 female subjects (39 with IBS and 30 healthy controls), +sympathetic excess in IBS patients was observed during +stimulation (handgrip exercise and orthostatic test) when +compared to the healthy controls. In contrast, Punyabati et +al. [35] reported increased parasympathetic reactivity and +elevated levels of anxiety in 65 IBS patients. +The relaxing and calming effects of Savasana (total +relaxation) and pranayama (breath control) have been widely +studied and reported. The effects of these practices provide a +short-term “time out” from stress and also by creating posi- +tive physiological changes in the whole body through mod- +ulating the nervous system [36]. Sudarshan Kriya is a simple +rhythmic breathing technique with specific natural rhythms +of the breath, harmonizing the body, mind, and emotions. +It is shown to alleviate symptoms of anxiety, depression, +and stress-related ailments [37]. Slow and deep breathing +techniques could be used to minimize physiologic responses +to stress by increasing the parasympathetic response [38]. +Breathing through right nostril was shown to increase oxygen +consumption, an indicator of increased metabolism and the +sympathetic activity, whereas left-nostril breathing led to +parasympathetic shift [39]. A two-month study of 21 male +adult IBS-D patients (Yoga group = 9; conventional group = +12), with Yoga intervention of a few postures and “voluntary” +regulated right-nostril breathing, to be practiced at home, +showed that both groups had positive changes over time in +general autonomic functions, bowel symptoms, state anxiety +scores, and gastric motility (electrogastrography (EGG)) +amplitude. The Yoga group showed significant improvements +in autonomic symptom score, bowel symptom score, state +anxiety, and physical flexibility whereas the control group +had significant improvements in resting EGG amplitude [40]. +Though beneficial effects of Yoga were reported in this study, +the sample size lacked female patients in whom IBS is more +prevalent. As the evidence is clear that IBS patients could +have sympathetic/parasympathetic dominance, balancing the +autonomic nervous system should be a focus, rather than +emphasizing on right nostril breathing which could increase +the sympathetic activity. This emphasizes an urgent need of +a systematic clinical trial, testing the most practical Yoga +module, for the better management of IBS. +3.3. Yoga and Psychological Well-Being. A large number of +studies confirm that Yoga enhances general psychological +well-being. A moving meditation called “Cyclic Meditation” +based on stimulation and relaxation [41] showed reduced +oxygen consumption compared to resting in supine position +and reduced sympathetic activity and increased parasympa- +thetic dominance [42]. A subsequent study showed reduced +stress and increased quality of sleep after 23 minutes of +Cyclic Meditation [43]. Rosary (Ave Maria) and certain +Yoga mantras when recited at specific frequencies (six times +a minute) improved physiological and psychological well- +being and also an increase in the synchronicity of cardio- +vascular rhythms were observed in 23 healthy volunteers +[44]. Yoga is also shown to reduce anxiety and symptoms +of depression and enhance quality of life. Two studies have +reiterated that three and four months of Yoga practice had +significantly improved the subjective well-being and quality +of life [45, 46]. +Yoga intervention for IBS adolescent patients that con- +sisted of four weeks of daily home practices showed lower +levels of functional disability, less use of emotion-focused +avoidance, and lower anxiety than the control group. A 10- +minute video was provided to the children to practice at home +for four weeks. A 65% practice was reported. Most of the +children also reported that when in pain, they did not practice +and, other times, could not find time to practice [47]. Even +though the study reported improvement, a close supervision +of Yoga sessions was deficient. A recent study on 51 adolescent +and young adult IBS patients using Iyengar Yoga for 6 weeks, +90 minute class twice a week, reported positive changes in +IBS symptoms, sleep, fatigue, and psychological distress when +compared to control group with usual care [48]. Iyengar Yoga +is characterized by great attention to detail and precise focus +on body alignment, with the use of “props” such as cushions, +benches, blocks, straps, and sand bags which the IBS patients +4 +Evidence-Based Complementary and Alternative Medicine +might not appreciate. Timing (how long to hold a position), +technique (precision of the body alignment), and sequence +of the asanas are very important for this style of Yoga, which +could be a challenge for these patients. +3.4. Yoga and Quality of Life. In an eight-week intervention +of mindfulness meditation study, meditators were shown to +have higher activation in left-sided frontal lobe that is associ- +ated with positive feelings such as joy, happiness, compassion, +and lower levels of anxiety, when compared with the control +group of nonmeditators [49]. A recent study investigated +the effects of Brain Wave Vibration (BWV), a meditation +involving rhythmic movements of the head, neck, and body +practiced with related Yoga style exercises for eight weeks. +Thirty-one healthy adults were assessed in total for both +groups. BWV group showed better mood, sleep, mindfulness, +health, and well-being compared to controls that participated +in Yoga style exercise without the movements [50]. +An earlier study [51] assessed the role of stress in 50 +medical students, in which the Yoga group practiced one +hour Yoga, three times a week, for a month and the control +group did reading/writing for the same duration. Yoga group +showed improvements in various parameters such as sense +of well-being, feeling of relaxation, improved concentration, +self-confidence, improved efficiency, better interpersonal +relationship, increased attentiveness, lowered irritability lev- +els, and optimistic outlook in life. Similar findings were +reported in the Yoga practitioners by later studies. In a survey, +61 Yoga practitioners had a positive outlook on life, and +happiness within, when compared to 135 who were non- +yoga-practitioners [52]. Rocha and colleagues [53] concluded +that regular Yoga practice (6 months) can improve aspects +of cognition and quality of life for healthy individuals. Slow +and deep breathing for six weeks improved cognition and +general well-being and increased parasympathetic activity as +compared to controls [54]. In yet another survey, 1,045 Yoga +practitioners reported to have improved energy, happiness, +social relations, and sleep [55]. +Taken together, Yoga practices enhance physical flexibil- +ity, energy levels, and quality of life with improved psycholog- +ical disorders. It also increases self-awareness, and happiness +within, and also makes one feel relaxed and rejuvenated. +Therefore, Yoga practices are considered much more useful +in IBS patients at various levels to better manage their +symptoms. +4. Pancha Kosha-Balanced Approach of +Yoga Therapy (PK-BAYT) +Yoga is being explored for potential health benefits in the +recent past, with the advent of increased awareness for pre- +vention of diseases. Most of the scientific evidences available +to date used parts of Yoga, that is, postures, or breathing +exercises or meditations to show the benefits of Yoga. In +fact, Patanjali’s Ashtanga Yoga encompasses a variety of +mind-body-breath practices: Yama (rules for virtuous living +in the external world), Niyama (the moral injunctions for +healthy living for oneself), ¨ +Asanas or postures, Pr¯ +an¯ +ay¯ +ama +Anandamaya kosha/ +bliss/harmony/expanded +awareness +Vijnanamaya kosha/ +intellect/wisdom/balance +of mind +Manomaya kosha/ +mind/thoughts +Pranamaya kosha/ +vital life force +Annamaya +kosha/ +physical body +Figure 2: Schematic representation of Pancha Kosha, five layers of +human existence. +or breath control, and four stages of meditation (Pratyahara, +Dh¨ +arana, Dhy¨ +an¨ +a, and Sam¨ +adhi) that enables mastery over +the mind. Thus, Yoga has the potential to bring about +physical, mental, emotional, and spiritual well-being in the +practitioners. The concepts of Pancha Kosha and Adhi/Vyadhi +are very helpful in explaining the modern day psychosomatic +illnesses or disorders and in creating appropriate therapeutic +Yoga modules. We have explored the ancient Indian literature +in understanding the Yoga concept of illness and patho- +physiology of IBS from the texts (Adhi/Vyadhi from Yoga +Vasistha, Pancha Kosha, the five layered human existence, +from Taittiriya Upanishad) in providing a comprehensive +Yoga module as a remedial therapy for IBS. +Taittiriya Upanishad [56] described Pancha Kosha con- +cept of five intertwined layers of human existence (Figure 2). +The first four layers are interacting and interdependent layers +on the background of the fifth layer of bliss in which there are +perfect balance, harmony, and health. Accordingly, the goal +of human life is to transcend to the 5th layer of bliss, beyond +all disturbing mental processes, by performing each and every +duty/action in blissful awareness without unwanted reactions +to chronically demanding situations of life. This is the key to +achieving total peace that leads to perfect health. +4.1. Annamaya Kosha (Physical Body). Annamaya kosha is +the physical frame of the body and is the grossest of all five +layers, representing the anatomy that is a conglomeration of +subtle particles (such as electrons) that go on to form highly +organized systems. This is nurtured by the nutrients, the food +we eat. A healthy body is the key to maintain homeostasis of +different systems within. +4.2. Pranamaya Kosha (Vital Life-Force). The pranamaya +kosha ensures the harmonious functioning of these organs +by the physiological processes. Prana (vital life-force) is the +basic life energy inside and outside the body. A uniform flow +Evidence-Based Complementary and Alternative Medicine +5 +of this life-force to each and every cell of the physical body +(annamaya kosha) keeps it healthy. If there is a disturbance +in the flow of Prana to any organ, it can lead to dysfunction +of that organ at the physical body level. +4.3. Manomaya Kosha (Mind). Manomaya kosha is the men- +tal and emotional library of the human system. According +to Bhagavadgita [57] (ch II, verses 60–62), the psychological +stresses (emotions) begin as uncontrolled rewinding surge of +thoughts in this layer. Meditation is the tool to manage the +stresses from mind level. +4.4. Vijnanamaya Kosha (Intellect). Vijnanamaya kosha is the +discriminating faculty (inner mind, conscience) which guides +the manomaya kosha constantly to get mastery over the basic +instincts perceived by the sense organs. In a recent review +article, Deshmukh explains that, in Dhy¨ +an¨ +a-Yoga (Sanskrit +word for meditation), there is a natural sense of well-being +with self-understanding, spontaneous joy, serenity, freedom, +and “self-fulfillment” [58]. The secret for happiness, accord- +ing to scriptures, is conquering the mind through knowledge. +Once the mind is calm, it operates with logic and is able to +deal with situations in a balanced way that leads to healthy +functioning of the physical body. +4.5. Anandamaya Kosha (Bliss). Anandamaya kosha is the +most subtle layer in the array of the five layers of human +existence. This layer is not bound by time or space and is +devoid of emotions, a state of total silence, complete harmony, +and perfect health [59]. Happiness is within us, a state of +inner silence. Taittiriya Upanishad describes the process in +which a student realizes that all layers of our existence emerge +from anandamaya kosha [60]. It leads to the insight that +happiness is within us and “each one of us” in our causal +state is “Ananda” (bliss) embodied. Practicing Yoga with +complete awareness and involvement of mind-body-breath +is the technique to achieve a healthy body and a blissful +state. This underscores that only with the awareness and +involvement of “mind-body-breath” one could experience the +therapeutic benefits of Yoga. +5. Yogic Perspective of Pathophysiology +of Illness +“Yoga Vasistha” [61] provides Yoga perspective of the patho- +physiology of diseases. According to this text (ch II, verses +709–723), psychosomatic diseases originate from the mind, +percolate to subtle energy called the vital life-force, and settle +in the physical body, inflicting damage to the weakest organ +affecting the physiology and functioning of those organs. In +the case of IBS, the target organ is the gastrointestinal tract. +There are two kinds of diseases: Adhija (originated +by mind) and Anadhija (non-stress-related) vyadhis. Adhis +are twofold: Samanya (ordinary) and Sara (essential). +Samanya/ordinary diseases could be termed as life style +noncommunicable diseases since these are produced during +the interactions (mental conflicts) with the world. Sara adhija +Vyadhi (ailments) +by conflicts of mind) +Anadhi Vyadhi +(non-stress-related) +Sara (essential) +congenital birth +defects (remedy: +self-realization) +Injury, infection, +and toxins (remedy: +available +medications) +Samanya +(ordinary) +psychosomatic +ailments (remedy: +life style changes) +Adhi Vyadhi (originated +Figure 3: Yogic classification of diseases. +vyadhi is the essential disease of being caught in the birth- +rebirth cycle that can be understood in modern terms as +congenital diseases. The sara adhija vyadhi does not cease +until knowledge of the self (atma jnana) is attained [62]. +Anadhi vyadhis are non-stress-related diseases like those due +to injury, infection, and toxins and could be treated with any +available modern and Ayurvedic medicines. +In the layer of bliss, a human being is the healthiest, with +harmony and balance of all sense organs. At the vijnanamaya +kosha, there are disturbances in the mind but are channeled +in the right direction [59]. The imbalances start at the +manomaya kosha, mind layer. Likes and dislikes, happiness +and sorrow, and love and hatred are some of the dualities +that start governing the human actions, often directed by +emotions and not the intellect. When these imbalances +intensify, they result in mental conflicts called “Adhis” [61]. +Yoga looks at these mental conflicts as uncontrolled speed +of thoughts in the mind. The consequence is wrong life +style; four components of the lifestyle, diet, lack of exercise, +dire habits (smoking, alcohol, and uncontrolled desires), and +emotional stress, are all traceable to mind. With the repetition +of mental conflicts comes a habituated response of anxiety, +depression, or anger ultimately affecting the functioning of +various systems. Figure 3 depicts schematically yogic under- +standing of ailments. +Yoga can bring about changes in the Samanya type of +Adhis corresponding to the modern day mind-body diseases. +When the mind is agitated constantly, the vital life-force +(varistha prana) in the body is affected by imbalances in the +breath and causes dysfunction in the five channels of life- +force. The five channels of prana are: (1) Prana, controls the +functioning of the heart and lungs and all the activities in +the chest region like breathing, swallowing, and circulation of +blood; (2) Apana, controls the function of the excretory and +reproductive organs and hence is responsible for all down- +ward activities like urination, defecation, and menstruation; +(3) Samana, activates and controls proper digestion and is +responsible for balancing Prana and Apana; (4) Udana, is +responsible for all upward activities such as belching and +vomiting; and (5) Vyana, is responsible for all activities on +6 +Evidence-Based Complementary and Alternative Medicine +the periphery like nerve impulses and cellular activity in +all cells and gives extra boost to other four channels when +required [63, 64]. +Due to the imbalance in the vital life-force (varistha +prana), caused by the mental conflicts, the autonomic ner- +vous system is disturbed and it might result in heightened +bowel contractility. Of the five life-forces, the most important +for the healthy functioning of the body is “Samana,” a life- +force that is responsible for digestion and balancing two other +major life-forces, “Apana” and “Prana.” When “Samana” is +disturbed, the food ingested cannot be digested properly. This +leads to overdigestion (atijirnatvam), nondigestion (ajirnat- +vam), or wrong digestion (kujirnatvam) and thus improperly +digested food when settles in the body leads to diseases [65]. +If “Samana” becomes dominant, it leads to gastroesophageal +problems, including epigastric pain, hyperacidity and gastric +reflux. Ajirnatvam and heightened sympathetic activity (dis- +turbed ANS) results in IBS-C. Disturbed “Samana” causes an +imbalance in “Apana,” and excess Apana along with parasym- +pathetic dominance manifests as IBS-D (atijirnatvam) or IBS- +M (kujirnatvam) (Figure 4; [66]). In other words, heightened +parasympathetic activity results in IBS-D and heightened +sympathetic activity results in IBS-C. Increased peristaltic +waves lead to diarrhea and excess saccular contractions +due to sympathetic activity leads to constipation [67, 68]. +Remarkably, this ancient concept of Adhi/Vyadhi appears +very similar to the modern scientific pathway of stress- +induced brain-gut axis dysfunction as outlined in Figure 1. +6. Yoga as Remedial Therapy for +Management of IBS +Long standing persisting anxiety, anger, and depression (stre- +sses) that lead to mind body illnesses are the habituated +pattern of responses characterized by this rewinding vio- +lent loop of thoughts. Hence the remedy is to slow down +(prashamana) these looping thoughts that would have gath- +ered enough power to disturb the grosser layers of pranamaya +and annamaya koshas [62]. According to Patanjali, mastery +over the modifications of the mind is Yoga [69]. Pancha +Kosha-Balanced Approach of Yoga Therapy (PK-BAYT) uti- +lizes mind-body-breath healing techniques to balance and +harmonize the disturbances of psychosomatic ailments at all +the five levels of our existence. Physical exercise is a key +component to maintain health at annamaya kosha. Physical +movements with breathing are emphasized at this kosha, +breathing practices to expand lung capacity and loosening +practices to stretch and relax the muscles and loosen the +joints; Yoga postures can provide the strength and endurance +to the physical body and provide deep relaxation to the +body and mind. Varying postures are used based on the spe- +cific ailment. Kriyas (cleansing techniques) are also used in +enhancing the treatment to the physical layer. At pranamaya +kosha, various breathing practices are used to expand the lung +capacity and to balance the breath in order to impact the +functioning of the cells by calming the nervous system. The +first step is to master the Asana or posture to control the body +Imbalanced ANS +IBS-D, C, M +Vyadhi/physical ailments- +abdominal pain, bloating, +and discomfort +Overdigestion, nondigestion, +and wrong digestion +kujirnatvam) +Problems in bowel +contractility +Disturbed Samana +Disturbed Apana +Manomaya kosha-Adhi/mental conflicts +Pranamaya kosha +Annamaya kosha +Disturbed +varistha prana +(atijirnatvam, ajirnatvam, and +Figure 4: Schematic representation of Adhi becoming Vyadhi in +the context of IBS. Conflicts in the mind disturb the vital life-force +(varistha prana) that affects Samana (responsible for digestion) and +disturbed autonomic nervous system. When Samana is disturbed, +there is an imbalance in Apana in case of IBS patients. Disturbed +varistha prana causes imbalance in the ANS and bowel contractility +issues. All these disturbances are thought to be the onset of IBS +(diarrhea, constipation, or both mixed). +and sit comfortably for a length of time to practice pranayama +[70]. This helps to achieve varying breathing exercises and get +relief from the dysfunctional parts of our body. +At manomaya kosha, various levels of meditation that +includes Pratyahara (withdrawal of mind from the objects of +sense perception), Dh¨ +arana (focusing on a single thought), +Dhy¨ +an¨ +a (effortless flow of a single thought in the mind), and +Sam¨ +adhi (merger in the object of meditation) [69] are used to +calm down the mind. Notional corrections and self-analysis +to enhance better judgment are some techniques that are +helpful in balancing the vijnanamaya kosha. At anandamaya +kosha, action-in-relaxation is practiced to experience bliss +continually. +Johannesson and colleagues observed that any moderate +physical activity ranging from 20 to 60 minutes, three times a +week, improved symptom severity of IBS when compared to +controls that did not do physical exercise [71]. In this study, +duration and type of the activity was not constant for all +subjects. +In light of these studies, and with the knowledge of +ancient scriptures, various aspects of traditional Yoga (Patan- +jali and Yoga Vasistha) are used to create a Remedial Yoga +Module for the management of IBS symptoms. A brief +summary of Yoga practices that would be most applicable for +IBS patients with the goals of balancing each kosha is given in +Table 1. Yoga sessions were standardized to create consistency +among patients and instructors. A distinct and concise Yoga +module for IBS is given as follows that is very practical to +follow under the supervision of a certified Yoga instructor +and adherence to it. +Evidence-Based Complementary and Alternative Medicine +7 +Table 1: Pancha Kosha-Balanced Approach of Yoga Therapy (PK-BAYT). +Layers/koshas +Natural state +Altered state +Yogic remedy +Physical (annamaya) +Relaxed +Muscular tensions, abdominal pain, +bloating, constipation, and diarrhea +Stimulate the body with various +loosening practices, relax with postures, +and cleanse the internal organs with +cleansing techniques +Life force (pranamaya) +Slow rhythmic +breath +Haphazard breathing, wrong direction, +wrong quantities, and imbalances +Slow down the breath with breath control +and balance the flow of vital life force +Mind (manomaya) +Calm state +Mental agitations, stress, anxiety, and +depression +Calm down the mind with meditation +and devotion +Intellectual (vijnanamaya) +Wisdom +Wrong perceptions, distorted cognition, +and lack of discrimination +Notional corrections and self-inquiry for +better judgment and increased +self-confidence +Bliss (anandamaya) +Harmony +Disharmony and unhappiness +Action in relaxation, to experience the +bliss continuously, selflessness, and +happiness within +Summary of Remedial Yoga Module for IBS +Names of Yoga Practice +(1) Starting affirmation (A-U-M, sound three times and +OM, three times); +(2) Breathing practices: +(a) hands-stretch breathing, +(b) Vyaghrasana/tiger pose breathing, +(c) Shashankasana/moon pose breathing, +(d) Padottanasana/straight leg raise breathing (sup- +ine position, both legs); +(3) Savasana/instant relaxation; +(4) Sithilikarana Vyayama/loosening exercises: +(a) forward and backward bending, +(b) side bending, +(c) twisting, +(d) Pavanamuktasana Kriya/Wind relieving pose +with leg rotation; +(5) Savasana/quick relaxation; +(6) Asanas/postures (standing, sitting, prone, and sup- +ine): +(a) Ardhakati cakrasana/half-waist wheel pose, +(b) Ardha cakrasana/half wheel pose, +(c) Padahastasana/hands to feet pose, +(d) Trikonasana/triangle pose, +(e) Parivritta trikonasana/revolved triangle pose, +(f) Vrikshasana/tree pose, +(g) Vakrasana/half spinal twist, +(h) Pascimottanasana/seated forward bend pose, +(i) Bhujangasana/cobra pose, +(j) Shalabhasana/locust pose, +(k) Sarvangasana/shoulder stand, +(l) Viparitakarani with wall support/legs up the +wall, +(m) Matsyasana/fish pose; +(7) Savasana/deep relaxation; +(8) Kriya/cleansing and pranayama/regulated breathing: +(a) Kapalabhati/forceful exhalation, +(b) Uddiyana Bandha and Agnisara/abdominal lock +and rigorous movement of abdomen, +(c) Vibhagiya Svasana/sectional breathing, +(d) NadiShuddhi pranayama/alternate nostril brea- +thing, +(e) Sitali/cooling pranayama, +(f) Sitkari/cooling pranayama, +(g) Bhramari/M-chanting; +(9) Dhyana/meditation: +(a) Nadanusandhana/Yoga of sound (A-U-M), +(b) OM meditation (OM); +(10) Closing affirmation, OM three times. +Given the gradual personalized training pace, people with +discomfort also can follow this Yoga module that is designed +to cover the whole body with particular focus on the abdom- +inal region. Stretching and twisting of the abdomen with +awareness that offers deep local rest to the abdominal viscera +are emphasized; this would help in alleviating distension +and pain in the abdomen. Uddiyana Bandha (abdominal +lock) and Kriyas [72] like Basti (colon cleansing), Agnisara +(rigorous movement of the abdominal muscles), and Vipar- +itakarani kriya (cleansing breath in half shoulder stand) are +considered very helpful for IBS patients. Pr¯ +an¯ +ay¯ +ama relevant +to IBS, in harmonizing the autonomic nervous system, such +as slow sectional breathing, alternate nostril breathing, and +cooling Pr¯ +an¯ +ay¯ +ama have been included. A-U-M meditation +and OM meditation are included to calm down the mind. +8 +Evidence-Based Complementary and Alternative Medicine +The Yoga module that we have come up with is different from +others for the reasons that all the patients will practice for +an hour, under the supervision of a certified Yoga instructor, +it is easy to follow, and it includes targeted practices of the +abdomen. The practices designed are easy to perform from +easy breathing practices to abdomen-stretching, twisting +postures, and resting the body and systems with relaxation +to give relief to the symptoms. Since there is an instructor in +the class, the patients are actively guided and monitored. This +module emphasizes “mind-body-breath” connection more +than physical alignment, timing, or sequencing of asanas as +it would be challenging for beginners of Yoga. Hence, this +would be a highly practical module for IBS patients to pursue +and adhere to. +7. Conclusion +In this review, we attempted to provide a distinct synthesis +of the Eastern (India) scriptural concepts of IBS as of +mental origin, and thus Yoga approach of managing IBS +as implemented in our randomized clinical trial (Clinical +Trial Number: ISRCTN42102754; manuscript in preparation) +with our design of concise an hour Remedial Yoga Module. +The Yoga module comprises the essential components of +traditional Yoga, that is, “postures, breathing, and medita- +tion” that can be easily practiced by most patients, with +least complications to enhance the therapeutic impact on +IBS. Importantly, Yoga modality is envisioned from the cost +effectiveness in managing IBS and its related comorbidities +like anxiety, depression, and fatigue. +Conflict of Interests +The authors declare that there is no conflict of interests +regarding the publication of this paper. +Authors’ Contributions +Vijaya Kavuri performed extensive literature searches and +prepared the draft of the review and the revisions. Nagarathna +Raghuram and Ariel Malamud contributed to the critical +revision of the review. Senthamil R. Selvan conceptualized +overall theme and structure for the review, interpreted +research in the field, and contributed to writing and critical +revision of the review. All authors approved the final version +to be published and agreed with all aspects of the work. +Acknowledgments +Authors thank Dr. Deepeshwar Singh, Dr. Apar Saoji, Dr. +Arjunan Mooventhan, and Dr. Hemant Bhargav (SVYASA, +Bangalore, Karnataka State, India) for providing useful dis- +cussions and assistance in preparing the review, Dr. Madan +Thangavelu (Trustee, Research Council for Complementary +Medicine, UK) for critical reading and suggestions, and Dr. +Subbaramaiah Kavuri, Chakrapani Kallur, Babu Gandhi, and +Bhiku Bhai Patel (VYRF, Norwalk, CA, USA) and Dr. H. R. +Nagendra (SVYASA, Bangalore, Karnataka State, India) for +their support with this work. +References +[1] L. J. Brandt, W. D. Chey, A. E. Foxx-Orenstein et al., “An +evidence-based position statement on the management of +irritable bowel syndrome,” The American Journal of Gastroen- +terology, vol. 104, supplement 1, pp. S1–S35, 2009. +[2] M. W. Schmulson and L. Chang, “Diagnostic approach to the +patient with irritable bowel syndrome,” The American Journal +of Medicine, vol. 107, pp. 20S–26S, 1999. +[3] K. B. Holten, A. Wetherington, and L. Bankston, “Diagnosing +the patient with abdominal pain and altered bowel habits: is it +irritable bowel syndrome?” American Family Physician, vol. 67, +no. 10, pp. 2157–2162, 2003. +[4] IFFGD, Statistics—aboutIBS.org, IFFGD, 2013, http://www +.aboutibs.org/site/what-is-ibs/facts/statistics. +[5] E. Quigley, Irritable Bowel Syndrome: A Global Perspective, +World Gastroenterology Organisation, 2009. +[6] O. Grundmann and S. L. Yoon, “Irritable bowel syndrome: +epidemiology, diagnosis and treatment: an update for health- +care practitioners,” Journal of Gastroenterology and Hepatology, +vol. 25, no. 4, pp. 691–699, 2010. +[7] A. Mulak, Y. Tach´ +e, and M. Larauche, “Sex hormones in the +modulation of irritable bowel syndrome,” World Journal of +Gastroenterology, vol. 20, no. 10, pp. 2433–2448, 2014. +[8] D. Hulisz, “The burden of illness of irritable bowel syndrome: +current challenges and hope for the future,” Journal of Managed +Care Pharmacy, vol. 10, no. 4, pp. 299–309, 2004. +[9] NIDDK Scientists, Irritable Bowel Syndrome, National Institute +of Diabetes and Digestive and Kidney Diseases (NIDDK), 2014, +http://www.niddk.nih.gov/health-information/health-topics/ +digestive-diseases/ibs/Pages/facts.aspx#what. +[10] A. S. Fauci, E. Braunwald, K. J. Isselbacher et al., Eds., Harrison’s +Principles of Internal Medicine, McGraw Hill, New York, NY, +USA, 1998. +[11] W. E. Whitehead, O. Palsson, and K. R. Jones, “Systematic +review of the comorbidity of irritable bowel syndrome with +other disorders: what are the causes and implications?” Gas- +troenterology, vol. 122, no. 4, pp. 1140–1156, 2002. +[12] J. A. Cole, K. J. Rothman, H. J. Cabral, Y. Zhang, and F. A. +Farraye, “Migraine, fibromyalgia, and depression among people +with IBS: a prevalence study,” BMC Gastroenterology, vol. 6, +article 26, 2006. +[13] E. A. Mayer, B. D. Naliboff, L. Chang, and S. V. Coutinho, +“Stress and the gastrointestinal tract V. stress and irritable bowel +syndrome,” American Journal of Physiology—Gastrointestinal +and Liver Physiology, vol. 280, no. 4, pp. G519–G524, 2001. +[14] P. C. Konturek, T. Brzozowski, and S. J. Konturek, “Stress +and the gut: pathophysiology, clinical consequences, diagnostic +approach and treatment options,” Journal of Physiology and +Pharmacology, vol. 62, no. 6, pp. 591–599, 2011. +[15] W. C. Orr, M. D. Crowell, B. Lin, M. J. Harnish, and J. D. Z. +Chen, “Sleep and gastric function in irritable bowel syndrome: +derailing the brain-gut axis,” Gut, vol. 41, no. 3, pp. 390–393, +1997. +[16] J. Jailwala, T. F. Imperiale, and K. Kroenke, “Pharmacologic +treatment of the irritable bowel syndrome: a systematic review +of randomized, controlled trials,” Annals of Internal Medicine, +vol. 133, no. 2, pp. 136–147, 2000. +Evidence-Based Complementary and Alternative Medicine +9 +[17] K. E. Trinkley and M. C. Nahata, “Medication management of +irritable bowel syndrome,” Digestion, vol. 89, pp. 253–267, 2014. +[18] C. J. Bijkerk, J. W. M. Muris, J. A. Knottnerus, A. W. Hoes, and +N. J. de Wit, “Systematic review: the role of different types of +fibre in the treatment of irritable bowel syndrome,” Alimentary +Pharmacology and Therapeutics, vol. 19, no. 3, pp. 245–251, 2004. +[19] O. Grundmann and S. L. Yoon, “Complementary and alterna- +tive medicines in irritable bowel syndrome: an integrative view,” +World Journal of Gastroenterology, vol. 20, no. 2, pp. 346–362, +2014. +[20] Y.-H. A. Shen and R. Nahas, “Complementary and alternative +medicine for treatment of irritable bowel syndrome,” Canadian +Family Physician, vol. 55, no. 2, pp. 143–148, 2009. +[21] R. Sharma and B. Dash, Caraka Samhita, Chaukamba Sanskrit +Series office, Varanasi, India, 2005. +[22] B. Petric, “Irritable Bowel Syndrome: The Ayurvedic Approach,” +2013, http://www.ayurvedacollege.com/articles/students/IBS. +[23] B. Tapas, Ekta, S. Biswas, P. K. Asit, and M. D. Kousik, “Man- +agement of irritable Bowel syndrome (Grahni) with ayurveda +and yoga,” Universal Journal of Pharmacy, vol. 2, no. 4, pp. 11– +14, 2013. +[24] I. K. Taimni, The Science of Yoga: The Yoga-S¯ +utras of Pata˜ +njali +in Sanskrit with Transliteration in Roman, Translation and +Commentary in English, Theosophical Publishing House, 1999. +[25] A. Walton, The Top 10 Cities for Yoga in The U.S. Forbes, 2013, +http://www.Forbes.com/sites/alicegwalton/2013/04/26/the-top +-10-cities-for-yoga-in-the-u-s/. +[26] American College of Sports Medicine, ACSM's Guidelines for +Exercise Testing and Prescription, 2006. +[27] U. Ray, K. Hegde, and W. Selvamurthy, “Effect of yogic asanas +and physical exercises on body flexibility in middle-aged men,” +Indian Journal of Medical Research, vol. 83, pp. 343–348, 1986. +[28] P. Tekur, S. Chametcha, R. N. Hongasandra, and N. Raghuram, +“Effect of yoga on quality of life of CLBP patients: a randomized +control study,” International Journal of Yoga, vol. 3, no. 1, pp. 10– +17, 2010. +[29] H. E. Tilbrook, H. Cox, C. E. Hewitt et al., “Yoga for chronic low +back pain: a randomized trial,” Annals of Internal Medicine, vol. +155, no. 9, pp. 569–578, 2011. +[30] C. Wood, “Mood change and perceptions of vitality: a compar- +ison of the effects of relaxation, visualization and yoga,” Journal +of the Royal Society of Medicine, vol. 86, no. 5, pp. 254–258, 1993. +[31] A. Woolery, H. Myers, B. Sternlieb, and L. Zeltzer, “A yoga +intervention for young adults with elevated symptoms of +depression,” Alternative Therapies in Health and Medicine, vol. +10, no. 2, pp. 60–63, 2004. +[32] P. Ducrott´ +e, “Irritable bowel syndrome: current treatment +options,” Presse Medicale, vol. 36, no. 11, pp. 1619–1626, 2007. +[33] P. Karling, H. Nyhlin, U. Wiklund, M. Sj¨ +oberg, B.-O. Olofsson, +and P. Bjerle, “Spectral analysis of heart rate variability in +patients with irritable bowel syndrome,” Scandinavian Journal +of Gastroenterology, vol. 33, no. 6, pp. 572–576, 1998. +[34] W. S. Waring, M. Chui, A. Japp, E. F. Nicol, and M. J. Ford, “Auto- +nomic cardiovascular responses are impaired in women with +irritable bowel syndrome,” Journal of Clinical Gastroenterology, +vol. 38, no. 8, pp. 658–663, 2004. +[35] O. Punyabati, K. K. Deepak, M. P. Sharma, and S. N. Dwivedi, +“Autonomic nervous system reactivity in irritable bowel syn- +drome,” Indian Journal of Gastroenterology, vol. 19, no. 3, pp. +122–125, 2000. +[36] S. Uyterhoeven, “Yoga and the ANS—yoga therapy today— +volume 2, number 3/August 2006—International Association of +Yoga Therapists (IAYT),” Yoga Therapy Today, vol. 2, pp. 23–25, +2006. +[37] N. Janakiramaiah, B. N. Gangadhar, P. J. Naga Venkatesha +Murthy, M. G. Harish, D. K. Subbakrishna, and A. Vedamurtha- +char, “Antidepressant efficacy of Sudarshan Kriya Yoga (SKY) in +melancholia: a randomized comparison with electroconvulsive +therapy (ECT) and imipramine,” Journal of Affective Disorders, +vol. 57, no. 1–3, pp. 255–259, 2000. +[38] R. Jerath, J. W. Edry, V. A. Barnes, and V. Jerath, “Physiology +of long pranayamic breathing: neural respiratory elements may +provide a mechanism that explains how slow deep breathing +shifts the autonomic nervous system,” Medical Hypotheses, vol. +67, no. 3, pp. 566–571, 2006. +[39] S. Telles, R. Nagarathna, and H. R. Nagendra, “Breathing +through a particular nostril can alter metabolism and auto- +nomic activities,” Indian Journal of Physiology and Pharmacol- +ogy, vol. 38, no. 2, pp. 133–137, 1994. +[40] I. Taneja, K. K. Deepak, G. Poojary, I. N. Acharya, R. M. Pandey, +and M. P. Sharma, “Yogic versus conventional treatment in +diarrhea-predominant irritable bowel syndrome: a randomized +control study,” Applied Psychophysiology Biofeedback, vol. 29, no. +1, pp. 19–33, 2004. +[41] H. R. Nagendra and R. Nagarathna, New Perspectives in Stress +Management, Swami Vivekananda Yoga Prakashana, Benga- +luru, India, 1997. +[42] P. S. Sarang and S. Telles, “Oxygen consumption and respiration +during and after two yoga relaxation techniques,” Applied +Psychophysiology Biofeedback, vol. 31, no. 2, pp. 143–153, 2006. +[43] S. Patra and S. Telles, “Positive impact of cyclic meditation on +subsequent sleep,” Medical Science Monitor, vol. 15, no. 7, pp. +CR375–CR381, 2009. +[44] L. Bernardi, P. Sleight, G. Bandinelli et al., “Effect of rosary +prayer and yoga mantras on autonomic cardiovascular rhythms: +comparative study,” British Medical Journal, vol. 323, no. 7327, +pp. 1446–1449, 2001. +[45] A. Malathi, A. Damodaran, N. Shah, N. Patil, and S. Maratha, +“Effect of yogic practices on subjective well being,” Indian +Journal of Physiology and Pharmacology, vol. 44, no. 2, pp. 202– +206, 2000. +[46] A. Damodaran, A. Malathi, N. Patil, N. Shah, and S. Marathe, +“Therapeutic potential of yoga practices in modifying cardio- +vascular risk profile in middle aged men and women,” Journal +of Association of Physicians of India, vol. 50, no. 5, pp. 633–640, +2002. +[47] L. Kuttner, C. T. Chambers, J. Hardial, D. M. Israel, K. Jacobson, +and K. Evans, “A randomized trial of yoga for adolescents with +irritable bowel syndrome,” Pain Research and Management, vol. +11, no. 4, pp. 217–223, 2006. +[48] S. Evans, L. Cousins, J. C. I. Tsao, B. Sternlieb, and L. K. Zeltzer, +“Protocol for a randomized controlled study of Iyengar yoga for +youth with irritable bowel syndrome,” Trials, vol. 12, article 15, +2011. +[49] R. J. Davidson, J. Kabat-Zinn, J. Schumacher et al., “Alterations +in brain and immune function produced by mindfulness +meditation,” Psychosomatic Medicine, vol. 65, no. 4, pp. 564–570, +2003. +[50] D. E. Bowden, D. McLennan, and J. Gruzelier, “A randomised +controlled trial of the effects of Brain Wave Vibration training +on mood and well-being,” Journal of Complementary and +Integrative Medicine, vol. 11, pp. 223–232, 2014. +10 +Evidence-Based Complementary and Alternative Medicine +[51] A. Malathi and A. Damodaran, “Stress due to exams in medical +students—role of yoga,” Indian Journal of Physiology and Phar- +macology, vol. 43, no. 2, pp. 218–224, 1999. +[52] E. Monk-Turner and C. Turner, “Does yoga shape body, mind +and spiritual health and happiness: differences between yoga +practitioners and college students,” International Journal of +Yoga, vol. 3, no. 2, pp. 48–54, 2010. +[53] K. K. F. Rocha, A. M. Ribeiro, K. C. F. Rocha et al., “Improve- +ment in physiological and psychological parameters after 6 +months of yoga practice,” Consciousness and Cognition, vol. 21, +no. 2, pp. 843–850, 2012. +[54] S. S. Chandla, S. Sood, R. Dogra, S. Das, S. K. Shukla, and S. +Gupta, “Effect of short-term practice of pranayamic breathing +exercises on cognition, anxiety, general well being and heart rate +variability,” Journal of the Indian Medical Association, vol. 111, no. +10, pp. 662–665, 2013. +[55] A. Ross, E. Friedmann, M. Bevans, and S. Thomas, “National +survey of yoga practitioners: mental and physical health ben- +efits,” Complementary Therapies in Medicine, vol. 21, no. 4, pp. +313–323, 2013. +[56] S. Nikhilananda, The Upanishads, vol. 4, Ramakrishna-Vive- +kananda Center, New York, NY, USA, 3rd edition, 1994. +[57] S. Chinmayananda, The Holy Gita, Central Chinmaya Mission +Trust, Mumbai, India, 9th edition, 1992. +[58] V. D. Deshmukh, “Neuroscience of meditation,” TheScientific- +WorldJournal, vol. 6, pp. 2239–2253, 2006. +[59] R. Nagarathna and H. Nagendra, Integrated Approach of +Yoga Therapy for Positive Health, Swami Vivekananda Yoga +Prakashana, Bengaluru, India, 3rd edition, 2006. +[60] S. Gambhirananda, Taittiriya Upanishad. With the Commentary +of Sankaracharya, Advaita Ashrama, Pithoragarh, India, 1986. +[61] S. Venkatesananda, The Concise Yoga Vasistha, State University +of New York, New York, NY, USA, 1st edition, 1985. +[62] B. L. Atreya and Samvid, The Vision and the Way of Vasistha +Darsanam, Indian Heritage Trust, Madras, India, 1993. +[63] S. N. Saraswati, Prana Pranayama Prana Vidya, Yoga Publica- +tions Trust, Munger, India, 2nd edition, 1994. +[64] H. Nagendra, Pranayama—The Art and Science, Swami Vive- +kananda Yoga Prakashana, Bengaluru, India, 2011. +[65] S. Shankaradevananda, Practices of Yoga for the Digestive System, +Yoga Publications Trust, Munger, India, 2006. +[66] R. Nagarathna and H. Nagendra, Yoga for Digestive Disorders, +Swami Vivekananda Yoga Prakashana, Bangalore, India, 2nd +edition, 2002. +[67] F. Lechin and B. van der Dijs, “Central nervous system plus +autonomic nervous system disorders responsible for gastroin- +testinal and pancreatobiliary diseases,” Digestive Diseases and +Sciences, vol. 54, no. 3, pp. 458–470, 2009. +[68] U. Szmulowicz and T. Hull, “Colonic Physiology,” in The ASCRS +Textbook of Colon and Rectal Surgery, D. E. Beck, P. L. Roberts, +T. J. Saclarides et al., Eds., pp. 1–15, Springer, 2011. +[69] S. S. Saraswati, Four Chapters on Freedom: Commentary on Yoga +Sutra of Patanjali, Yoga Publications Trust, Munger, India, 2002. +[70] S. Sivananda, The Science of Pranayama, Divine Life Society, +Himalayas, India, 16th edition, 1997. +[71] E. Johannesson, M. Simr´ +en, H. Strid, A. Bajor, and R. Sadik, +“Physical activity improves symptoms in irritable bowel syn- +drome: a randomized controlled trial,” American Journal of +Gastroenterology, vol. 106, no. 5, pp. 915–922, 2011. +[72] S. S. Saraswati, Asana Pranayama Mudra Bandha, Bihar Yoga +Bharati, Bihar, India, 1997. +Submit your manuscripts at +http://www.hindawi.com +Stem Cells +International +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +MEDIATORS +INFLAMMATION +of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Behavioural +Neurology +Endocrinology +International Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Disease Markers +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +BioMed +Research International +Oncology +Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Oxidative Medicine and +Cellular Longevity +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +PPAR Research +The Scientific +World Journal +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Immunology Research +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Journal of +Obesity +Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 + +Computational and +Mathematical Methods +in Medicine +Ophthalmology +Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Diabetes Research +Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Research and Treatment +AIDS +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Gastroenterology +Research and Practice +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Parkinson’s +Disease +Evidence-Based +Complementary and +Alternative Medicine +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com diff --git a/subfolder_0/Knowledge, Attitude, and Practice of Yoga in Rural and Urban India, KAPY 2017 A Nationwide Cluster Sample Survey..txt b/subfolder_0/Knowledge, Attitude, and Practice of Yoga in Rural and Urban India, KAPY 2017 A Nationwide Cluster Sample Survey..txt new file mode 100644 index 0000000000000000000000000000000000000000..438ef2d26551d5749896007b314c4aed66f0f205 --- /dev/null +++ b/subfolder_0/Knowledge, Attitude, and Practice of Yoga in Rural and Urban India, KAPY 2017 A Nationwide Cluster Sample Survey..txt @@ -0,0 +1,1041 @@ + + +Medicines 2020, 7, 8; doi:10.3390/medicines7020008 +www.mdpi.com/journal/medicines +Article +Knowledge, Attitude, and Practice of Yoga in Rural +and Urban India, KAPY 2017: A Nationwide +Cluster Sample Survey +Amit S Mishra 1, Rajesh SK 1, Vadiraja HS 1, Raghuram Nagarathna 1,*, Akshay Anand 2,†, +Himshikha Bhutani 2, Madhava Sai Sivapuram 3, +Amit Singh 1 and Hongasandra Ramarao Nagendra 1 +1 Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru 560019, India; dirghayuh@gmail.com +(A.S.M.); rajesheskay@svyasa.org (R.S.K.); vadiraj77@gmail.com (V.H.S.); dramits90@gmail.com (A.S.); +chancellor@svysasa.edu.in (H.R.N.) +2 Neuroscience Research Lab, Department of Neurology, Postgraduate Institute of Medical Education and +Research, Chandigarh 160012, India; himshikha.bhutani@gmail.com +3 Department of General Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research +Foundation, Chinna-Avutapalli 521101, India; madhavasai2011@gmail.com +* Correspondence: rnagaratna@gmail.com +† Co-correspondence: akshay1anand@rediffmail.com. +Received: 20 October 2020; Accepted: 19 January 2020; Published: 5 February 2020 +Abstract: Background: To examine the knowledge, attitudes, and practice gap of yoga across India +based on implicit perceptions. Methods: The present study is a nationwide door-to-door survey +conducted using a questionnaire/screening form. The data were collected from a national survey +conducted under the Niyantrit Madhumeh Bharat (NMB) program initiated by The Ministry of +Ayurveda, Yoga, Unani, Siddha, Homeopathy (AYUSH), Government of India, from all major zones +of the country. A total of 162,330 participants who joined the NMB program were recruited in our +study. Results: Out of the total respondents to the survey, it was observed that 11.8% +[13,336/112,735] practice yoga, which was highest in the north zone [4,567/112,735] and lowest in +the east zone [971/112,735]. Out of 101,643 respondents, 94,135 of the individuals who participated +in the survey believed that yoga improved their lifestyle, and 90,102/98,518 believed that yoga +prevented diabetes, revealing a huge knowledge–practice gap. Conclusions: The scale of the +knowledge–practice gap coupled with the general acceptability of yoga calls for a change in the +conventional healthcare provisions by its integration with modern medicine. The population-wide +positive perceptions about yoga as a preventive health tool can not only catalyze consensus disease- +specific yoga modules but also bridge the knowledge–practice gap that exists because of limited +yoga centers and professionals. +Keywords: yoga; health; lifestyle; integrative medicine + +1. Introduction +The latest ‘global action plan on physical activity’, by the WHO (World Health Organization) +stresses health and wellness as an outcome of being ‘active’ [1]. Health is a broad concept, finding its +roots in physical, mental, social, and spiritual wellness [2]. In this context, public health delivery is +critical for provisioning an evidence-based integration of alternative approaches for the public good. +This is possible by analyzing health-seeking behavior based on the knowledge–practice gap in the +population (a knowledge–practice gap is defined as the failure of the public to adopt the existing +Medicines 2020, 7, 8 +2 of 12 + +practices despite knowledge that it promotes the health of an individual). As an integrative medicine +(IM) approach that incorporates a broad range of therapies for holistic health based on preferences +for Western and traditional medicine and has shown varying acceptability, there is a need for national +survey for understanding the knowledge–practice gap in popular health promotion activities such as +yoga in a population where yoga originated. To exemplify, a study conducted in Hong Kong by +Wong et al. revealed that 40% of people turned to Traditional Chinese Medicine (TCM) mostly as a +second option [3]. Similarly, a Taiwan based study by Ma et al. depicted a very low prevalence of +TCM among children with asthma, with almost all parents opting for Western medicine [4]. Among +other mind–body techniques, T’ai chi/Qigong practice was reported to have a lifetime prevalence of +3.1% in the United States of America (U.S.A) [5]. Similarly, the data collected in Australia over 10 +years (2001–2010) showed a 3% prevalence rate for yoga/pilates, 0.6% for T’ai chi/Qigong, and 19.2% +for other fitness activities across the country [6]. In contrast, 84% of the physicians in Japan use +Kampo, a traditional Japanese medicine, in their practice and practice acupuncture (a TCM), which +is accepted across 103 countries with 29 countries having regulators for acupuncture in the world [7]. +This calls for the need to integrate the traditional medicine/complementary medicine with modern +medicine in the world. The importance of existing traditional/complementary medicine can be +highlighted by integrating it with modern medicine as required for universal health coverage (UHC). +The WHO is also working toward bringing traditional/complementary medicine into national +policies for the achievement of UHC [7,8]. +As India struggles under the burden of diabetes and rising non-communicable diseases, the +integration of cost-effective traditional systems, complementary and alternative medicine with the +conventional medical systems, under Indian Ministry of AYUSH (Ayurveda, Yoga, Unani, Siddha, +and Homeopathy) is inevitable, as it seeks to promote holistic health [9]. A cross-sectional study +based on data collected from the National Health Interview Survey at Centre for Disease Control and +Prevention in the United States has highlighted the prevalence of such approaches. In this study, +yoga was recognized as one of the seven most frequently used complementary health approaches +(CHA) among adults aged 65 or older, and it was concluded that 29.2% (11.7 million) of the older +adult population used any of these seven CHAs [10]. This shows the increasing acceptance of +complementary approaches among people. Telles et al., in a cross-sectional survey, had studied the +characteristics of yoga practitioners in India in a manner similar to studies previously undertaken in +the U.S.A. and Australia. Based on the response to the survey, it was found that yoga practitioners in +India are predominantly males, with the chief reason to practice yoga being physical fitness [11] and +not disease prevention. However, evidence suggests that yoga plays a pivotal role in changing the +physiology of the body. Some of the yoga practices used in these studies included (a) abdominal +stretching asanas (postures) that may help in the rejuvenation and regeneration of pancreatic cells +beneficial to diabetes patients [12], (b) pranayama (breathing exercises), and (c) meditation that +regulates the hypothalamic–pituitary–adrenal axis, resulting in decreased cortisol levels, heart rate, +and heart rate variability [13,14]. +When the world recognized 21 June [the summer solstice, the longest day of the year in the +northern hemisphere] as the International Day of Yoga, the Ministry of AYUSH, India devised a +Common Yoga Protocol for the promotion of positive health. This included loosening exercises +followed by sitting, standing, and supine postures in combination with breathing exercises and +meditation [15]. We wanted to know about health awareness in the Indian population, particularly +with respect to perceptions of yoga (and not its subtypes) and the number of people practicing yoga +in order to understand whether there is any knowledge–practice gap among Indians for a practice +that originated in India. Besides, the implementation of yoga protocols, as public policy, requires +evidence that there is not only positive perceptions about yoga but also an increased proportion of +yoga practitioners in India. For example, in a school-based yoga program, which was developed and +implemented in the U.S.A., about 5400 trained yoga instructors were employed to cover 940 schools +to teach four basic aspects of yoga to school-going children [16]. Similar such policies and programs +were developed in other states of the U.S.A and need to be developed in India as well. Consequently, +Medicines 2020, 7, 8 +3 of 12 + +the role of yoga, as mind–body training in schools and public health became critical in its +implementation, as explained in the aforementioned report. +Thus, it is becoming important to not only acquire data about the acceptability and perception +about yoga in the population but also health care professionals in order to understand the +knowledge–practice gap and availability of yoga resources in different zones of the country. This +would help in establishing more yoga wellness centers and the orientation of health care workers to +advocate its health-promoting effects. This would also provide the required evidence of the extent of +acceptability of yoga with respect to its knowledge, acceptability, and practice before any new policy +intervention. Thus, it is imperative that data from such a survey regarding yoga awareness, attitudes, +and its practice are made available to lawmakers and scientists for research and translation. In view +of this, the present study was designed to estimate the state of knowledge, attitude and practice of +yoga (KAP-Y) for diabetes prevention and management. The results from our studies constitute the +first-ever structured report of KAP yoga in Asia. +2. Materials and Methods +This study was a nationally representative survey conducted across India. The respondents of +this survey belonged to both rural and urban areas in all zones of India. This study was named in +Hindi as Niyantrita Madhumeha Bharata (NMB) (or control diabetes in India) using a yoga-based +lifestyle for the prevention and management of diabetes. +This study was funded by the Ministry of Health and Family Welfare and the Ministry of +AYUSH, Government of India, New-Delhi, coordinated by Indian Yoga Association (IYA) and +assigned to Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA, Bengaluru), who is a +member organization of IYA. The study was approved by the Institute Ethical Committee of Indian +Yoga Association (vide Res/IEC-IYA/001 dt 16.12.16). Signed written informed consent was obtained +from all participants. The approval date is 16 December 2016. +Details of the methodology have been published as two articles [17,18]. In brief, in order to plan +the survey, 65 districts from the 30 (out of 35 in India) most populous states and union territories +from all six zones (Figure 1) were selected randomly depending on each state’s population density. +Further, urban and rural clusters were identified from north, south, east, west, and central areas of +each district using randomization. After identifying these clusters, the trained volunteers conducted +the study in two phases of screening using a mobile app developed for the purpose by the +international research advisory team. The first phase included a short questionnaire to identify +individuals with high risk for diabetes and yoga awareness; the second phase included detailed data +acquisition from those with high risk. Before the initiation of the study, all the volunteers undertook +a six-day training explaining the content and manner of operationalization of the questionnaire, the +importance of informed consents, and documentation of all the details in the questionnaire. The +volunteers who had not undergone the training were not allowed to be a part of the study. +Medicines 2020, 7, 8 +4 of 12 + + +Figure 1. Representing six different zones of India. +The first phase of the study included a door-to-door survey by knocking on all the doors across +all the identified regions (urban and rural). The participants who consented were recruited for the +study. At this time, they were not informed about the second phase of the study, neither were they +compensated for their participation. This phase was a survey that consisted of the three-page item +questionnaire, which was read out by interviewer in their native language or self-administered +depending upon the convenience of the subject. This included demographic details of their socio- +economic status (based on a modified Kuppuswamy scale] [19], Indian Diabetes Risk Score (IDRS) +score [20], and yoga awareness. Three questions about KAP-Y were asked by reading the +questionnaire. This became the basic conceptual framework for this manuscript. The yoga-related +questions were as follows: (a) Do you think yoga can help in the prevention and management of +Diabetes? (b) Do you think yoga can help change your lifestyle? (c) Do you practice yoga? (Practice +of yoga implies the inclusion of standing, sitting, prone, and lying postures, deep breathing and/or +meditation practice, if practiced previously in their lifetime or currently practicing.) As the subjects +needed to be contacted again, the demographic details of the subjects were noted down; therefore, +the option to retain the anonymity of participants was not given to subjects. Apart from the +demographic details and the IDRS score, the rest of the questions are open-ended with ‘Yes’ or ‘No’ +options. Therefore, it is unlikely that the administration of the questionnaire influenced the answers +of the participants or introduced any perceivable bias. +2.1. Data Curation +The data was simultaneously collected from all over the country, as outlined in Figure 1. Since +it was a large data set, the uploaded data from the NMB Apps was cross-verified randomly with hard +copies before analysis. The coding of the data was also centralized at S-VYASA. The curated data +excluding the missing data are represented in Figure 2, which shows the study profile. +Medicines 2020, 7, 8 +5 of 12 + + +Figure 2. KAP-Y Study Profile. KAP-Y: state of knowledge, attitude and practice of yoga. +2.2. Statistical Analysis +To analyze the documented data, both descriptive statistics i.e., profile mapping and cross- +tabulation were performed using the Statistical Package for Social Sciences (IBM Statistics for +windows, SPSS v21.0) at S-VYASA, Bengaluru, India. +3. Results +A total of 162,330 participants were a part of the initial door-to-door survey and filled out the +NMB questionnaire. As explained above, the questionnaire was administered by the volunteers +recruited for the study. + + +Medicines 2020, 7, 8 +6 of 12 + +3.1. Knowledge and Attitude about Role of Yoga in Changing Lifestyle +Table 1. KAPY 2017. +Do you think yoga can help with changing your lifestyle? +Characteristics +YES +NO +Total +p-Value +N +% +N +% +N +% +Gender +Male +49,586 +92.8 +3856 +7.2 +53,442 +100 +<0.0001 +Female +44,549 +92.4 +3652 +7.6 +48,201 +100 +<0.0001 +Total +94,135 +92.6 +7508 +7.4 +101,643 +100 + +Zone +East +13,247 +87.3 +1935 +12.7 +15,182 +100 +<0.0001 +West +17,680 +95.4 +851 +4.6 +18,531 +100 +<0.0001 +North +25,046 +96.0 +1037 +4.0 +26,083 +100 +<0.0001 +South +28,306 +98.7 +378 +1.3 +28,684 +100 +<0.0001 +Central +4442 +61.3 +2808 +38.7 +7,250 +100 +<0.0001 +Northeast +5859 +91.3 +555 +8.7 +6,414 +100 +<0.0001 +Total +94,580 +92.6 +7564 +7.4 +102,144 +100 + +Area +Rural +43,420 +92.1 +3721 +7.9 +47,141 +100 +<0.0001 +Urban +48,413 +92.9 +3718 +7.1 +52,131 +100 +<0.0001 +Total +91,833 +92.5 +7439 +7.5 +99,272 +100 + +Self- +Reported +Status of +T2DM +No T2DM +80,952 +92.2 +6833 +7.8 +87,785 +100 +<0.0001 +Known T2DM +9859 +95.1 +508 +4.9 +10,367 +100 +<0.0001 +Total +90,811 +92.5 +7341 +7.5 +98,152 +100 + +Age +20-39 +45,028 +92.1 +3836 +7.9 +48,864 +100 +<0.0001 +40-59 +35,589 +92.7 +2822 +7.3 +38,411 +100 +<0.0001 +60-79 +12,667 +93.6 +863 +6.4 +13,530 +100 +<0.0001 +Above 80 +257 +95.9 +11 +4.1 +268 +100 +<0.0001 +Total +93,541 +92.5 +7532 +7.5 +101,073 +100 + +Socio- +economic +level +Low +160 +97.0 +5 +3.0 +165 +100 +<0.0001 +Upper low +7626 +93.3 +545 +6.7 +8,171 +100 +<0.0001 +Lower–middle +30,318 +91.8 +2717 +8.2 +33,035 +100 +<0.0001 +Upper–middle +17,003 +92.4 +1390 +7.6 +18,393 +100 +<0.0001 +Upper +885 +87.8 +123 +12.2 +1,008 +100 +<0.0001 +Total +55,992 +92.1 +4780 +7.9 +60,772 +100 + +Table 1 shows the answers to question, “Do you think yoga can help with changing your +lifestyle?” Most individuals (94,135/101,643) believed that yoga improves their lifestyle, out of which +49,586 were males and 44,549 were females. Upon classification as per various zones, central India +(4442/102,144) revealed the popular belief that yoga improves lifestyle to a lesser extent as compared +to the rest of India, and the highest is seen in south India (28,306/102,144). Furthermore, 43,420/99,272 +participants of rural India and 48,413/99,272 participants of the urban India believed that yoga +improves lifestyle. Both diabetic (9,859/10,367) and non-diabetic (80,952/87,785) participants also +responded positively in this context (Table 1). +3.2. Perception of Yoga for Diabetes Prevention +Table 2 shows the answers to question, “Do you think yoga can help in the prevention and +management of diabetes?” A vast majority of the participants (47,488 males and 42,614 females out +of 98,518 participants) believed that yoga prevents and aids in the management of diabetes. A total +of 9454/9930 participants with Type 2 Diabetes Mellitus (T2DM) and 77,635/85,414 participants with +no diabetes reported that Yoga helps in preventing Diabetes (Table 2). + + +Medicines 2020, 7, 8 +7 of 12 + +Table 2. KAPY 2017. +Answers to: “Do you think yoga can help in the prevention and management of diabetes?” +Characteristics +YES +NO +Total +p-Value +N +% +N +% +N +% +Gender +Male +47,488 +91.5 +4428 +8.5 +51,916 +100 +<0.0001 +Female +42,614 +91.4 +3968 +8.6 +46,602 +100 +<0.0001 +Total +90,102 +91.5 +8416 +8.5 +98,518 +100 + +Self- +Reported +Status of +T2DM +No T2DM +77,635 +90.9 +777 +9.1 +85,414 +100 +<0.0001 +Known +T2DM +9454 +95.2 +476 +4.8 +9930 +100 +<0.0001 +Total +87,089 +91.3 +8255 +8.7 +95,344 +100 + +3.3. Yoga Practitioner Count and Characteristics Vary Across India +The study revealed that 11.8% (13,336/112,735) of people practice yoga and 88.2% +(99,399/112,735) of people don’t practice yoga across India. Among the population practicing yoga, +7010/112.735 of males and 6233/112,735 of females are practicing yoga. Among various zones, +minimal practice was noted from the east zone (971/112,735) and the highest practice was noted from +the north zone (4567/112,735). It is noted that 6939/109,888 of the urban population and 6277/109,888 +of the rural population was found to be practicing yoga. The difference in the number of yoga +practitioners among the diabetic population (1789/11,342) versus non-diabetic population +(11,042/98,776) was noted (Table 3). +Table 3. Socio-demographic distribution of practitioners of yoga in India. +Characteristics +Practicing Yoga +Not practicing +Yoga +Total +p-Value +N +% +N +% +N +% +Overall +13,336 +11.8 +99,399 +88.2 +112,735 +100 + +Gender +Male +7010 +11.9 +52,035 +88.1 +59,045 +100 +<0.0001 +Female +6233 +11.7 +46,969 +88.3 +53,202 +100 +<0.0001 +Zone +East +971 +5.3 +17,219 +94.7 +18,190 +100 +<0.0001 +West +2057 +10.5 +17,551 +89.5 +19,608 +100 +<0.0001 +North +4567 +17.2 +21,901 +82.7 +26,468 +100 +<0.0001 +South +3732 +14.5 +22,093 +85.5 +25,825 +100 +<0.0001 +Central +1096 +10.3 +9575 +89.7 +10,671 +100 +<0.0001 +North east +913 +7.6 +11,060 +92.4 +11,973 +100 +<0.0001 +Total +13,336 +11.8 +99,399 +88.2 +112,735 +100 + +Area +Rural +6277 +11.9 +46,414 +88.1 +52,691 +100 +<0.0001 +Urban +6939 +12.1 +50,258 +87.9 +57,197 +100 +<0.0001 +Total +13,216 +12.0 +96,672 +88.0 +109,888 +100 + +Self- +Reported +Status of +T2DM +No T2DM +11,042 +11.2 +87,734 +88.8 +98,776 +100 +<0.0001 +Known +T2DM +1789 +15.8 +9553 +84.2 +11,342 +100 +<0.0001 +Total +12,831 +11.7 +97,287 +88.3 +110,118 +100 + +Age +20–39 +6256 +11.8 +46,934 +88.2 +53,190 +100 +<0.0001 +40–59 +5105 +11.8 +37,987 +88.2 +43,092 +100 +<0.0001 +60–79 +1839 +12.1 +13,296 +87.9 +15,135 +100 +<0.0001 +Above 80 +20 +6.6 +282 +93.4 +302 +100 +<0.0001 +Total +13,220 +11.8 +98,499 +88.2 +111,719 +100 + +Socio- +economic +level +Low +17 +10.3 +148 +89.7 +165 +100 +<0.0001 +Upper low +1004 +11.7 +7575 +88.3 +8579 +100 +<0.0001 +Lower– +middle +4577 +12.6 +31,655 +87.4 +36,232 +100 +<0.0001 +Upper– +middle +2853 +13.5 +18,207 +86.5 +21,060 +100 +<0.0001 +Medicines 2020, 7, 8 +8 of 12 + +Upper +121 +10.5 +1035 +89.5 +1156 +100 +<0.0001 +Total +8572 +12.8 +58,620 +87.2 +67,192 +100 + +4. Discussion +This pan India cluster sample survey constituted 162,330 participants, revealing 11.8% of the +population to be practicing yoga. There was an almost equal prevalence of yoga practice among +various categories—the males and females, urban, new diabetics, pre-diabetics, and age group (60– +79 years) besides the upper–middle class socio-economic status. +This study provides a significant insight regarding the widely held views of yoga’s efficacy. This +is evident from the results of knowledge and attitude sampling. Although it shows that it is perceived +as useful for lifestyle modifications (92.6%), the proportion of those adopting the practice of yoga is +not comparable (11.8%). This knowledge–practice gap can be due to various reasons. The comparison +of our results with data across the world shows that there are a comparable proportion of yoga +practitioners. However, other surveys were not sampled as door to door in a cluster design and were +not carried out for such a large sample. The other methods of surveys included emails, online, and +convenient sampling, all of which lack the reliability, interface, and rigor that the door-to-door survey +provides. +The increased awareness could be partly because of yoga’s origins and popularity in India and +partly because the current Indian PM’s role modeling of yoga for health on each International Day of +Yoga may have aligned this cultural practice with health and wellness. +4.1. Germany +A representative sample size of 2041 participants from Germany in the age group of more than +14 years were interviewed, and it was found that 68 participants (3.3%) acknowledged practicing +yoga when quizzed at the time of interview, while 241 participants (11.8%) practiced yoga prior to +the interview. It was estimated that around 15.7 million Germans either practice yoga or are +interested in practicing yoga. They concluded that the lifetime prevalence of yoga practice in +Germany was 15.1% with a point prevalence of 3.3%. A greater popularity of yoga was found linked +with females, better education, and employment status. The authors reported that their survey had +the limitation of retrospective analysis and an inability to account for the different components and +quality of yoga. When compared with our study, the sample size is much smaller, and the prevalence +of practicing yoga is also not comparable [21]. The quality of yoga being practiced in the absence of +popular yoga gurus or institutions in this country is also not clear. +4.2. United Kingdom (UK) +Annual cohort studies conducted during the period of 1997 to 2008 in the United Kingdom (UK) +included physical activity questions. The data were collected during household visits via the +interviews at three time points (1997 to 1999; 2003 to 2004; and 2006/2008) and were asked with an +open-ended question about the practice of yoga in the last four weeks. A total of 81,090 participants +(1997–1999: 38,409; 2003–2004: 27,580, and 2006/2008: 15,101) responded to the interviews. The +proportion of females, educated individuals, and the working class was higher with a point +prevalence to be at 0.46% (175 respondents during 1997–1999), 0.94% (260 respondents during 2003– +2004), and 1.11% (168 participants during 2006/2008), which shows an increasing trend [22]. However, +this was a long duration study in which the knowledge, attitude, and practice may have changed +over time. Moreover, the sample size was far smaller than that of the current study from India. +4.3. Australia +In a national cross-sectional survey of the Australian women, where data was collected from the +Australian Longitudinal Study on Women’s Health (ALSWH), a self-reporting questionnaire was +sent to randomly selected women. The response rate was 42% to 56%, which included a total of 28,695 +women on three different cohorts based on birth year, 9151 women in 1946–1951; 8200 women in +Medicines 2020, 7, 8 +9 of 12 + +1973–1978; 11,345 women in 1989–1995. It was found that the prevalence of practicing +yoga/meditation is about 20.7% (1946–1951 cohort), 21.7% (1973–1978 cohort) and 29% (1989–1995 +cohort), respectively. It is worth mentioning from the cohorts that the popularity of yoga is prominent +among the younger population, but the regularity in the practice is more pronounced in the older +population with a prevalence of 11.1% (1946–1951 cohort), 7.7% (1973–1978 cohort), and 9.2% in +(1989–1995 cohort). The major limitation of this study was that a single open-ended question was +asked on both the practice of either yoga or meditation; therefore, the results stated in the study +cannot inform us of whether the prevalence is only for yoga, for meditation, or for both [23]. +4.4. USA +This pattern was also found to be consistent with National Health Interview Survey (NHIS- +2012), which revealed that 31 million adults had practiced yoga ever, whereas 21 million adults +practiced yoga in the previous 12-month period with a lifetime prevalence of 13.2% and 12-month +prevalence being 8.9%. The popularity was more among females, educated individuals, and the +working class [24]. This survey was not as large as the current one in terms of duration of +operationalization and method of execution (door to door). Interestingly, there was a increase in the +awareness of yoga in U.S.A from the year 1998, where it was assessed that 15 million adults practiced +yoga, whereas 7.4 million adults practiced yoga in the previous 12-month period with a lifetime +prevalence of 7.5% and 12-month prevalence being 3.8% [25] to 13.2% lifetime prevalence and 8.9% +of 12-month prevalence [24]. It is also interesting to note that prevalence studies for the practice of +meditation in the U.S.A adult population indicated greater prevalence among females and those who +were college educated. A total of 9.3 million adults practiced meditation in the previous 12-month +period with a lifetime prevalence of 5.2% and 12-month prevalence being 4.1% [26]. The overall +practice of yoga has increased in the U.S.A.; however, the use of medicalized/referral-based yoga has +decreased, as per a study by Patwardhan and Lloyd [27]. +4.5. India +As cited before in this paper, the survey conducted by Telles et al. [11] studied the educational +background of 5157 yoga practitioners in India and reported them to be high school graduates with +more male practitioners (67.3) as compared to females (32.7). This was the first study in an Asian +population that has shown a higher prevalence in males than females when compared to studies in +the west. This is similar to our study in which males were marginally higher than females. +From the current study, we note that the prevalence of the yoga in India is 11.8%, and 91.5% of +participants believe that yoga yields health benefits such as the control of T2DM. This is higher +compared to Western countries. This may be due to the cultural origins of yoga, which is aligned to +Indian traditions and lifestyle, manifesting as yoga literature in Sanskrit and Hindi. Apart from these, +there are many yoga role models such as Baba Ramdev promoting yoga from many years through +various platforms such as television and social media. Even the Prime Minister of India, Narendra +Modi advocates yoga [28] and its benefits. This has also promoted yoga in the Indian community. +After the United Nations (UN) adopted 21 June as the International day of Yoga, it has since been +adopted by other Western countries [21,22,24]. +4.6. Knowledge of Yoga for Health Benefits +In our present study, we noticed that 92.6% of the participants, irrespective of their gender, +believed that yoga helps in superior health outcomes. The study may provoke further investigation +about what roles poorer self-regulation and implicit attitudes play on the reduced practice of yoga in +contrast to nationwide popular perception that it prevents diabetes. The practice of yoga also requires +training by expert yoga practitioners. The number of expert practitioners is believed to be limited to +only 2034, in which 1360 practitioners are limited to the Tamil Nadu and Karnataka states of India +[29]. This shows the need for a greater number of yoga practitioners and training schools in the +country. +Medicines 2020, 7, 8 +10 of 12 + +In contrast, allopathic practice, which is widely prevalent, usually shows a general compliance +of about 30–50% [30]. Even though India is open to complementary and alternative medicine (CAM) +practice, it was noted in a study done by Roy et al. (2015) that only 28% of the patient population +practice CAM [31]. +4.7. Yoga as CAM +A cross-cultural comparative analysis was carried out to examine the health-seeking behavior of +university students from New Delhi (India), Newcastle upon Tyne (United Kingdom) and Atlanta +(United States). The Indian students opted for CAM over allopathic medicine, and nutrition-based +approaches [supplements, etc.] were found to be most prevalent among the students. Considering +the unique health care systems of the three countries, it was concluded that 55% of Indian students +considered CAM as a more affordable approach than routine healthcare practices [32]. +According to a KAP study done by Kong et al. (2013) among the medical practitioners, it was +observed that 71% of medical practitioners feel that CAMs are effective with allopathic treatment +[33]. According to Roy et al. (2015) even though 58% of the doctors use CAMs for themselves, only +37% recommend their patients and enquire about the utilization of them. This highlights the +importance of creating awareness among the medical practitioners [31]. +5. Limitations +Since the data obtained was through recall and self-reporting, there may have been bias in +recalling the individual practice of yoga. The study has shown missing data due to some of the +following reasons. (a) The completion of the entire questionnaire was not mandatory, as the subjects +in the survey could choose not to answer some of the questions. (b) In some of the rural and tribal +areas of India, the language was a significant barrier, and the missing data was reported. The study +would have been benefitted by asking the question, “Would you like to practice yoga?” This question +would have explained the attitude of yoga among the India population more convincingly. However, +belief that yoga in lifestyle modification and the prevention and management of diabetes mellitus in +all the age groups provides an indirect evidence of the positive attitude of yoga in India. Despite +these limitations, this is the largest study on KAP-Y use in Asia. +6. Conclusion +The study highlights the variation in prevalence of yoga practice based on the demographic +characteristics and concludes that 11.8% of the Indian population practices yoga across both rural +and urban areas. However, further studies are required to identify the therapeutic or preventive +benefits of yoga in various clinical conditions along with an evidence-based inclusion of yoga in +clinics, which may partially bridge the chasm that exists between the knowledge and practice of yoga. +The study also recommends education and training for yoga theory and practice for practitioners as +well as physicians. In addition, research studies will help yoga be integrated for public education, +training, and the management of diseases. +Author Contributions: Conceptualization, R.N. and H.R.N.; methodology, R.N.; validation, R.N.; ethics, R,N.; +raw data, A.S.M.; data curation, A.S.M., R.S. K., and V.H.S.; writing—original draft preparation, H.B., M.S.S., +and A.S.; writing—review and editing, A.A.; supervision, A.S.M.; project administration, A.S.M. and R.N.; +conceptualization of manuscript and editing, A.A.; All authors have read and agreed to the published version +of the manuscript. +Funding: This study was funded by the Indian Yoga Association, Central Council for Research in Yoga and +Naturopathy (CCRYN), Ministry of AYUSH, Ministry of Health and Family Welfare, Government of India. +(F.No. 16-63/2016-17/CCRYN/RES/Y&D/MCT/Dated: 15.12.2016) +Acknowledgments: The authors would like to acknowledge the support of Suchitra Patil, Swami Vivekananda +Yoga Anusandhana Samsthana, India for the contribution towards data analysis, CCRYN for manpower, +MOHFW for supporting the cost of investigations, and IYA for the overall project implementation +Medicines 2020, 7, 8 +11 of 12 + +Conflicts 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. The funders had no role in the +design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in +the decision to publish the results. +References +1. +NCDs. Global Action Plan on Physical Activity 2018–2030: More Active People for a Healthier World; World +Health +Organization: +2019. +Available +online: +https://www.who.int/ncds/prevention/physical- +activity/global-action-plan-2018-2030/en/ (accessed on 8 February 2019). +2. +Dhar, N.; Chaturvedi, S.K.; Nandan, D. Spiritual health scale 2011: Defining and measuring 4th dimension +of health. ICJM 2011, 36, 275. +3. +Wai, W.T.; Lan, W.S. Prevalence and determinants of the use of traditional Chinese medicine in Hong Kong. +Asia Pac. J. Public Health 1995, 8, 167–170. +4. +Ma, Y.C.; Lin, C.C. Time trend analysis of the prevalence and incidence of diagnosed asthma and traditional +Chinese medicine use among adults in Taiwan from 2000 to 2011: A population-based study. PLoS ONE +2015, 10, e0140318. +5. +Lauche, R.; Wayne, P.M. Prevalence, patterns, and predictors of T’ai Chi and qigong use in the united states: +Results of a nationally representative survey. J. Altern. Complement. Med. 2016, 22, 336–342. +6. +Vergeer, I.; Bennie, J.A. Participation trends in holistic movement practices: A 10-year comparison of +yoga/Pilates and t’ai chi/qigong use among a national sample of 195,926 Australians. BMC Complement. +Altern. Med. 2017, 17, 296. +7. +World Health Organization. The Regional Strategy for Traditional Medicine in the Western Pacific (2011– +2020). Available online: https://iris.wpro.who.int/handle/10665.1/5538 (accessed on 25 December 2019). +8. +Qi, Z. WHO Traditional Medicine Strategy: 2014–2023; World Health Organization: Geneva, Switzerland, +2013. Available online: https://apps.who.int/iris/handle/10665/92455 (accessed on 25 December 2019). +9. +Fan, D. Holistic integrative medicine: Toward a new era of medical advancement. Front. Med. 2017, 11, 152– +159. +10. +Rhee, T.G.; Marottoli, R.A. Patterns and perceived benefits of utilizing seven major complementary health +approaches in US older adults. J. Gerontol. Ser. A 2018, 73, 1119–1124. +11. +Telles, S.; Sharma, S.K. characteristics of Yoga Practitioners, Motivators, and Yoga Techniques of choice: A +cross-sectional study. Front. Public Health 2017, 5, 184. +12. +Sahay, B.K.; Murthy, K.J. Long term follow up studies on effect of yoga in diabetes. Diabetes Res. Clin. Pract. +1988, 5 (Suppl. 1), S655. +13. +Balaji, P.A.; Varne, S.R.; Ali, S.S. Physiological effects of yogic practices and transcendental meditation in +health and disease. N. Am. J. Med Sci. 2012, 4, 442. +14. +Pascoe, M.C.; Thompson, D.R.; Ski, C.F. Yoga, mindfulness-based stress reduction and stress-related +physiological measures: A meta-analysis. Psychoneuroendocrinology 2017, 86, 152–168. +15. +Ministry of AYUSH. GOI. Available online: http://ayush.gov.in/genericcontent/common-yoga-protocol- +2017 (accessed on 8 February 2019). +16. +Butzer, B.; Ebert, M. School-based yoga programs in the United States: A survey. Adv. Mind Body Med. 2015, +29, 18. +17. +Nagendra, H.R.; Nagarathna, R.; Rajesh, S.K. Niyantrita Madhumeha Bharata 2017, Methodology for a +Nationwide Diabetes Prevalence Estimate: Part 1. Int. J. Yoga 2019, 12, 179–192. +18. +Nagarathna, R.; Rajesh, S.K.; Amit, S. Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a +Nationwide Multicentric Trial on the Effect of a Validated Culturally Acceptable Lifestyle Intervention for +Primary Prevention of Diabetes: Part 2. Int. J. Yoga 2019, 12, 193–205. +19. +Singh, T.; Sharma, S. Socio-economic status scales updated for 2017. Int. J. Res. Med. Sci. 2017, 5, 32. +20. +Mohan, V.; Deepa, R.; Deepa, M. A simplified Indian Diabetes Risk Score for screening for undiagnosed +diabetic subjects. J. Assoc. Physicians India 2005, 53, 759–763. +21. +Cramer, H. Yoga in Germany-results of a nationally representative survey. Forschende Komplementarmedizin +(2006) 2015, 22, 304–310. +22. +Ding, D.; Stamatakis, E. Yoga practice in England 1997–2008: Prevalence, temporal trends, and correlates +of participation. BMC Res. Notes 2014, 7, 172. +Medicines 2020, 7, 8 +12 of 12 + +23. +Cramer, H.; Sibbritt, D. Is the practice of yoga or meditation associated with a healthy lifestyle? Results of +a national cross-sectional survey of 28,695 Australian women. J. Psychosom. Res. 2017, 101, 104–109. +24. +Cramer, H.; Ward, L. Prevalence, patterns, and predictors of yoga use: Results of a US nationally +representative survey. Am. J. Prev. Med. 2016, 50, 230–235. +25. +Saper, H.B.; Eisenberg, D.M. Prevalence and patterns of adult yoga use in the United States: Results of a +national survey. Altern. Ther. Health Med. 2004, 10, 44–49. +26. +Cramer, H.; Hall, H. Prevalence, patterns, and predictors of meditation use among US adults: A nationally +representative survey. Sci. Rep. 2016, 6, 36760. +27. +Patwardhan, A.R.; Lloyd, L. Decline in the Use of Medicalized Yoga Between 2002 and 2012 While the +Overall Yoga Use Increased in the United States: A Conundrum. J. Evid. Based Complement. Altern. Med. +2017, 22, 567–572. +28. +Yoga Integral Part of Our Culture, Says PM Modi [Internet]. The Economic Times. 2019. Available online: +https://m.economictimes.com/news/politics-and-nation/yoga-integral-part-of-our-culture-says-pm- +modi/articleshow/69884350.cms (accessed on 28 November 2019). +29. +The Economic Times. Available online: https://economictimes.indiatimes.com/news/politics-and- +nation/over-2000-yoga-practitioners-in-india-tamil-nadu-has-highest-at-751-ayush-minister-shripad- +yesso-naik/articleshow/48347167.cms (accessed on 8 February 2019). +30. +Vermeire, E.; Hearnshaw, H. Patient adherence to treatment: Three decades of research. A comprehensive +review. J. Clin. Pharm. Ther. 2001, 26, 331–342. +31. +Roy, V.; Gupta, M. Perception, attitude and usage of complementary and alternative medicine among +doctors and patients in a tertiary care hospital in India. Indian J. Pharmacol. 2015, 47, 137. +32. +Subramanian, K.; Midha, I. Prevalence and Perspectives of Complementary and Alternative Medicine +among University Students in Atlanta, Newcastle upon Tyne, and New Delhi. Int. Sch. Res. Not. 2016, 2016, +1–9. +33. +Kong, F.H.; Man, L.K. Knowledge, attitude and practice of complementary and alternative medicine (CAM) +among medical practitioners. IJRRMS 2013, 3, 5–9. + + +© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access +article distributed under the terms and conditions of the Creative Commons Attribution +(CC BY) license (http://creativecommons.org/licenses/by/4.0/). + diff --git a/subfolder_0/Kundalini yoga meditation for complex psychiatric disorders.txt b/subfolder_0/Kundalini yoga meditation for complex psychiatric disorders.txt new file mode 100644 index 0000000000000000000000000000000000000000..15931892ddecb6d824953de0b49cd1b1c6b7050d --- /dev/null +++ b/subfolder_0/Kundalini yoga meditation for complex psychiatric disorders.txt @@ -0,0 +1,238 @@ +Volume 5 | Issue 2 | July-December | 2012 +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 +Editorial +Models and mechanisms in yoga research +Original Articles +Yoga in Australia: Results of a national survey +Yoga breathing through a particular nostril is associated with contralateral event-related potential changes +Immediate effect of chandra nadi pranayama (left unilateral forced nostril breathing) on cardiovascular parameters in hypertensive patients +Effect of holistic yoga program on anxiety symptoms in adolescent girls with polycystic ovarian syndrome: A randomized control trial +Comparative study of conventional therapy and additional yogasanas for knee rehabilitation after total knee arthroplasty +Study of the effect of yoga training on diffusion capacity in chronic obstructive pulmonary disease patients: A controlled trial +A comparative study of the effects of yoga and swimming on pulmonary functions in sedentary subjects +Contents +ISSN 0973-6131 +161 +International Journal of Yoga  Vol. 5  Jul-Dec-2012 +Kundalini yoga meditation for complex psychiatric +disorders +Author: David S Shannahoff Khalsa +Year: 2010 +Publishers: Norton Professional Book, New York, USA. +Book Review +chapter 3 (treating personality disorders), the traditional +method of therapy for patients with personality disorders +i.e., of Dialectical Behavior Therapy is mentioned along +with that of yoga through scientific research studies +(pages 122–131). Further, how certain symbols can be +used as associations in therapy have been detailed (e.g., +cave, tall tree, low tree, spiral shell, stick or branch, +waterfall, snake, stone, claw, bird; page 150). In chapter +4 (treating pervasive developmental disorders, PDD) the +authors have emphasized the need for therapy as an +important part of the treatment, as in PDD’s medications +are observed to only help deal with the behavioral +problems. Yogic methods to improve eye-to-eye contact +and other symptoms of PDD have been detailed with +the surmise that the effectiveness of the therapy would +depend on the degree of trainability of the patient (page +280). Finally in the last chapter on ‘multimorbilities’, +the author has detailed the principles of therapy to deal +with these complex cases (page 270) and the importance +of continued therapy for effective outcomes. +Certain issues raised by the author during the course of the +book could, however, require further thought and debate: +1. Desire to self heal: All the case histories reported in +this book have been successful in healing the patient, +because of their ‘desire to self heal’ (Chapter 2, Page 53). +However, the basic challenge in treating any psychiatric +patient with the conventional modalities of treatment +and more so with the yogic protocols is the patients’ +lack of insight regarding their own disorder. The +Mental Status Examination (MSE) of any psychiatric +patient involves assessing his insight which in turn +enables the psychiatrist to prescribe pharmacological/ +non-pharmacological treatment.[2] The level of insight +(about one’s own disorder) in a patient can indirectly +predict his co-operation to treatment and recovery.[2] +Psychiatrists, hence, aim to first stabilize the patient’s +symptoms and insight through pharmacological +treatment modalities, and once the patient is amenable +Through his book titled, ‘Kundalini Yoga Meditation +for Complex Psychiatric Disorders – Techniques specific +for treating the psychoses, personality and pervasive +developmental disorders’, Shannahoff-Khalsa has provided +field-tested protocols of Kundalini Yoga Meditation +for severe psychiatric disorders. These protocols are +substantiated with evidence-based case studies, which add +to the validity of the prescribed Kundalini yoga techniques. +The author has written this book as an extension of his +first book on Kundalini Yoga Meditation, where he focused +on protocols for specific psychiatric disorders like OCD, +couples therapy and personal growth. His introductory +chapter clearly states that the focus of the present book is +to target Kundalini yoga meditation for severe psychiatric +disorders like schizophrenia, pervasive developmental +disorders and personality disorders and toward dealing +with psychiatric ‘multimorbidity’ conditions (Chapter 5, +Page 270) which seem to be common in USA.[1] +In each of his subsequent chapters on treating +schizophrenia and other psychotic disorders (Chapter 2), +treating personality disorders (Chapter 3), treating +pervasive developmental disorder (Chapter 4) and treating +multimorbidity in psychiatric disorders (Chapter 5), he +eloquently details the diagnostic details of each disorder, +its prevalence, conventional modalities of treatment, +yogic view of etiology and yogic protocols for treatment +along with successfully treated case histories. Certain +notable and new concepts have also been discussed in +each of the chapters. For example: in chapter 2 on ‘treating +schizophrenia’, the patient’s ‘desire to self-heal’ in the +process of treatment has been emphasized (page 53). In +Access this article online +Website: +www.ijoy.org.in +Quick Response Code +International Journal of Yoga  Vol. 5  Jul-Dec-2012 +162 +Book Review +to suggestions of a therapist, the patient could be +prescribed conventional or alternative therapy. In cases +of severe psychiatric disorders like schizophrenia, +personality disorders and autism, yoga as a therapy, +requires the patient to have at least a moderate level +of insight[2] (‘desire to self heal’), without which results +could be discouraging. +2. Add-on therapy with medication: In continuation +with the above point of discussion, yoga could +possibly be looked at as a more effective add on +treatment, than a stand alone treatment especially in +psychiatric disorders such as schizophrenia, where +some psychiatric symptoms (positive symptoms of +schizophrenia) show initial good response only to +drugs.[2] This issue is indirectly validated in this book +as two out of three cases of psychosis mentioned, were +either already on medications when they started the +yoga treatment or were advised to start yoga along with +medication treatment. Kundalini yoga could be looked +at as a stand alone treatment in the case of personality +disorders and pervasive developmental disorders where +the mainstay of treatment is non-pharmacological. +Therapists however need to be cognizant that in dealing +with ‘multimorbid’ psychiatric disorders, the decision +to prescribe yoga as a stand alone treatment could be +complex. +3. Continuing yoga therapy: Yoga is as an effective +alternative treatment in patients who do not obtain +remission or satisfactory symptom-relief even +after taking pharmacological treatment.[3] This +effectiveness is, however, pronounced only if yoga +is practiced on a continuous basis over a period of +time.[4] The negative symptoms of schizophrenia such +as lack of motivation deter patients from indulging +in any activity. Further lack of insight about ones +disorder may make the patient believe that they do not +require the treatment. Research studies in yoga have +reported logistic as well as illness related barriers +to yoga therapy which requires to be understood +before prescribing yoga to patients with psychiatric +problems.[5] Most of the cases in this book were +referred by the consultant doctor or by the family +member of the patient, a possible cause for continuing +with the treatment. +4. Chakras stimulation/ Meditation: The Kundalini yoga +meditation techniques mentioned in this book are +novel in the field of psychiatry as most other studies +on patients with psychiatric disorders are limited +to yogasanas and pranayama variants only. This +is because, studies have depicted that meditation +could possibly result in a risk of exacerbating +psychosis. Some patients have the risk of activation +of psychosis during meditation.[6] In patients with +schizophrenia, a good proportion of who suffer from +motivational defects, ensuring these mindful practices +is a challenge.[7] The effectiveness of Kundalini yoga +meditation techniques though seen to be effective in +this book could require further investigation in large +sample randomized controlled studies to counter the +criticism of including meditation techniques in yoga +protocols for treatment of (especially) patients with +psychosis. +5. Tackling macro issues of mental health care through +Yoga: The author has concluded his book with +an epilogue which discusses yoga as an effective +preventive treatment to counter the health care market +forces. It is true that in the USA (where health care +is privatized) as well as in developing countries like +India, liberalization, privatization and globalization +of mental health care have caused rise in the costs of +medication and mental health care treatment. Despite +the success of District Mental Health Programme in +some states, the common person of India finds it +difficult to access affordable mental health care in the +community. To tackle this growing issue, introduction +of yoga as a preventive, alternative and complementary +treatment for patients with psychiatric disorders in +India could be an effective solution for three basic +reasons: (1) yoga which originated in India is seen +to be a practical and accepted therapy for patients to +practice at home, (2) the number of yoga therapists is +more than the number of mental health professionals +available in India, and finally, (3) yoga is cost-effective +and has no side-effects as in the case of psychiatric +medications. +Overall, the book provides practical and feasible yogic +protocols for treatment of severe psychiatric disorders +which were considered till date to be incurable even with +pharmacological medications. By reading the success +stories of the cases mentioned in this book, family members +of psychiatric patients can seek solace in the existence +of a possible alternative treatment for severe psychiatric +disorders. +References +1. +Angst J, Sellaro R, Ries Merikangas K. Multimorbidity of psychiatric +disorders as an indicator of clinical severity. Eur Arch Psychiatry Clin +Neurosci 2002;252:147-54. +2. +Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: +Behavioral Sciences/Clinical Psychiatry, 7th Ed. USA: Lippincott Williams +& Wilkins; 2000. +3. +Buckley PF, Stahl SM. Pharmacological treatment of negative symptoms of +schizophrenia: Therapeutic opportunity or cul-de-sac? Acta Psychiatr Scand +2007;115:93-100. +4. +Patañjali (1989; Feuerstein, G. translation). The Yoga-Sutra of Patañjali: +A  New Translation and Commentary, Inner Traditions International; +Rochester, Vermont, Verse/Page: 1.14. +5. +Baspure S, Jagannathan A, Kumar S, Varambally S, Thirthalli J, +163 +International Journal of Yoga  Vol. 5  Jul-Dec-2012 +Book Review +Venkatasubramanain G, et al. Barriers to yoga therapy as an add-on treatment +for schizophrenia in India. Int J Yoga 2012;5:70-3. +6. +Walsh R, Roche L. Precipitation of acute psychotic episodes by intensive +meditation in individuals with a history of schizophrenia. Am J Psychiatry +1979;136:1085-6. +7. +Gangadhar BN, Varambally S, Thirthalli J, Jagannathan A., Kumar S., +Venkatasubramanian G., et al. Therapeutic efficacy of add-on yogasana +intervention in stabilized outpatient schizophrenia: Randomized controlled +comparison with exercise and waitlist. Indian J Psychiatry 2012 [in press]. +Aarti Jagannathan +Assistant Professor, Division of Yoga and + +Life Sciences, Swami Vivekananda + +Yoga Anusandhana Samasthana (SVYASA), +Bangalore – 560 019, India. +E-mail: jaganaarti@gmail.com diff --git a/subfolder_0/Lifestyle - A Common Denominator for the Onset and Management of Migraine Headache_ Complementing Traditional Approaches with Scientific Evidence.txt b/subfolder_0/Lifestyle - A Common Denominator for the Onset and Management of Migraine Headache_ Complementing Traditional Approaches with Scientific Evidence.txt new file mode 100644 index 0000000000000000000000000000000000000000..d868dc7dce66918dce307205ea8c6c6790280ce3 --- /dev/null +++ b/subfolder_0/Lifestyle - A Common Denominator for the Onset and Management of Migraine Headache_ Complementing Traditional Approaches with Scientific Evidence.txt @@ -0,0 +1,476 @@ +Int J Yoga. 2019 May-Aug; 12(2): 146–152. +doi: 10.4103/ijoy.IJOY_59_18 +PMCID: PMC6521746 +PMID: 31143023 +Lifestyle - A Common Denominator for the Onset and Management of +Migraine Headache: Complementing Traditional Approaches with +Scientific Evidence +MS Vasudha, NK Manjunath, and HR Nagendra +Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana a Deemed to be +University, Bengaluru, Karnataka, India +Address for correspondence: Dr. Vasudha MS, Division of Yoga and Life Sciences, Swami Vivekananda +Yoga Anusandhana Samsthana University, Prashanthi Kutiram, Jigani Hobli, Anekal Taluk, Bengaluru - 560 +106, Karnataka, India. E-mail: vasudhamsharma@gmail.com +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 +Background: +Ayurveda and Yoga have gained popularity in the management of various chronic health problems +associated with pain including migraine headache. It is evident from both scientific as well as +traditional literature that stress, diet, sleep, and exposure to extreme climatic conditions act as +triggering factors for the onset of migraine. Hence, it is essential to focus on lifestyle including diet as +important factors for prevention and as adjuvant factors in the management of migraine headache. +Aim: +The aim was to propose a new perspective to the understanding of migraine headache keeping in view +the role of lifestyle including diet. +Methods: +Classical Ayurveda texts and traditional Yoga scriptures were used to compile information on the role +of lifestyle including diet in the onset and management of migraine headache. This was complemented +by PubMed-based review of scientific literature. +Outcome: +Ayurveda texts provide an extensive information about the basic understanding, causes, precipitating +factors, and management of migraine headache, while Yoga texts refer to the concept of mental stress +(adhi) leading to physical health problems (vyadhi). It is evident from the literature that diet, sleep, +exposure to extreme climatic conditions, and mental stress play an important role in the onset and +management of migraine headache. +Conclusion: +Lifestyle appears to be the common factor for both onset and management of migraine headache. +Keywords: Ayurveda, diet, lifestyle, migraine headache, yoga +Introduction +A migraine is one of the most common primary headache disorders, characterized by unilateral, +pulsatile, or throbbing sensations in the head. It is associated with greater degree of disability and is +triggered by psychological and physiological stressors.[1] A number of intrinsic and extrinsic factors +can trigger an episode of migraine. The important triggers are stress, food, fasting, sleep deprivation, +and change in weather conditions.[2] The need for lifestyle modification, including physical exercise, +healthy habits, proper diet, and stress adaptability, has become essential factors in the management of +most chronic ailments like migraine. Exploring this understanding as per Ayurveda and Yoga texts and +correlating it with available scientific literature aims at providing a value addition with supporting +evidence in the management of migraine headache. +Ayurveda, an ancient system of Indian medicine, defines health as a state of well-being resulting from a +synergistic balance in Doshas (principal systems functions - Vata, Pitta, and Kapha), Dhatu (body +tissues), Mala (excretory products), and Agni (digestive fire). A blissful state of Atma (spirit), Indriya +(sense organs), and Manas (mind) is also said to be important to achieve the state of positive health.[3] +Migraine headache is referred as Ardhavabedhaka under the classification of Shiroroga (diseases +related to the head region) in Ayurveda treatises.[4] The pain associated is one-sided, intense, and +piercing in nature. The onset of Ardhavabhedaka is attributed to various causes, such as fasting, intake +of dry food items, alcohol, weeping, suppression of natural urges, daytime sleeping, anxiety, fear, and +grief. The line of treatment for migraine involves administration of samshodhana (Panchakarma-Bio- +purificatory techniques) with special mention of kaya virechana (therapeutic purgation),[5] diet and +lifestyle regulation. Pathya ahara (wholesome regulated diet) and vihara (wholesome regulated +lifestyle) are the primary approaches to maintain homeostasis of all dosha's for prevention and +management of diseases. Scientific literature also shows that diet, lifestyle, and stress can contribute to +increased prevalence of migraine headache and their understanding helps in its management.[6] +According to Yoga, migraine is considered as an adhija vyadhi (mind-body disorder)where the +disturbances in the mind influence the flow of Prana (the vital force/breath) resulting in physical +problems and affecting the weakest system in the body.[7] Yogic principles of diet are based on +trigunas (the three inherent qualities of food), which emphasize on intake of healthy and nourishing +vegetarian diet. The concept of achara and vichara denoting healthy activities such as practice of +asana, right thoughts, and attitude, respectively, play a key role in the prevention and management of +diseases. +Scientific literature mentions diet and lifestyle as migraine triggers and also states that education on the +same plays a major role in its prevention.[6] Complementing the traditional understanding with +scientific evidence, therefore, would add value in designing a more holistic and integrative line of +treatment. Hence, this concept paper aims at compiling information from both traditional and modern +literature to present a new perspective to the management of migraine headache. +Methods +Seven major texts of Ayurveda which included Bruhtrayis (three major texts), Laghutrayis (three minor +texts) and Yoga Ratnakara were reviewed, and relevant information was compiled under two headings: +(i) factors responsible for the onset of migraine and (ii) factors which play a key role in the +management of migraine apart from conventional Ayurveda therapies. The factors were further +categorized into two (i) diet and (ii) lifestyle (stress, sleep, habits, and others). The texts reviewed +included Charaka samhita, Sushruta samhita, Ashtanga Hridaya, BhavaPrakasha, Madhava nidana, +Sharangadhara samhita, and YogaRatnakara. The compilation also includes information on headache- +related disorders (shiroroga), as migraine is grouped under this category in some Ayurveda texts. +Similarly, an attempt was made to classify the appropriate information from ancient Yogic texts under +the categories mentioned above. The texts included Upanishads, Bhagavadgita (B.G.), Hatha Yoga +Pradipika, Patanjali Yoga Sutras (P.Y.S), Shatdarshana and Yoga Vasishta. Although we found no +Role of diet in the onset +direct mention of migraine headache in the texts, selected concepts related to disease and pain were +considered. +Furthermore, a focused search of modern literature was conducted using PubMed as the data base +during July 2018. Since the objective was to derive complementary information to the traditional +understanding and not to do a systematic review, we considered PubMed as the only search engine for +this purpose. The keywords used for the search were lifestyle, diet, stress, sleep in relation to a +migraine headache. The type of articles considered included review articles, cross-sectional studies, +randomized controlled trials, cohort studies, and surveys. +Description of common factors responsible for the onset and management of migraine +Further to the compilation, the concepts have been described to arrive at an understanding of diet and +lifestyle as common factors which would play an important role in both onset and management of a +migraine. +The etiological factors as mentioned in Ayurveda treatises, Yogic scriptures, and modern medical +research show lot of similarities. +Studies show that stress is one of the four most acknowledged triggers. The other three are fatigue, not +eating on time and lack of sleep.[8] The triggers are also broadly classified as dietary causes and +lifestyle based causes which includes stress. +Factors responsible for the onset of migraine headache +Concepts based on Ayurveda texts +The etiological factors described here are the concepts propounded by the great Ayurveda scholars +known as Acharya (an accomplished practitioner and teacher known for his wisdom in Ayurveda). +Acharya Charaka mentions independent and specific nidana (causes) for the onset of Ardhavabhedaka +(migraine), whereas Acharya Vagbhata has explained only Samanya shiroroga nidana (general +etiology of headache) which triggers any type of Shiroroga (diseases of the head) including +Ardhavabhedaka (migraine). The other Ayurveda texts have also outlined similar details. The important +verses in Sanskrit and their translation to English are cited under respective sections. +Acharya Vagbhata in the Ayurveda treatiz “Ashtanga Hridaya” under Uttarasthana (A.H.U) explains +the samanya nidana (general etiology) as: +Dhūmātapatuṣārāmbukrīḍātisvapnajāgaraiḥ | +Utsvēdādhipurōvātabāṣpanigraharōdanaiḥ | A.H.U. 23/1 || +Atyambumadyapānēna kr +̥ mibhirvēgadhāraṇaiḥ | +Upaghātamr +̥ jābhyaṅgadvēṣādhaḥpratatēkṣaṇaiḥ || A.H.U. 23/2 || +Asātmyagandhaduṣṭāmabhāṣyādyaiśca śirōgatāḥ | +Janayantyāmayān dōṣāḥ || A.H.U. 23/3 ||. +The smoke, sunlight, dew, playing in water, excessive sleep, keeping awake at night, excessive +sweating, stress, wind, suppression of tears, crying, excessive intake of water and alcohol, helminthic +infection, suppression of natural urges, avoidance of hygiene, dislike towards abhyanga (massage), +constant gazing, bad odor, excessive talking may increase the ama formation leading to accumulation +of dosha in the head region causing various diseases of the head region.[9] +Acharya Charaka in Siddhisthana (C.Si) explains the specific etiology as: +Rūkṣātyadhyaśanāt pūrvavātāvaśyāyamaithunaiḥ| +Vēgasandhāraṇāyāsavyāyāmaiḥ || C.Si. 9/74 ||. +The intake of dry items, excessive intake of food, less intake of food, exposure to wind, controlling the +natural urges of tears, sexual drive, bowel, and bladder evacuation vitiate the vata.[5] +Most of the causative factors mentioned under samanya nidana (general etiology) aggravate vata, pitta, +and kapha and vitiate rakta. From the available information on samanya nidana of shiroroga and +specific nidana of Ardhavabhedaka, the etiological factors have been classified as aharaja nidana +(dietary causes), viharaja nidana (lifestyle causes), and manasika nidana (mental causes). +Specific dietary causes (aharaja nidhana) and the underlying mechanisms: +Adhyashana (consumption of food before the digestion of previous meal): It leads to ama +formation which enters the circulation and vitiates rakta. When it lodges in ardhashiras (one side +of the head), it produces Ardhavabhedaka[5] +Amla ahara (sour food): Excessive intake of sour food articles which have laghu (light), +snighdha (unctuous), and ushna (hot) guna (quality) does the vilayana (melting down) of kapha +and pitta rakta dooshana (vitiate pitta and rakta) +Anashana (intake of less food): It may be abhojana/alpamatra bhojana (not taking food/taking +less food) which leads to rikta kosta (empty stomach) and vata prakopa (aggravation)[5] +Atisheetambu pana (intake of excessively cold water): It causes agnimandya (weak digestion) +leading to the formation of ama (byproduct of improper digestion). Sheeta guna (cold quality) +which vitiates vata in turn causes sankocha (constriction) of sira (arteries) in the body. It causes +kapha prakopa (aggravation of kapha) by its snigdha (unctuous), manda (slow) and guru (heavy) +guna causing raktadusti (vitiation of blood), srotodusti (vitiation of body channels) in the shiras +(head) leading to ardhavabhedaka[5] +Ati madya sevana (excessive intake of alcohol): It leads to dooshana of pitta and rakta (vitiation +of pitta and blood). It also causes the vidaha (inflammation) of rakta by its ushna (hot), vyavayi +(diffuse), vikasi (spreading nature) gunas (qualities), results in kshobha (constriction) of +raktavaha sira (disturbance in blood vessels), which leads to vatadi prakopa (aggravation of +vata) and shiroroga (diseases of the head)[9] +Guru Ahara (heavy food): It leads to agnimandya (weak digestion), causes kapha prakopa there +by acting as a trigger for headache[9] +Rookshashana (dry food): It causes vata prakopa which leads to formation of kledamsha (waste) +leading to the srotorodha (blockage of channels) leading to Ardhavabhedaka +Sambhojana (eating food which is completely filling): It causes tridosha prakopa and cause +amotpatti (production of ama) leading to shirashoola (headache).[5] +Concepts according to Yoga texts +Taittiriya Upanishad summarizes the importance and role of food in an individual's life. It says: +“Annam Brahmeti vyajanaat,” i.e. food is Brahman (Universal consciousness), because it is food from +which all beings are born, sustain and finally merge into. Food, therefore, plays an important role in +health and disease.[10] +Hatha Yoga Pradipika explains food along with yama (restraints on behavior) and niyama +(observances). It mentions that food taken should be of moderate quantity, pleasant, and sweet leaving +one-fourth of the stomach empty. Food items which are sour, pungent, and hot-like mustard, alcohol, +fish, meat, curds etc., reheated food, salty food are those advised to be avoided.[11] +The B.G. explains the importance of diet in the context of disease as follows: +Āyuḥsattvabalārōgyasukhaprītivivardhanāḥ| +Rasyāḥ snigdhāḥ sthirā hrṛdyā āhārāḥ sāttvikapriyāḥ || B.G. 17/8 || +Kaṭvamlalavanṛātyuṣnṛatīkṣnṛarūkṣavidāhinaḥ| +Role of lifestyle in the onset of migraine headache +Āhārā rājasasyēṣṭā duḥkhaśōkāmayapradāḥ || B.G. 17/9 || +Yātayāmaṃ gatarasaṃ pūti paryuṣitaṃ ca yat| +Ucchiṣṭamapi cāmēdhyaṃ bhōjanaṃ tāmasapriyam || B.G. 17/10 ||. +Food in the mode of goodness increases the duration of life, purify one's existence and gives strength, +health, happiness, and satisfaction. Such food are sweet, juicy, nourishing, and palatable and are known +as Satvic food. Foods that are too bitter, too sour, salty, pungent, dry and hot, are liked by people in the +modes of passion. Such foods cause pain, distress, and disease. These are Rajasic foods. The food +cooked for more than 3 h before being eaten, which is tasteless, stale, putrid and unclean, is food liked +by people in the mode of ignorance. It is called Tamasic food. Hence, it can be postulated that the +rajasic and tamasic food when consumed inappropriately trigger diseases associated with pain as both +of them aggravate pitta which is a principle factor in the onset of headache.[12] +Complimenting concepts based on scientific literature +Scientific evidence shows that the food we consume acts as a potential trigger for migraine and is +second to stress responsible for its onset. +Food items, such as dairy, processed food, fermented, pickled and marinated food, and those which +contain nitrates (hot dogs, salami, and bacon), tyramine (aged cheese, beans, citrus fruits, avocado, +banana, onion, red wine) caffeine and histamine (seafood),[13] are found to be the triggers of migraine. +The onset of headache due to the above can be understood by theories of brain-gut axis where a +sensitive nervous system develops hyperexcitability as a response to multiple environmental and +immunological factors.[14] +Diet and nutrition can also bring about neurogenic and vascular inflammatory changes. Following +ingestion of certain food, studies show that the rate in which neurons synthesize neurotransmitters is +influenced.[15] This can be supported by studies where decreased serotonin levels have shown to +trigger migraine and diet can contribute to increase in serotonin levels.[16] +Concepts according to Ayurveda (viharaja karana) +The following factors are known to trigger the onset of migraine according to Ayurveda texts: +Avashyaya/Tushara sevana (excessive exposure to mist): It increases vata and kapha because of +its sheeta guna (cold quality)[5] +Atapa sevana (excessive exposure to sunlight): This causes vilayana of kapha and aggravation of +pitta guna results in raktadusti[9] +Atimaithuna (excessive sexual indulgence): It causes shukra kshaya (oligospermia) which inturn +leads to vata dusti (vitiation of vata) and causes shiroroga (disease of the head)[5] +Ayasa (fatigue/exertion): Fatigue can be both physical and mental in origin. Physical fatigue +occurs due to ativyayama (excessive exercise), and mental fatigue may be due to rodana +(crying), chinta (worrying), etc., All these causes increase rooksha guna, leading to shoshana of +dhatus in the body. The vata gets vitiated in ardha shiras (half part of the head) to produce +ardhvabhedaka (migraine)[9] +Diwa swapna (day sleep): It causes kapha prakopa (vitiation of kapha) and increases medas +leading to raktadusti (vitiation of blood) and avarodha in the shiras (blockage in blood vessels) +to produce vata prakopa and shirashoola (headache)[9] +Pragvata (exposure to cold breeze from eastern direction): This causes vata kapha prakopa by +increasing sheeta guna. This causes sankocha of siramukha in shiras (obstruction of blood +vessels) to produce shiroroga (headache)[9] +Ratri jagarana (keeping awake during night): It does prakopa of vata by its rookshaguna[9] +Vega dharana (suppression of natural urges): Suppression of urges such as chardi (vomiting) and +kshavatu (sneezing), induces vata prakopa[9] +Asatmendriyartha samyoga (improper stimulation of sense organs) is considered an important +factor for trigger of diseases as Ayurveda considers the sense organs to be the route to the brain. +Constant glare, starring, bright light, loud noise, certain types of smell could trigger migraine.[9] +Role of lifestyle in health and disease according to Yoga +Yoga encompasses factors which are physical, mental, social, and spiritual in nature which can +influence health and disease. The principles might appear general and subtle, but plays vital role in the +overall understanding of health and disease. +Acharya Patanjali has provided the most comprehensive description of the five stress producing factors +called Kleshas. They are Avidya asmita raga dwesha and abhiniveshaha. +Ignorance, ego, desire, dislike, and fear of change are the five stress producing factors. The fivefold +kleshas are responsible for the onset of dukha (pain) which may be physical or mental. Diseases are +considered as dukha and can be overcomed through cittavritti nirodha (regulation of mental +modifications). We could overcome the fivefold klesha by practicing kriyayoga (tapas [austerity], +swadhyaya [self study], ishwarapranidhana [surrendering to the divine])and by ashtanga yoga (Eight +limbs of Yoga).[17] +Acharya Patanjali also mentions about cittavikshepa (obstacles) as the impediments in the path of +achieving the control of mind. Cittavikshepa leads to dukha (pain). They are vyadhi (disease), styana +(mental laziness), samshaya (doubt), pramada (lack of enthusiasm), alasya (physical lethargy), avirati +(craving for sense pleasure), bhrantidarshana (illusionary vision), alabdhabhumikatva (despair due to +failure to concentrate) and anavasthitatva (unsteadiness in concentration). There are seven methods +mentioned by Patanjali as a remedy and for the sake of simple study, we could understand that keeping +a positive attitude, practicing breathing techniques, and meditation on various objects help one to get +rid of the vikshepa.[17] +The Lifestyle modifications are better understood by knowing more on yamas (restraints) and niyamas +(observances) as explained in P.Y.S. +Ahiṁsā-satya-asteya brahmacarya-aparigrahāḥ yamāḥ ǁP.Y.S. 2/30ǁ +Śauca saṁtoṣa tapaḥ svādhyāy-eśvarapraṇidhānāni niyamāḥ ǁ P.Y.S. 2/32ǁ. +The yama (ethical living) guidelines have been mentionedas ahimsa: nonviolence, non-harming, satya: +truthfulness, honesty, asteya: Nonstealing, to the extent that one should not even desire something that +is not his own, brahmacharya: Walking in awareness of the highest reality, remembering the divine and +practicing the path of celibacy, aparigraha: Non possessiveness, nongreedy, nonindulgence. +The niyamas (ethical observances) are shaucha: Cleanliness and purity of body and mind. It results in +purification of the subtle mental essence, brings pleasantness, mastery over the senses, and capability +for self-realization, santosha: Contentment or comfortable acceptance of what one currently has. It +brings joy and happiness from within, tapah: Through training of the senses, there comes a destruction +of mental impurities and an ensuing mastery over the body and the mental organs of senses and actions, +svadhyaya: Self-study, reflection on sacred words, and study of the scriptures. Through this one attains +communion with the underlying natural reality, Ishvarapranidhana: Surrender and dedication to the +Supreme Being or Causal Source, devotion, and surrender of fruits of practice. It helps in achieving the +state of perfect concentration (samadhi). Yama and Niyama when not practiced as applicable to +common man can, therefore, lead to diseases.[17] +Scientific literature on lifestyle as a trigger in the onset +An episode of migraine is triggered by external factors such as fatigue, fasting, sleep disruption, +exercise, and weather conditions.[18] +Fatigue has been evaluated and has been significantly seen 12 h before a migraine episode.[19] +Studies demonstrate that peripheral and central sensitization of the trigeminovascular projection to the +dural vasculature can exacerbate neuronal responses to innocuous mechanical and noxious intracranial +dural inputs. This is considered a reason for trigger of migraine following physical activities such as +exercise.[20] +Sleep has been extensively studied as a cause of migraine. Lack of sleep, excess of sleep lead to +migraine[21] and migraineurs report poor sleep quality and daytime tiredness when compared to non- +migraineurs.[22] Reduced serotonin,[23] increased catecholamine's[24] and hypothalamic orexinergic +system[25] play a role in the onset of migraine. Orexin-containing neurons in the hypothalamus fire in +wakeful states, and disruption of orexinergic signaling results in excessive sleepiness. Orexinergic cells +affect not only monoaminergic activity across the sleep cycle but also pain modulation. The melatonin +levels which get synthesized by the pineal gland during darkness may not trigger migraine but may +predispose the onset of headache leading to awakening from sleep.[26] +Since hypothalamus is said to be involved in physiological functions as a regulator for homeostasis and +therefore plays a key role in sleep cycle, thirst, feeding, arousal, and urination. Hypothalamic activation +has been demonstrated in migraine during and before an episode of migraine in imaging studies.[27] +We, therefore, understand how lifestyle plays a role as a trigger of migraine. +Role of stress as a triggering factor +Ayurveda explains the concept of pragyaparadha (intellectual blasphemy). This unrighteousness is the +main cause of somatic diseases and can induce all the pathological conditions.[28] Stress can be +therefore considered as pragyaparadha. It is a factor due to which a person cannot perform optimum +levels of intellectual functions and cannot discriminate between right and wrong. This increases Vata +and hence aids manifestation of shoola (pain). +According to the Yoga text - Yoga Vasista, the concept of “Adhija vyadhi” explains about the diseases +originating from stress and “Anadhija vyadhi” explains the diseases which are not due to stress. The +duality of likes - dislikes, love – hatred, etc. which govern human emotions start creating imbalance at +the level of manomaya kosha and when intensify cause “Adhi's.”[7] These conflicts bring about the +speed in mind and is termed “stress.” The repetition brings in the response of anxiety, depression, anger +and affects the various systems. This is a state of mind described in P.Y. Sas “kshipta” featured by +agitation and restlessness and predominant with rajas. The B.G. illustrates the process of how stress +can lead to manifold problems. Repeated thinking and dwelling on the same thoughts have been +identified as source of all problems. This leads to attachment, desire, anger, delusion, memory loss, +lack of discrimination, and finally destroys oneself.[12] +According to Scientific literature, stress can be due to physical, mental or psychological factors. A +study on 3259 civil servants has shown that high strain jobs with low social support is associated with +migraine.[29] It is found that prolonged stress activates immune system and may facilitate pain. The +pro-inflammatory mediators such as tumor necrosis factor alpha, interleukin (IL)-1beta, IL-6 and +nitrous oxide are activated due to stress leading to migraine.[30] +Factors which play an important role as an adjuvant in the management of +migraine +The comprehensive Ayurvedic approach in the management of migraine +The first line of treatment for migraine is nidana-parivarjana (abstinence from etiological factors). The +objective is to reduce the frequency of attacks and to improve the quality of life. By adapting +dinacharya (daily regimen) and rutucharya (seasonal regimen), the frequency of headache episodes has +reduced. Pitta individuals have strong agni (digestive power), and the dietary causes such as overeating +of spicy food aggravate Pitta, leading to the formation of ama and further can trigger headache. +Therefore, they are advised to avoid Pitta aggravating food. Lifestyle-based causes (Viharaja nidana), +such as, weather-related causes, exposure to sunlight, wind, improper bowel, inadequate sleep and +excessive exercise should be avoided as they increase pitta and therefore increase the tendency of +shoola (pain).[4] +The description given in Sharangadhara Samhita Parishistam (S.P) provides a comprehensive +recommendation of diet (Pathya-Apathya) in the management of headache. +Śāli yavaṁ māṁsa rasaṁ vārtākuñca paṭolakam | +Drākṣādāḍimakharjūraphalani ca payastathā || +Niśāpānaṁ nadīsnānaṁ gandhadravya niśevaṇam | +Śirorogeṣu sarveṣu hitamuktaṁ yathāyatham || +Dravyāṇi ca atitīkṣṇāni durjarāṇi ca yāni vā | +Tānyaniṣṭapradānyatra tīkṣṇāśca nikhilāaḥ kriyāaḥ || (S.P 66). +Intake of red rice, barley, meat soup, snake gourd, grapes, pomegranates, dates, drinking milk at night +is indicated in the management of all types of headache including migraine. Excessive exercise and +strong smell are always contraindicated in the management of headache.[31] +Stress explained as manasika nidana, requires satvavajaya chikitsa for its management. A detailed +counseling restores adaptability and is essential to alleviate the condition. +Another unique concept in the management is Sadvritta (personal conduct). It brings in good health and +control over senses and desires, therefore, influencing the control and treatment of any disease +including headache. +Although diet, lifestyle, and code of conduct have been mentioned in the management of +Ardhavabhedaka (migraine), Ayurveda provides a line of treatment which involves snehana (internal +and external oleation), shodhana (purificatory teachniques), shamana (pacificatory therapy), vamana +(therapeutic vomiting), virechana (therapeutic purgation), basti (enema) and nasya (nasal errhines) as +antahparimarjana chikitsa (internal cleansing therapies). Lepa (medicated paste application), upanaha +(poultice), swedana (fomentation), and shirobasti (oil retention on the head) are mentioned as +bahirparimarjana chikitsa (external cleansing therapies) and siravyadha and agnikarma are the shastra +pranidhana (surgical therapies) for the management of migraine headache.[4] +Therapeutic yoga - a customized approach in the management of migraine +Yuktāhāra-vihārasya yukta-ceṣṭasya karmasu | +Yukta-svapnāvabodhasya yogo bhavati duḥkha-hā || B.G. 6/17 |||. +The Gita, explains that the one who follows the right diet, lifestyle, does proper actions, whose hours of +sleeping and waking up are regulated can mitigate pain (disease) through Yoga. +Yoga emphasizes on healthy and nourishing food for the management of illness. Modern-day +psychosomatic diseases are fostered by the inappropriate diet and wrong eating habits. If the mind is +controlled through Yoga, the craving for wrong food and the discrimination between right and wrong +would be clear in individuals to bring in better health to the society.[12] +Yama and Niyama enhance the internal healing capacity due to the cultivation of right habits and moral- +ethical living. Harming animals is an act of violence. Therefore, Yogic concepts suggest avoiding Non- +vegetarian food and to follow the path of ahimsa to avoid the increase in rajas leading to diseases. In +this way aspects of yama and niyama can be adapted in disease management.[17] +The beneficial effects of yoga in the management of disorders have been explained in Hatha yoga +pradipika. By the practice of asana, an individual attains steadiness of the body and mind, +diseaselessness and lightness of the body. The text describes that the practice of asana such as +matsyendrasana (fish pose) and pashchimottanasana (seated forward bend pose) improves digestive +fire (jataragni) and therefore alleviates diseases.[11] +Pranayama practices are known to help in balancing the flow of subtle energy across the nadi. The +three practices, right nostril breathing, left nostril breathing and alternate nostril breathing which use +uni-nostril voluntarily regulated breathing aim to stimulate, relax, and balance the flow of prana across +the two main nadis - Ida and Pingala.[11] +Yoga also prescribes reduced sensory stimulation and sensory withdrawal through the process called +pratyahara as an important technique.[17] Considering the precipitating factors for migraine headache, +intense focusing as involved in dharana shall be avoided. Perhaps, meditation which takes an +individual to an effortless state of expansion featured by alertful rest should be the practice of choice. +Hatha yoga pradipika in addition talks about the internal cleansing practices called “Kriya.” +Hence, an integrated approach involving asana (physical postures), pranayama (regulated breathing), +kriya (cleansing techniques), meditation, and relaxation techniques are used in the management of +migraine headache.[11] +Scientific literature on Conventional medical concepts of management +While the conventional medical approach prescribes oral analgesics as a symptomatic treatment in the +management of migraine, equal importance has been given for regulating lifestyle and diet. +Modern nutritionists encourage mindful eating behaviors along with restriction of carbohydrate, gluten, +alcohol, and caffeine. This is said to fit well with lifestyle management including stress reduction, +adequate sleep, regular exercise, and weight management.[13] +In a study during Ramadan, the most common triggers for headache were stress, physical activity, +change in weather and fasting. While 50% achieved relief by nonsteroidal anti-inflammatory drugs, +45% achieved through sleep.[32] Another study has shown that stress management has advantages +compared to pharmacological treatments and the therapeutic effects are maintained for at least 7 years. +[33] +Conclusion +Lifestyle including stress and diet as major factors plays an important role for the onset and +management of migraine headache. Traditional approaches would provide a better understanding of the +preventive and management strategies, and the combination of Ayurveda and Yoga therapy shall +provide long-term solutions to the management of migraine which is one of the most disabling +headache disorders of the present day. +Financial support and sponsorship +Nil. +Conflicts of interest +There are no conflicts of interest. +References +1. Menken M, Munsat TL, Toole JF. The global burden of disease study: Implications for neurology. +Arch Neurol. 2000;57:418–20. [PubMed] [Google Scholar] +2. Alessandro SZ, Birthe LR. Symptomatology of migraine without aura. In: Olesen J, Hensen P, Welch +KM, editors. The Headache. 2nd ed. Philadelphia, PA: Lippincott Williams and Willkins; 2000. pp. +337–43. [Google Scholar] +3. Shastry AD, editor. Sushrutha Samhita of Maharshi Sushruta with Hindi commentary, Sutrasthana. +Chap 15/48. 9th ed. Varanasi, India: Chaukhambha Sanskrit Samsthan; 1995. p. 64. [Google Scholar] +4. Shastry AD, editor. Sushrutha Samhita of Maharshi Sushruta with Hindi commentary, Uttara Tantra. +Chap 25/15. 11th ed. Varanasi, India: Chaukhambha Sanskrit Samsthan; 1997. p. 128. [Google Scholar] +5. Shastry K, Chaturvedi G, editors. Charaka Samhita of Agnivesha with Vidyotini Hindi Commentary, +Siddhi Sthana. Chap 9/75-78. 22nd ed. Varanasi, India: Chaukhambha Bharati Academy; 2001. p. +1067. [Google Scholar] +6. Fukui PT, Gonçalves TR, Strabelli CG, Lucchino NM, Matos FC, Santos JP, et al. Trigger factors in +migraine patients. Arq Neuropsiquiatr. 2008;66:494–9. [PubMed] [Google Scholar] +7. Venkatesananda S. The Concise Yoga Vasistha. Chap 2. 1st ed. New York, USA: State University of +New York; 1985. pp. 709–23. [Google Scholar] +8. Spierings EL, Donoghue S, Mian A, Wöber C. Sufficiency and necessity in migraine: How do we +figure out if triggers are absolute or partial and, if partial, additive or potentiating? Curr Pain Headache +Rep. 2014;18:455. [PubMed] [Google Scholar] +9. Yadunandan U, editor. Ashtanga Hrudayam of Vagbhata with Vidyotini Hindi commentary, +Uttarasthana. Chap 13/1-2. 12th ed. Varanasi, India: Chaukhambha Sanskrit Sansthan; 1997. p. 533. +[Google Scholar] +10. Gambhirananda S. Pithoragarh. India: Advaita Ashrama; 1986. Taittiriya Upanishad. With the +Commentary of Sankaracharya. [Google Scholar] +11. Muktibodhananda S. Hatha Yoga Pradipika. Chap 1/58-60. 2nd ed. Munger, India: Yoga +Publications Trust; 1993. pp. 135–8. [Google Scholar] +12. Chinmayananda S. The Holy Gita. 9th ed. Mumbai, India: Central Chinmaya Mission Trust; 1992. +[Google Scholar] +13. Slavin M, Ailani J. A clinical approach to addressing diet with migraine patients. Curr Neurol +Neurosci Rep. 2017;17:17. [PubMed] [Google Scholar] +14. Cady RK, Farmer K, Dexter JK, Hall J. The bowel and migraine: Update on celiac disease and +irritable bowel syndrome. Curr Pain Headache Rep. 2012;16:278–86. [PubMed] [Google Scholar] +15. Wurtman RJ. Dietary treatments that affect brain neurotransmitters. Effects on calorie and nutrient +intake. Ann N Y Acad Sci. 1987;499:179–90. [PubMed] [Google Scholar] +16. Young SN. How to increase serotonin in the human brain without drugs. J Psychiatry Neurosci. +2007;32:394–9. [PMC free article] [PubMed] [Google Scholar] +17. Chowdhary S, Gopinath JK. Clinical hypnosis and patanjali yoga sutras. Indian J Psychiatry. +2013;55:S157–64. [PMC free article] [PubMed] [Google Scholar] +18. Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007;27:394–402. +[PubMed] [Google Scholar] +19. Houtveen JH, Sorbi MJ. Prodromal functioning of migraine patients relative to their interictal state +– An ecological momentary assessment study. PLoS One. 2013;8:e72827. [PMC free article] [PubMed] +[Google Scholar] +20. Goadsby PJ, Holland PR, Martins-Oliveira M, Hoffmann J, Schankin C, Akerman S, et al. +Pathophysiology of migraine: A Disorder of sensory processing. Physiol Rev. 2017;97:553–622. +[PMC free article] [PubMed] [Google Scholar] +21. Andress-Rothrock D, King W, Rothrock J. An analysis of migraine triggers in a clinic-based +population. Headache. 2010;50:1366–70. [PubMed] [Google Scholar] +22. Zhu Z, Fan X, Li X, Tan G, Chen L, Zhou J, et al. Prevalence and predictive factors for poor sleep +quality among migraineurs in a tertiary hospital headache clinic. Acta Neurol Belg. 2013;113:229–35. +[PubMed] [Google Scholar] +23. Panconesi A. Serotonin and migraine: A reconsideration of the central theory. J Headache Pain. +2008;9:267–76. [PMC free article] [PubMed] [Google Scholar] +24. Leiby SN, Welch KM, Giovanni A, Grunfeld S, Brown E. Event-related slow potentials and +associated catecholamine function in Migraine. Cephalalgia. 1990;10:317–29. [PubMed] +[Google Scholar] +25. Holland PR. Headache and sleep: Shared pathophysiological mechanisms. Cephalalgia. +2014;34:725–44. [PubMed] [Google Scholar] +26. Bruera O, Sances G, Leston J, Levin G, Cristina S, Medina C, et al. Plasma melatonin pattern in +chronic and episodic headaches: Evaluation during sleep and waking. Funct Neurol. 2008;23:77–81. +[PubMed] [Google Scholar] +27. Géraud G, Donnet A. Migraine and hypothalamus. Rev Neurol (Paris) 2013;169:372–9. [PubMed] +[Google Scholar] +28. Shastry K, Chaturvedi G, editors. Charaka Samhita of Agnivesha with Vidyotini Hindi +Commentary, Vimana Sthana. Chap 3/20. 22th ed. Varanasi, India: Chaukhambha Bharati Academy; +2001. p. 1067. [Google Scholar] +29. Santos IS, Griep RH, Alves MG, Goulart AC, Lotufo PA, Barreto SM, et al. Job stress is associated +with migraine in current workers: The Brazilian longitudinal study of adult health (ELSA-Brasil) Eur J +Pain. 2014;18:1290–7. [PubMed] [Google Scholar] +30. Sauro KM, Becker WJ. The stress and migraine interaction. Headache. 2009;49:1378–86. +[PubMed] [Google Scholar] +31. Shastri P, editor. Sharangadhara Samhita, Parishistam 66. Varanasi, India: Oriental Publishers and +Distributors; 1985. [Google Scholar] +32. Al-Shimmery EK. Precipitating and relieving factors of migraine headache in 200 Iraqi Kurdish +patients. Oman Med J. 2010;25:212–7. [PMC free article] [PubMed] [Google Scholar] +33. Blanchard EB. Psychological treatment of benign headache disorders. J Consult Clin Psychol. +1992;60:537–51. [PubMed] [Google Scholar] +Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow +Publications diff --git a/subfolder_0/Measures of heart rate variability in women following a meditaton technique.txt b/subfolder_0/Measures of heart rate variability in women following a meditaton technique.txt new file mode 100644 index 0000000000000000000000000000000000000000..d6cff88b9d96095a8de1291f742674d2786b8225 --- /dev/null +++ b/subfolder_0/Measures of heart rate variability in women following a meditaton technique.txt @@ -0,0 +1,417 @@ +International Journal of Yoga  Vol. 3  Jan-Jun-2010 +6 +this study therefore was to examine certain time domain +and frequency domain measures for women following the +practice of CM. We also report changes in the sampling +entropy (SampEn)[6] discussed below as this is a non-linear +measure that has been found to be useful even for short- +term recordings and has been widely discussed in the +literature. The changes in SampEn and the pNNx measures +that are described below have not been studied before in +the context of heart rate variability. These measures are +described in greater detail below. +mateRials and methOds +subjects and study protocol +The subjects, 28 in number, were healthy female +volunteers, resident at the center where this study was +carried out. Their mean age was 25 ± 3.4 years. Each +subject participated in two different sessions – one of CM +lasting 23 min and another of supine rest (SR) lasting an +equal number of minutes. Each session was on a different +day. In the SR position, the subjects were asked to lie +down and were asked to remain passive but awake with +natural breathing. CM is a guided relaxation practice and +the practitioner is supposed to allow the breath to flow +naturally – there is definitely no attempt at controlling the +breathing rate or trying to synchronize it with the body +movements that are very slow. All subjects were given +practice in the technique prior to the actual recording, +which was performed in individual sessions with the +subject following taped instructions. +intROductiOn +Cyclic meditation (CM) is a practice that originated in +Prashanti Kuteeram, a yoga therapy center in South +India. Briefly described, the practice consists of very slow +movements performed with awareness of subtle shifts of +balance and muscle tension during the entire exercise. +People who go through the practice uniformly report +a feeling of calmness and well-being at the end of the +procedure. This paper describes the changes in certain +measures of heart rate variability in women following the +practice. The practice, performed with closed eyes, lasts +about 25 min in the version used for this study. The effects +of this practice on heart rate variability have previously +been studied in healthy men.[1] That study examined the +Fourier power spectrum of the RR interval series and found +a significant decrease in the low frequency (LF) component +and a significant increase in the high frequency (HF) +component following the practice, indicating a shift toward +parasympathetic dominance. +There have been other studies on meditation and heart rate +variability. Kubota et al.,[2] studied the relationship between +cardiac autonomic function and activity of the medial frontal +neural circuitry. Murata et al.[3] also observed an increase in +the HF power and decrease in the LF/HF ratio. It has been +noted in the literature that heart rate dynamics may be +different between men and women.[3,4] These studies have +reported increased complexity in approximate entropy and +a higher HF component in short-term electrocardiogram +recordings in women compared with men.[5] The aim of +Certain time domain, frequency domain and a nonlinear measure of heart rate variability are studied in women following a +meditative practice called cyclic meditation. The nonlinear measure studied is the sampling entropy. We show that there is an +increase in the sampling entropy in the meditative group as compared to the control group. The time domain measure called +pNNx is shown to be useful in distinguishing between the meditative state and a normal resting state. +Keywords: Heart rate variability, meditation, sampling entropy, pNN50, pNN30 +ABSTRACT +Measures of heart rate variability in women following a +meditation technique +Hyorim An, Ravi Kulkarni, R Nagarathna, HR Nagendra +Vivekananda Yoga Research Foundation, Bangalore, India +Address for correspondence: Dr. Ravi Kulkarni, +Eknath Bhavan, 19 Gavipuram Circle, Bangalore - 560 019, India. +E-mail: ravi.kulk@gmail.com +DOI: 10.4103/0973-6131.66772 +Original Article +www.ijoy.org.in +7 +International Journal of Yoga  Vol. 3  Jan-Jun-2010 +The RR intervals were recorded for a period of 5 min before +and after the practice of CM and the same protocol was also +followed for the SR sessions. The data therefore consisted +of 5-min recordings before and after each practice (CM +and SR) for each subject. The RR intervals were recorded +using RMS Polyrite D, a digitized polygraph manufactured +by Recorders and Medicare Systems, Chandigarh, India. +The sampling rate was 256 Hz and was interpolated at +4 Hz. Each recording was edited manually to detect and +eliminate spurious noise. +frequency domain analysis +Fourier analysis of the RR-interval series was performed +using the freely available HRV Analysis software version +1.1, developed by the Biomedical Signal Analysis Group +at the University of Kuopio, Finland.[7] The 5-min RR +interval recordings used for frequency domain analysis +were detrended using smoothness priors and interpolated +at 4 Hz. The absolute power and the power in normalized +units in the LF band (0.04–0.15 Hz) and in the HF band +(0.15–0.4 Hz) were used for analysis. +time domain analysis +In addition to the mean and the standard deviation of the +RR intervals, measures derived from interval differences +were also calculated. These were the root mean square of +successive differences (RMSSD) and the pNNx measures. +The earliest of the pNNx measures described in the +literature was pNN50, which is the percentage of RR +intervals that differ by more than 50 ms from its immediate +successor.[8] A generalization of the pNN50 statistic, called +the pNNx measures, was introduced soon after,[9] where x is +an interval <50 ms. The aim of these added measures was +to provide more robust discrimination between the groups +than the pNN50 statistic and was applied successfully, +e.g., to distinguish between healthy subjects while asleep +and healthy subjects while awake. This study reports the +pNN50 and the pNN30 statistic before and after each of +the two sessions. The RMSSD, the square root of the mean +squared differences of successive RR intervals, is another +measure that is sensitive to HF (short-term) variations in +the heart rate. Its changes are also reported here. +non-linear analysis +SampEn[6,10] is a non-linear measure that is used to quantify +the amount of complexity in a time series and has been +widely studied in the context of the RR-interval series. +SampEn is a modified version of an earlier measure +called approximate entropy (ApEn),[11] which has also +been widely studied. SampEn quantifies the repetition +of patterns in the series of RR intervals. Larger values of +entropy correspond to greater complexity while smaller +values imply more recognizable patterns in the data. These +entropy measures, unlike most non-linear measures of +heart rate variability, can be used on data taken for short +periods. They depend on a parameter m (the length of the +sequence being matched) and a recording of 10m – 20m +RR intervals is judged sufficient to estimate the entropy. +[12] SampEn was calculated for 300 RR intervals in this +study, with m=2 and a tolerance of 0.2, using the program +available at the PhysioNet website.[13] +Results +In describing the results below, the two practices of cyclic +meditation and supine rest are abbreviated to CM and SR. +The sessions before and after are referred to as PRE and +POST. +frequency domain +Table 1 shows the means of the normalized LF and HF +values and also the LF/HF ratio. Table 1 shows the actual +power in both the LF (0.04–0.15 Hz) and the HF (0.15–0.4 +Hz) bands. The data for the LF- and HF-normalized values +were found to be normally distributed while the LF/HF +ratios were not. +Paired sample t-tests for the normalized LF data showed +the following: the difference between the means of the two +PRE sessions was not significant. The means in the POST +session were significantly different (P=0.007), with the +CM group showing a lower value [Table 1]. The CM group +showed a significant decrease (P=0.011) in LF while the +SR group did not show any significant change. Because +this analysis was on the normalized units, the P values +for the HF data are obviously exactly the same, with all +differences reversed in sign. Thus, the CM group showed +a significant increase (P=0.011) in HF +. +The Wilcoxon test for the LF/HF ratio showed the following: +there is a significant reduction for the CM group (P=0.011) +while the reduction for the SR group is not significant. The +PRE values of the two groups are not significantly different +while the POST values are (P=0.007), with the CM group +showing a lower value [Table 1]. +The absolute powers were not normally distributed and +the HF absolute power showed a significant increase + +(P=0.034, Wilcoxon test) between the PRE and POST CM +sessions. There were no significant changes or differences +in the absolute power otherwise. +time domain +The heart rate data were normally distributed and +the mean decreased significantly after both practices + +[Table 1] (t-tests, P<0.001 after CM and P=0.01 after SR). +Measures of heart rate variability in women +International Journal of Yoga  Vol. 3  Jan-Jun-2010 +8 +An, et al. +The difference between the two PRE sessions was not +significant while the heart rate after CM was significantly +less than that after SR (P=0.024). +The means and standard deviations of pNN50 and +pNN30 are given in Table 1. The data were normally +distributed. t-tests show that the pNN50 count increased +significantly after CM (P=0.007). No other significant +changes/differences were observed in the pNN50 statistic. + +The pNN30 statistic shows a significant increase after +CM (P=0.003) and also shows a significant difference +between the POST CM and SR sessions (P=0.024), the +PRE difference not being significant. +The RMSSD data were normally distributed. Their +behavior mimics that of the pNN50 statistic; the RMSSD +increased significantly after the CM session (P=0.037) and +no other changes/differences were observed. Table 1 shows +the means and standard deviations. +sampen +The data were normally distributed. An increase in the +CM session of SampEn (2, 0.2) was seen, but this was not +significant (P=0.268). A slight decrease was observed in +the SR session, which was not significant (P=0.939). There +were no significant differences between the sessions. Table +1 shows the means and the standard deviations. +discussiOn +This study was performed with the aim of looking at +changes in certain measures of heart rate variability after +the practice of CM in women. +The observed decrease in the LF power (normalized units) +and the corresponding increase in the HF power are similar +to that observed in men after the practice of CM, and Patil[1] +suggests that the practice results in a shift toward vagal +dominance. The observed decrease in the heart rate is also +clearly an indication of parasympathetic dominance after +the practice. Telles, Reddy and Nagendra[14] have shown +that this reduction in the heart rate after the practice is +coupled with a reduction in the respiratory rate and oxygen +consumption. +Mietus et al.[15] carried out three different comparisons on +data from the PhysioNet databases and demonstrated that +separation between groups based on their RR intervals is +consistently improved by using threshold values <50 ms; +the threshold values being as low as 10 ms. Thus, the pNNx +measures with x <50 provide useful information about the +very short-term control of sinus rhythm dynamics. In the +data discussed here, this is clearly demonstrated by the +fact that the pNN50 measure could not distinguish between +the CM and the SR sessions while the pNN30 measure +could. The increased pNN50 count in the CM session +group argues for an increased complexity in the dynamics +of the heart after the practice – while there is a significant +increase of parasympathetic activity, as evidenced by the +increase in the HF component and indicative of a calming +effect, the variation in the inter-RR intervals has increased. +The results relating to the pNN30 statistic bear this out +– the significantly larger pNN30 count in the meditation +group implies a more complex signal after the practice as +compared to SR. The RMSSD is known to be correlated to +the pNN50[16] and the significant increase in the RMSSD +after the CM session is indicative of this fact. +Both sampling and approximate entropy measure the +complexity in the dynamics of a time series. SampEn has +an advantage over approximate entropy, its precursor, in +having better consistency.[10] SampEn depends on two +parameters, m and r, m being the length of the sequence +being matched and r being the tolerance limit. The SampEn +calculations were performed in this study with m=2 and +r=0.2 because this is suited to a short time-series (300 +RR-intervals in this case). An increased value of SampEn +is indicative of increased complexity in the signal. There +is a multitude of evidence to support a deterioration of +complexity (decrease in entropy) in different kinds of +time series in subjects with ill-health.[17] In the context +of heart-rate variability, a decrease in entropy has been +associated with an increased risk of cardiac failure. Given +the subjective feeling of relaxation that is experienced by +individuals after the practice of CM, an increase in the +Table 1: Means and standard deviations +CM pre +CM post +SR pre +SR post +LF +37.62 ± 12.53 +31.61 ± 13.19 +37.25 ± 19.75 +38.80 ± 15.28 +HF +62.38 ± 12.53 +68.39 ± 13.19 +62.75 ± 19.75 +61.20 ± 15.28 +LF/HF +0.69 ± 0.46 +0.52 ± 0.37 +0.81 ± 0.76 +0.78 ± 0.67 +LF (power) +334.69 ± 224.35 +369.50 ± 348.61 +364.88 ± 341.04 +416.27 ± 266.46 +HF (power) +691.19 ± 575.53 +881.00 ± 722.31 +744.81 ± 848.31 +723.77 ± 512.41 +pNN50 +28.01 ± 19.66 +34.16 ± 20.78 +29.67 ± 20.71 +30.69 ± 20.31 +pNN30 +49.92 ± 21.26 +57.19 ± 16.50 +50.17 ± 22.55 +53.27 ± 18.56 +RMSSD +52.10 ± 24.50 +58.21 ± 26.36 +51.07 ± 26.78 +55.50 ± 25.84 +SampEn +2.135 ± 0.367 +2.218 ± 0.470 +2.197 ± 0.434 +2.191 ± 0.283 +HR +72.29 ± 8.43 +68.43 ± 7.73 +72.00 ± 8.72 +70.16 ± 8.15 +LF = Low frequency, HF = High frequency, RMSSD = Root mean square of successive differences, SampEn = Sampling entropy, HR = Heart rate +9 +International Journal of Yoga  Vol. 3  Jan-Jun-2010 +SampEn was hypothesized in the period immediately after +the practice. The accompanying graph [Figure 1] shows +the changes that occurred following the two practices. +The SampEn increased in the CM group and decreased +marginally in the other group. While the increase in the +CM group is not significant (P=0.268), a comparison of +the effect sizes for each practice is instructive. The effect +size gives an absolute measure of the change seen and +is defined to be the difference in means divided by the +standard deviation of the difference scores. The effect +size is 0.2 for the CM group and only 0.02 for the control +group. A post hoc calculation of the power showed that the +PRE-POST study had a power of only 0.3. This suggests +that a significant difference could be found by increasing +the sample size (which increases the power) or altering +the design. Another improvement in the current study +would be to use an instrument with a faster sampling rate +than the one used here (256 Hz). An improved version of +this study, focusing on the SampEn, will be reported later. +The difference in heart rate variability between men and +women has been commented on before,[2] where it was +observed that baroreflex responsiveness is attenuated and +vagal activity is augmented in women compared with men. +Because the LF component of the heart rate variability +reflects, in part, the baroreflex-mediated control of the +heart rate, women tend to display a lower value of power +in the LF spectrum of the heart rate variations. The absolute +powers displayed in Table 1 demonstrate this. Thus, the +values in the LF and HF columns in Table 1 would be +interchanged for men. +cOnclusiOns +This study has shown that the state of relaxation after +CM results in parasympathetic dominance in women, +as evidenced by the increased HF component of the RR- +interval series. The fact that the dynamics of heart rate +variability is different in women as compared to men has +also been seen. The observed significant increase in the +pNNx counts and the increase in the SampEn after the +practice when the subjects report a sense of calmness and +well-being would seem to imply a complex dynamics that +requires further study. +RefeRences +1. +Patil SP, Telles S. Changes in heart rate variability during and after two yoga +based relaxation techniques. Int J Stress Manage 2006;13:460-73. +2. +Kubota Y, Sat W, Toichi M, Murai T, Okada T, Hayashi A, et al. Frontal +midline theta rhythm is correlated with cardiac autonomic activities during +the meditation procedure, Brain Res Cogn Brain Res 2001;11:281-7. +3. +Murata T, Takahashi T, Hamada T, Omori M, Kosaka H, Yoshida H, et al. +Individual trait anxiety levels characterizing the properties of Zen meditation. +Neuropsychobiology 2004;50:189-94. +4. +Huikuri HV, Pikkujämsä SM, Airaksinen KE, Ikäheimo MJ, Rantala AO, +Kauma H, et al. Sex-related differences in autonomic modulation of heart +rate in middle-aged subjects. Circulation 1996;94:122-5. +5. +Ryan SM, Goldberger AL, Pincus SM, Mietus J, Lipsitz LA. Gender- and +age-related differences in heart rate dynamics: Are women more complex +than men? J Am Coll Cardiol 1994;24:1700-7. +6. +Richman JS, Moorman JR. Physiological time-series analysis using +approximate entropy and sample entropy. Am J Physiol Heart Circ Physiol +2000;278:H2039-49. +7. +The Biosignal and Medical Analytsis Group. Available from: http://bsamig. +uku.fi. Citation date - 1 March 2009 +8. +Bigger JT Jr, Kleiger RE, Fleiss JL, Rolnitzky LM, Steinman RC, Miller +JP. Components of heart rate variability measured during healing of acute +myocardial infarction. Am J Cardiol 1988;61:208-15. +9. +Mietus JE, Peng CK, Henry I, Goldsmith RL, Goldberger AL. The pNNx +files: Re-examining a widely used measure of heart rate variability measure. +Heart 2002;88:378-80. +10. Richman JS, Moorman JR. Physiological time-series analysis using +approximate entropy and sample entropy. Am J Physiol Heart Circ Physiol +2000;278:H2039-49. +11. +Pincus SM. Approximate entropy as a measure of system complexity. Proc +Natl Acad Sci USA 1991;88:2297-301. +12. Pincus SM, Goldberger AL. Physiological time-series analysis: What does +regularity quantify? Am J Heart Circ Physiol 1994;266:H1643-56. +13. PhysioNet: The research resource for complex physiological signals +Available from: +http://www.physionet.org/physiotools/sampen. Citation date - 1 March 2009. +14. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration +following two yoga relaxation techniques, Appl Psychpysiol Biofeedback +2000;25:221-7. +15. Mietus JE, Peng CK, Henry I, Goldsmith RL, Goldberger AL. The pNNx +files: Re-examining a widely used heart rate variability measure. Heart +2002;88:378-80. +16. Heart rate variability: Standards of measurement, physiological interpretation +and clinical use. Task Force of the European Society of Cardiology and +the North American Society of Pacing and Electrophysiology. Circulation +1996;93:1043-65. +17. Seely AJ, Macklem PT. Complex systems and the technology of variability +analysis. Crit Care 2004;8:R367-84. +Measures of heart rate variability in women +Figure 1: Sampling entropy diff --git a/subfolder_0/Mid-Latency Auditory Evoked Potentials in 2 meditative states.txt b/subfolder_0/Mid-Latency Auditory Evoked Potentials in 2 meditative states.txt new file mode 100644 index 0000000000000000000000000000000000000000..eea0021ef32beb64f0f251387290c7a3df4ac7cb --- /dev/null +++ b/subfolder_0/Mid-Latency Auditory Evoked Potentials in 2 meditative states.txt @@ -0,0 +1,909 @@ +Mid-Latency Auditory Evoked Potentials +in 2 Meditative States +Shirley Telles1, Bhat Ramachandra Raghavendra1, +Kalkuni Visweswaraiah Naveen1, Nandi Krishnamurthy Manjunath1 and +Pailoor Subramanya1 +Abstract +Mid-latency auditory evoked potentials (MLAEPs) were assessed in 60 participants during 4 mental states described in traditional +yoga texts. These 4 mental states are random thinking, nonmeditative-focused thinking, meditative focusing, and meditation. +Assessments were made before (5 minutes), during (20 minutes), and after (5 minutes) each of the 4 states, on 4 separate days. +There were prolonged latencies of 2 MLAEPs components, the Na and Pa waves during meditation (P < .05, post hoc analyses +following analysis of variance [ANOVA]), suggesting that auditory information transmission at the level of the medial geniculate +and primary auditory cortex (ie, the neural generators corresponding to the Na and Pa waves) was delayed. Hence, meditation +influenced MLAEPs, while meditative focusing did not. +Keywords +mid-latency auditory evoked potentials, meditation, yoga +Received February 19, 2011; revised December 13, 2011; accepted December 14, 2011. +Introduction +MLAEPs have been used to assess cortical and subcortical +changes in meditation.1 It is believed that even if the main +changes occur in the cortex, corticoefferent connections would +result in subcortical changes.2 The auditory modality of stimuli +was chosen as it was found to be least disturbing to the medi- +tator during their practice.3 +An early study on experienced meditators who were asked +to mentally repeat the Sanskrit syllable, OM, showed a group +with a significant decrease in the Nb latency.4 Reduced latency +of a specific component signifies that neural transmission in the +generator corresponding to that component is occurring sooner +than usual.5 The Nb component corresponds to the dorsoposter- +ior medial part of the Heschl gyrus, that is the primary auditory +cortex.6 Therefore, it is suggested that, in experienced medita- +tors, mental repetition of OM facilitates the transmission of +neural information at the level of the dorsoposterior medial +area of the Heschl gyrus. +In a subsequent study on experienced and naive meditators, +who were asked to mentally repeat ‘‘OM’’ on 1 day and ‘‘one’’ +on another day, there was a significant change in the Na com- +ponent.1 When both experienced and naive meditators repeated +‘‘one’’ there was a significant decrease in the peak amplitude of +the Na wave. The Na wave is known to correspond to the +mesencephalic or diencephalic level.7 An increased peak +amplitude suggests recruitment of a greater number of +neurons.2 Therefore, the decreased Na amplitude indicated a +possible decrease in neurons recruited at the mesencephalic +or diencephalic level while mentally repeating ‘‘one.’’ +In contrast, when experienced meditators and naive persons +were asked to mentally repeat ‘‘OM’’ on another day, the +results were quite different. The Na wave peak amplitude sig- +nificantly increased in experienced meditators but significantly +decreased in naive persons.1 These results were suggestive of +recruitment of increased neurons at the mesencephalic–dience- +phalic level in experienced meditators repeating OM, whereas +naive practitioners had fewer neurons recruited at that level. +Since the number of neurons recruited generally correlates with +the level of activity,8 the results showed that mental repetition +of a syllable with specific connotations and significance (ie, +OM) produces changes in opposite directions in the peak +amplitude in experienced and naive meditators. +MLAEPs during another meditation (Brahmakumaris Raja +Yoga meditation practiced with eyes open), in experienced +1 ICMR Center for Advanced Research in Yoga and Neurophysiology, +S-VYASA University, Bengaluru, India +Corresponding Author: +Shirley Telles, Patanjali Research Foundation, Patanjali Yogpeeth, Haridwar, +Uttarakhand 249408, India +Email: shirleytelles@gmail.com +Clinical EEG and Neuroscience +43(2) 154-160 +ª EEG and Clinical Neuroscience +Society (ECNS) 2012 +Reprints and permission: +sagepub.com/journalsPermissions.nav +DOI: 10.1177/1550059412439963 +http://eeg.sagepub.com +meditators showed a significant decrease in the peak latency of +the Na wave during meditation.9 Hence, these results support +the idea that Brahmakumaris Raja Yoga meditation facilitated +transmission at the mesencephalic–diencephalic level. Another +study evaluated both auditory evoked potentials and visual con- +trast sensitivity in epileptics who practiced Sahaja Yoga med- +itation,10 which is characterized by thoughtless awareness or +mental silence.11 Among other changes, an increased Na-Pa +amplitude was reported. +Most of these meditation techniques (ie, Brahmakumaris +Raja Yoga meditation, Sahaja Yoga meditation, and meditation +on OM) have been derived within the last 200 years. Differ- +ences in results between meditation techniques could be related +to the method used.1 So far, a single study attempted to assess +the effects of meditation as described in the traditional yoga +texts.12 +The first, and possibly most recent, comprehensive compila- +tion among the ancient texts is the Patanjali’s Yoga Sutras +(circa 900 BC). In Patanjali’s Yoga Sutras (circa 900 BC), there +are 2 meditative states described, one leading to the other.13 +The first stage is meditative focusing, confining the mind +within a limited mental area (Patanjali’s Yoga Sutras, chapter +III, verse 1). The next stage is meditation or effortless expan- +sion (Patanjali’s Yoga Sutras, chapter III, verse 2). This state +is characterized by the uninterrupted flow of the mind toward +the object chosen for meditation. When the mind is not in +meditation, the ancient texts say that it may be in 2 states, ran- +dom thinking (Bhagavad Gita, chapter VI, verse 34) and +nonmeditative-focused thinking (Bhagavad Gita, chapter +VI, verse 12).14 +When brain stem auditory evoked potentials were studied in +meditators who practiced meditative focusing, meditation +without focusing, nonmeditative-focused thinking, and random +thinking on 4 separate days, the effects of the 4 different mental +states differed.12 The wave V peak latency increased signifi- +cantly in random thinking, nonmeditative-focused thinking, +and meditative focusing, but not in meditation. Since the wave +V is considered to correspond to the inferior colliculus,5 these +results suggest that neural transmission at the mid-brain level +may be improved by meditation without focusing. +There has been no study assessing the changes, if any, in +MLAEPs during the 4 mental states described in the ancient +yoga texts. The present study was aimed at assessing whether +MLAEPs corresponding to thalamic and cortical generators +change with meditation, when the description of meditation +was based on the ancient texts. +Materials and Methods +Participants +Participants were recruited by announcements in the university +newsletter and flyers on the notice boards. The 110 volunteers +were screened for age, health status, meditation experience, +and socioeconomic status. Sixty male volunteers with ages +ranging from 18 to 31 years (group mean age + standard +deviation [SD], 22.78 + 2.73) who met the criteria were +recruited for the trial. They were all students at a yoga univer- +sity in South India. Their health status was assessed by a rou- +tine case history and clinical examination.15 The participants +had normal health and were not on any medication or herbal +remedies. The conditions to exclude participants from the trial +were any chronic illness, particularly psychiatric or neurological +disorders. Male volunteers alone were selected as evoked poten- +tials are known to vary with the phases of the menstrual cycle.16 +All meditators had been practicing meditation on the Sanskrit +syllable OM for 30 minutes each day, for 4 days in a week. They +had a minimum of 6 months of experience in meditation (group +average experience + SD, 20.95 + 14.21 months). The charac- +teristics of participants are shown in Table 1. +The project was approved by the institution’s ethics com- +mittee. The study protocol was explained to the participants +and their signed consent was obtained. They were not compen- +sated for their time and participation in the study. +Design +Each participant was assessed in 4 sessions, to which they were +assigned randomly. Two of them were meditation sessions +(these were meditative focusing and meditative de-focusing +or effortless meditation sessions) and 2 of them were nonmedi- +tation sessions (these were nonmeditative-focused thinking +and random thinking). All 4 sessions consisted of 3 states: pre +(5 minutes), during (20 minutes), and post (5 minutes). The +nonmeditative-focused thinking and random thinking sessions +were the 2 nonmeditation sessions and were considered as con- +trol sessions for the 2 meditation sessions, viz, meditative +focusing and meditation. The design is presented schematically +in Figure 1. +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. The purpose of this +Table 1. Characteristics of Participants +Characteristics +Age (in years), group mean + SD +22.78 + 2.73 +Education +Postgraduates +23 (38.3%) +Graduates +27 (45%) +Undergraduates +10 (16.7%) +Type of meditation +Meditation on the +Sanskrit syllable OM +Experience of meditation practice (in months) +20.95 + 14.21 +6-12 months +29 (48.3%) +13-24 months +17 (28.3%) +25-36 months +7 (11.7%) +37-48 months +5 (8.3%) +48-60 months +2 (3.3%) +Socioeconomic status +High-income group +5 (8.3%) +Mid-income group +52 (86.7%) +Low-income group +3 (5%) +Telles et al. +155 +orientation was for all participants to practice the 2 different +states of meditation, viz, meditative focusing and meditation +based on specific instructions, in the same way. +Assessments +Recording conditions. MLAEPs were assessed in the 4 ses- +sions (ie, random thinking, nonmeditative-focused thinking, +meditative focusing, and meditation. Participants were seated +in a sound attenuated, dimly lit cabin and monitored on a closed +circuit television. Instructions were given through a 2-way +intercom, so that participants could remain undisturbed during +a session. Participants were observed on the closed-circuit +television to detect whether they moved or fell asleep during +a session. The temperature in the cabin and the recording +room was maintained at 24.0C + 1.0C. The average +humidity was 56% on the days the experiments were con- +ducted. The background noise level of the acoustically +shielded chamber was 26 dB. MLAEPs were recorded in the +100 ms, poststimulus time period without any prestimulus +delay, using a 4-channel system (Nicolet Biomedical Inc, +Madison, WI, USA). Recordings were from the vertex (Cz) +referred to linked earlobes, with the ground electrode on the +forehead (FPz). Electrodes were placed according to the +International 10-20 System.17 Electrode impedance was kept +below 5 kilo-ohms at all sites. +The amplifier bandwidth was set at 10 to 1500 Hz and 1500 +responses were averaged for each assessment. Rejection was +set at 90% of the full-scale range of the analog-to-digital con- +verter. Binaural click stimuli of 50 ms duration and alternating +polarity at the rate of 5.0 Hz were delivered through acousti- +cally shielded earphones (Amplivox, United Kingdom). The +threshold of hearing was noted for each participant to verify +that their hearing was normal. The threshold of hearing was +checked as follows: (i) decreasing the intensity in 5 dB steps +until the participant could no longer hear the clicks and (ii) +increasing the intensity in 5 dB steps until the clicks were +audible. The click threshold was taken as the midpoint between +the intensities at which the clicks could and could not be heard. +This procedure was repeated twice. The threshold of hearing +was noted for each participant and the intensity was kept at +80 dB normal hearing level (nHL). +Components of MLAEPS +Components of MLAEP, viz, Na, Pa, and Nb waves, were mea- +sured from a 0 DC baseline. Peak latency was measured from +the time of click delivery. The peak latencies and peak ampli- +tudes of the following components were measured: the Na +wave (a negative wave between 14 and 19 ms), is the maximum +negative peak preceding the Pa wave which is a positive com- +ponent between 25 and 32 ms. The Nb wave, which is a neg- +ative component between 35 and 65 ms, is also the first +maximum negative component immediately following the +Pa wave.18 Components of MLAEPs and their neural genera- +tors are described in Table 2. +Participants’ compliance for the meditation orientation +program and for the recordings was 100%. +Interventions +Throughout all sessions, participants sat cross-legged and kept +their eyes closed following pre-recorded instructions. An +MLAEPs +MLAEPs +MLAEPs +Pre (5min) +D1 (5min) +D4 (5min) +D3 (5min) +D2 (5min) +Post (5min) +During-Non-meditave focused thinking 20 min +Pre (5min) +D1 (5min) +D4 (5min) +D3 (5min) +D2 (5min) +Post (5min) +Pre (5min) +D1 (5min) +D4 (5min) +D3 (5min) +D2 (5min) +Post (5min) +During-Meditaon 20 min +During-Random thinking 20 min +Pre (5min) +D1 (5min) +D4 (5min) +D3 (5min) +D2 (5min) +Post (5min) +During-Meditave focusing 20 min +Figure 1. Schematic representation of the study design. D1 indicates during 1; D2, during 2; D3, during 3; D4, during 4. +Table 2. Components of MLAEPs and Their Neural Generators +Sl. no. +MLAEPs +component +Latency +range (ms) +Neural generators +1 +Na +14-19 +Medial geniculate +2 +Pa +25-32 +Superior temporal gyrus +3 +Nb +35-65 +Dorsoposterior medial +part of the Heschl gyrus +Abbreviations: MLAEPs, mid-latency auditory evoked potentials. +156 +Clinical EEG and Neuroscience 43(2) +emphasis was placed on carrying out the practices slowly, with +awareness of physical and mental sensations, and relaxed. For +all sessions, the duration was 20 minutes. The sessions were +conducted 6 days a week, between 06.00 and 06.30 hours. +On the first day theoretical aspects of the 2 meditative states, +viz, meditative focusing and meditation, were detailed by the +meditation teacher. After this, the practice sessions started +with pre-recorded instructions. The evaluation of the partici- +pants’ practice of meditative focusing and meditation was +based on their self-report as well as consultations with the +meditation teacher. +Random thinking. Participants were asked to allow their +thoughts to wander freely as they listened to a compiled audio +CD consisting of brief periods of conversation, announce- +ments, advertisements, and talks on diverse topics recorded +from a local radio station transmission. All these conversa- +tions were not connected and could induce the state of random +thinking. +Nonmeditative-focused thinking. Participants listened to a pre- +recorded lecture on meditation. This was not about medita- +tion, on the Sanskrit syllable OM, but about meditation, in +general, which was supposed to induce a state of nonmedita- +tive focusing. +Meditative focusing. Participants were asked to open their +eyes and gaze at the syllable ‘‘OM’’ as it is written in Sanskrit. +During this time, guided instructions required them to direct +their thoughts to the physical attributes of the syllable (ie, the +shape and color) and then to close their eyes and continue to +visualize the syllable mentally. The main emphasis during +meditative focusing was that thoughts are consciously brought +back (if they wander) to the single thought of OM. +Meditative de-focusing or effortless meditation. During this +session, participants were instructed to keep their eyes closed +and dwell on thoughts of OM, without any effort, particularly +on the subtle (rather than physical) attributes and connotations +of the syllable. This involved effortless de-focusing combined +with mental chanting of OM. This would gradually allow the +participants to experience brief periods of silence, which they +reported after the sessions. +Data Analysis +Statistical analysis was done using SPSS (version 16.0). Data +were tested for normality by the Kolmogorov-Smirnov test. +Since the same individuals were assessed in repeat sessions +on separate days (ie, random thinking, nonmeditative-focused +thinking, meditative focusing, and meditation), repeated mea- +sures analyses of variance (ANOVAs) were performed with 2 +within-participant factors, that is factor 1: sessions; random +thinking, nonmeditative-focused thinking, meditative focusing, +and meditation and factor 2: states; ‘‘pre,’’ ‘‘during’’ (Dur1 to +Dur4), and ‘‘Post.’’ Repeated measures ANOVAs were carried +out for each wave of MLAEPs separately, for both peak laten- +cies and peak amplitudes. This was followed by post hoc anal- +yses with Bonferroni adjustment for multiple comparisons +between the mean values of different states (during and post), +and all comparisons were made with the respective pre state. +Results +The group mean values + SD for the peak latencies (ms) +and peak amplitudes (mV) of Na, Pa, and Nb components +of MLAEPs in 4 sessions (random thinking, nonmeditative- +focused thinking, meditative focusing, and meditation) in +pre, during, and post states are given in Tables 3 and 4, +respectively. +Analysis of Variance +The significant changes in the peak latencies (ms) and peak +amplitudes (mV) of Na, Pa, and Nb components of MLAEPs +in 4 sessions are shown in Table 5. +Post Hoc Analyses With Bonferroni Adjustment +Post hoc analyses with Bonferroni adjustment were performed +and all comparisons were made with respective ‘‘pre’’ states +summarized in Table 6. +In summary, there was a significant increase in the peak +latencies of Na and Pa waves during meditation (P < .05, post +hoc analyses following ANOVA) and of Nb wave in the post- +period of nonmeditative-focused thinking (P < .05) compared +to pre-period. The peak amplitude of Pa wave was signifi- +cantly decreased during random thinking (P < .001), +nonmeditative-focused thinking (P < .001), meditative focus- +ing (P < .01), and meditation (P < .05) compared to the +respective pre-states. +Discussion +Mid-latency auditory evoked potentials were recorded during +random thinking, nonmeditative focusing, meditative focus- +ing, and meditation. A consistent finding was prolonged +peak latencies of 2 components (the Na wave and the Pa +wave) during meditation. The Pa wave amplitude decreased +during all 4 sessions. +Among MLAEPs,the Na wave is believed to be due to activity +at the mesencephalic or diencephalic level,7 and the Pa wave cor- +responds to activity atthe superior temporal gyrus,18while the Nb +wave appears relatively localized in the dorsoposterior medial +area of the Heschl gyrus, that is the primary auditory cortex.6 +A decrease in peak latency is considered suggestive of +facilitated transmission due to increased speed of conduction +in the underlying neural generators.5 On the other hand, an +increase in peak latency can be assumed to suggest inhibited +transmission due to slower conduction in the underlying neural +generators. Increased amplitudes of evoked potential compo- +nents are interpreted as activation of the underlying neural gen- +erator with recruitment of a greater number of neurons.2 +Telles et al. +157 +Table 4. Mid-Latency Auditory Evoked Potentials (MLAEPs) Showing Peak Amplitude for 4 Sessions in 6 States for Na, Pa, and Nb Wavesa +Peak amplitude (mV) +Waves +Sessions +Pre +During +Post +During 1 +During 2 +During 3 +During 4 +Na wave +Random thinking +0.60 + 0.53 +0.47 + 0.29 +0.51 + 0.40 +0.44 + 0.36 +0.48 + 0.34 +0.50 + 0.44 +Nonmeditative-focused thinking +0.58 + 0.54 +0.52 + 0.43 +0.51 + 0.41 +0.50 + 0.31 +0.50 + 0.37 +0.44 + 0.40 +Meditative focusing +0.54 + 0.47 +0.49 + 0.38 +0.45 + 0.38 +0.44 + 0.42 +0.54 + 0.42 +0.57 + 0.58 +Meditation +0.49 + 0.43 +0.52 + 0.43 +0.49 + 0.39 +0.42 + 0.30 +0.47 + 0.38 +0.64 + 0.62 +Pa wave +Random thinking +1.33 + 0.47 +0.84 + 0.35d +0.77 + 0.30d +0.83 + 0.43d +0.90 + 0.37d +1.32 + 0.59 +Nonmeditative-focused thinking +1.22 + 0.61 +0.95 + 0.43d +0.93 + 0.43d +1.00 + 0.45b +0.98 + 0.52b +1.42 + 0.58 +Meditative focusing +1.28 + 0.54 +1.08 + 0.51c +1.23 + 0.48 +1.26 + 0.47 +1.29 + 0.47 +1.32 + 0.48 +Meditation +1.30 + 0.63 +1.20 + 0.61 +1.13 + 0.58b +1.17 + 0.52 +1.19 + 0.60 +1.26 + 0.62 +Nb wave +Random thinking +0.42 + 0.30 +0.32 + 0.29 +0.35 + 0.30 +0.42 + 0.29 +0.34 + 0.30 +0.48 + 0.40 +Nonmeditative-focused thinking +0.41 + 0.37 +0.31 + 0.28 +0.38 + 0.27 +0.42 + 0.33 +0.41 + 0.30 +0.50 + 0.38 +Meditative focusing +0.46 + 0.38 +0.40 + 0.28 +0.44 + 0.35 +0.45 + 0.37 +0.44 + 0.37 +0.49 + 0.39 +Meditation +0.45 + 0.37 +0.42 + 0.31 +0.37 + 0.31 +0.43 + 0.32 +0.46 + 0.38 +0.54 + 0.37 +Abbreviations: SD, standard deviation; RM-ANOVA, repeated measures analysis of variance. +a Values are group Mean + S.D. +b P < .05. +c P < .01. +d P < .001; RM-ANOVA with Bonferroni adjustment comparing during and post values with pre values. +Table 3. Mid-Latency Auditory Evoked Potentials (MLAEPs) Showing Peak Latencies for 4 Sessions in 6 States for Na, Pa, and Nb Wavesa +Peak latency (ms) +Waves +Sessions +Pre +During +Post +During 1 +During 2 +During 3 +During 4 +Na wave +Random thinking +16.02 + 1.59 +16.22 + 1.71 +16.44 + 1.80 +16.48 + 1.97 +15.88 + 1.94 +16.14 + 1.78 +Nonmeditative-focused thinking +16.24 + 1.80 +16.33 + 1.55 +16.37 + 1.53 +16.34 + 1.90 +16.32 + 1.73 +16.26 + 2.08 +Meditative focusing +16.03 + 1.62 +16.36 + 1.59 +16.36 + 1.66 +16.44 + 1.65 +16.33 + 1.63 +16.01 + 1.64 +Meditation +15.97 + 1.59 +16.43 + 1.58 +16.49 + 1.72 +16.49 + 1.75b +16.43 + 1.75 +16.13 + 1.95 +Pa wave +Random thinking +34.76 + 2.79 +34.47 + 2.86 +34.82 + 2.64 +34.58 + 2.85 +35.30 + 2.52 +35.17 + 2.74 +Nonmeditative-focused thinking +35.01 + 2.50 +35.28 + 2.59 +35.38 + 1.70 +35.33 + 2.00 +34.93 + 2.48 +35.50 + 2.38 +Meditative focusing +34.95 + 2.61 +35.44 + 1.87 +35.08 + 2.35 +35.70 + 2.39 +35.32 + 2.38 +35.17 + 3.17 +Meditation +34.60 + 2.89 +35.18 + 2.35 +35.19 + 2.57 +35.33 + 2.58 +35.55 + 2.08b +35.25 + 2.78 +Nb wave +Random thinking +52.73 + 9.01 +53.01 + 8.30 +53.63 + 8.47 +54.01 + 8.05 +55.48 + 8.09 +54.77 + 8.96 +Nonmeditative-focused thinking +53.76 + 9.15 +53.38 + 7.93 +54.01 + 7.68 +55.88 + 8.31 +56.09 + 8.70 +56.86 + 9.03b +Meditative focusing +53.39 + 8.96 +53.71 + 7.70 +55.12 + 8.35 +55.16 + 7.94 +54.46 + 8.40 +54.66 + 8.77 +Meditation +53.29 + 8.75 +53.25 + 8.17 +54.40 + 8.35 +55.43 + 7.89 +55.19 + 8.21 +54.93 + 8.55 +Abbreviations: SD, standard deviation; RM-ANOVA, repeated measures analysis of variance. +a Values are group mean + SD. +b P < .05, RM-ANOVA with Bonferroni adjustment comparing during and post values with pre values. +Table 5. Summary of ANOVA Showing Statistically Significant Results +Variables +Factor +F value +df +Huynh-Feldt epsilon +Level of significance +Pa wave amplitude +Sessions +18.05 +(2.7, 159.56) +.901 +P < .001 +Na wave latency +States +3.63 +(4.29, 253.33) +.859 +P < .01 +Na wave amplitude +States +3.19 +(3.65, 215.35 +.73 +P < .05 +Pa wave amplitude +States +31.56 +(4.27, 252.15) +.855 +P < .001 +Nb wave latency +States +9.30 +(3.58, 211.47) +.717 +P < .001 +Nb wave amplitude +States +5.40 +(4.42, 261.02 +.885 +P < .001 +Na wave amplitude +Sessions  States +2.58 +(11.52, 679.91) +.768 +P < .01 +Pa wave latency +Sessions  states +1.86 +(13.38, 789.43) +.892 +P < .05 +Pa wave amplitude +Sessions  states +9.69 +(15, 885) +.967 +P < .001 +Abbreviation: ANOVA, analysis of variance. +158 +Clinical EEG and Neuroscience 43(2) +In the present study, the prolonged latencies of the Na and +Pa waves suggest slowing of auditory information transmission +at mesencephalic–diencephalic levels and at the level of the +primary auditory cortex. These findings are similar to those +of an earlier study which reported a prolonged latency of the +Nb wave related to the practice of a meditation called cyclic +meditation.19 The results following cyclic meditation were +believed to be related to the activation of inhibitory mechan- +isms in cortical areas within the auditory pathway. A previous +study which reported increased gamma-amino-butyric-acid +(GABA) levels following a 1-hour yoga session20 was consid- +ered to support the results. This is because GABA is a well- +recognized inhibitory neurotransmitter in the central nervous +system.21 +As described above, GABA activity increased after yoga +practice. In one study, experienced yoga practitioners had a sig- +nificant 27% increase in GABA levels using magnetic resonance +spectroscopy.20 The increase in GABA levels was seen in expe- +rienced yoga practitioners after a 60-minute session of practicing +yoga postures compared to no change in GABA levels in con- +trols after they were asked to read for the same amount of time. +This study raised the question whether the increase in GABA +levels was specific to yoga or was due to an overall increase +in physical activity. The same authors provided the answer for +this in the subsequent study which compared GABA levels in +a yoga and a walking group.22 The 12-week yoga intervention +was associated with greater improvements in mood and lower +anxiety, compared to a metabolically matched walking exercise +group. This study was also the first to demonstrate that increased +thalamic GABA levels are associated with improved mood and +decreased anxiety. The implications of the study were that +GABA may be mediating some, if not all, of the beneficial +effects of yoga on mood and anxiety. The present results cannot +be directly compared to these studies, as meditation differs from +yoga postures. However, the mental state during yoga postures is +ideally the same as in meditation.13 +The increased latency of the Nb wave after nonmeditative +focusing in the present study suggests that following, but not +during, focusing without meditation there is also cortical inhi- +bition, though at a different level along the auditory pathway, +compared to meditation. The Nb wave corresponds to a neural +generator which is more distal along the auditory pathway, viz, +the Heschl gyrus.6 The delay in auditory transmission follow- +ing nonmeditative focusing may be related to the fact that atten- +tion modulates excitatory and inhibitory lateral interactions in +the cortex.23 During selective attention, there is effective filter- +ing of irrelevant information by modulatory influences.24 There- +fore, for selective attention during nonmeditative focusing, +inhibition of auditory transmission at the level of the Heschl +gyrus may be necessary. +Decreased amplitudes of the Pa wave occurred during all +4 sessions. As already mentioned, an increase in amplitude +suggests that a greater number of neurons were recruited. It +may have been expected that listening to the pre-recorded +instructions during the sessions would have activated the +primary auditory cortex in all 4 sessions. The present +results show that this did not occur. The reason for the +decrease in Pa amplitudes in all sessions may be due to selec- +tive inhibition of certain areas within the primary auditory +cortex. Hence, we speculate that sensory responses may have +been suppressed to reduce distracting auditory stimuli, so +that participants could direct their attention to the taped +instructions.25 +The findings are limited by the fact that (i) there was no way +to be certain that the participants were in the 2 meditative +states, except for their self-reports and reports of the teacher +and (ii) it was also not possible to rule out that participants fell +asleep during recordings despite CCTV monitoring and +reviewing the raw electroencephalogram (EEG) trace. These +limitations may be corrected in future studies if a reliable phy- +siological marker for the 2 stages is found, and the EEG is +recorded throughout along with the eye movements and muscle +tone to rule out sleep episodes. Despite these limitations, the +present study showed that when meditation was considered +as 2 stages, as it is described in the ancient texts, changes in +MLAEPs occurred in 1 stage, that is meditation without focus- +ing but not in the other, that is meditative focusing. Hence, +separating the stages based on the way they were described +in the ancient texts may yield new and different effects of +meditation. +Acknowledgment +The authors gratefully acknowledge the funding from the Indian +Council of Medical Research (ICMR), Government of India, as part +Table 6. Significant Results of Post Hoc Analyses, Where the Arrows Show the Direction of Change +Variable +Session +During +Post +During 1 +During 2 +During 3 +During 4 +Na wave latency +Meditation +NS +NS +<.05 " +NS +NS +Pa wave latency +Meditation +NS +NS +NS +<.05 " +NS +Nb wave latency +Nonmeditative-focused thinking +NS +NS +NS +NS +<.05 " +Pa wave amplitude +Random thinking +<.001 # +<.001 # +<.001 # +<.001 # +NS +Nonmeditative-focused thinking +<.001 # +<.001 # +<.05 # +<.05 # +NS +Meditative focusing +<.01 # +NS +NS +NS +NS +Meditation +NS +<.05 # +NS +NS +NS +Abbreviations: NS, not significant; ", increase; #, decrease. +Telles et al. +159 +of a grant (Project No. 2001-05010) toward the Center for Advanced +Research in Yoga and Neurophysiology (CAR-Y&N). +Declaration of Conflicting Interests +The authors declared no potential conflicts of interest with respect to +the research, authorship, and/or publication of this article. +Funding +The authors disclosed receipt of the following financial support for the +research, authorship, and/or publication of this article: The study was +funded by the Indian Council of Medical Research (ICMR), Govern- +ment of India, as part of a grant (Project No. 2001-05010) toward the +Center for Advanced Research in Yoga and Neurophysiology (CAR- +Y&N). +References +1. Telles S, Nagarathna R, Nagendra HR, Desiraju T. Alterations in +auditory middle latency evoked potentials during meditation on a +meaningful symbol—‘Om.’ Int J Neurosci. 1994;76(1-2):87-93. +2. Woods DL, Clayworth CC. Age-related changes in human middle +latency auditory evoked potentials. Electroen Clin Neurophysiol. +1986;65(4):297-303. +3. Telles S, Joseph C, Venkatesh S, Desiraju T. Alteration of audi- +tory middle latency evoked potentials during yogic consciously +regulated breathing and attentive state of mind. Int J Psychophy- +siol. 1993;14(3):189-198. +4. Telles S, Desiraju T. Recording of auditory middle latency +evoked potentials during the practice of meditation with the syl- +lable ‘OM.’ Indian J Med Res. 1993;98:237-239. +5. Malhotra A. Auditory Evoked Response in Clinical Practice. New +York, NY: Springer-Verlag; 1997. +6. Lie +´geois-Chauvel C, Musolino A, Badier JM, Marquis P, Chauvel +P. Evoked potentials recorded from the auditory cortex in man: +evaluation and topography of the middle latency components. +Electroen Clin Neurophysiol. 1994;92(3):204-214. +7. Deiber MP, Iban +˜ez V, Fischer C, Perrin F, Mauguie +`re F. +Sequential mapping favours the hypothesis of distinct generators +for Na and Pa middle latency auditory evoked potentials. Elec- +troen Clin Neurophysiol. 1988;71(3):187-197. +8. Ehlers MD. Activity level controls postsynaptic composition and +signaling via the ubiquitin-proteasome system. Nat Neurosci. +2003;6(3):231-242. +9. Telles S, Naveen KV. Changes in middle latency auditory evoked +potentials during meditation. Psychol Rep. 2004;94(2):398-400. +10. Panjwani U, Selvamurthy W, Singh SH, Gupta HL, Mukhopadhyay +S, Thakur L. Effect of Sahaja yoga meditation on auditory evoked +potentials (AEP) and visual contrast sensitivity (VCS) in epileptics. +Appl Psychophysiol Biofeedback. 2000;25(1):1-12. +11. Devi NM. Sahaja Yoga: A Beginner’s Guide. Bombay, India: +Vishwa Nirwala Dharma; 2006. +12. Kumar S, Nagendra H, Naveen K, Manjunath N, Telles S. +Brainstem auditory-evoked potentials in two meditative mental +states. Int J Yoga. 2010;3(2):37-41. +13. Taimini IK. The Science of Yoga. Madras, India: The Theosophi- +cal Publishing House; 1986. +14. Saraswati M, Swami G. Bhagavad Gita. Calcutta, India: Advaita +Ashrama; 1998. +15. Hutchison R, Swash M. Hutchinson’s clinical methods. London, +England: Bailliere Tindale; 1989. +16. Yadav A, Tandon OP, Vaney N. Auditory evoked responses dur- +ing different phases of menstrual cycle. Indian J Physiol Pharma- +col. 2002;46(4):449-456. +17. Jasper HH. The ten-twenty electrode system of the International +federation. Electroen Clin Neurophysiol. 1958;10(2):371-375. +18. Morlet D, Bertrand O, Salord F, Boulieu R, Pernier J, Fischer C. +Dynamics of MLAEP changes in midazolam-induced sedation. +Electroen Clin Neurophysiol. 1997;104(5):437-446. +19. Subramanya P, Telles S. Changes in midlatency auditory evoked +potentials following two yoga-based relaxation techniques. Clin +EEG Neurosci. 2009;40(3):190-195. +20. Streeter CC, Jensen JE, Perlmutter RM, et al. Yoga Asana ses- +sions increase brain GABA levels: a pilot study. J Altern Comple- +ment Med. 2007;13(4):419-426. +21. Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Sci- +ence. 4th ed. New York, NY: McGraw-Hill; 2000. +22. Streeter CC, Whitfield TH, Owen L, 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(11): +1145-1152. +23. Setic +´ M, Domijan D. Modeling the top-down influences on the lat- +eral interactions in the visual cortex. Brain Res. 2008;1225:86-101. +24. Erickson KI, Prakash RS, Kim JS, Sutton BP, Colcombe SJ, +Kramer AF. Top-down attentional control in spatially coincident +stimuli enhances activity in both task-relevant and task-irrelevant +regions of cortex. Behav Brain Res. 2009;197(1):186-197. +25. Nun +˜ez A, Malmierca E. Corticofugal modulation of sensory infor- +mation. Adv Anat Embryol Cell Biol. 2007;187:1-74. +160 +Clinical EEG and Neuroscience 43(2) diff --git a/subfolder_0/Muscle power, dexterity skill and visual perception in community home girls trained yoga or sports and in regular school girl.txt b/subfolder_0/Muscle power, dexterity skill and visual perception in community home girls trained yoga or sports and in regular school girl.txt new file mode 100644 index 0000000000000000000000000000000000000000..b433bd723e46ba69b5c5438993c0bd7642ebdf19 --- /dev/null +++ b/subfolder_0/Muscle power, dexterity skill and visual perception in community home girls trained yoga or sports and in regular school girl.txt @@ -0,0 +1,1896 @@ +Indian J Physiol Pharmacol +1997; 41 (4) : 409-415 +MUSCLE POWER, DEXTERITY SKILL AND VISUAL PERCEPTION +IN COMMUNITY +HOME GIRLS TRAINED +IN YOGA +OR SPORTS AND IN REGULAR SCHOOL GIRLS +P. RAGHURAJ +AND +SHIRLEY +TELLES* +Vivekananda +Kendra +Yoga Research +Foundation, +19, Eknath +Bhavan, +K. G. Nagar, +Bangalore +- 560 019 +( Received +on March +15, 1997) +Abstract: +The +present +study +was +conducted +to compare +critical +flicker +fusion +frequency +(CFF), +degree +of optical +illusion +C'di"), dexterity +scores, +and +grip +strength +in three +groups +of subjects, +viz community +home +girls +who had learned +yoga for 6 months +(CHY), age-matched +community +home +girls +who had physical +activity +training +for 6 months +(CHP), and girls +who +were attending +a regular +school (SCH). There +were equal +numbers +in each +group +for each of the 4 assessment +(range +11 to 30 subjects) +and age range +was 12 to 16 years +of age. The CHP group had significantly +lower CFF and +"di" was significantly +higher +(one factor +ANOVA, t test +for unpaired +data) +in the +CHP +group, +both +compared +to CHY and +SCH groups. +Right +hand +grip +strength +was +also +significantly +less +in the +CHP group +compared +to +SCH. +The +results +were +explained +by previous +reports +of high +levels +of +anxiety +and +aggression +in +community-home +groups, +which +is known +to +influence +the +four parameters +described +here. +The better +performance +of +the +CHY group +compared +to CHP, +suggested +that +yoga +practice +has +a +beneficial +effect +in these +subjects. +Key +words: +community +home +physical +activity +INTRODUCTION +Children +who are +unable +to adjust +at +home, at school or in society are admitted +to community +homes. Previous +studies +have +established +that these children were socially +and +emotionally +traumatized, +although +physically +normal +(1). They +also reported +anxiety and fears and were more aggressive. +A report +on physiological +measures +showed +that +the +resting +electrical +activity +in +yoga +motor +strength +and +skill +visual +per::eption +selected facial and back muscles +(EMG) was +significantly +higher +in +community +home +boys compared +to boys of the same +age in +an ordinary +school (2). This +increase +was +attributed +to a high level of stress, +as the +EMG tone was found to decrease +after +the +subj ects +underwent +a +program +which +included +both +physical +training +and +relaxation. +A subsequent +report +compared +the +effects +of increased +physical +activity +with +those +of relaxation +with +awareness +*Corresponding +Author +410 +Raghuraj +and +Telles +through +yoga in community +home girls (3). +To begin with, +community +home girls had +higher +respiratory +rates +and +lower +skin +resistance +values +compared +to +an +age +matched +group of girls who were staying +at +home and attending +a regular +school. At the +end of six months the community-home +yoga +group had a greater +decrease +in heart +rate, +respiratory +rate +and +an increase +in skin +resistance, +compared +to +a +matched, +community-home +physical +activity +group. +These +changes +also +suggested +that +yoga +decreased +physiological +signs of stress. +The +present +study +was +conducted +to +compare +the +motor +and +sensory +(visual) +performance +of community +home girls who +had learnt +yoga with +that +of community- +home girls trained +in physical +activity +and +of girls +staying +at home. Four tests +were +used, +viz. (0 hand +grip +strength +as +an +indicator +of muscle +power, +(ii) degree +of +optical illusion +using Muller-Lyer +lines as +a measure +of accuracy of visual perception, +(iii) critical +flicker fusion frequency +also to +assess +visual +perception, +and (iv) tweezer +dexterity +to +assess +motor +skills. +The +community-home +girls +belonged +to +two +categories. +Prior +to the +assessments +one +category +had +training +in +yoga +for +six +months, +while +the +other +category +had +a +program +of increased +physical +activity +for +the same duration. +This study also compared +both +categories +of community-home +girls +with +age matched +girls +from an ordinary +school. +METHODS +Subjects: +The subjects were 80 girls from +a +state +community-home. +They +were +between +12 and 16 years +of age and had +Indian J Physiol Pharmacol +1997; 41 (4) +been +admitted +because +of difficulty +in +adjusting +at home, at school, or in society. +Fifteen +were from broken +homes, +with one +or both parents +dead +or separated. +Their +duration +of stay in the home ranged +from 6 +to 36 months. The 80 girls were divided into +pairs matched +for age and duration +of stay +in the home. It was possible to form 30 such +pairs. +Subjects +of a pair +were +randomly +assigned +to either +one of two groups, +viz. +yoga (CHY) and physical +activity +(CHP). A +third +group +of girls +who were +staying +at +home +and +attending +an +ordinary +school +(SCH), were matched +as far as possible for +age (± 6 months +to 2 years) +with +the two +groups from the community-home. +All three +groups +(CHP, +CHY, SCH) were +assessed +similarly. +However, +it was not possible +to +collect data on the degree of optical illusion +in the control +(SCH) subjects. +Hence data +obtained on adults living at home were used +as control values. +For each of the tests +the +number +of subjects +was different +(Table I). +Design +of the study: +All three +groups, +i.e. +community-home +group +who +had +practised +yoga +for +six +months +(CHY), +community-home +group who had training +in +physical +activity +for +the +same +duration +(CHP), and girls who were staying +at home +and attending +a normal +school (SCH), (or +as described above, for the degree of illusion +assessment, +normal +adults), +were assessed +for" each of the four tests +(detailed +below) +on four separate +occasions. +Parameters: +All subjects +were +assessed +in the four parameters +described +below: +(i) Hand +grip +strength +was +measured +using +a hand +grip dynamometer. +Subjects +were asked to extend their arms horizontally +Indian J Physiol +Pharmacol +1997; 41 (4) +Sensorimotor +Skills in Community +Home Girls +411 +TABLE +I: +Number +of subjects +(n) and mean age ± SD of each group for all the four assessments. +Groups +Assessment +n +CHY +CHP +SCH +Mean +age +SD +Mean +age +SD +Mean +age +SD +Grip +strength +1.3 +1.4 +11 +13.9 +Tweezer +dexterity +15 +13.6 +2.9 +Critical +flicker +fusion +30 +13.9 +1.9 +Optical +illusion +30 +13.9 +1.9 +12.9 +2.6 +28.9* +6.3 +* = adult +subjects +parallel +to the ground, +without +support +and +grip +the +dynamometer +using +maximum +strength. +Three +trials +were +given for each +hand, +alternately, +with 10 see gap between +trials. +The highest +among the three +values +was used for analysis. +(ii) +Tweezer +dexterity +was +measured +using +the +O'Connor +tweezer +dexterity +apparatus, +which consists +of a metal +plate +which has +100 holes +(2.0 mm in diameter +and 20.0 mm deep) spaced +15.0 mm apart. +The subject was instructed +to pick up metal +pins (1.5 mm in diameter +and 25.0 mm in +length) +with +a tweezer +and place +them +in +the holes as quickly as possible. The number +of pins placed +within +4 min was noted. +(iii) Critical +flicker +fusion +frequency +was +measured +using +an electronic +flicker fusion +apparatus, +with +flicker +rate +ranging +from +12 to 95 Hz. The flickering +stimulus +was a +red light, +6 mm in diameter +with intensity +of 50 mcd, surrounded +by a white +surface +with illumination +of 150 lux. Subjects +were +seated 50 em away from the apparatus, +with +their gaze on level with it. All subjects were +13.6 +13.8 +1.1 +13.8 +1.8 +1.8 +11.4 +12.9 +13.6 +1.5 +2.6 +assessed +in +ten +ascending +trials, +which +began with minimum +frequency +(12 Hz for +the +apparatus +used). +The +frequency +was +increased +at the rate +of 0.5 Hz per step, till +the subjects +felt that +the stimulus +was no +longer flickering, +i.e. it was "fused" +(fusion +threshold). +(iv) Opticalillusion. +was measured +using +Muller-Lyer +lines. +Subjects +were +assessed +in two types +of trials, +i.e. "in" +and +"out" +using +"the +method +of limits", +with +the +experimenter +varying +the +lengths +of the +lines. The Muller-Lyer +lines, though of equal +length, +appear +unequal +due to two different +types +of arrows +drawn +at the +ends +of the +line. In the apparatus +used for the present +study, +the line on the left had close-ended +arrows +at +either +end, +making +it +appear +shorter. +The length +was fixed (in mrn). In +contrast +the length +of the line on the right +could be varied. +This line had +open-ended +arrows +at either +end which made it appear +longer. +The experimenter +manipulated +the +length +of the line according +to the subject's +specifications. +The exact +position +at which +the subject +perceived +the two lines to be of +412 +Raghuraj +and +Telles +equal +length +was +noted, +i.e. +subjective +reading +- "sr". +The difference +between +the +reading +at which +the +lines +were +actually +equal +and +the +"sr" +gave +the +degree +of +illusion, +"di". Each +subject +of three +groups +was assessed +in two types of trials +(ten each, +give +alternately). +For +"in" +trials +the +examiner +adjusted +the +length +of +the +adjustable +line, +1 mm at a time, +changing +the length +from maximum +(200 mrn) till the +subjects +perceived +the length +to be equal to +that +of the fixed line (actual +length += 160 +mm). For +"out" +trial +the +procedure +was +reverse, +the +adjustable +line +was +kept +to +minimum +length +and +the +length +was +gradually +increased +till +the +subjects +perceived +the +length +to equal +that +of the +fixed line. +In both +cases +the +difference +(in +mrn) between +the actual +length +of the fixed +line and the perceived +length +was noted +as +the degree +of illusion, +"di". +For all 4 tests the apparatuses +were from +Anand +Agencies, +Pune, +India +Yoga +training: +Staff +members +of the +community-home +who +were +previously +trained +in yoga, were involved +in teaching +and +supervision. +A trained +yoga +teacher +visited +the +class +every +fortnight +to check +the practice. +Yoga techniques +included: +(i) +simple yogasanas +for 50 minutes, +(these +are +postures +which +are maintained +for as long +as possible, +while +relaxed), +and +(ii) +a 10 +minute +period +of relaxation +in +shavasan +(corpse posture). +Throughout +both practices +the +emphasis +was +on +relaxation +and +awareness +of physical +and other sensations. +Physical +act un.ty : +Physical +activity +training +included +stationary +jogging, +rapid +bending +forwards +and backwards, +twisting, +Indian +J Physiol +Pharmacol +1997; 41 (4) +and +bending +sidewards. +These +pr act ices +were +for +40 +minutes. +The +session +also +included +20 minutes +of playing +games +such +as relay +races +in which +all the girls had to +participate +actively. +RESULTS +The data +for all four assessments +(grip +strength, +tweezer +dexterity, +critical +flicker +fusion +frequency, +and +degree +of optical +illusion +(Mul Ier-Lyer +lin es l) of the +three +CRITICAL FLICKER +FUSION +FREQUENCY +Hz +~CHY +~CHP +DSCH +DEGREE OF OPTICAL ILLUSION +OUTTRIALS +5 +•• +t: +em +3 +IN TRIALS +2 +1 +OL..---.J<:.=~-L_~ +~CHY +WCHP +DSCH +•• p< -OS +.11- P< -001 +Fig. 1: Critical +flicker +fusion +frequency +and +degree +of +optical +illusion +in community +home yoga group +(CHY) and community home physical training group +(CHP) compared +to ordinary +school group (SCH). +*P<.05, **P<.OOl, 't' test for unpaired +data. +Indian +J Physiol +Pharmacol +1997; 41 (4) +groups +were +compared +for +significant +differences +using +separate +single-factor +analysis +of variance +(ANOVA). The group +average +values +were tested +for significant +differences +using +the +'t' test +for unpaired +data +comparing +two groups +at a time. The +single +factor ANOVA showed a significant +difference between the critical flicker fusion +frequency values of the 3 groups, [F = 18.36, +F.001 (2) 2, 87 = 8.30, hence +P<.OOl] and +for the degree of optical illusion +using the +Muller-Lyer +lines +during +"in +trials" +[F = +18.99, F.001 (2) 2, 87 = 8.30, hence P<.OOl] +HAND +GRIP +STRENGTH +RIGHT +HAND +LEFT +HAND +~CHY +ill]CHP +DSCH +TWEEZER +DEXTERITY +50 +No. of pins/1.0 +I. min +30 +20 +~CHY +C3 CHP +DSCH +Fig. 2: Hand grip strength +and tweezer +dexterity +scores +in +community +home +yoga +group +(CHY) +and +community +home physical +training +group (CHP) +compared +to ordinary +school group (SCH). +Sensorimotor +Skills +in Community +Home Girls +413 +(Fig. 1). There was no significant +difference +between +the +three +groups +for +degree +of +optical +illusion +for "out +trials", +hand +grip +strength +scores obtained +for either +hand or +for the tweezer +dexterity +scores +(P^`@ +'2<>^`@ +'2,>^`@ +'2,>^`@ + +'2<>^`@ +Figure 1: Conceptual framework of pathways to care in type 2 diabetes mellitus DOI: Duration of illness, DOY: Duration of yoga, BS: Blood sugars, T2DM: Type 2 +diabetes mellitus, MED: Oral medicine +Access this article online +Website: +www.ijoy.org.in +Quick Response Code +DOI: +10.4103/0973-6131.154074 +[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82] diff --git a/subfolder_0/Performance in the Stroop Task and Simultaneously Recorded Heart Rate Variability.txt b/subfolder_0/Performance in the Stroop Task and Simultaneously Recorded Heart Rate Variability.txt new file mode 100644 index 0000000000000000000000000000000000000000..6b81562ad26fc2d04fc5e177908028e0340ae632 --- /dev/null +++ b/subfolder_0/Performance in the Stroop Task and Simultaneously Recorded Heart Rate Variability.txt @@ -0,0 +1,799 @@ +International Journal of Brain and Cognitive Sciences 2015, 4(1): 8-14 +DOI: 10.5923/j.ijbcs.20150401.03 +Performance in the Stroop Task and Simultaneously +Recorded Heart Rate Variability before and after +Meditation, Supine Rest and No -Intervention +Pailoor Subramanya1, Shirley Telles2,* +1Indian Council of Medical Research, Center for Advanced Research in Yoga and Neurophysiology, SVYASA, Bengaluru, India +2Patanjali Research Foundation, Patanjali Yogpeeth, Haridwar, Uttarakhand, India + +Abstract In an earlier study heart rate variability (HRV) recordings after cyclic meditation (CM) suggested a shift +towards vagal dominance. In a separate study, CM improved the performance in a task for attention. Generally, attention +tasks result in sympathetic activation. The present study was intended to assess whether CM would change the autonomic +status when practitioners performed an attention task, with simultaneous HRV recording Methods: Twenty-five male +volunteers with group average age ± S.D., 23.9 ± 5.0 years were each assessed on three separate days in three sessions, (i) CM, +(ii) supine rest (S R), and (iii) quiet sitting (QS). Each session was for 23 minutes. Simultaneous assessments were made +before and after each of the three sessions and included the HRV, respiratory rate and performance in the Stroop task. Results: +Following CM the LF power increased and HF power decreased (P < 0.05). There was an increase in the word scores, color +scores and color-word scores of the Stroop task (P < 0.001, Repeated measures ANOVA, followed by Bonferroni adjusted +post-hoc analyses). Conclusion: The results suggest that there was reduced parasympathetic activity after CM and possibly +increased sympathetic activity, when participants simultaneously performed the Stroop task. Their improved performance in +the Stroop task suggests better response inhibition, interference resolution, word reading and activation along with reduced +physiological arousal based on HF power of the HRV. +Keywords Stroop, HRV, Yoga + +1. Background +Meditation has been described as a state of consciousness +in which deep relaxation and increased internalized attention +co-exist [1]. Meditation is not always easy for novices to +practice, and in yoga texts meditation has been described as +the seventh of eight stages required to reach ultimate mental +transcendence, called Samadhi, in Sanskrit [2]. A meditation +technique called CM, which has its’ origin in ancient yoga +texts [3, 4], was derived especially for novices. CM has +alternating cycles of practicing yoga postures slowly, with +deep awareness, interspersed with periods of SR. CM differs +from other meditation techniques as it includes the practice +of yoga postures practiced slowly with heightened internal +awareness. Tai-Chi-Qui-Gong is a comparable technique and +these practices have been called ‘moving meditations’ [5]. +Despite the fact that CM includes the practice of yoga +postures, following twenty-three minutes of the practice +there was a reduction in heart rate, as well as in the low + +* Corresponding author: +shirleytelles@gmail.com (Shirley Telles) +Published online at http://journal.sapub.org/ijbcs +Copyright © 2015 Scientific & Academic Publishing. All Rights Reserved +frequency power of the HRV, while the HF power increased, +suggesting a shift in cardiac autonomic balance towards +vagal dominance after the practice (Cohen’s d = 0.87) [6]. +The LF band of the HRV is believed to be chiefly but not +entirely related to sympathetic activity when expressed in +normalized units [7], while efferent vagal activity mainly +contributes to the HF band [8]. +Sympathetic activation is of interest in the present study +since it is associated with increased vigilance and hence may +be considered essential for performing an attentional task [9]. +An early study showed improvement in different aspects of +attention in practitioners of Transcendental Meditation [10]. +More recently studies on practitioners of CM have shown +improved performance in tasks requiring attention and other +executive functions. In forty-two experienced meditators the +P300 was measured before and after a session of CM on one +day, and similarly before and after a comparable duration of +SR on another day (Cohen’s d = 0.85) [11]. The P300 is an +event related potential which reflects fundamental cognitive +events requiring attentional and immediate memory- +processes [12]. Following CM there was a decrease in the +P300 peak latency and an increase in the P300 peak +amplitude suggesting a greater improvement in cognitive +processes after CM compared to SR [11]. + + +International Journal of Brain and Cognitive Sciences 2015, 4(1): 8-14 +9 + +Similarly the performance in a cancellation task was +assessed in sixty- nine volunteers immediately before and +after sessions of CM and SR on separate days [13]. +Cancellation tasks assess attention, concentration, and +visuo-spatial scanning abilities [14]. The net scores +improved after both CM (by 24.9 percent) and SR (by 13.6 +percent). These results also suggested that CM favorably +impacts attention, concentration, visual scanning abilities +and a repetitive motor response. It was speculated that the +improvement in attention in these studies was related to a +reduction in anxiety, as anxiety affects performance in tasks +requiring attention [15]. +However, as already mentioned attention is generally +associated with increased sympathetic activity [16], which +normally decreases when anxiety levels are low [17]. The +association between HRV and trait anxiety was assessed in +92 healthy persons along with self- rating of trait anxiety and +perceived emotional stress [18]. In an earlier study on +healthy participants there was a shift towards vagal +dominance in the HRV after CM [6]. Till now, the HRV has +not been recorded in meditators in the same session as the +attention task. Hence the present study was designed to +record the HRV and respiratory rate before and after the +Stroop task, in the same session [19]. The hypothesis being +tested was that CM would improve Stroop task performance +while reducing sympathetic activity. +2. Methods +Participants +There were twenty- five self-reported healthy male +participants with ages ranging between 18 and 38 years +(group mean ± S.D., 23.9 ± 5.0 years). The participants did +not report any history of hospitalization or medication in the +past six months. The temperature and blood pressure of the +subjects were normal on the days of their participation in the +study. The sample size was not determined prior to designing +the study. However post-hoc analyses based on the effect +size showed that the power of the tests used was 0.95 [20]. +Participants were staying at a residential yoga c enter located +in south India. For inclusion in the study participants had to +meet the following criteria: (i) they had to be healthy based +on a standard medical examination, (ii) literate and able to +understand and perform the Stroop task, and (iii) have +adequate experience of both CM and relaxation while supine +i.e., 3 to 6 months. Exclusion criteria included: (i) color +blindness based on the Ishihara charts, (ii) consumption of +caffeine, nicotine containing substance s or any medicine +which could influence cognition or autonomic function, and +(iii) presence of extra systoles in the EKG. Participants were +recruited by flyers on the notice board of the institution. The +method of the study was explained to the participants, but not +the hypothesis. No incentive was given to the participants for +participation in the study. None of the participants was +involved in any other ongoing yoga research at the center. +Design +Every participant was assessed in three types of practice +sessions (CM, S R and QS sessions). The assessments were +made on three different days for every participant. The +sequence of practice was randomly allocated to balance the +effect of the order of the sessions. The study design was +explained to the participants and their signed informed +consent was obtained. The study had the approval of the +institutional ethics committee. +Time allocation within the sessions +The Stroop task, HRV and respiratory rate were measured +‘before’ and ‘after’ the interventions. The first 5 minutes of +the ‘before’ period was in the sitting position, followed by 23 +minutes of the ‘d uring’ period, where participants were +given (i) CM practice using taped instructions, or (ii) SR in +the corpse posture (= shavasana, in Sanskrit) without +instructions or (iii) in the QS session participants were seated +at ease. This was followed by 5 minutes of the ‘after’ period. +In (i) ‘d uring’ periods of S R and QS session and (ii) ‘before’ +and ‘after’ periods of all 3 sessions the participants were not +given any specific instructions. The study design and +assessment schedule are given schematically in Figure 1. +Assessments +The twenty-five participants were assessed before and +after three types of sessions, (i) CM, (ii) SR, and (iii) QS. +Assessments were made in a dimly lit, sound attenuated +room (sound level 26 dB) with ambient temperature 24±2℃ +while being observed throughout on a closed circuit +television. The HRV and respiratory rate were recorded for 5 +minutes using the Standard Limb Lead II configuration and +volumetric pressure transducer respectively. The recordings +were made immediately before the Stroop task prior to the +intervention and after the Stroop task on completion of the +intervention. There were no differences in results based on +the order of the sessions, when the ‘after’ values were +compared (P > 0.05, t-test for unpaired data). +Heart rate variability and Respiratory rate +HRV and respiratory rate were assessed using a MP100 +BIOPAC data acquisition system (BIOPAC S ystems, Inc., +U.S. A.). The EKG was recorded using Ag/AgC l pre-gelled +electrodes. The recording was made with a standard limb +Lead II configuration and an AC amplifier with 1.5 Hz low +cut filter and 99 Hz high cut filter settings. The data were +acquired at the sampling rate of 1024 Hz. Respiratory rate +was recorded with a volumetric pressure transducer fixed +around the trunk about 8 cm below the lower costal margin +when the participants sat erect. +Stroop Task +The Stroop task consisted of a worksheet of 3 pages, each +page having 100 items printed as 20 rows and 5 columns +arranged randomly over a 8.5” 11” white sheet. The task +used three colors, viz., b lue, green, and red. There were the +standard Word page, Color page and Color- Word page. +Instructions given were based on the Stroop task manual [21]. + +10 +Pailoor Subramanya et al.: Performance in the Stroop Task and Simultaneously Recorded Heart + +Rate Variability before and after Meditation, Supine Rest and No -Intervention +The participants were instructed to read the words, name the +colors, and finally, name the color of the ink printed words +which did not match, as quickly and as accurately as possible +in the three tasks within 90 seconds for the complete task. All +tasks were conducted and scored by a person who was +unaware whether the participant was in a (i) CM or (ii) S R or +(iii) QS session. +Inte rvention +Cyclic meditation session (CM) +During CM practice, participants kept their eyes closed +and followed pre-recorded instructions. The instructions +emphasized carrying out the practice slowly, with awareness +and relaxation. The practice began by repeating a verse (0:40 +min) from the yoga text, the Mandukya Upanishad [4]; +followed by isometric contraction of the muscles of the body +ending with supine rest (1:00 min.); slowly coming up from +the supine position and standing at ease ( called tadasana) +and ‘balancing’ the weight on both feet, called centering +(2:00 min.); then the first actual posture, bending to the right +(ardhakaticakrasana, 1:20 min.); with 1:10 min. in tadasana +for instructions about relaxation and awareness; bending to +the left (ardhakaticakrasana, 1:20 min.); 1:10 min. as before; +forward bending (padahastasana, 1:20 min.); another 1:10 +min.; backward bending (ardhacakrasana, 1:20 min.); and +slowly coming down to the supine position with instructions +to relax different parts of the body in sequence (10:30 min.). +The postures were practiced slowly, with awareness of all the +sensations experienced. The total duration of the practice +was 23 min. [6]. +Supine rest session (SR) +SR was practiced as traditional shavasana (the corpse +posture), which meant lying supine, with the legs apart, and +arms away from the sides of the body, with the palms facing +upwards, while the eyes were closed [22]. This practice +lasted 23 min., so that the duration was the same as for CM. +Participants were not given any instructions. +Quiet sitting session (QS) +Subjects were seated at ease and their thoughts were +allowed to wander at random. They were not given any +specific instructions except for the fact that they were told +that they were to avoid meditating. The session was also at +the same time of the day as the CM and SR sessions. +Thus in the present study, comparing the effects of +practicing CM, SR and a QS session in the same subjects on +separate days reduce d the possibility of bias. F urther, the +order of the sessions (CM, S R and QS) was randomized to +eliminate the effect of the order of sessions influencing the +results. +Data extraction +Heart rate variability and Respiration +The frequency domain and time domain analys es of HRV +data were carried out for 5 minute recordings for each of the +following sessions CM, SR and QS. These 5 minutes epochs +were recorded before and after each intervention. The data +recorded were visually inspected off- line and only noise free +data were included for analysis. None of the data had to be +excluded due to noise. The heart rate was obtained based on +R-R inter-beat interval analysis. The HRV power spectrum +was obta ined using Fast Fourier transform analysis (FF T). +The data were analyzed with an HRV analysis program +developed by the Biosignal Analysis and Medical Imaging +Group, University of Eastern F inland, Kuopio, F inland [23]. +The energy in the HRV series in the following specific +frequency bands was studied viz., the VLF band (0.0 - 0.04 +Hz), LF band (0.04 - 0.15 Hz) and HF band (0.15 - 0.4 Hz). +The LF and HF band values were expressed as normalized +units. The following components of time domain HRV were +analyzed: (i) mean RR interval (the mean of the intervals +between adjacent QRS complexes or the instantaneous heart +rate), (ii) RMSSD (root mean square of successive +differences), (iii) NN50 (the number of interval differences +of successive NN intervals greater than 50 ms), and (iv) +pNN50 (the proportion of NN50 divided by total number of +NN intervals). Mean respiratory rate was calculated before +and after the sessions. +Stroop Task +As per the manual the correct responses were scored as ‘1’ +depending on the response of the participant and if the +responses were incorrect it was scored as ‘0’ [21]. Hence, the +outcome measures were color scores, word scores, and +color-word scores. + +Figure 1. Schematic representation of the design of the study and assessment schedule + + +International Journal of Brain and Cognitive Sciences 2015, 4(1): 8-14 +11 + +Table 1. Group mean values ± S.D. of Frequency domain, Time domain analyses of the HRV and Respiratory rate recorded before and after, sessions of +Cyclic Meditation (CM), Supine Rest (SR) and Quiet Sitting (QS) +Frequency domain analysis of the HRV +Sessions +CM +SR +QS + +Before +After +Before +After +Before +After + + + + + + + +VLF (ms2) +26.82±12.38 +29.59±17.85 +29.56±18.97 +28.22±14.12 +32.53±15.74 +32.32±17.33 +LF (nu) +55.67±17.55 +63.75±19.82* +61.50±22.21 +64.78±16.89 +58.98±22.88 +63.19±18.14 +HF (nu) +44.33±17.55 +36.25±19.82* +38.50±22.21 +35.22±16.89 +41.02±22.88 +36.81±18.14 +LF/HF (ratio) +1.74±1.50 +4.93±9.85 +3.25±3.76 +3.90±7.07 +3.07±4.02 +3.31±5.29 +Time Domain analysis of the HRV spectrum +Sessions +CM +SR +QS + +Before +After +Before +After +Before +After +Mean RR (cpm) +806.55±104.73 +800.54±124.69 +794.70±105.99 +811.78±98.72 +781.80±114.57 +795.28±84.57 +Mean HR (bpm) +76.13±10.45 +77.07±11.03 +77.22±10.50 +75.43±8.90 +78.78±11.54 +76.73±8.15 +RMSSD (ms) +46.00±21.22 +48.13±30.34 +41.07±19.35 +45.59±18.20 +42.20±19.54 +41.30±18.60 +NN50 (count) +85.52±56.74 +77.68±52.32 +71.12±58.29 +72.92±51.41 +72.96±58.56 +70.40±63.75 +pNN50 (%) +24.44±17.76 +22.40±17.45 +20.48±18.71 +20.94±16.70 +20.92±18.71 +20.23±19.51 +Respiratory Rate + +CM +SR +QS + +Before +After +Before +After +Before +After +Respiratory +rate +(breaths/min) + + +17.60±0.81 + + +17.45±0.59 + + +17.30±0.65 + + +17.52±0.76 + + +17.46±0.81 + + +17.31±0.54 +*p < 0.05 Repeated Measures ANOVA, with Bonferroni adjustment, before compared with after for the respective sessions +Table 2. Group mean values ± S.D. for the Stroop Task recorded before and after sessions of Cyclic Meditation (CM), Supine Rest (SR), and Quiet Sitting +(QS) +Sessions +CM +SR +QS + +Before +After +Before +After +Before +After +Word Task +[W] +99.68±23.75 +108.20±23.11 *** +103.44±22.51 +109.60±19.00* +105.24±17.69 +110.24±16.96* +Color Task +[C] +65.32±14.22 +73.60±11.73*** +71.44±9.84 +72.52±8.77 +69.96±8.95 +74.88±11.47** +Color – +Word Task +[CW] +77.96±26.63 +84.68±27.78*** +81.04±27.05 +84.24±28.96 +81.88±25.11 +83.84±23.98 +*p < 0.05, **p < 0.01, ***p < 0.001, RM ANOVA, with Bonferroni adjustment, before compared with after for the respective sessions +Data analysis +Statistical analysis was done using P ASW (Version 18.0). +Repeated measures analyses of variance (ANOVA) were +performed with two 'within subjects' factors, i.e., Factor 1: +Sessions; CM, SR and QS and Factor 2: States; ‘before’, and +‘after’. This was followed by a post-hoc analysis with +Bonferroni adjustment for multiple comparisons between the +mean values of different states, and after- values were +compared to the respective ‘before’ values. Data recorded in +the before states of CM, S R, and QS sessions were +compared for baseline differences with a one-way ANOVA. +3. Results +The group means and standard deviations for scores +obtained in the HRV and respiratory rate are shown in +Table 1, Stroop task [i.e., word task, color task, and +color-word task scores] taken before and after CM, S R, and +QS sessions are shown in Table 2. +Repeated measures analyses of variance +Heart Rate Variability + +12 +Pailoor Subramanya et al.: Performance in the Stroop Task and Simultaneously Recorded Heart + +Rate Variability before and after Meditation, Supine Rest and No -Intervention +Frequency domain analysis of the HRV spectrum +The repeated- measures analyses of variance (ANOVA) +showed a significant difference between States (F = 5.75, df += 1, 24, Huynh-Feldt epsilon = 1, P < 0.05) for LF and HF. +For VLF, LF, HF, and LF/HF, there were no significant +differences between Sessions, or interaction between +Sessions and S tates. +Time domain analysis of the HRV spectrum +There were no significant differences between Sessions, +States or their interaction for mean RR, mean HR, RMSSD, +NN50 and pNN50. +Respiratory Rate +For the respiratory rate there were no significant +differences between Sessions, S tates or their interaction. +Stroop Task +The repeated- measures analyses of variance (ANOVA) of +Stroop task scores showed a significant difference between (i) +Sessions [for word scores, color scores and color-word +scores] (F = 24.67, df = 2.26, 54.26, Huynh-Feldt epsilon = +0.28, P < 0.001) and (ii) S tates [Pre and Post] (F= 44.97, +df = 1, 24, Huynh-Feldt epsilon = 1, P < 0.001). The +interaction between Sessions and S tates was not significant +for word scores, color scores or color-word scores. +Post-hoc analyses +Heart Rate Variability +Frequency domain analysis of the HRV spectrum +Post-hoc tests for multiple comparisons were performed +with Bonferroni adjustment and all comparisons were made +with the respective before states. After the Cyclic Meditation +session, there was a significant increase in LF power +(P < 0.05) and a decrease in HF power (P < 0.05). There +were no significant differences after both supine rest and +quiet sitting sessions. +Time domain analysis of the HRV spectrum +There was no significant difference between Sessions, +States or their interaction for mean RR, mean HR, RMSSD, +NN50 and pNN50, hence no further post-hoc analyses were +performed. +Respiratory Rate +For the respiratory rate there were no significant +differences between Sessions, S tates or their interaction, +hence no further post-hoc analyses were performed. +Stroop Task +Post-hoc tests for multiple comparisons were performed +with Bonferroni adjustment and all comparisons were made +with the respective before states. After the CM session there +was a significant increase in the word scores of the S troop +task (P < 0.001), color scores (P < 0.001) and color-word +scores (P < 0.001), compared to values of the before state. +Also, after SR sessions there was a significant increase in +word scores (P < 0.05) and after the QS session there was an +increase in word scores (P < 0.05) and color scores +(P < 0.01). +4. Discussion +Participants performed better in the Stroop task with +increased color-word scores after CM but not after SR or QS. +However the better performance was accompanied by an +increased power in the LF component of the HRV, with a +decrease in the HF component. +As already mentioned in the introduction the LF band of +the HRV is believed to be chiefly but not exclusively due to +sympathetic activity when expressed in normalized units [7], +while efferent vagal activity contributes mainly to the HF +band of the HRV [8]. The breath rate did not change after +either of the interventions. This is relevant as it is known that +there is an acute increase in LF, total spectrum HRV and in +vagal baroreflex gain during slow breathing [24]. Training to +increase the amplitude of respiratory sinus arrhythmia +maximally increases the amplitude of heart rate oscillations +at approximately 0.1 Hz [25]. However, considering that +breath rate did not change in the present study, the breath +frequency could not have influ enced the HRV. Hence the +results suggest that after CM there was a shift in the +autonomic balance towards parasympathetic decrease with a +possible increase in sympathetic activity. As was already +mentioned sympathetic activation is associated with +increased vigilance considered necessary to perform an +attentional task [6]. +In an earlier study the LF band of the HRV reduced after +CM, while the HF power increased [6]. However there were +the following differences between that study and the present +one: (i) in the earlier study participants were asked to +practice CM and SR on two different days and the HRV and +respiration were recorded. They were not given any task. In +the present study participants were given the Stroop task to +perform before and after the prac tice of CM or SR or QS, +and the HRV and the respiration were recorded after the task. +Hence, the earlier studies assessed practitioners of CM when +they were doing the meditation without any task. The present +results suggest that when given a task the physiologically +relaxing effects of CM were not sufficient to reduce the +sympathetic +arousal +associated +with +vigilance +and +performance of a task requiring attention in addition to other +cognitive processes. +The absence of change in time domain measures which +generally reflect parasympathetic tone, may be explained as +follows: the sympathovagal balance is tonically and +phasically modulated by at least three main factors, (i) +central neural integration, (ii) peripheral inhibitory reflex +mechanisms, +and +(iii) +peripheral +excitatory +reflex +mechanisms [26, 27]. While, variable phenomena such as the +heart rate (recorded as the HRV) can be described as a +function of time they may be better described as the sum of +elementary oscillatory components [28]. Hence, the +frequency domain may reflect those changes in the +sympathovagal balance which are not detected by time + + +International Journal of Brain and Cognitive Sciences 2015, 4(1): 8-14 +13 + +domain analysis. +The S troop task requires the participant to suppress a +habitual response and respond to an unusual one, in this case +naming the color of the ink in which incongruously named +color-words were printed [29]. The cognitive processes +required to perform the Stroop task are complex. They +include +response +inhibition, +interference +resolution, +behavioral conflict resolution, word reading and production, +and visual attention [30]. The present results suggest a +possible benefit of practicing CM to improve abilities +required to perform the Stroop task. Participants did not have +any additional benefit of reduced sympathetic activation +after performing CM and while doing the Stroop task. These +results resemble those of a recent study in which Vipassana +expert meditators showed greater P3b amplitudes to the +target tones after meditation than they did both before +meditation and after the no- meditation sessio n. They also +simultaneously showed a larger LF/HF ratio during +Vipassana meditation [31]. Hence Vipassana meditation was +associated with better P3 potentials (suggestive of improved +attention) along with increased sympathetic activity. +The limitations of the study are as follows: (i) in earlier +studies [13, 32] the tasks used to assess performance before +and after CM were different from the Stroop task used in the +present study. The reason for this difference is that the +participants in the present study had taken part in other +studies in the residential yoga institution which used the +tasks which were previously assessed. Hence, they would +have approached the earlier tasks with a certain degree of +familiarity and monotony. However in introducing a new +task the results of the previous studies cannot be directly +compared with the present results. (ii) All twenty- five +participants were assessed in three types of sessions. Even +though the order of the sessions was randomized the +participants might have performed better after CM not +merely because of the effects of CM per se, but because the +CM session kept them busy and engaged while the other +sessions did not. (iii) The sample size (n=25) in the present +study was smaller than the sample sizes in the previous +studies o n cancellation task performance (n=47), memory +task performance (n=57) and HRV and respiration (n=47). +Despite these limitations the present results showed that +when participants were given a task to perform following +meditation, their perfor mance in the task which required +focused attention was better, however there was also a shift +in the autonomic balance towards decreased parasympathetic +activity and possibly increased sympathetic activity. +ACKNOWLEDGEMENTS +The authors gratefully acknowledge the funding from the +Department of Science and Technology (DS T), Government +of India, as part of a grant (Project No. SR/CSI/22/2009) +under Cognitive Science Research Initiative (CSI). The +authors also acknowledge H.R. Nagendra P h.D. who +derived the Cyclic Meditation technique from an ancient +yoga text and Naveen K.V., P h.D., Co-P.I. of the project for +his suggestions at different stages. + +REFERENCES +[1] +Murata, T., Takahashi, T., Hamada, T., Omori, M., Kosaka, +H., Yoshida, H., & Wada, Y. (2004). Individual trait anxiety +levels characterizing the properties of Zen meditation. +Neuropsychobiology, 50(2), 189-194. +[2] +Taimini, I.K. (1986). The science of yoga. Madras, India: The +Theosophical Publishing House. +[3] +Nagendra, H.R., & Nagarathna, R. (1997). New perspectives +in stress management. Bangalore, India: Swami Vivekananda +Yoga Prakashana. +[4] +Chinmayananda, S. (1984). Mandukya Upanishad. Bombay: +Sachin P ublishers. +[5] +Chao, Y. F., Chen, S.Y., Lan, C., & Lai, J.S. (2002). The +cardio respiratory responses and energy expenditure of Tai-C +hi-Qui-Gong. The American Journal of Chinese Medicine, 30, +451-461. +[6] +Sarang, P., & Telles, S. (2006). Effects of two yoga based +relaxation techniques on heart rate variability. International +Journal of Stress Management, 13, 460-475. +[7] +Doğru, M.T., Başar, M.M., Yuvanç, E., Simşek, V., & Sahin, +O. (2010). The relationship between serum sex steroid levels +and heart rate variability parameters in males and the effect of +age. Türk Kardiyoloji Derneği arşivi, 38, 459-465. +[8] +Malliani, A., Pagani, M., Lombardi, F., & Cerutti, S. (1991). +Cardiovascular neural regulation explore in the frequency +domain. Circulation, 84, 482-492. +[9] +Fredrikson, M., & Engel, B.T. (1985). Cardiovascular and +electrodermal adjustments during a vigilance task in patients +with borderline and established hypertension. Journal of +Psychosomatic Research, 29(3), 235-246. +[10] Peletier, K.R. (1972). Altered attention deployment in +meditators. Berkeley, USA: Psychology Clinic, University of +California. +[11] Sarang, S. P., & Telles, S. (2006). Changes in P300 following +two yoga-based relaxation techniques. International Journal +of Neuroscience, 116(12), 1419-1430. +[12] Polich, J. (1999). Electroencephalography: basic principles, +clinical applications and related fields. In P300 in clinical +applications. Edited by E. N iedermeyer, F. Lopes da S ilva. +Baltimore- Munich: Urban and Schwarzenberg, 1073-1091. +[13] Sarang, S.P., & Telles, S. (2007). Immediate effect of two +yoga based relaxation techniques on performance in a +letter-cancellation task. Perceptual and Motor Skills, 105(2), +379-385. +[14] Uttl, B., & Pilkenton-Taylor, C. (2001). Letter cancellation +performance across the adult life span. The Clinical +Neuropsychologist, 15(4), 521-530. +[15] Subramanya, P., & Telles, S. (2009). Performance on +psychomotor tasks following two yoga-based relaxation +techniques. Perceptual and Motor Skills, 109(2), 563-576. + +14 +Pailoor Subramanya et al.: Performance in the Stroop Task and Simultaneously Recorded Heart + +Rate Variability before and after Meditation, Supine Rest and No -Intervention +[16] Hamada, T., Murata, T., Takahashi, T., O htake, Y., Saitoh, +M., K imura, H., Wada, Y., & Yoshida, H. (2006). Changes in +autonomic function and EEG power during mental arithmetic +task and their mutual relationship. Rinsho byori, 54(4), +329-334. +[17] Van Honk, J., Hermans, E. J., d'Alfonso, A. A., Schutter, D. J., +van Doornen, L., & de Haan, E. H. (2002). A left-prefrontal +lateralized, sympathetic mechanism directs attention towards +social threat in humans: evidence from repetitive transcranial +magnetic stimulation. Neuroscience letters, 319(2), 99-102. +[18] Dishman Rod, K., Nakamura, Yoshio., Garcia Melissa, E., +Thompson Ray, W., Dunn Andrea, L., & Blair Steven, N. +(2000). Heart rate variability, trait anxiety, and perceived +stress among physically fit men and women. International +Journal of Psychophysiology, 37(2), 121-133. +[19] Hoshikawa, Y., & Yamamoto, Y. (1997). Effects of Stroop +color-word conflict test on the autonomic nervous system +responses. American Journal of Physiology, 272(3), +H1113-H1121. +[20] 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(2), 175-191. +[21] Golden, C.J. (2003). Stroop Color and Word Test Adult’s +Version: A manual for clinical and experimental uses. Wood +Dale, IL: U.S.A. Stoelting Co. +[22] Muktibodhananda, S. (2004). Hatha Yoga Pradipika. 2nd +edition. Munger, Bihar, India: Yoga Publication Trust. +[23] Tarvainen, M. P., Niskanen, J. P., Lipponen, J. A., Ranta-Aho, +P. O., & Karjalainen, P. A. (2014). Kubios HRV–Heart rate +variability analysis software. Computer methods and +programs in biomedicine, 113(1), 210-220. +[24] Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. E., Eckberg, +D. L., Edelberg, R., & Hamer, R. M. (2003). Heart rate +variability biofeedback increases baroreflex gain and peak +expiratory flow. Psychosomatic Medicine, 65(5), 796-805. +[25] Lehrer, P.M., Vaschillo, E., & Vaschillo, B. (2000). Resonant +frequency biofeedback training to increase cardiac variability: +Rationale and manual for training. Applied Psychophysiology +and Biofeedback, 25, 177-191. +[26] Malliani, A. (1982). Cardiovascular sympathe tic afferent +fibers. +Reviews +of +Physiology, +Biochemistry +and +Pharmacology, 94, 11-74. +[27] Malliani, A., Pagani, M., & Lombardi, F. (1986). Positive +feedback reflexes, in Zanchetti A, Tarazi RC (eds): Handbook +of +Hypertension: +Volume +8. +Pathophysiology +of +Hypertension. Amsterdam, Elsevier Science P ublishing Co, +Inc, 69-81 +[28] Malliani, A., Pagani, M., Lombardi, F., & Cerutti, S. (1991). +Cardiovascular neural regulation explored in the frequency +domain. Circulation, 84(2), 482-492. +[29] Davidson, D. J., Zacks, R.T., & Williams, C.C. (2003). +Stroop interference, practice, and aging. Neuropsychology, +development, +and +cognition. +Section +B, +Aging, +neuropsychology and cognition, 10(2), 85-98. +[30] Adleman, N. E., Menon, V., Blasey, C. M., White, C. D., +Warsofsky, I. S., Glover, G. H., & Reiss, A. L. (2002). A +developmental fMRI study of the Stroop color-word task. +Neuroimage, 16(1), 61-75. +[31] Delgado-Pastor, L. C., Perakakis, P., Subramanya, P., Telles, +S., & Vila, J. (2013). Mindfulness (Vipassana) meditation: +Effects on P3b event-related potential and heart rate +variability. International Journal of Psychophysiology, 90(2), +207-214. +[32] Subramanya, P., & Telles, S. (2009). Effect of two +yoga-based relaxation techniques on memory scores and state +anxiety. Biopsychosocial Medicine, 3(1), 8-12. + + diff --git a/subfolder_0/Potential benefits of yoga in pregnancyrelated complications during the COVID-19.txt b/subfolder_0/Potential benefits of yoga in pregnancyrelated complications during the COVID-19.txt new file mode 100644 index 0000000000000000000000000000000000000000..f1546e614ebfc6c2c3b358e006ab0091305d3a5f --- /dev/null +++ b/subfolder_0/Potential benefits of yoga in pregnancyrelated complications during the COVID-19.txt @@ -0,0 +1,2293 @@ +Uncorrected Author Proof +Work xx (2020) x–xx +DOI:10.3233/WOR-203277 +IOS Press +1 +Commentary +1 +Potential benefits of yoga in pregnancy- +related complications during the COVID-19 +pandemic and implications for working +women +2 +3 +4 +5 +Pooja Nadholtaa, Parul Balib, Amit Singhc and Akshay Ananda,∗ +6 +aNeuroscience Research Lab, Post Graduate Institute of Medical Education and Research, Chandigarh, India +7 +bDepartment of Biophysics, Post Graduate Institute of Medical Education and Research, Chandigarh, India +8 +cSwami Vivekananda Yoga Research Foundation (SVYASA), Bangalore, India +9 +Received 30 June 2020 +10 +Accepted 16 August 2020 +11 +Abstract. +12 +BACKGROUND: Pregnancy is a vulnerable period of growth and enrichment along with many physiological and psycho- +logical challenges. These changes can lead to complications if compounded by external stress and anxiety. COVID-19 has +emerged as a chief stressor among the general population and is a serious threat among vulnerable populations. Therefore, +there is a need for stress management tools, such as Yoga and physical exercises, both at home and at work. These can be +adopted during the pandemic with proper maintenance of social distancing. +13 +14 +15 +16 +17 +OBJECTIVE: To evaluate and compile literature that has reported the health outcomes of Yoga intervention on pregnancy +at the workplace and analyzes both the restrictions as well as advantages of its beneficial effects in comparison to physical +exercises. +18 +19 +20 +METHODOLOGY: A comprehensive literature review was conducted utilizing PubMed and Google Scholar. The key- +words used for the search include “Yoga”, “work”, “complications”, “physical exercise”, “drugs” and “COVID” indifferent +permutations and combinations with “pregnancy”. We compiled the literature with respect to pregnancy complications and +the effects of drugs, physical activity and Yoga for preventing these complications. +21 +22 +23 +24 +RESULTS: We noted that pregnancy-related complications are becoming more prevalent because of a sedentary lifestyle, +restricted physical activity and growing stress. In such situations, a home or workplace Yoga protocol can combine both +exercise and mindfulness-based alleviation of anxiety for both working and non-working women. +25 +26 +27 +CONCLUSION: Yoga can be effective for combating stress and anxiety besides boosting immunity in pregnant working +women confronted with the COVID-19 pandemic. +28 +29 +Keywords: Pregnancy, yoga, mindfulness, COVID-19, meditation +30 +∗Address for correspondence: Akshay Anand, PhD., Profes- +sor Neuroscience Research Lab Department of Neurology, Post +Graduate Institute of Medical Education and Research, Chandi- +garh, India. Tel.: +91 9914209090; E-mail: akshay1anand@rediff +mail.com. +1. Introduction +31 +Pregnancy is associated with physical and emo- +32 +tional changes, which are directly linked to the health +33 +of the expectant mother and are detrimental to fetal +34 +and maternal health outcomes [1]. Maternal stress +35 +1051-9815/20/$35.00 © 2020 – IOS Press and the authors. All rights reserved +Uncorrected Author Proof +2 +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +is associated with pregnancy-related complications +36 +such as low birth weight (LBW), preterm labor +37 +(PTL), pregnancy-induced hypertension (PIH), and +38 +delayed neuropsychological development in affected +39 +offspring [2]. Psychological distress, anxiety and +40 +depression are already associated with pregnancy and +41 +COVID-19 has become an additional stressor dur- +42 +ing this pandemic, thereby worsening stress, anxiety +43 +and further causing sleep disruption among pregnant +44 +women [3]. Studies have shown that women tend to +45 +develop higher stress during disease outbreak and +46 +they are at higher risk of developing depression [4, +47 +5]. The tendency to develop mental distress is higher +48 +among pregnant workers during the COVID-19 pan- +49 +demic as they have to leave home to not only retain +50 +their jobs but also to cater to the sick in hospitals. +51 +Therefore, novel intervention strategies and protec- +52 +tive factors are essential for alleviating psychological +53 +distress caused by the uncertainty of COVID-19. +54 +Due to an increasing sedentary lifestyle, a large +55 +population is physically inactive either due to avail- +56 +abilityofmaidsforhouseholdchores,increasedhours +57 +of on desk work, or traveling to workplaces with +58 +leisure time devoted to watching television or spend- +59 +ing time on social media [6, 7]. Duration of sitting +60 +hours also increase for working pregnant women due +61 +to long hours of workplace requirements defined for +62 +pregnancy. +63 +Covid-19 is a potentially fatal disease caused by +64 +SARS CoV-2 and has become a serious public health +65 +issue since December 2019. The virus can get trans- +66 +mitted from person-to-person, which makes it a major +67 +threat to human health. The more vulnerable and +68 +susceptible populations such as children, the aged, +69 +pregnant women, newborns and health care work- +70 +ers (HCW) need additional care during pandemic so +71 +that the spread of pandemic can be minimized among +72 +this population [8]. Pregnant women have higher +73 +propensity of infection as they are more receptive to +74 +respiratory pathogens and develop pneumonia more +75 +frequently as compared to non-pregnant women [9]. +76 +Probability of infection increases when above men- +77 +tioned vulnerable population is not able to adhere to +78 +physical distancing due to work requirements, hospi- +79 +tal exposure, travelling etc. +80 +It is also pertinent to note that there is an increased +81 +burden on the health care system for providing critical +82 +care, with general hospitals being converted into crit- +83 +ical care wards [10]. This has further complicated the +84 +pregnancy outcomes for working women. In current +85 +times, the anxiety and stress is further compounded +86 +due to the inability to visit hospitals coupled with fear +87 +of being infected by COVID-19 and anticipated trans- +88 +mission of infection to other family members. On +89 +the other hand, pregnant HCWs experience increased +90 +stress at work for fear of contracting the disease +91 +at hospitals coupled with physical stress of wear- +92 +ing PPE in hot and humid tropical environment. In +93 +India, this is further complicated by fear of losing +94 +employment and shrinking help from house maids +95 +[11]asmostworkingwomendependonthemfortheir +96 +daily chores. Therefore, the control of the COVID- +97 +19 spread among pregnant women and the potential +98 +risk of its vertical transmission has become a subject +99 +of raging debate which includes mind management +100 +practices. +101 +We propose that prenatal Yoga is a feasible and +102 +acceptable intervention for pregnant women with +103 +symptoms of anxiety and/or depression [12] and can +104 +also be practiced at the workplace. Prenatal Yoga +105 +contains all aspects of Yoga, for instance breathing +106 +practices (pranayamas), postures (asanas) that can be +107 +practiced easily by pregnant women besides medita- +108 +tion (dhayana) [13]. Implementation of Yoga during +109 +pregnancy may help to reduce symptoms of stress +110 +and anxiety and thereby increases the quality of life +111 +[14, 15] if adopted by employers for employees at +112 +the workplace. A Yoga protocol can be developed +113 +and adopted universally during pregnancy. +114 +2. Effect of COVID-19 on pregnancy +115 +As mentioned, COVID-19 has become a stressor +116 +among general population and pregnant HCWs are +117 +more worried for fear of this viral infection that has +118 +no treatment so far [16]. Preliminary evidence from +119 +available data suggests that anxiety, depression and +120 +stress constitute common response to COVID-19. +121 +This can be further associated with a disrupted sleep +122 +pattern [17]. Pregnant women, children, individuals +123 +suffering with chronic obstructive pulmonary disease +124 +and the elderly are more susceptible to COVID- +125 +19 infection [18]. COVID-19-confirmed pregnant +126 +women have been shown to have lower counts of +127 +WBC, neutrophils, C - reactive protein and transient +128 +increase in postpartum blood with premature rupture +129 +of membrane (PROM), premature delivery [19]. +130 +In hospitals, pregnant women not only worry about +131 +neonatal delivery, neonatal care, such as postpartum +132 +vaccination, and screening but also its impact on their +133 +employment if they get infected [20]. Intrauterine +134 +transmission of corona viruses from mother to fetus +135 +is low but the risk of adverse pregnancy outcome +136 +Uncorrected Author Proof +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +3 +Fig. 1. COVID-19 has become a major stressor among the gen- +eral population exerting an adverse impact on lifestyle and mental +health due to the fear of being infected, unemployment, poor +quality of sleep, sedentary lifestyle and stress. These factors may +worsen the health of both the mother and fetus. +like preterm delivery, intrauterine growth restriction +137 +(IUGR), spontaneous abortion and perinatal death +138 +increase after infection [21]. Congenital anomalies +139 +associated with COVID-19 remain unknown, adding +140 +to the growing anxiety. Usually, viral infections +141 +during pregnancy are associated with fetal death, +142 +intrauterine infections, congenital malformations, +143 +perinatal diseases, mental retardation and cerebral +144 +palsy [22]. +145 +3. Pregnancy – A challenge during the +146 +pandemic +147 +Pregnant women experience multiple challenges +148 +and varying psychological and emotional distress +149 +coupled with physical changes that support the grow- +150 +ingfetus[23,24].PregnantHCWswhoreporttowork +151 +during pandemic remain anxious due to the inherent +152 +risks. As the health of a mother is directly linked +153 +with health of fetus, therefore, any unforeseen infec- +154 +tion may directly affect the child’s health and future +155 +employment of the working mother. +156 +In general, many maternal complications includ- +157 +ing obstructed labor, antepartum hemorrhage (APH), +158 +infections, pregnancy-induced hypertension (PIH) +159 +and eclampsia also have direct effect on fetal outcome +160 +[25]. Hyperlipidemia, i.e. increased lipid concentra- +161 +tion in plasma, is common during pregnancy which +162 +can lead to coronary heart diseases and other vascu- +163 +lar complications [26] and is further compounded by +164 +extended lockdown, loss of employment and associ- +165 +ated sedentary lifestyle [27]. +166 +Metabolic alterations are common during preg- +167 +nancy and often result in excessive weight gain fur- +168 +ther compounded by a sedentary lifestyle. Excessive +169 +weight gain can cause obesity, which is associated +170 +with increased possibilities of developing pelvic floor +171 +problems and adverse pregnancy outcomes. These +172 +complications can be reduced to some extent by +173 +doing general muscle strengthening exercises during +174 +pregnancy [28–30]. Respiratory physiology and car- +175 +diovascular function are altered to suit the metabolic +176 +demands of mother and fetus. For example, the +177 +mechanical alteration in chest wall and diaphragm +178 +serves to accommodate the developing fetus in +179 +uterus [31]. These respiratory changes may induce +180 +pregnancy-induced hypertension (PIH), which is a +181 +major complication that occurs during pregnancy. +182 +This may cause fetal growth retardation, premature +183 +delivery, maternal morbidity and mortality and fetal +184 +morbidity and mortality [32, 33]. +185 +4. The psychological impact of COVID-19 +186 +quarantine +187 +During the ongoing pandemic, the fear of losing +188 +job coupled with prolonged home quarantine has pro- +189 +moted boredom and frustration besides causing rest- +190 +lessness due to unpredictable pregnancy outcomes +191 +[34, 35]. The fear of getting infected or transmit- +192 +ting the infection to other members of the family +193 +results in increased stress and anxiety of a working +194 +mother. These feelings may be negatively associated +195 +with systematic inflammation and increased inflam- +196 +matory response in the body. WHO suggests that +197 +meditation and deep breathing can help to remain +198 +calm and reduce stress [36]. For this standardized +199 +and validated protocols are required. A survey of +200 +1987 pregnant women showed an increased rate +201 +of pregnancy-related stress, anxiety and depression. +202 +These psychological changes may have long term +203 +adverse effects on mother and child [37]. +204 +As discussed, the maternal prenatal stress ad- +205 +versely affects fetal development and may be asso- +206 +ciated with preterm birth and low birth weight and +207 +negatively affecting child cognition in later life [38, +208 +39]. Preterm birth (PTB) and low birth weight (LBW) +209 +can lead to neonatal and childhood morbidities, +210 +mortality, and neuro-developmental impairment and +211 +disabilities [40–42]. Prenatal depression and anxi- +212 +ety also affect the fetal brain development and may +213 +impact child’s socio-behavioral and socio-economic +214 +function. Prenatal stress is thought to affect maternal +215 +hypothalamic-pituitary-adrenal (HPA) axis, which +216 +increases the cortisol in maternal blood flowing +217 +through placenta to fetus, impacting fetal develop- +218 +ment [43]. +219 +Uncorrected Author Proof +4 +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +A placental enzyme11-hydroxysteroid dehydro- +220 +genase type 2(11-HSD2) is known to convert +221 +active cortisol into inactive cortisone but the level +222 +of this enzyme is downregulated during chronic +223 +stress resulting in increased exposure of fetus to +224 +maternal hormones [44]. Prenatal stress also causes +225 +the downregulation of placental 11-HSD2 activity +226 +and consequent exposure of the fetus to corti- +227 +sol. This may obstruct the fetal adrenal growth +228 +and maturation characteristic of low birth weight +229 +neonates. Prenatal stress or anxiety is also associ- +230 +ated with adverse neuro-developmental outcomes, +231 +which includes schizophrenia, autism, emotional or +232 +behavioral problems and reduced cognitive abilities +233 +[45]. It is widely believed that there is an associa- +234 +tion between adverse outcome and gestational age +235 +as various regions of the brain develop at different +236 +stages [45]. +237 +Khashan et al. suggested that infant born from +238 +the women who was exposed to stress during first +239 +trimester have more chances of schizophrenia [46]. +240 +Autism is also associated with the maternal stress dur- +241 +ing prenatal period [47]. The corticotropin-releasing +242 +hormone (CRH) level in maternal blood plasma +243 +increases stress and is considered a potential marker +244 +of preterm birth [48]. Chronic stress is associated +245 +with pregnant HCWs. This may contribute to preterm +246 +births and the rate of anticipated preterm births can +247 +be decreased by organized stress reduction strategies +248 +such as relaxation, Yoga and mindfulness and appro- +249 +priate prenatal care [49]. At present, the COVID-19 +250 +pandemic is the greatest stressor to the working +251 +pregnant women and is anticipated to have a neg- +252 +ative impact on maternal and fetal outcome. We +253 +propose a non-pharmacological therapeutic interven- +254 +tion, namely a pregnancy Yoga protocol that can help +255 +mothers cope with mental stress and phobia. +256 +5. Sedentary lifestyle during pregnancy +257 +Sedentary behavior is not a lack of physical activ- +258 +ity but includes activities that utilize less than 1.5 +259 +metabolic equivalent energy and do not increase +260 +energy expenditure above the resting level. This con- +261 +cerns activities such as sitting, sleeping, lying down +262 +and screen-based entertainment such as social media, +263 +watching television, and playing online games [50]. +264 +Epidemiological studies suggest that more than 50% +265 +of the population spend half of their waking hours in +266 +sedentary behavior [51] which may have increased +267 +during lockdown. Pregnant women also spend half of +268 +the day being sedentary, similar to general population +269 +which may be associated with abnormal metabolic +270 +changes, abnormal blood pressure, cardiovascular +271 +diseases and GDM [52–54]. More time spent e.g. +272 +sitting while watching TV, using social media and +273 +no involvement in any kind of physical activity may +274 +develop anxiety and depression in expectant mother +275 +[55]. This has adverse effects on working pregnant +276 +women who have desk sitting jobs and remain devoid +277 +of any kind of physical activity. This is further com- +278 +plicated due to availability of maids for household +279 +chores. Sedentary behavior is associated with car- +280 +diovascular disease, type 2 diabetes, stress, obesity, +281 +excessive weight gain and adverse fetal and maternal +282 +outcomes including occasional mortality [56]. +283 +6. Effect of medication in pregnancy +284 +About 2–3% birth defects are caused by the use +285 +of drugs [57]. Earlier pregnant women who took +286 +thalidomide during pregnancy gave birth to children +287 +with phocomelia and later the teratogenic effects +288 +of diethylstilbestrol led to concern about medica- +289 +tion during pregnancy. In 1979, the Food and Drug +290 +Administration (FDA) sought to examine the ter- +291 +atogenic risk of drugs by obtaining the data from +292 +human and animal studies and categorized the preg- +293 +nancy drugs into different categories [58, 59]. A +294 +survey of the French Health Insurance Service on +295 +drug prescriptions during pregnancy in southwest +296 +France showed that about 99% women (among 1000 +297 +women) received prescription for at least one drug +298 +during pregnancy and 1.6% women get prescription +299 +of X category (e.g. misoprostol (one), clomiphene +300 +(three), topical or oral estradiol or oestriol (nine)) +301 +drugs (fetal risk outweighs benefits) [60]. +302 +According to FDA guidelines, pregnancy drugs are +303 +classified on the basis of risk they cause to fetus. +304 +Drugs are classified in various categories: A (no +305 +risk to the fetus if taken during the first trimester- +306 +controlled studies in women), B (no risk to fetus in +307 +animal studies but no controlled studies in human), C +308 +(adverse effect on fetus in animal studies but absent +309 +controlled studies in human), D (risk for human fetus, +310 +but benefits outweighs risk) and X (fetal abnormal- +311 +ities and the risk outweighs benefit) [61]. Nearly all +312 +drugs consumed by women during pregnancy, includ- +313 +ing antidepressants and their metabolites, cross the +314 +placenta and reach the fetus [62, 63]. Antiepileptic +315 +drugs (AEDs) such as Valproate and Phenobarbital +316 +are associated with a high risk of major malformation +317 +Uncorrected Author Proof +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +5 +Table 1 +Categorization of drugs on the basis of their side effects to the mother and fetus as classified by the Food and Drug Administration (FDA) +guidelines +Drug +Side effects +Amphetamines +Increased incidences of clefting, cardiac anomalies, and fetal growth reduction [68] +Diethylstilbestrol +Genetic tract anomalies in young female child with vaginal adenosis, polyps and ridges, uterine anomalies, clear +cell adenocarcinoma of vagina. Infertility in males child [69]. +Ethanol +Fetal teratogen, retro micrognathia and ear/preauricular anomalies, cranial and facial malformations, affect brain +and ocular system of infant [70]. +Para- tri- methadone +Abortion or malformation, cleft palate, Malformed ears, cardiac defects, urogenital malformations, and skeletal +abnormalities [71]. +Sex steroids +VACTERAL syndrome [72] +Streptomycin +Retardation of growth and pronounced nervous hyper excitability [73]. +Tolbutamide +Increased incidences of fetal anomalies [74]. +Barbiturates +Abnormal neural and biochemical differentiation of the central nervous system, deficits in learning [75]. +Lithium +Cardiac anomalies [76] +The table contains some drugs with their side effects, which are used during pregnancy to reduce associated complications. +in the fetus and can cause birth deformities if taken +318 +during pregnancy [64]. +319 +During childbearing period, women are at high +320 +risk of developing major depressive disorder (MDD), +321 +which is associated with adverse maternal health and +322 +abnormal fetal growth. The use of selective sero- +323 +tonin reuptake inhibitors (SSRIs), an antidepressant, +324 +causes a low APGAR (Appearance, Pulse, Gri- +325 +mace, Activity, and Respiration) score and increases +326 +the chances of perinatal complications [65]. Multi- +327 +ple immunological changes occur during pregnancy +328 +and immunosuppressive medication taken during the +329 +pregnancy can cause adverse effects on the fetus +330 +[66]. Therefore, efforts should be directed to mini- +331 +mize the use of drugs during pregnancy for improved +332 +fetal outcomes. As majority of drugs used during +333 +pregnancy can cross placenta and can be injuri- +334 +ous to the fetus during fetal development, therefore, +335 +non-pharmacological remedial measures for stress- +336 +induced GDM and hypertension are imperative. It is +337 +also known that that hypertension and diabetes render +338 +a subject vulnerable to COVID-19 infections. Table 1 +339 +includes a few drugs prescribed during pregnancy +340 +along with the associated anomalies [67]. +341 +7. Importance of physical activity in +342 +alleviating pregnancy-related consequences +343 +Drug consumption should be minimized during +344 +pregnancy due to its various side effects and negative +345 +impact on mother and fetus. Exercise can be an effec- +346 +tive preventive measure for pregnancy-related com- +347 +plications which, in later stages, become a threat to +348 +the mother and child. Exercise during pregnancy have +349 +numerous health benefits and is safe for maternal and +350 +fetal health. Some of the benefits of exercise during +351 +pregnancy include the control of excessive weight +352 +gain, prevention and control of GDM, reduction of +353 +lower back pain complaints and positive effects on +354 +maternal mental health and quality of life [77]. Exer- +355 +cise is supposed to be effective in the prevention +356 +of GDM, particularly in obese working women who +357 +spentmostofthetimesittingandeating[78].Physical +358 +activity during pregnancy also reduces the chances +359 +of GDM [79], excess maternal weight gain [80] +360 +and complications during labor for the mother [81] +361 +besides improving the stress response in utero and +362 +reduced risk of childhood obesity in the fetus [82]. +363 +According to the American College of Obstet- +364 +rics and Gynecology (ACOG) guidelines, if pregnant +365 +women are healthy and complication free, they +366 +should continue or start doing exercises [83]. Phys- +367 +ical exercise during pregnancy is beneficial for both +368 +maternal and fetal health and it improves pregnancy +369 +outcome by minimizing the risk of developing GDM, +370 +preeclampsia (PE) and abnormal fetal growth [84] +371 +as explained above. Exercise during pregnancy is +372 +also associated with lower chances of preterm deliv- +373 +ery, reduction in the rate of cesareans, instrumental +374 +deliveries, hypertension and gestational weigh gain +375 +(GWG) [85–87] even though the mental component +376 +of exercise is rather limited when compared to other +377 +mind-body practices [88]. +378 +Pregnancy is a period of emotional and physical +379 +stress in which expectant mother experiences a lot of +380 +changes, abdominal growth and challenges [89]. If a +381 +woman is involved in physical exercises during preg- +382 +nancy, the risk of cesarean delivery is significantly +383 +reduced [90], however, the emotional changes during +384 +this period are rarely addressed unless supplanted by +385 +mindfulness or Yoga protocols. As the current pan- +386 +demic imposes restrictions on the outdoor physical +387 +Uncorrected Author Proof +6 +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +Table 2 +Benefits of regular physical activity during pregnancy +Benefits of doing exercise during pregnancy, which are limited +due to the COVID-19 pandemic +• Less physical discomforts (e.g. fatigue, nausea, leg cramps, +backache, constipation, round ligament pain, shortness of +breath) +• Decreased incidence of complications such as gestational +hypertension, preeclampsia and operative delivery +• Controlled blood glucose in GDM +• Reduced stress and anxiety and better sleep +• Increased placental weight along with blood flow and infant +birthweight +• Maintenance of fitness level +• Reduced gestational weight gain +• Improved posture +• Faster postpartum recovery +The table contains some of the potential benefits of doing exer- +cise during pregnancy, which include reduction in physical pain, +stress, anxiety, excessive weight gain, hypertension and operative +delivery along with improving the sleep quality, birth weight and +postpartum recovery. +activity, the working pregnant women are left with +388 +few choices on how and when to access a stress man- +389 +agement Yoga protocol in order to alleviate anxiety, +390 +phobia and fear. Table 2 shows some of the benefits +391 +of doing exercise during pregnancy [91]. +392 +In2002,theAmericanCollegeofObstetriciansand +393 +Gynecologists published guidelines for exercise dur- +394 +ing pregnancy and suggested that any women without +395 +pregnancy complication can do moderate exercise for +396 +at least 30 minutes a day or most of the days [92]. Ges- +397 +tational hypertension and preeclampsia, excessive +398 +gestational weight gain (GWG), GDM and macroso- +399 +mia (fetus with more birth weight) were found to be +400 +decreased after exercise [93]. The above studies show +401 +that moderate exercise during pregnancy is good for +402 +both maternal and fetal health but intense exercise +403 +should be avoided as it may harm the fetus. Hence, +404 +the working pregnant women must carefully choose +405 +a regimen which includes both mental and physical +406 +attributes. +407 +8. Effect of yoga during pregnancy +408 +Yoga is derived from the Sanskrit word “yuj”, +409 +which means “to yoke and join together”. It includes +410 +stretching exercises and asana combined with breath- +411 +ing and meditation regimen to unify the emotional, +412 +physical and spiritual needs. Yoga has been shown +413 +to help reduce stress, anxiety, depression, arthri- +414 +tis, chronic low back, migraine, hypertension and +415 +diabetes in adults [94]. As discussed previously, +416 +Yoga is a combination of exercises aligned to cer- +417 +tain breathing techniques and meditation. It may help +418 +overcomethedrawbacksofotherinterventions(drugs +419 +and physical activity only) adapted during pregnancy. +420 +Yoga does not include any vigorous exercise but slow +421 +dynamic and static movements with focused breath- +422 +ing, and controlled stretching; therefore, it is safe +423 +during pregnancy. +424 +Yoga practice has been found to improve quality +425 +of life by decreasing stress, anxiety and sleep distur- +426 +bance during pregnancy [95]. Yoga has been shown +427 +to be more effective than a standard exercise regi- +428 +men as it is a good intervention for women who are +429 +depressed, at high risk, have lumbo-pelvic pain, or +430 +are healthy [96] besides being confined to lockdowns +431 +or hospital workplace. Mindfulness Yoga helps to +432 +reduce the depression symptoms in pregnant women +433 +while improving mental health. It is said to increase +434 +the mother’s attachment towards her child which is +435 +helpful for child’s health [97]. Mindfulness and Yoga +436 +also regulates eating habits and can benefit glycemic +437 +control in pregnant women with GDM [98]. +438 +Narendran et al. have shown the effect of Yoga +439 +on various pregnancy-related complications and +440 +described that the Integrated Yoga Approach during +441 +Pregnancy (IYAP) improves birth weight and preg- +442 +nancy outcomes, and decreases preterm labor (PTL), +443 +intrauterinegrowthrestriction(IUGR),lowbackpain +444 +(LBP), pregnancy-induced hypertension (PIH) and +445 +other complications associated with pregnancy [99]. +446 +Yoga is emerging as an acceptable intervention dur- +447 +ing pregnancy, not only due to its tremendous benefits +448 +during pregnancy, but also due to increased sense of +449 +uncertainty of the COVID-19 pandemic which has +450 +superimposed a new dimension of anxiety experi- +451 +enced by pregnant HCWs. Other studies have shown +452 +that Yoga decreases various pregnancy-related com- +453 +plications such as preterm labor, IUGR and physical +454 +discomforts [100, 101]. In the absence of outdoor +455 +physical activity, Yoga may be effective in reduc- +456 +ing the risk factors of prediabetes, obesity and the +457 +metabolic syndrome. This may be beneficial in gly- +458 +caemic control in type 2 diabetes and GDM [102]. +459 +In high risk pregnancies, Yoga reduces the stress +460 +and is a safe and effective intervention to be adapted +461 +[103]. Prenatal Yoga shows significant effect on sys- +462 +tolic blood pressure, and the fetal heart rates in +463 +primigravida (women who is pregnant for the first +464 +time) mothers [104]. As briefly described above, +465 +stress has a negative impact on the immune system, +466 +rendering a pregnant working women vulnerable to +467 +Uncorrected Author Proof +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +7 +infections. Certain twisting Yoga poses are believed +468 +to compress and rejuvenate immune organs and chan- +469 +nels. It is believed to balance various immune cells +470 +by inhibiting the sympathetic aspect of hypothala- +471 +mus in response to stressful stimuli [105]. In response +472 +to stress hypothalamic-pituitary-adrenal (HPA) axis, +473 +it activates and hypothalamus thereby producing +474 +corticotropin-releasing factor which stimulates the +475 +pituitary gland to produce adreno-corticotropin, +476 +which leads to the secretion of cortisol [106, 107]. +477 +During pregnancy, cortisol level rises continu- +478 +ously as placenta and adrenal both release cortisol +479 +[108]. Cortisol is considered as a biomarker of both +480 +psychological and physical health [109]. Further, +481 +cortisol release during stress reduces cellular immu- +482 +nity,salivaryimmunoglobulin(IgA)andincreasesthe +483 +risk of infections. Prenatal Yoga has been shown to +484 +reduce cortisol (stress hormone) and enhance the IgA +485 +(immune biomarker) during pregnancy [110]. The +486 +level of cortisol along with inflammatory cytokine, +487 +interleukin (IL)-6 and tumor necrosis factor (TNF) +488 +has shown to be decreased after Yoga interven- +489 +tion,while-endorphinlevelincreasesconcomitantly +490 +[111]. Besides during pregnancy, the Diabetic Yoga +491 +Protocol has also been shown to reduce the HbA1c +492 +level and stress in pre-diabetic non pregnant women +493 +[112] +494 +9. Does yoga help in balancing +495 +neuropsychological changes during +496 +pregnancy? +497 +Pregnancy is associated with changes in mood and +498 +anxiety with marked hormonal fluctuations [113]. +499 +This is more pronounced in working mothers as these +500 +places are characterized by its own work load and +501 +deadlines. Children of depressed mothers are more +502 +prone to develop depression and other psychiatric +503 +disorders throughout their lifetimes as compared to +504 +children of non-depressed mothers. Prenatal Yoga +505 +is a feasible intervention for pregnant women with +506 +symptoms of anxiety and/or depression [114] and +507 +can even be practiced at workplace. Yoga has ben- +508 +eficial effects on cognitive and emotional health and +509 +has been shown to improve mental health, decrease +510 +anxietyanddepression.Yogaimprovesadaptiveauto- +511 +nomic response to stress and reduces perceived stress +512 +inhealthypregnantwomen[115].Fortreatingdepres- +513 +sion, Yoga is more acceptable therapy as compared +514 +to other standard depression treatments [116]. Mind- +515 +body practice, in conjunction with usual care, is much +516 +beneficial and cost effective intervention than only +517 +usual prenatal care [117]. +518 +Corticotropin-releasing hormone (CRH) is relea- +519 +sed from hypothalamus in response to stress and +520 +increased level of CRH during pregnancy is linked +521 +to pathogenesis like fetal growth retardation, preterm +522 +labor and preeclampsia, which are leading causes +523 +of perinatal morbidity and mortality among preg- +524 +nant women [118]. It is also known that stress can +525 +trigger the pro-inflammatory cytokine, TNF  that +526 +targets vascular endothelial death and mediates mis- +527 +carriage by ischemic death of embryo [119]. All +528 +these abnormalities are associated with stress and fre- +529 +quency of occurrence of these abnormalities which +530 +can be reduced by alleviating stress and depres- +531 +sion during pregnancy. Further reducing stress and +532 +depression during pregnancy can reduce the fre- +533 +quency of occurrence of these abnormalities. Prenatal +534 +Yoga practice has been shown to reduce stress, anx- +535 +iety, depression symptoms and other uncomfortable +536 +experiences related to pregnancy [120] at work or +537 +otherwise. +538 +Implementation of Yoga during pregnancy helps to +539 +decrease symptoms of stress and anxiety an increases +540 +the quality of life [121, 122] if implemented by +541 +employers at the workplace. Together with usual care, +542 +Yoga can empower pregnant women in increasing +543 +the quality of life by reducing the uncomfortable +544 +experiences, stress, anxiety and depression that are +545 +pronounced during the COVID-19 pandemic. It is +546 +an effective, useful and recommended intervention, +547 +which can be prescribed during pregnancy. +548 +10. Conclusion +549 +Mind-body practices have the potential to address +550 +both physical and mental attributes and hence it +551 +is better, safe and preventive intervention as com- +552 +pared to drugs and physical exercise alone. Therefore, +553 +Yoga, along with usual care, can empower pregnant +554 +women in increasing the quality of life by reducing +555 +the uncomfortable experiences, stress, anxiety and +556 +depression that are pronounced during the COVID-19 +557 +pandemic. It is an effective, useful and recommended +558 +intervention, which can be prescribed during preg- +559 +nancy. We propose this Yoga protocol which can +560 +be adapted universally by pregnant women during +561 +the COVID-19 pandemic. Further research must be +562 +carried out to understand the mechanism by which +563 +Yoga exerts its influence on mental and physical +564 +health. +Uncorrected Author Proof +8 +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +Acknowledgments +565 +We thank Dr. P K Saha for his input and discus- +566 +sions. +567 +Conflict of interest +568 +None to report. +569 +References +570 +[1] +Hueston WJ, Kasik-Miller S. Changes in functional health +571 +status during normal pregnancy. Journal of Family Prac- +572 +tice. 1998;47(3):209-12. +573 +[2] +Cardwell MS. Stress: pregnancy considerations. Obstetri- +574 +cal & Gynecological Survey. 2013;68(2):119-29. +575 +[3] +Lebel C, MacKinnon A, Bagshawe M, Tomfohr-Madsen +576 +L, Giesbrecht G. Elevated depression and anxiety among +577 +pregnant individuals during the COVID-19 pandemic. +578 +[4] +Lee DT, Sahota D, Leung TN, Yip AS, Lee FF, Chung +579 +TK. Psychological responses of pregnant women to an +580 +infectious outbreak: a case-control study of the 2003 +581 +SARS outbreak in Hong Kong. Journal of Psychosomatic +582 +Research. 2006;61(5):707-13. +583 +[5] +Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, Ho RC. +584 +Immediate psychological responses and associated factors +585 +during the initial stage of the 2019 coronavirus disease +586 +(COVID-19) epidemic among the general population in +587 +China. International Journal of Environmental Research +588 +and Public Health. 2020;17(5):17 +589 +[6] +Walsh SM, Meyer MR, Stamatis A, Morgan GB. Why +590 +women sit: Determinants of leisure sitting time for work- +591 +ing women. Women’s Health Issues. 2015;25(6):673-9. +592 +[7] +Agrawal P, Gupta K, Mishra V, Agrawal S. Effects +593 +of sedentary lifestyle and dietary habits on body mass +594 +index change among adult women in India: findings +595 +from a follow-up study. Ecology of Food and Nutrition. +596 +2013;52(5):387-406. +597 +[8] +Rothan HA, Byrareddy SN. The epidemiology and patho- +598 +genesis of coronavirus disease (COVID-19) outbreak. +599 +Journal of Autoimmunity. 2020:102433. +600 +[9] +Qiao J. What are the risks of COVID-19 infection in preg- +601 +nant women? The Lancet. 2020;395(10226):760-2. +602 +[10] +Xie J, Tong Z, Guan X, Du B, Qiu H, Slutsky AS. Critical +603 +care crisis and some recommendations during the COVID- +604 +19 epidemic in China. Intensive Care Medicine. 2020:1-4. +605 +[11] +Arnado JM. Maternalism in mistress-maid relations: The +606 +Philippine experience. Journal of international Women’s +607 +Studies. 2003;4(3):154-77. +608 +[12] +Satyapriya M, Nagarathna R, Padmalatha V, Nagendra +609 +HR. Effect of integrated yoga on anxiety, depression & +610 +well being in normal pregnancy. Complementary Thera- +611 +pies in Clinical Practice. 2013;19(4):230-6. +612 +[13] +Li AW, Goldsmith CA. The effects of yoga on anxiety and +613 +stress. Alternative Medicine Review. 2012;17(1). +614 +[14] +Jamieson DJ, Theiler RN, Rasmussen SA. Emerging +615 +infections and pregnancy. Emerging Infectious Diseases. +616 +2006;12(11):1638. +617 +[15] +Li N, Han L, Peng M, Lv Y, Ouyang Y, Liu K, Yue L, Li Q, +618 +Sun G, Chen L, Yang L. Maternal and neonatal outcomes +619 +of pregnant women with COVID-19 pneumonia: a case- +620 +control study. Clinical Infectious Diseases. 2020. +621 +[16] +Xiao H, Zhang Y, Kong D, Li S, Yang N. The effects +622 +of social support on sleep quality of medical staff treat- +623 +ing patients with coronavirus disease 2019 (COVID-19) +624 +in January and February 2020 in China. Medical Science +625 +Monitor: International Medical Journal of Experimental +626 +and Clinical Research. 2020;26:e923549-1. +627 +[17] +Rajkumar RP. COVID-19 and mental health: A review +628 +of the existing literature. Asian Journal of Psychiatry. +629 +2020;102066. +630 +[18] +Duan L, Zhu G. Psychological interventions for people +631 +affected by the COVID-19 epidemic. The Lancet Psychi- +632 +atry. 2020;7(4):300-2. +633 +[19] +Li N, Han L, Peng M, Lv Y, Ouyang Y, Liu K, Yue L, Li Q, +634 +Sun G, Chen L, Yang L. Maternal and neonatal outcomes +635 +of pregnant women with COVID-19 pneumonia: a case- +636 +control study. Clinical Infectious Diseases. 2020. +637 +[20] +Fakari FR, Simbar M. Coronavirus Pandemic and Worries +638 +during Pregnancy; a Letter to Editor. Archives of Aca- +639 +demic Emergency Medicine. 2020;8(1). +640 +[21] +Schwatz DA, Grahan AL. Potential Maternal and Infant +641 +Outcomes from Coronavirus 2019-nCoV (SARS-CoV-2) +642 +Infecting Pregnant Women: Lessons from SARS, MERS, +643 +and Other Human Coronavirus Infections. Viruses. +644 +2020;12(2):194. +645 +[22] +Wright Jr HT. Congenital anomalies and viral infections +646 +in infants—the etiologic role of maternal viral infections. +647 +California Medicine. 1966;105(5):345. +648 +[23] +Colman AD, Colman LL. Pregnancy: The psychological +649 +experience. New York: Herder and Herder. 1971. +650 +[24] +Bailey LA, Hailey BJ. The psychological experience of +651 +pregnancy. The International Journal of Psychiatry in +652 +Medicine. 1987;16(3):263-74. +653 +[25] +Koblinsky MA. Beyond maternal mortality—magnitude, +654 +interrelationship and consequences of women’s health, +655 +pregnancy-related complications and nutritional status on +656 +pregnancy outcomes. International Journal of Gynecology +657 +& Obstetrics. 1995;48(Supplement):S21-32. +658 +[26] +Qureshi IA, Xi XR, Limbu YR, Bin HY, Chen MI. +659 +Hyperlipidaemiaduringnormalpregnancy,parturitionand +660 +lactation. Annals of the Academy of Medicine, Singapore. +661 +1999;28(2):217-21. +662 +[27] +Holm K, Penckofer S, Keresztes P, Biordi D, Chandler +663 +P. Coronary artery disease in women: assessment, diag- +664 +nosis, intervention, and strategies for life style change. +665 +AWHONN’s Clinical Issues in Perinatal and Women’s +666 +Health Nursing. 1993;4(2):272-85. +667 +[28] +Baeten JM, Bukusi EA, Lambe M. Pregnancy com- +668 +plications and outcomes among overweight and obese +669 +nulliparous women. American Journal of Public Health. +670 +2001;91(3):436. +671 +[29] +Barakat R, Pelaez M, Montejo R, Luaces M, Zakynthi- +672 +naki M. Exercise during pregnancy improves maternal +673 +health perception: a randomized controlled trial. Amer- +674 +ican Journal of Obstetrics and Gynecology. 2011;204(5): +675 +402-e1. +676 +[30] +Sengupta PA. The bliss yoga inculcates during the dif- +677 +ferent stages of pregnancy. Int J Pharm Pharm Sci. +678 +2014;6(10):86-7. +679 +[31] +Hegewald MJ, Crapo RO. Respiratory physiology in preg- +680 +nancy. Clinics in Chest Medicine. 2011;32(1):1-3. +681 +[32] +Zhang J, Zeisler J, Hatch MC, Berkowitz G. Epidemiol- +682 +ogy of pregnancy-induced hypertension. Epidemiologic +683 +Reviews. 1997;19(2):218-32 +684 +Uncorrected Author Proof +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +9 +[33] +Kamath U, Rao G, Kamath SU, Rai L. Maternal and fetal +685 +indicators of oxidative stress during pregnancy-induced +686 +hypertension (PIH). Intern J Appl Biol Pharmaceut Tech- +687 +nol. 2011;2(1):405-10. +688 +[34] +Brooks SK, Webster RK, Smith LE, Woodland L, Wes- +689 +sely S, Greenberg N, Rubin GJ. The psychological impact +690 +of quarantine and how to reduce it: rapid review of the +691 +evidence. The Lancet. 2020. +692 +[35] +Knopf A. Importance of helping pregnant women with +693 +SUDs. The Brown University Child and Adolescent +694 +Behavior Letter. 2020;36(7):9-10. +695 +[36] +DiGiovanni C, Conley J, Chiu D, Zaborski J. Factors +696 +influencing compliance with quarantine in Toronto during +697 +the 2003 SARS outbreak. Biosecurity and Bioterrorism: +698 +Biodefense Strategy, Practice and Science. 2004;2(4): +699 +265-72. +700 +[37] +Lebel C, MacKinnon A, Bagshawe M, Tomfohr-Madsen +701 +L, Giesbrecht G. Elevated depression and anxiety among +702 +pregnant individuals during the COVID-19 pandemic. +703 +[38] +Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, +704 +Katon WJ. A meta-analysis of depression during preg- +705 +nancy and the risk of preterm birth, low birth weight, +706 +and intrauterine growth restriction. Archives of General +707 +Psychiatry. 2010;67(10):1012-24. +708 +[39] +Tarabulsy +GM, +Pearson +J, +Vaillancourt-Morel +MP, +709 +Bussi` +eres EL, Madigan S, Lemelin JP, Duchesneau AA, +710 +Hatier DE, Royer F. Meta-analytic findings of the relation +711 +between maternal prenatal stress and anxiety and child +712 +cognitive outcome. Journal of Developmental & Behav- +713 +ioral Pediatrics. 2014;35(1):38-43. +714 +[40] +Swamy GK, Østbye T, Skjærven R. Association of preterm +715 +birth with long-term survival, reproduction, and next- +716 +generation preterm birth. Jama. 2008;299(12):1429-36. +717 +[41] +Wilson-Costello D, Friedman H, Minich N, Fanaroff +718 +AA, Hack M. Improved survival rates with increased +719 +neurodevelopmental disability for extremely low birth +720 +weight infants in the 1990s. Pediatrics. 2005;115(4):997- +721 +1003. +722 +[42] +Allen MC, Jones JM. Medical complications of prematu- +723 +rity. Obstetrics and Gynecology. 1986;67(3):427-37. +724 +[43] +Madigan S, Oatley H, Racine N, Fearon RP, Schumacher +725 +L, Akbari E, Cooke JE, Tarabulsy GM. A meta-analysis of +726 +maternal prenatal depression and anxiety on child socioe- +727 +motional development. Journal of the American Academy +728 +of Child & Adolescent Psychiatry. 2018;57(9):645-57. +729 +[44] +Welberg LA, Thrivikraman KV, Plotsky PM. Chronic +730 +maternal stress inhibits the capacity to up-regulate pla- +731 +cental 11-hydroxysteroid dehydrogenase type 2 activity. +732 +Journal of Endocrinology. 2005;186(3):R7-12. +733 +[45] +O’donnell K, O’connor TG, Glover V. Prenatal stress and +734 +neurodevelopment of the child: focus on the HPA axis +735 +and role of the placenta. Developmental Neuroscience. +736 +2009;31(4):285-92. +737 +[46] +KhashanAS,AbelKM,McNameeR,PedersenMG,Webb +738 +RT, Baker PN, Kenny LC, Mortensen PB. Higher risk +739 +of offspring schizophrenia following antenatal maternal +740 +exposure to severe adverse life events. Archives of General +741 +Psychiatry. 2008;65(2):146-52. +742 +[47] +Kinney DK, Miller AM, Crowley DJ, Huang E, Gerber E. +743 +Autism prevalence following prenatal exposure to hurri- +744 +canes and tropical storms in Louisiana. Journal of Autism +745 +and Developmental Disorders. 2008;38(3):481-8. +746 +[48] +Hobel CJ, Dunkel-Schetter C, Roesch SC, Castro LC, +747 +Arora CP. Maternal plasma corticotropin-releasing hor- +748 +mone associated with stress at 20 weeks’ gestation in +749 +pregnancies ending in preterm delivery. American Journal +750 +of Obstetrics and Gynecology. 1999;180(1):S257-63. +751 +[49] +Straub H, Qadir S, Miller G, Borders A. Stress and +752 +stress reduction. Clinical Obstetrics and Gynecology. +753 +2014;57(3):579-606. +754 +[50] +Pate RR, O’neill JR, Lobelo F. The evolving definition +755 +of” sedentary". Exercise and Sport Sciences Reviews. +756 +2008;36(4):173-8. +757 +[51] +Spittaels H, Van Cauwenberghe E, Verbestel V, De +758 +Meester F, Van Dyck D, Verloigne M, Haerens L, Deforche +759 +B, Cardon G, De Bourdeaudhuij I. Objectively mea- +760 +sured sedentary time and physical activity time across +761 +the lifespan: a cross-sectional study in four age groups. +762 +International Journal of Behavioral Nutrition and Physical +763 +Activity. 2012;9(1):149. +764 +[52] +Evenson KR, Wen F. Prevalence and correlates of +765 +objectively measured physical activity and sedentary +766 +behavior +among +US +pregnant +women. +Prev +Med. +767 +2011;53(1–2):39–43. doi: 10.1016/j.ypmed.2011.04.014 +768 +[53] +Healy GN, Dunstan DW, Salmon JO, Shaw JE, Zimmet +769 +PZ, Owen N. Television time and continuous metabolic +770 +risk in physically active adults. Medicine and Science in +771 +Sports and Exercise. 2008;40(4):639-45. +772 +[54] +Zhang C, Solomon CG, Manson JE, Hu FB. A prospective +773 +study of pregravid physical activity and sedentary behav- +774 +iors in relation to the risk for gestational diabetes mellitus. +775 +Archives of Internal Medicine. 2006;166(5):543-8. +776 +[55] +Fazzi C, Saunders DH, Linton K, Norman JE, Reynolds +777 +RM. Sedentary behaviours during pregnancy: a systematic +778 +review. International Journal of Behavioral Nutrition and +779 +Physical Activity. 2017;14(1):32. +780 +[56] +de Wit L, van Straten A, Lamers F, Cuijpers P, Penninx +781 +B. Are sedentary television watching and computer use +782 +behaviors associated with anxiety and depressive disor- +783 +ders? Psychiatry Research. 2011;186(2-3):239-43. +784 +[57] +Porter RS, editor. The Merck Manual’s Online Medical +785 +Library. Whitehouse Station: Merck Research Lab. 2004. +786 +[58] +Pangle BL. Drugs in Pregnancy and Lactation. In: +787 +HerfindalET,GourleyDR,editors.TextbookofTherapeu- +788 +tics, Drug and Disease Management. 8th ed. Philadelphia: +789 +Lippincott William Wilkins. 2006. pp. 434-48. +790 +[59] +Melton MW. Take two Aspirin or not? Risk of med- +791 +ication use during pregnancy. Mother Baby J. 1999;4: +792 +25-32. +793 +[60] +Lacroix I, Damase-Michel C, Lapeyre-Mestre M, Montas- +794 +truc JL. Prescription of drugs during pregnancy in France. +795 +The Lancet. 2000;356(9243):1735-6. +796 +[61] +Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy +797 +and lactation: a reference guide to fetal and neonatal risk, +798 +4th edn. Baltimore: Williams and Wilkins, 1994:975. +799 +[62] +Heikinen T, Ekblad U, Laine K. Transplacental transfer of +800 +amitriptyline and nortriptyline in isolated perfused human +801 +placenta. Psychopharmacology. 2001;153:450-4 +802 +[63] +Hernandez-Diaz S, Smith CR, Shen A, Mittendorf R, +803 +Hauser WA, Yerby M, Holmes LB. Comparative safety +804 +of antiepileptic drugs during pregnancy. Neurology. +805 +2012;78(21):1692-9. +806 +[64] +Casper RC, Fleisher BE, Lee-Ancajas JC, Gilles A, Gay- +807 +lor E, DeBattista A, Hoyme HE. Follow-up of children of +808 +depressed mothers exposed or not exposed to antidepres- +809 +sant drugs during pregnancy. The Journal of Pediatrics. +810 +2003;142(4):402-8. +811 +[65] +Bermas BL, Hill JA. Effects of immunosuppressive drugs +812 +during pregnancy. Arthritis & Rheumatism. 1995;38(12): +813 +1722-32. +814 +Uncorrected Author Proof +10 +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +[66] +Einarson A, Selby P, Koren G. Abrupt discontinuation of +815 +psychotropic drugs during pregnancy: fear of teratogenic +816 +risk and impact of counselling. Journal of Psychiatry and +817 +Neuroscience. 2001;26(1):44. +818 +[67] +Parboosingh J. The effects of medication during preg- +819 +nancy. Canadian Family Physician. 1981;27:1013. +820 +[68] +Plessinger MA. Prenatal exposure to amphetamines: risks +821 +and adverse outcomes in pregnancy. Obstetrics and Gyne- +822 +cology Clinics of North America. 1998;25(1):119-38. +823 +[69] +Kinch RA. Diethylstilbestrol in pregnancy: an update. +824 +Canadian Medical Association Journal. 1982;127(9):812. +825 +[70] +Iveli MF, Morales S, Rebolledo A, Savietto V, Salemme +826 +S, Apeztegu´ +ıa M, Cecotti N, Drut R, Milesi V. Effects +827 +of light ethanol consumption during pregnancy: increased +828 +frequency of minor anomalies in the newborn and altered +829 +contractility of umbilical cord artery. Pediatric Research. +830 +2007;61(4):456-61. +831 +[71] +Feldman GL, Weaver DD, Lovrien EW. The fetal trimetha- +832 +dione syndrome: report of an additional family and further +833 +delineation of this syndrome. American Journal of Dis- +834 +eases of Children. 1977;131(12):1389-92. +835 +[72] +Lammer EJ, Cordero JF, Khoury MJ. Exogenous sex hor- +836 +mone exposure and the risk for VACTERL association. +837 +Teratology. 1986;34(2):165-9. +838 +[73] +Rubin A, Winston J, Rutledge ML. Effects of streptomycin +839 +uponthehumanfetus.AMAAmericanJournalofDiseases +840 +of Children. 1951;82(1):14-6. +841 +[74] +Smoak IW. Teratogenic effects of tolbutamide on early- +842 +somite mouse embryos in vitro. Diabetes Research and +843 +Clinical Practice. 1992;17(3):161-7. +844 +[75] +Reinisch JM, Sanders SA. Early barbiturate exposure: The +845 +brain, sexually dimorphic behavior and learning. Neuro- +846 +science & Biobehavioral Reviews. 1982;6(3):311-9. +847 +[76] +Weinstein MR, Goldfield MD. Cardiovascular malforma- +848 +tions with lithium use during pregnancy. The American +849 +Journal of Psychiatry. 1975. +850 +[77] +Nascimento SL, Surita FG, Godoy AC, Kasawara KT, +851 +Morais SS. Physical activity patterns and factors related +852 +to exercise during pregnancy: a cross sectional study. PloS +853 +One. 2015;10(6). +854 +[78] +Dye TD, Knox KL, Artal R, Aubry RH, Wojtowycz MA. +855 +Physical activity, obesity, and diabetes in pregnancy. Am +856 +J Epidemiol. 1997;146:961-965 +857 +[79] +Dempsey JC, Butler CL, Sorensen TK, Lee IM, Thompson +858 +ML, Miller RS, Frederick IO, Williams MA. A case- +859 +control study of maternal recreational physical activity and +860 +risk of gestational diabetes mellitus. Diabetes Research +861 +and Clinical Practice. 2004;66(2):203-15. +862 +[80] +Little KD. Effect of recreational exercise on pregnancy +863 +weight gain and subcutaneous fat deposition. Medicine +864 +and Science in Sports and Exercise. 1995;27(2):170-7. +865 +[81] +Clapp III JF. The course of labor after endurance exer- +866 +cise during pregnancy. American Journal of Obstetrics and +867 +Gynecology. 1990;163(6):1799-805. +868 +[82] +Clapp III JF. Exercise during pregnancy: a clinical update. +869 +Clinics in Sports Medicine. 2000;19(2):273-86. +870 +[83] +Committee on Obstetric Practice. ACOG committee +871 +opinion. Exercise during pregnancy and the postpartum +872 +period. Number 267, January 2002. American College of +873 +Obstetricians and Gynecologists. International Journal of +874 +Gynaecology and Obstetrics: The Official Organ of the +875 +International Federation of Gynaecology and Obstetrics. +876 +2002;77(1):79. +877 +[84] +Mudd LM, Owe KM, Mottola MF, Pivarnik JM. Health +878 +benefits of physical activity during pregnancy: an inter- +879 +national perspective. Med Sci Sports Exerc. 2013;45(2): +880 +268-77. +881 +[85] +Barakat R, Pelaez M, Montejo R, Refoyo I, Coteron J. +882 +Exercise throughout pregnancy does not cause preterm +883 +delivery: a randomized, controlled trial. Journal of Physi- +884 +cal Activity and Health. 2014;11(5):1012-7. +885 +[86] +Barakat R, Pelaez M, Lopez C, Montejo R, Coteron J. +886 +Exercise during pregnancy reduces the rate of cesarean and +887 +instrumental deliveries: results of a randomized controlled +888 +trial. The Journal of Maternal-Fetal & Neonatal Medicine. +889 +2012;25(11):2372-6. +890 +[87] +Barakat R, Pelaez M, Cordero Y, Perales M, Lopez C, +891 +Coteron J, Mottola MF. Exercise during pregnancy pro- +892 +tects against hypertension and macrosomia: randomized +893 +clinical trial. American Journal of Obstetrics and Gyne- +894 +cology. 2016;214(5):649-e1. +895 +[88] +Siddarth D, Siddarth P, Lavretsky H. An observational +896 +study of the health benefits of yoga or tai chi compared +897 +to aerobic exercise in community-dwelling middle-aged +898 +and older adults. The American Journal of Geriatric Psy- +899 +chiatry: Official Journal of the American Association for +900 +Geriatric Psychiatry. 2014;22(3):272. +901 +[89] +Colman AD, Colman LL. Pregnancy: The psychological +902 +experience. New York: Herder and Herder; 1971. +903 +[90] +Domenjoz I, Kayser B, Boulvain M. Effect of physical +904 +activity during pregnancy on mode of delivery. Ameri- +905 +can Journal of Obstetrics and Gynecology. 2014;211(4): +906 +401-e1. +907 +[91] +Olson D, Sikka RS, Hayman J, Novak M, Stavig C. +908 +Exercise in pregnancy. Current Sports Medicine Reports. +909 +2009;8(3):147-53. +910 +[92] +Zavorsky GS, Longo LD. Exercise guidelines in preg- +911 +nancy. Sports Medicine. 2011;41(5):345-60. +912 +[93] +Wallace AM, Engstrom JL. The effects of aerobic exercise +913 +on the pregnant woman, fetus, and pregnancy outcome: A +914 +review. Journal of Nurse-Midwifery. 1987;32(5):277-90. +915 +[94] +Field T. Yoga clinical research review. Complementary +916 +Therapies in Clinical Practice. 2011;17(1):1-8. +917 +[95] +Babbar S, Parks-Savage AC, Chauhan SP. Yoga during +918 +pregnancy: a review. American Journal of Perinatology. +919 +2012;29(06):459-64. +920 +[96] +Jiang Q, Wu Z, Zhou L, Dunlop J, Chen P. Effects of yoga +921 +intervention during pregnancy: a review for current status. +922 +American Journal of Perinatology. 2015;32(06):503-14. +923 +[97] +Muzik M, Hamilton SE, Rosenblum KL, Waxler E, Hadi +924 +Z. Mindfulness yoga during pregnancy for psychiatrically +925 +at-risk women: preliminary results from a pilot feasibil- +926 +ity study. Complementary Therapies in Clinical Practice. +927 +2012;18(4):235-40. +928 +[98] +Youngwanichsetha S, Phumdoung S, Ingkathawornwong +929 +T. The effects of mindfulness eating and yoga exercise +930 +on blood sugar levels of pregnant women with ges- +931 +tational diabetes mellitus. Applied Nursing Research. +932 +2014;27(4):227-30. +933 +[99] +Narendran S, Nagarathna R, Narendran V, Gunasheela +934 +S, Nagendra HR. Efficacy of yoga on pregnancy out- +935 +come. Journal of Alternative & Complementary Medicine. +936 +2005;11(2):237-44. +937 +[100] +Beddoe AE, Yang CP, Kennedy HP, Weiss SJ, Lee +938 +KA. The effects of mindfulness-based yoga during preg- +939 +nancy on maternal psychological and physical distress. +940 +Journal of Obstetric, Gynecologic & Neonatal Nursing. +941 +2009;38(3):310-9. +942 +[101] +Buttner MM, Brock RL, O’Hara MW, Stuart S. Efficacy +943 +of yoga for depressed postpartum women: a randomized +944 +Uncorrected Author Proof +P. Nadholta et al. / Potential benefits of yoga in pregnancy-related complications during the COVID-19 +11 +controlled trial. Complementary Therapies in Clinical +945 +Practice. 2015;21(2):94-100. +946 +[102] +Naik D, Thomas N. Yoga-a potential solution for diabetes +947 +& metabolic syndrome. The Indian Journal of Medical +948 +Research. 2015;141(6):753. +949 +[103] +Deshpande CS, Rakshani A, Nagarathna R, Ganpat TS, +950 +Kurpad A, Maskar R, Sudheer DC, Nagendra HR, Abbas +951 +R, Raghuram N, Anura K. Yoga for High-Risk Pregnancy: +952 +A Randomized Controlled Trial. Annals of Medical and +953 +Health Sciences Research. 2013;3(3):341-4. +954 +[104] +Hamdiah H, Suwondo A, Hardjanti TS, Soejoenoes A, +955 +Anwar MC. Effect of prenatal yoga on anxiety, blood pres- +956 +sure, and fetal heart rate in primigravida mothers. Belitung +957 +Nursing Journal. 2017;3(3):246-54. +958 +[105] +Arora +S, +Bhattacharjee +J. +Modulation +of +immune +959 +responses in stress by Yoga. International Journal of Yoga. +960 +2008;1(2):45. +961 +[106] +WaffarnF,DavisEP.Effectsofantenatalcorticosteroidson +962 +the hypothalamic-pituitary-adrenocortical axis of the fetus +963 +and newborn: experimental findings and clinical consid- +964 +erations. American Journal of Obstetrics and Gynecology. +965 +2012;207(6):446-54. +966 +[107] +Chida Y, Steptoe A. Cortisol awakening response and psy- +967 +chosocial factors: a systematic review and meta-analysis. +968 +Biological Psychology. 2009;80(3):265-78. +969 +[108] +O’Donnell K, O’Connor TG, Glover V. Prenatal stress and +970 +neurodevelopment of the child: focus on the HPA axis and +971 +role of the placenta. Dev Neurosci. 2009;31(4):285-292 +972 +[109] +An K, Starkweather A, Sturgill JL, et al. State of the sci- +973 +ence: salivary biomarker utilization for stress research. +974 +Perspect Nurs Sci. 2014;11(6):87-93 +975 +[110] +Chen PJ, Yang L, Chou CC, Li CC, Chang YC, Liaw JJ. +976 +Effects of prenatal yoga on women’s stress and immune +977 +function across pregnancy: A randomized controlled trial. +978 +Complementary Therapies in Medicine. 2017;31:109-17. +979 +[111] +Yadav RK, Magan D, Mehta N, Sharma R, Mahapatra SC. +980 +Efficacy of a short-term yoga-based lifestyle intervention +981 +in reducing stress and inflammation: preliminary results. +982 +The Journal of Alternative and Complementary Medicine. +983 +20121;18(7):662-7. +984 +[112] +Singh AK, Kaur N, Kaushal S, Tyagi R, Mathur D, Siva- +985 +puram MS, Metri K, Bammidi S, Podder V, Modgil S, +986 +Khosla R. Partitioning of radiological, stress and biochem- +987 +ical changes in pre-diabetic women subjected to Diabetic +988 +Yoga Protocol. Diabetes & Metabolic Syndrome: Clinical +989 +Research & Reviews. 2019;13(4):2705-13 +990 +[113] +Sanna E, Mostallino MC, Murru L, Carta M, Talani G, +991 +Zucca S, Mura ML, Maciocco E, Biggio G. Changes in +992 +expression and function of extrasynaptic GABAA recep- +993 +tors in the rat hippocampus during pregnancy and after +994 +delivery. Journal of Neuroscience. 2009;29(6):1755-65. +995 +[114] +Davis K. The feasibility of yoga in the treatment of ante- +996 +natal depression and anxiety: A pilot study. +997 +[115] +Satyapriya M, Nagendra HR, Nagarathna R, Padmalatha +998 +V. Effect of integrated yoga on stress and heart rate +999 +variability in pregnant women. International Journal of +1000 +Gynecology & Obstetrics. 2009;104(3):218-22. +1001 +[116] +Battle CL, Uebelacker LA, Magee SR, Sutton KA, Miller +1002 +IW. Potential for prenatal yoga to serve as an interven- +1003 +tion to treat depression during pregnancy. Women’s Health +1004 +Issues. 2015;25(2):134-41. +1005 +[117] +Beddoe AE, Lee KA. Mind-body interventions during +1006 +pregnancy. Journal of Obstetric, Gynecologic & Neonatal +1007 +Nursing. 2008;37(2):165-75. +1008 +[118] +Tian L, Philp JA, Shipston MJ: Glucocorticoid block of +1009 +protein kinase C signalling in mouse pituitary corticotroph +1010 +AtT20 D16:16 cells. J Physiol. 1999;516:757-768. 16. +1011 +Gatti G +1012 +[119] +Krishnan L, Guilbert L, Russell AS, Wegmann TG, Mos- +1013 +mann TR, Belosevic M: Pregnancy impairs resistance +1014 +of C57BL/6 mice to Leishmania major infection and +1015 +causes decreased antigen-specific IFN-gamma response +1016 +and increased production of T helper 2 cytokines. J +1017 +Immunol. 1996;156:644-652. +1018 +[120] +Bershadsky S, Trumpfheller L, Kimble HB, Pipaloff D, +1019 +Yim IS. The effect of prenatal Hatha yoga on affect, cor- +1020 +tisol and depressive symptoms. Complementary therapies +1021 +in clinical practice. 2014;20(2):106-13. +1022 +[121] +Satyapriya M, Nagarathna R, Padmalatha V, Nagendra +1023 +HR. Effect of integrated yoga on anxiety, depression & +1024 +well being in normal pregnancy. Complementary Thera- +1025 +pies in Clinical Practice. 2013;19(4):230-6. +1026 +[122] +Li AW, Goldsmith CA. The effects of yoga on anxiety and +1027 +stress. Alternative Medicine Review. 2012;17(1). +1028 diff --git a/subfolder_0/Psychiatric disorders and holistic therapies.txt b/subfolder_0/Psychiatric disorders and holistic therapies.txt new file mode 100644 index 0000000000000000000000000000000000000000..e38c5c198215c9b575a9ae69514eeb800c088d58 --- /dev/null +++ b/subfolder_0/Psychiatric disorders and holistic therapies.txt @@ -0,0 +1,91 @@ +3/8/2017 +Psychiatric disorders and holistic therapies +https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997229/?report=printable +1/2 +Int J Yoga. 2010 Jul­Dec; 3(2): 35–36. +doi:  10.4103/0973­6131.72627 +PMCID: PMC2997229 +Psychiatric disorders and holistic therapies +Thaiyar M Srinivasan +Swami Vivekananda Yoga Anusandhana Samsthana (A Yoga University), No.9, Appajappa Agrahara Chamarajpet, Bangalore ­ 560 018, India. +E­mail: tmsrini@gmail.com +Copyright © International Journal of Yoga +This is an open­access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, +distribution, and reproduction in any medium, provided the original work is properly cited. +Psychiatric disorders are the most prevalent problems of modern living, with drugs for the management of +these disorders selling in billions of dollars every year around the world. It is estimated that about 50 million +people have either moderate or severe forms of psychiatric disorders in India.[1] The same article mentions +that India provides one bed per 40,000 population and three psychiatrists per million population. This works +out to approximately 3000 trained psychiatrists for the entire country. The expertise is available mostly in the +cities and not for the rural population, wherein the requirements for psychiatric support and management are +critical. The rural group can ill afford loss of workdays, hospital admissions, costly tests, and other +requirements of modern medicine. +It is believed that over 46 per cent of the U.S. population might be affected with at least one psychiatric +disorder and at least a quarter of the population of that country have two or more disorders [3, p. 1]. This is a +shocking revelation; unfortunately, many industrially advanced countries reveal similar numbers. Although +the Indian statistics are not as threatening, nonetheless, the prevalence of psychiatric disorders enormously +outstrip the available resources. Hence, there is an urgent need for both prevention and non­pharmacological +management of psychiatric disorders. +There are many non­pharmacological methods for the management of psychiatric problems. Biofeedback +and Yoga are emerging as two specific techniques that seem to help these patients. In the biofeedback +procedures, instantaneous information regarding a physiological variable (such as heart rate) is provided to +the client and the client learns to control the parameter using the desirable methods. In the example of the +heart rate, the patient may be asked to reduce the heart rate through ‘appropriate thinking’ and he/she learns +to do so with some hours of training. Similarly, skin temperature, sweating, blood pressure, +electromyographic activity, Heart Rate Variability (HRV), and so on, can be controlled if the person is made +aware of them through proper instrumentation. +Learning to control physiological functions that are normally autonomic seem to have many advantages. +There is information transfer from the periphery to the center; for example, learning to control the +temperature of a finger sends strong signals to the brain to reset some of the physiological functions within +limits. The heart sends signals to the brain through many ways: through hormones, through its electrical +activity, through vagus nerve, and through blood pressure waves.[2] The Mind–Body complex can be made +to go through a relaxed, hypometabolic, parasympathetic dominance. Such a change in physiology results in +reduced stress and anxiety, reduces cortisol levels, increases DHEA or dehydroepiandrosterone, and +improves the functioning of the prefrontal cortex, enhancing mental clarity. A client, who has learned the +biofeedback procedure, can control the physiological function even without a feedback instrument; this gives +confidence to the person and the ability to master one’s own physiology, within normal limits. +Al present, some biofeedback types seem to be useful, while others are still in the experimental stages. +Neurofeedback for Attention Deficit Hyperactivity Disorder (ADHD) has been around for almost 15 years +with a positive response from the clients. Here the electroencephalogram (EEG) of the person is displayed as +a game module. The person is trained to increase beta waves under normal, eyes­open condition, and there +3/8/2017 +Psychiatric disorders and holistic therapies +https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997229/?report=printable +2/2 +are clinical improvements in the ADHD of the clients. Biofeedback is also seen to enhance memory, improve +sleep in insomnia patients, as also depression and PTSD (Post Traumatic Stress Disorder). Although it +usually takes a long time for the client to train in biofeedback procedures, it has no known side effects, +trauma or negative emotional responses. It is not known whether the changes seen are long lasting; however, +short­term gains are observed in both the clinical and personal outcomes. +Yoga is another method for the management of psychiatric disorders. A recent book, written by a dedicated +Kundalini Yoga teacher and an avid researcher, has a wealth of information about psychiatric disorders, +especially those with multiple problems.[3] An earlier book by the same author deals with specific +psychiatric disorders including obsessive­compulsive disorder, acute stress disorder, PSTD, ADD/ADHD +and other psychiatric problems.[4] In the recent book,[3] a detailed summary of the latest research in many +psychiatric problems has been brought out and the difficulty in the management of these problems through +drugs alone is summarized from the published literature. Each chapter then provides detailed Kundalini Yoga +practices for specific disorders, followed by case studies and results, as narrated by the patients themselves. It +is undoubtedly a well­researched book, both on the pharmacological intervention of psychiatric disorders +(which is complex with many side effects) and Kundalini Yoga methods. There is no doubt that Yoga and +meditation can provide an excellent alternative for the treatment of psychiatric disorders. +It is necessary for Indian Yoga Research Institutes to look into this alternative closely and provide an +integrated approach to many psychiatric problems. There are a few articles by Indian researchers on the +effect of Yoga on psychiatric disorders.[5,6] However, more work is needed to move this from the +experimental to a clinic setting. After all, if citta could be brought under control, it is likely all else follows. +Mental poise, biochemical homeostasis, neurological normalcy followed by karmasu kausalam or skill in +action would be possible. +REFERENCES +1. Barua A. Need for a realistic mental health program in India. Indian J Psychological Med. 2009;31:48–9. +[PMCID: PMC3168081] +2. Kemper KJ. Biofeedback and Mental Health. J Altern Complement Therapies. 2010;2:208–11. +3. Shannahoff­Khalsa D. Kundalini Yoga Meditation for Complex Psychiatric Disorders. London: W. W. +Norton & Co; 2010. +4. Shannahoff­Khalsa D. Kundalini Yoga Meditation: Techniques Specific for Psychiatric Disorders, +Couples Therapy, and Personal Growth. N.Y: W. W. Norton & Co; 2006. +5. Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN. Yoga therapy as an add­on treatment in the +management of patients with schizophrenia: A randomized controlled trial. Acta Psychiatr Scand. +2007;116:226–32. [PubMed: 17655565] +6. Raghuraj P, Nagarathna R, Saraswathi A, Nunn H, Telles S. Proceedings of the International Symposium +on Innovations in Psychiatric Rehabilitation, Richmond Fellowship Asia­Pacific Forum. Bangalore, India: +The Richmond Fellowship Society; 2000. Effects of yoga on schizophrenics; pp. 193–5. +Articles from International Journal of Yoga are provided here courtesy of Medknow Publications diff --git a/subfolder_0/Quality of life improvement with rehabilitation according to constitution of the World Health Organization for coronary artery bypass graft surgery patients_ A descriptive review.txt b/subfolder_0/Quality of life improvement with rehabilitation according to constitution of the World Health Organization for coronary artery bypass graft surgery patients_ A descriptive review.txt new file mode 100644 index 0000000000000000000000000000000000000000..bbea14433328b50a2e6d33b50fbdaf4d8cd8c022 --- /dev/null +++ b/subfolder_0/Quality of life improvement with rehabilitation according to constitution of the World Health Organization for coronary artery bypass graft surgery patients_ A descriptive review.txt @@ -0,0 +1,420 @@ +Ayu. 2017 Jul-Dec; 38(3-4): 102–107. +doi: 10.4103/ayu.AYU_152_17 +PMCID: PMC6153913 +PMID: 30254387 +Quality of life improvement with rehabilitation according to constitution of +the World Health Organization for coronary artery bypass graft surgery +patients: A descriptive review +Amaravathi Eraballi and Balaram Pradhan +Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru, +Karnataka, India +Yoga and Life Science, Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru, +Karnataka, India +Address for correspondence: Dr. Amaravathi Eraballi, Division of Yoga and Life Sciences, Swami +Vivekananda Yoga Anusandhana Samsthana University, 19 Eknath Bhavan, Gavipuram Circle, Kempegowda +Nagar, Bengaluru - 560 019, Karnataka, India. E-mail: om.amaravathi@gmail.com +Copyright : © 2018 AYU (An International Quarterly Journal of Research in Ayurveda) +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 +This is a descriptive review focusing on trends of treatments required for postoperative coronary artery +bypass graft surgery (CABG) patients to improve the quality of life (QOL). +Methodology: +The sources of literary research to understand the concepts of coronary artery disease according to +Indian scriptures are Ayurveda texts, Bhagavad Gita, Patanjali Yoga Sutra. The data was typed in +Sanskrit using Devanagari script and explanation in English was given. As per new research +techniques, surgery, physiotherapy rehabilitation and Yoga are serving CABG patient's medical and +psychological health better. The World Health Organization (WHO) defines health as physical, mental +and social well-being later redefined with additional terms like environmental and spiritual health. This +definition is similar to the Panchakosha concept in Yoga and Pancha Mahabhutas in Ayurveda. In +cases of emergency or passive treatment, medication serves as a better option for physical health. In +circumstances where the person is able to move in daily activities (just after discharge), rehabilitation +serves as a better option for physical, mental and social health. Travel and reactions to climatic change +serve environmental health. Last strategy, belief, cultural and traditional methods with scientific +background serves as the spiritual health. These step-wise treatments are required for CABG patients to +get the overall health or QOL. However, surgery and physiotherapy rehabilitation are advanced as per +modern era which serves physical, mental, and social health also, but environmental health and +spiritual health have yet to be addressed. As an ancient system of medicine, Yoga combines physical, +1 +1 +mental, social, environmental and spiritual practices and it should be added as treatment along with +surgery and physiotherapy rehabilitation. If all of these therapies were in the treatment protocol for +CABG surgery patients, we would observe the changes of QOL and fulfill the requirements of +constitution of the WHO. Integrating concepts of Yoga, Ayurveda, modern rehabilitation, surgery and +patient cooperation with lifestyle change are the key to QOL improvements after CABG. +Keywords: Coronary artery bypass graft, quality of life, rehabilitation, World Health Organization, +Yoga +Introduction +Coronary artery bypass graft (CABG) surgery and stent can help to restore blood flow to an area of the +heart but do not stop the progression of atherosclerosis.[1] Combination of surgery that is CABG with +medical therapy can improve the quality of life (QOL) better than medical therapy alone for coronary +artery disease (CAD).[2] Even though CABG and coronary artery stenting reduces symptoms, +recurrence of events of disease and requirement of procedures, mortality will be the same in the long +term.[3,4] Hence, personality which is the conduct of life or daily living, especially type-D personality +can affect the QOL of the cardiac diseased person.[5] As the sense of coherence reduces, health-related +QOL also reduces after 6 months of either CABG or percutaneous transluminal coronary angioplasty. +[6] Mortality rate increases by thrice from 1 to 3 year[4] and twice from 1 to 5 year with +definitive requirement of reoperation.[7] CABG alone can improve QOL much after 12 months, but +there is still the necessity of multidisciplinary rehabilitation which focuses on emotional support, +information about progression, patient education and peer education.[8] Secondary preventions such as +risk factor management and initiation of rehabilitation are essential components for postoperative +CABG patients to optimize graft patency and to achieve the highest level of physical health and QOL. +[9] There is a lot of importance for cardiac rehabilitation at the national and international level to +reduce rehospitalization.[10] A well structured, multicomponent cardiac rehabilitation is associated +with reduced mortality after CABG and in order to achieve high quality evidence, minimum standards +for planning, performing and presenting of controlled cohort studies are warranted.[11] +In CABG research, QOL is an important outcome to be measured, which should at least have +components such as, physical status, mental function, social interaction and disease-specific measure. +[12] It is important to assess physical, psychological and social variables as well to adjust life after +CABG.[13] A review study proved CABG is better than percutaneous coronary intervention (PCI) after +1 year of surgery in terms of QOL checked with many instruments.[14] QOL instrument selection is an +important factor to be considered in rehabilitation programs to draw conclusions. Furthermore, +randomized control trial (RCT) and pre-post designs are very much required to support researched +techniques for CABG.[15] This suggests the necessity of providing mobile tele-monitoring guided +cardiac rehabilitation because of the comfort zone and cost-effectiveness.[16] Home-based intervention +programs improve health related QOL after CABG nonsignificantly compared with normal +participants.[17] According to the “Constitution of WHO,” health is “a state of complete physical, +mental and social well being and not merely the absence of disease or infirmity.”[18] The integrative +approach of Yoga has similarities with the constitution of the World Health Organization(WHO) +regarding health. Yoga has proven to be beneficial for hypertension, diabetes mellitus, dyslipidemia, +high cholesterol levels, which are risk factors of cardiac diseases.[19] Yoga is a mind–body practice +that reduces anxiety, depression and blood pressure and also improves physical fitness as part of QOL. +[20] Hence, as there is a chance to develop the disease with these risk factors in the future, so there is +need to prove the effect of Yoga on CABG patients. +Methodology +The literary research was done in three steps; +st +rd +st +th +Step 1: Sources of Literary Research for understanding the concepts of CAD according to Indian +scriptures +1. Charaka Samhita: Written approximately 3000 BC, by Acharya Charaka, is the first and +among the most famous texts of Ayurveda classics. +2. Madhava Nidana: Diagnostic part of diseases in Ayurveda. +3. Sushruta Samhita: This is another famous Ayurvedic text that deals with the surgical +procedures and its complications. +4. Yoga Vashishtha: Yogic concept of manifestation of disease. +5. Bhagavad Gita: Concept of manifestation of disease and the role of mind in disease. +6. Patanjali Yoga Sutra: Concept of mind and conflicts of personality. It provides the basis +for most of the Yoga techniques used in the study. +Step-2: Literary research presentation +1. Selected verses related to CAD from above mentioned texts one by one. +2. Verses were written in Devanagari script first, transliteration and translation was done later +on. Further explanation wherever necessary has been given. +3. A summary of the same is presented with conclusions. +4. An Ayurveda/Yoga model of the origin and progress of CAD is presented. +Step-3: Key verses in classical texts. +As per Ayurveda in the cases of individuals with habitual intake of unwholesome food and with their +mind covered with Rajas and Tamas, Dosha gets vitiated jointly or severely and then they obstruct or +vitiates different channels resulting in the manifestation of diseases such as intoxication, fainting and +syncope. As per Yoga Vashishtha, diseases arise from the deep seated thoughts in the mind that is called +as Adi and also mentioned in Bhagavad Gita (Shloka 2.62, 2.63) when a hunanbeing dwells on the +objects of sense, it creates an attraction for them. Attraction develops into desire and desire breeds +anger. Anger induces delusion. Delusion leads to loss of memory; through loss of memory, reason is +shattered; and loss of reason leads to destruction. +Physical Health +Exercise-based cardiac rehabilitation improves the cardiac parameters after PCI[21] and other similar +changes can be expected after CABG. Strength training increases left ventricular (LV) size and early +diastolic function, whereas endurance training increases the thickness and segmentation of late LV +diastolic function in male athletics.[22] Low-intensity exercises involve large muscles and allow +cardiovascular adaptation and myocardial perfusion.[23] Rehabilitation with exercise and education +classes improves walking distance, gait speed and attendance preoperatively and 3 months after CABG +according to a pilot randomized control trial (RCT).[24] +As per a systematic review, telemonitoring and telehealth recovery focused intervention play an +important role in physical aspects of CABG patients.[25] The ischemic LV dysfunction and poor +exercise capacity are risk factors of increased mortality rates 5 years after CABG.[26] Exercise training +improves exercise capacity associated with restoration of peripheral oxygen utilization after CABG. +[27] Cardiac rehabilitation initiated in a home environment may more likely sustain physical and +psychosocial changes than institution based programs over 1 year after CABG.[28] Lifestyle +intervention composed of low-cholesterol and low fat diet, moderate exercise and stress management +could (1) increase the exercise capacity from 9.59 Metabolic Equivalents (METS) to 11.03 METS and +(2) reduced the weight from 187.3 pounds to 178 pounds (baseline to 3 years) to avoid +revascularization.[29] Faulty lifestyle leads to heart disease called Hridroga.[30] Yoga-based cardiac +rehabilitation improves ejection fraction and lipid profile after 1 year of CABG.[31] CABG surgery, +physiotherapy rehabilitation after CABG and Yoga rehabilitation after CABG serve physical and +mental health best at 1 year.[31] Yoga techniques meets the requirements of the constitution of +WHO[32] because it has many benefits such as increasing muscular strength and flexibility; promoting +improvements in respiratory and cardiovascular function; promoting recovery from addiction; reducing +stress, anxiety, depression, and chronic pain; improving sleep patterns and enhancing overall well- +being and QOL.[33] +Psychological Health +Type-D personality of CAD patients gave evidence that the physiological hyper-reactivity and +activation of pro-inflammatory cytokines may be responsible for detrimental effects on cardiac +prognosis.[5] As per a systematic review with meta-analysis, variables like psychological (stressful life +events, emotional distress and personality) factors should be examined to predict the progression of +disease and QOL after CABG.[34] Depression and anxiety are cardiac risk factors are less but continue +to be sustained even after 7 days,[35] 10 days[36] and after 5 years[37] of CABG. Psychosomatic +symptoms, especially anxiety, may be associated with irregularity in circadian rhythm, which can be +altered by basic lifestyle habits in healthy volunteers.[38] Hence, cognitive behavior therapy or +supportive stress management therapy is effective in treating depression after 3 months of CABG.[39] +As per a systematic review, telemonitoring and telehealth recovery-focused intervention also play +important role in psychological aspects of CABG patients.[25] Yoga based cardiac rehabilitation can +improve the positive effect, skills of managing anxiety and depression than physiotherapy based +rehabilitation alone after 1 year of CABG.[31] With all this research, surgery and rehabilitation are +beneficial for CABG patients. But specific practices, like Iyengar Yoga, reduce cardiac reactivity with +intentional stress, which is the risk factor for cardiac disease and improve QOL.[40] +Social-emotional, self-care, visualization and deep breathing can improve QOL by developing self +healing insights into life-threatening diseases like cancer.[41] Yoga, as an ancient system of medicine, +has specific techniques called meditation which increases the membrane potential of neurons and other +body cells and reduce the activity of amygdala and cortical areas.[42] +As per a systematic review and meta-analysis, the mind–body techniques such as mindfulness based +stress reduction, transcendental meditation, progressive muscle relaxation, and stress management will +improve the different domains of QOL in cardiac diseases.[43] The aerobic and resistance physical +training effectively improve cardiac response to stressful situations of daily life and also preoperative +cardiac disease.[20] +Even though there are positive results with meditation techniques for different diseases by modulating +the cortisol levels before CABG,[44] the postoperative condition has yet to be addressed. Hence, +psychological health is well served by surgery and rehabilitation treatments when combined with +counseling sessions and meditation techniques of Yoga.[31] Nontraditional cardiac rehabilitation can be +considered as a secondary preventive meditation where the involvement of meditation or mind during +physical movements reduces depression of CAD patients.[45] +Social Health +Socioeconomic factors such as age, education level and low income usually reduce QOL. Those who +return early to work for compensating economic situation could improve QOL better than those who do +not return to work.[46] If health-promoting programs start at the inpatient phase, then follow-up with +the help of family members can reduce the risk factors of CAD after CABG.[47] Cardiac rehabilitation +can improve social functioning through return to work after 1 year of CABG.[48] Team activities such +as play, sports and quizzes are all part of the personal interaction which makes or changes behaviors +and improves coping skills. Such programs are well developed in surgery teams and rehabilitation +teams as an option, but not concerned to do it as a team. +Yoga treatments have Kriya Yoga for any age by team in a particular way along with Asana, +Pranayama and meditation techniques. Hence, social health may be better served by Yoga +rehabilitation than other streams. Modification of rehabilitation as a cost-effective treatment for those +who cannot really afford to go to the center must be developed to improve QOL of CAD[33] and +CABG patients.[31] +The true knower realizes that they can never fully know infinity, whereas the ignorant thinks he knows +everything.[19] Hence, proper lifestyle modifications by the patient and social support will improve +QOL after CABG.[49] +Environmental Health +As per a systematic review with meta-analysis, variables like environmental or behavioral (adherence +to medication, management of diabetes, obesity and alcohol use) factors should be examined to predict +the progression of disease and QOL after CABG.[34] The return to work duration is more after CABG +make the person to think and may reduce QOL. Hence the rehabilitation program should reach the rural +areas to prevent dropping of QOL after CABG[50] The ability to work after CABG is little longer than +other surgeries.[51] Elderly people could reduce the rate of fall with regular exercises mostly at home +environments after 1 year of time shows the role of comfort zone for health status.[33] It was also +proved with review that home-based cardiac rehabilitation improves exercise capacity better than +center-based cardiac rehabilitation.[52] A systematic review revealed that the alternative models of +cardiac rehabilitation, like telephonic communication can reduce risk factors of CAD.[16] +The Pranayama practices of Yoga are meant to modulate breath capacity and increase the expected +lifespan by increasing oxygen consumption[2] and help in reduction of stress through parasympathetic +dominance.[53] If the individual is able to withstand such health challenges, then they are said to have +good environmental health. Firm holding on sense organs is Yoga and it literally means to unite the +lower self with the higher self; the worshiper with God.[19] Travelling or short migrations in routine +life put the health into challenging situations to cope up with the environmental changes such as +climate, temperature, food, water and different cultures.[54] Hence, this part of the WHO's requirement +may be served by Yoga rehabilitation. +As the advancement in analysis of world wars, the scientists brought the concept of health as per +cultural activities termed as spiritual health.[55] Hence, there is a need for techniques which can +concentrate on spiritual health also. Cultural methods as intervention can reduce anxiety levels.[56] +Faith is an independent and complex factor, influence the end life decision making ability which needs +much medical attention for CABG patients.[57] Hence, if a treatment has practical applications in the +form of cultural, devotional or spiritual programs, health can be maintained and uplifted from within. +Such programs are not seen in surgery teams and rehabilitation teams, but it can be seen in Yoga teams +in terms of Bhajans and sacred Mantra chanting. Hence, the WHO's requirement for spiritual health +may be served by Yoga treatments. The individual decision and conduct of life is the main concern for +preventing any disease progression. Cardiac disease processes can be reversed by lifestyle +modifications[29,58] and combining Yoga into standard rehabilitation programs.[50,59,60] QOL is the +measurement of the same lifestyle and can be changed if the person attempts to change.[61] This is the +similarity between modern and ancient concepts of wisdom.[62] Similarities should be identified for +integrating health systems and to serve society and the nation as per the requirements of the WHO +constitution. +Conclusion +QOL is comprised of different concepts of life. Treatment strategies are made as per this requirement, +then disease progression can be reduced or stopped. More feasible, less economical and time-saving +treatments can serve postoperative CABG patients better. Hence, integrating concepts of surgery, +physiotherapy rehabilitation, Yoga, Ayurveda and knowledge of ancient texts can improve the QOL of +CABG patients. +Financial support and sponsorship +Nil. +Conflicts of interest +There are no conflicts of interest. +Acknowledgment +The authors would like to thank the chairpersons for their ideas and also thank everyone of the +technical team. They would also like to thank the main base of this work, participants of CABG, from +the AYUSH project, Delhi. +References +1. Burazor I, Susak S. OS 04-06 How to control high blood pressure after coronary revascuarization in +patients referred to in-house cardiac rehabilitation?. Single center experience. J Hypertens. +2016;34(Suppl 1):e56. [Google Scholar] +2. Tyagi A, Cohen M. Oxygen consumption changes with yoga practices. J Evid Based Complement +Altern Med. 2013;18:290–308. [Google Scholar] +3. Weintraub WS, Jones EL, Morris DC, King SB, 3rd, Guyton RA, Craver JM, et al. Outcome of +reoperative coronary bypass surgery versus coronary angioplasty after previous bypass surgery. +Circulation. 1997;95:868–77. [PubMed] [Google Scholar] +4. Shahian DM, O Brien SM, Sheng S, Grover FL, Mayer JE, Jacobs JP, et al. Health Services and +Outcomes Research Predictors of Long-Term Survival After Coronary Artery Database (The ASCERT +Study) 2012 [Google Scholar] +5. Pedersen SS, Denollet J. Type D personality, cardiac events, and impaired quality of life: A review. +Eur J Cardiovasc Prev Rehabil. 2003;10:241–8. [PubMed] [Google Scholar] +6. Kattainen E, Meriläinen P, Sintonen H. Sense of coherence and health-related quality of life among +patients undergoing coronary artery bypass grafting or angioplasty. Eur J Cardiovasc Nurs. 2006;5:21– +30. [PubMed] [Google Scholar] +7. Weintraub WS, Jones EL, Morris DC, King SB 3rd, Guyton RA, Craver JM, et al. Outcome of +reoperative coronary bypass surgery versus coronary angioplasty after previous bypass surgery. +Circulation. 1997;95:868–77. [PubMed] [Google Scholar] +8. Merkouris A, Apostolakis E, Pistolas D, Papagiannaki V, Diakomopoulou E, Patiraki E, et al. +Quality of life after coronary artery bypass graft surgery in the elderly. Eur J Cardiovasc Nurs. +2009;8:74–81. [PubMed] [Google Scholar] +9. Kulik A. Secondary prevention after coronary artery bypass graft surgery: A primer. Curr Opin +Cardiol. 2016;31:635–43. [PubMed] [Google Scholar] +10. Turk-Adawi K, Sarrafzadegan N, Grace SL. Global availability of cardiac rehabilitation. Nat Rev +Cardiol. 2014;11:586–96. [PMC free article] [PubMed] [Google Scholar] +11. Rauch B, Davos CH, Doherty P, Saure D, Metzendorf MI, Salzwedel A, et al. The prognostic effect +of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review +and meta-analysis of randomized and non-randomized studies-the cardiac rehabilitation outcome study +(CROS) Eur J Prev Cardiol. 2016;23:1914–39. [PMC free article] [PubMed] [Google Scholar] +12. Cartwright CR, Mangano CM. Quality of life after coronary artery bypass surgery: Past progress +and future directions. Semin Cardiothorac Vasc Anesth. 1998;2:302–10. [Google Scholar] +13. Hawkes AL, Nowak M, Bidstrup B, Speare R. Outcomes of coronary artery bypass graft surgery. +Vasc Health Risk Manag. 2006;2:477–84. [PMC free article] [PubMed] [Google Scholar] +14. Fatima K, Yousuf-Ul-Islam M, Ansari M, Bawany FI, Khan MS, Khetpal A, et al. Comparison of +the postprocedural quality of life between coronary artery bypass graft surgery and percutaneous +coronary intervention: A systematic review. Cardiol Res Pract 2016. 2016;7 [PMC free article] +[PubMed] [Google Scholar] +15. Takousi MG, Schmeer S, Manaras I, Olympios CD, Makos G, Troop NA. Health-related quality of +life after coronary revascularization: A systematic review with meta-analysis. Hellenic J Cardiol. +2016;57:223–37. [PubMed] [Google Scholar] +16. Clark RA, Conway A, Poulsen V, Keech W, Tirimacco R, Tideman P, et al. Alternative models of +cardiac rehabilitation: A systematic review. Eur J Prev Cardiol. 2015;22:35–74. [PubMed] +[Google Scholar] +17. Huang K, Liu W, He D, Huang B, Xiao D, Peng Y, et al. Telehealth interventions versus center- +based cardiac rehabilitation of coronary artery disease: A systematic review and meta-analysis. Eur J +Prev Cardiol. 2015;22:959–71. [PubMed] [Google Scholar] +18. Lie I, Arnesen H, Sandvik L, Hamilton G, Bunch EH. Health-related quality of life after coronary +artery bypass grafting. The impact of a randomised controlled home-based intervention program. Qual +Life Res. 2009;18:201–7. [PubMed] [Google Scholar] +19. Ray IB, Menezes AR, Malur P, Hiltbold AE, Reilly JP, Lavie CJ, et al. Meditation and coronary +heart disease: A review of the current clinical evidence. Ochsner J. 2014;14:696–703. +[PMC free article] [PubMed] [Google Scholar] +20. Demarzo MM, Montero-Marin J, Stein PK, Cebolla A, Provinciale JG, García-Campayo J, et al. +Mindfulness may both moderate and mediate the effect of physical fitness on cardiovascular responses +to stress: A speculative hypothesis. Front Physiol. 2014;5:105. [PMC free article] [PubMed] +[Google Scholar] +21. Yang X, Li Y, Ren X, Xiong X, Wu L, Li J, et al. Effects of exercise-based cardiac rehabilitation in +patients after percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Sci +Rep. 2017;7:44789. [PMC free article] [PubMed] [Google Scholar] +22. Ventricular EL, Among R, Weiner RB, Deluca JR, Wang F, Lin J, et al. Baggish, Ventricular +Structure and Function Competitive Athletes. CIRCIMAGING.115.003651. 2015:1–10. +[Google Scholar] +23. RenuPattanshetty SS&SM. Effectiveness of low intensity exercises on six minute walk distance and +haemodynamic variables in CABG and valve replacement patients during phase 1 cardiac rehabilitation +in a tertiary care setup: A comparative study quick Response code. Int J Physiother Res. 2014;2:669– +76. [Google Scholar] +24. Sawatzky JA, Kehler DS, Ready AE, Lerner N, Boreskie S, Lamont D, et al. Prehabilitation +program for elective coronary artery bypass graft surgery patients: A pilot randomized controlled study. +Clin Rehabil. 2014;28:648–57. [PubMed] [Google Scholar] +25. Prescott E, Meindersma EP, van der Velde AE, Gonzalez-Juanatey JR, Iliou MC, Ardissino D, et al. +A EUropean study on effectiveness and sustainability of current cardiac rehabilitation programmes in +the elderly: Design of the EU-caRE randomised controlled trial. Eur J Prev Cardiol. 2016;23:27–40. +[PubMed] [Google Scholar] +26. Stewart RA, Szalewska D, She L, Lee KL, Drazner MH, Lubiszewska B, et al. Exercise capacity +and mortality in patients with ischemic left ventricular dysfunction randomized to coronary artery +bypass graft surgery or medical therapy: An analysis from the STICH trial (Surgical treatment for +ischemic heart failure) JACC Heart Fail. 2014;2:335–43. [PMC free article] [PubMed] +[Google Scholar] +27. Wu YT, Wu YW, Hwang CL, Wang SS. Changes in diastolic function after exercise training in +patients with and without diabetes mellitus after coronary artery bypass surgery. A randomized +controlled trial. Eur J Phys Rehabil Med. 2012;48:351–60. [PubMed] [Google Scholar] +28. Smith KM, Arthur HM, McKelvie RS, Kodis J. Differences in sustainability of exercise and health- +related quality of life outcomes following home or hospital-based cardiac rehabilitation. Eur J +Cardiovasc Prev Rehabil. 2004;11:313–9. [PubMed] [Google Scholar] +29. Ornish D. Avoiding revascularization with lifestyle changes: The multicenter lifestyle +demonstration project. Am J Cardiol. 1998;82:72T–76T. [PubMed] [Google Scholar] +30. III. Calcutta: S.L. Bhaduri, B.L., 10, Kashi Ghose's Lane, Calcutta; 1916. V. Library, An english +translation of The sushrutha samhitha. [Google Scholar] +31. Raghuram N, Parachuri VR, Swarnagowri MV, Babu S, Chaku R, Kulkarni R, et al. Yoga based +cardiac rehabilitation after coronary artery bypass surgery: One-year results on LVEF, lipid profile and +psychological states – A randomized controlled study. Indian Heart J. 2014;66:490–502. +[PMC free article] [PubMed] [Google Scholar] +32. World Health Organization, “Constitution of The World Health Organization,” Basic Doc. Forthy- +fifth Ed., no. January 1984. 2006:1–18. [Google Scholar] +33. Woodyard C. Exploring the therapeutic effects of yoga and its ability to increase quality of life. Int +J Yoga. 2011;4:49–54. [PMC free article] [PubMed] [Google Scholar] +34. Takousi MG, Schmeer S, Manaras I, Olympios CD, Makos G, Troop NA, et al. Health-related +quality of life after coronary revascularization: A systematic review with meta-analysis. Hellenic J +Cardiol. 2016 pii: S1109-9666(16)30145-2. [PubMed] [Google Scholar] +35. Krannich JH, Weyers P, Lueger S, Herzog M, Bohrer T, Elert O, et al. Presence of depression and +anxiety before and after coronary artery bypass graft surgery and their relationship to age. BMC +Psychiatry. 2007;7:47. [PMC free article] [PubMed] [Google Scholar] +36. Chaudhury S, Sharma S, Pawar AA, Kumar BK, Srivastava MK, Sudarsanan S, et al. Psychological +correlates of outcome after coronary artery bypass graft. Med J Armed Forces India. 2006;62:220–3. +[PMC free article] [PubMed] [Google Scholar] +37. Tully PJ, Winefield HR, Baker RA, Denollet J, Pedersen SS, Wittert GA, et al. Depression, anxiety +and major adverse cardiovascular and cerebrovascular events in patients following coronary artery +bypass graft surgery: A five year longitudinal cohort study. Biopsychosoc Med. 2015;9:14. +[PMC free article] [PubMed] [Google Scholar] +38. Nagane M, Suge R, Watanabe S. Relationship between psychosomatic complaints and circadian +rhythm irregularity assessed by salivary levels of melatonin and growth hormone. J Circadian +Rhythms. 2011;9:9. [PMC free article] [PubMed] [Google Scholar] +39. Freedland KE, Skala JA, Carney RM, Rubin EH, Lustman PJ, Dávila-Román VG, et al. Treatment +of depression after coronary artery bypass surgery: A randomized controlled trial. Arch Gen Psychiatry. +2009;66:387–96. [PMC free article] [PubMed] [Google Scholar] +40. Lakkireddy D, Atkins D, Pillarisetti J, Ryschon K, Bommana S, Drisko J, et al. Effect of yoga on +arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation: The YOGA +my heart study. J Am Coll Cardiol. 2013;61:1177–82. [PubMed] [Google Scholar] +41. Loizzo JJ, Peterson JC, Charlson ME, Wolf EJ, Altemus M, Briggs WM, et al. The effect of a +contemplative self-healing program on quality of life in women with breast and gynecologic cancers. +Altern Ther Health Med. 2010;16:30–7. [PubMed] [Google Scholar] +42. Jerath R, Barnes VA, Crawford MW. Mind-body response and neurophysiological changes during +stress and meditation: Central role of homeostasis. J Biol Regul Homeost Agents. 2014;28:545–54. +[PubMed] [Google Scholar] +43. Younge JO, Gotink RA, Baena CP, Roos-Hesselink JW, Hunink MG. Mind-body practices for +patients with cardiac disease: A systematic review and meta-analysis. Eur J Prev Cardiol. +2015;22:1385–98. [PubMed] [Google Scholar] +44. Kiran U, Ladha S, Makhija N, Kapoor PM, Choudhury M, Das S, et al. The role of rajyoga +meditation for modulation of anxiety and serum cortisol in patients undergoing coronary artery bypass +surgery: A prospective randomized control study. Ann Card Anaesth. 2017;20:158–62. +[PMC free article] [PubMed] [Google Scholar] +45. Lee J, Song Y, Lindquist R, Yoo Y, Park E, Lim S, et al. Nontraditional cardiac rehabilitation in +korean patients with coronary artery disease. Rehabil Nurs. 2017;42:191–8. [PubMed] +[Google Scholar] +46. Mehrdad R, Ghadiri Asli N, Pouryaghoub G, Saraei M, Salimi F, Nejatian M, et al. Predictors of +early return to work after a coronary artery bypass graft surgery (CABG) Int J Occup Med Environ +Health. 2016;29:947–57. [PubMed] [Google Scholar] +47. Safabakhsh L, Jahantigh M, Nosratzehi S, Navabi S. The effect of health promoting programs on +patient's life style after coronary artery bypass graft-hospitalized in shiraz hospitals. Glob J Health Sci. +2015;8:154–9. [PMC free article] [PubMed] [Google Scholar] +48. Simchen E, Naveh I, Zitser-Gurevich Y, Brown D, Galai N. Is participation in cardiac rehabilitation +programs associated with better quality of life and return to work after coronary artery bypass +operations?. The israeli CABG study. Isr Med Assoc J. 2001;3:399–403. [PubMed] [Google Scholar] +49. Strong PC, Lee SH, Chou YC, Wu MJ, Hung SY, Chou CL, et al. Relationship between quality of +life and aerobic capacity of patients entering phase II cardiac rehabilitation after coronary artery bypass +graft surgery. J Chin Med Assoc. 2012;75:121–6. [PubMed] [Google Scholar] +50. Dollard J, Smith J, R Thompson D, Stewart S. Broadening the reach of cardiac rehabilitation to +rural and remote australia. Eur J Cardiovasc Nurs. 2004;3:27–42. [PubMed] [Google Scholar] +51. Maznyczka AM, Howard JP, Banning AS, Gershlick AH. A propensity matched comparison of +return to work and quality of life after stenting or coronary artery bypass surgery. Open Heart. +2016;3:e000322. [PMC free article] [PubMed] [Google Scholar] +52. Claes J, Buys R, Budts W, Smart N, Cornelissen VA. Longer-term effects of home-based exercise +interventions on exercise capacity and physical activity in coronary artery disease patients: A +systematic review and meta-analysis. Eur J Prev Cardiol. 2017;24:244–56. [PubMed] [Google Scholar] +53. Kuppusamy M, Kamaldeen D, Pitani R, Amaldas J. Immediate effects of bhramari pranayama on +resting cardiovascular parameters in healthy adolescents. J Clin Diagn Res. 2016;10:CC17–9. +[PMC free article] [PubMed] [Google Scholar] +54. Bhishagratna KL. Sushruta Samhita. Sutrasthanam. 1:1–571. Sutrasthanam1907. [Google Scholar] +55. Larson JS. No. 2. Vol. 38. Springer: The World Health Organization; 2014. The World Health +Organization's Definition of Health: Social Versus Spiritual Health; pp. 181–92. [Google Scholar] +56. Hosseini M, Salehi A, Fallahi Khoshknab M, Rokofian A, Davidson PM. The effect of a +preoperative spiritual/religious intervention on anxiety in shia muslim patients undergoing coronary +artery bypass graft surgery: A randomized controlled trial. J Holist Nurs. 2013;31:164–72. [PubMed] +[Google Scholar] +57. Ai AL, Park CL, Shearer M. Spiritual and religious involvement relate to end-of-life decision- +making in patients undergoing coronary bypass graft surgery. Int J Psychiatry Med. 2008;38:113–32. +[PubMed] [Google Scholar] +58. Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL, Merritt TA, et al. Intensive lifestyle +changes for reversal of coronary heart disease. JAMA. 1998;280:2001–7. [PubMed] [Google Scholar] +59. Hartley L, Dyakova M, Holmes J, Clarke A, Lee MS, Ernst E, et al. Yoga for the primary +prevention of cardiovascular disease. Cochrane Database Syst Rev. 2014;5:CD010072. 2014. +[PubMed] [Google Scholar] +60. Lau HL, Kwong JS, Yeung F, Chau PH, Woo J. Yoga for secondary prevention of coronary heart +disease. Cochrane Database Syst Rev. 2012;12:CD009506. [PubMed] [Google Scholar] +61. Vyas M. Headway in ayurveda: Miles to go. Ayu. 2015;36:359–60. [PMC free article] [PubMed] +[Google Scholar] +62. Jeste DV, Vahia IV. Comparison of the conceptualization of wisdom in ancient indian literature with +modern views: Focus on the bhagavad gita. Psychiatry. 2008;71:197–209. [PMC free article] [PubMed] +[Google Scholar] +Articles from Ayu are provided here courtesy of Wolters Kluwer -- Medknow Publications diff --git a/subfolder_0/R2 - Study protocol for yoga-based lifestyle intervention for healthy aging phenotype in the older adults (yHAP) a two-armed, wait-list randomized controlled trial with multiple primary outcomes.txt b/subfolder_0/R2 - Study protocol for yoga-based lifestyle intervention for healthy aging phenotype in the older adults (yHAP) a two-armed, wait-list randomized controlled trial with multiple primary outcomes.txt new file mode 100644 index 0000000000000000000000000000000000000000..f01f61d9ac48d49c2b37a5a2cc0595ac3de89d0e --- /dev/null +++ b/subfolder_0/R2 - Study protocol for yoga-based lifestyle intervention for healthy aging phenotype in the older adults (yHAP) a two-armed, wait-list randomized controlled trial with multiple primary outcomes.txt @@ -0,0 +1,1203 @@ +1 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access +Study protocol for yoga-­ +based lifestyle +intervention for healthy ageing +phenotype in the older adults (yHAP): a +two-­ +armed, waitlist randomised +controlled trial with multiple +primary outcomes +Vijaya Majumdar  ‍ ‍ + ,1 Atmakur Snigdha  ‍ ‍ + ,1 N K Manjunath,1 +Raghuram Nagarathna,1 Ramesh Mavathur,1 Amit Singh,1 Kalpana S R,2 +Nagendra H R1 +To cite: Majumdar V, Snigdha A, +Manjunath NK, et al. Study +protocol for yoga-­ +based +lifestyle intervention for +healthy ageing phenotype in +the older adults (yHAP): a two-­ +armed, waitlist randomised +controlled trial with multiple +primary outcomes. BMJ Open +2021;11:e051209. doi:10.1136/ +bmjopen-2021-051209 +► +►Prepublication history and +additional supplemental material +for this paper are available +online. To view these files, +please visit the journal online +(http://​ +dx.​ +doi.​ +org/​ +10.​ +1136/​ +bmjopen-​ +2021-​ +051209). +Received 14 March 2021 +Accepted 18 August 2021 +1Swami Vivekananda Yoga +Anusandhana Samsthana, +Bengaluru, Karnataka, India +2Sri Jayadeva Institute of +Cardiovascular Sciences and +Research, Bangalore, Karnataka, +India +Correspondence to +Dr Vijaya Majumdar; +​ +majumdar.​ +vijaya@​ +gmail.​ +com +Protocol +© Author(s) (or their +employer(s)) 2021. Re-­ +use +permitted under CC BY-­ +NC. No +commercial re-­ +use. See rights +and permissions. Published by +BMJ. +ABSTRACT +Introduction  The conceptualisation of healthy ageing +phenotype (HAP) and the availability of a tentative panel +for HAP biomarkers raise the need to test the efficacy of +potential interventions to promote health in older adults. +This study protocol reports the methodology for a 24-­ +week +programme to explore the holistic influence of the yoga-­ +based intervention on the (bio)markers of HAP. +Methods and analysis  The study is a two-­ +armed, +randomised waitlist controlled trial with blinded +outcome assessors and multiple primary outcomes. +We aim to recruit 250 subjects, aged 60–80 years +from the residential communities and old age clubs in +Bangalore city, India, who will undergo randomisation +into intervention or control arms (1:1). The intervention +will include a yoga-­ +based programme tailored for the +older adults, 1 hour per day for 6 days a week, spread for +24 weeks. Data would be collected at the baseline and +post-­ +intervention, the 24th week. The multiple primary +outcomes of the study are the (bio)markers of HAP: +glycated haemoglobin, low-­ +density lipoprotein cholesterol +(LDL-­ +C), systolic blood pressure, and forced expiratory +volume in 1 s for physiological and metabolic health; Digit +Symbol Substitution Test, Trail Making Tests A and B for +cognition; hand grip strength and gait speed for physical +capability; loneliness for social well-­ +being and WHO +Quality of Life Instrument-­ +Short Form for quality of life. +The secondary outcomes include inflammatory markers, +tumour necrosis factor-­ +alpha receptor II, C reactive protein, +interleukin 6 and serum Klotho levels. Analyses will be by +intention-­ +to-­ +treat and the holistic impact of yoga on HAP +will be assessed using global statistical test. +Ethics and dissemination  The study is approved by +the Institutional Ethics Committee of Swami Vivekananda +Yoga Anusandhana Samsthana University, Bangalore (ID: +RES/IEC-­ +SVYASA/143/2019). Written informed consent +will be obtained from each participant prior to inclusion. +Results will be available through research articles and +conferences. +Trial registration number  CTRI/2021/02/031373. +INTRODUCTION +The swift demographic transition of an ageing +population does not only indicate extended +life expectancy but is also associated with an +increased risk of ageing-­ +associated diseases +and disabilities.1–6 It has been estimated +that there would be a worldwide increase in +the number of individuals aged  ≥60 years +by 500 million (from 900 million in 2015 +to 1400 million by 2030).2 The advancing +knowledge of the ageing trajectories has +led the scientific and clinical fraternity to +put forth the feasibility of holistic, multi- +disciplinary +lifestyle-­ +based +interventional +strategies to promote biological resilience +and reverse the course of deflection from +pathological trajectories at early time points +in the lifespan.6–11 These strategies seem +to overcome the barriers posed by the long +lifespan and the extended time course for the +symptomatic manifestation of ageing-­ +related +Strengths and limitations of this study +► +►First yoga-­ +based randomised controlled trial on +multiple potential (bio)markers of physiological and +psychological integrity. +► +►Free-­ +of-­ +charge and customised, yoga-­ +based inter- +vention with minimal reported adverse events. +► +►Expected health benefits on several physiological +and mental aspects of the participants. +► +►If found effective, the findings of the trial will lead to +a paradigm shift from individual management/pre- +vention of age-­ +associated medical conditions to a +holistic approach towards ageing per se. +► +►Generalisability of the intervention findings might be +restricted to healthy older adults only. +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from +2 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access +health decline in humans, against the clinical translation +of preclinical evidence on the modifiability of biological +ageing.7–9 This recent quest has led to the conceptuali- +sation of the healthy ageing phenotype (HAP), defined +as the condition of being alive while having preserved +functioning metabolic, hormonal and neuroendocrine +control systems.8 Hence, adopting the concept of the +HAP, Lara et al proposed a comprehensive panel of (bio) +markers to measure the influence of lifestyle-­ +based inter- +ventions on HAP.5 They reported several distinct domains +of HAP: cognition, physiological and metabolic health, +physical strength or capability, psychological and social +well-­ +being, and the corresponding tools to measure the +same.5 The selection of these biomarkers was guided by +their expected correlation with ageing and the related +phenotypes (such as morbidity, mortality, quality of life +(QoL), health span), and amenability to modification by +lifestyle interventions.5 Lifestyle, in particular physical +activity, has been considered as a driver for a healthy and +long life for older people. Despite the growing evidence +on the efficacy of physical activity, the participation of +older adults in physical activities remains poor.12 Approx- +imately 30%–60% of adults aged  ≥60 years across the +WHO regions do not meet the recommended activity +level 4, that is, ≥150 min of moderate-­ +intensity or 75 min +of vigorous-­ +intensity aerobic physical activity (or an equiv- +alent combination) per week.13 There is an immediate +need to test the efficacy of potential interventions against +the multiple outcomes (markers) proposed to measure +the HAP and establish a proof of principle to enable the +extension of the study outcomes at large community-­ +based settings to promote healthy ageing and reduce the +health burden imposed by ageing population.5 8–11 +Yoga is an ancient Indian holistic mind–body discipline, +classified as complementary medicine by the National +Institutes of Health.14 Over the years, yoga-­ +based lifestyle +interventions have been associated with several health-­ +related benefits in community settings. Several of these +benefits have also been reported in the older adults, +particularly balance and mobility, cardiac health, respira- +tory function, cognition, sleep quality and QoL.15–18 These +findings indicate key intersections with the domains +of HAP. The easy deployment of yoga-­ +based interven- +tions (YBIs) in community settings, cost-­ +effectiveness, +rising popularity and measurability across various health +domains strengthen their potency as geriatric interven- +tions. However, there are distinct perception-­ +related and +culture-­ +related barriers recognised towards participation +in yoga across older adults.15 19 The public awareness +and perception of yoga for geriatric health need extend +beyond fitness and flexibility, to other health outcomes, +such as physiological, metabolic, cognitive and social well-­ +being. This notion indicates an unmet need of capturing +the comprehensive influence of the health-­ +related bene- +fits of yoga in exploratory but well-­ +designed trials in +the older adults. Though few of the recent trials have +reported study protocols on yoga and healthy ageing, +they have primarily focused on the subjective well-­ +being +of the older individuals.9 10 We hereby report the study +protocol of a 24-­ +week yoga-­ +based lifestyle intervention +programme in a cohort of inactive older subjects towards +comprehensive enhancement of HAP, measured with +multiple primary outcomes using a waitlist randomised +controlled design. +METHOD AND ANALYSIS +Study design +The present study, yoga for the HAP (yHAP), is a two-­ +armed, randomised waitlist controlled trial with blinded +outcome assessors and multiple primary outcomes. The +yHAP aims at facilitating healthy ageing in the older +adults with yoga as a lifestyle intervention, with a holistic +influence on distinct domains of health, that is, physio- +logical and metabolic health, cognitive function, phys- +ical capability, and psychological and social well-­ +being.5 +The protocol was drafted following CONSORT (Consol- +idated Standards of Reporting Trials)20 (figure  1). The +study participants would be older Indian citizens aged +60–80 years, recruited from the residential communities +and old age clubs of Bangalore city, India. Recruitment +has started on 19 February 2021 through the distribu- +tion of pamphlets and door-­ +to-­ +door visits in the vicinity +of the intervention facility. We aim to complete the data +collection by March 2022. We want to ensure diversity +and a heterogeneous representation of lifestyle disorders, +diabetes, hypertension and obesity in the study cohort; +hence, participants will be recruited through purposive +sampling.21 22 Detailed study information will be provided +to all individuals while screening. Interested individuals +will be further screened for variables including age, life- +style disorders, chronic ailments, mobility restrictions and +prevalent cognitive impairment based on Mini-­ +Mental +Status Examination.23 Individuals not fitting into the +eligibility criteria will be excluded from participation (the +inclusion and exclusion criteria have been mentioned +separately in table 1). Written informed consent would +be obtained from voluntary participants, and they will +receive home visits for data collection. Data collection +will be conducted in different phases with an enrolment +of 15–20 participants at each phase; the process would +be repeated until the final number of 250 is achieved. +Assessments will be performed at baseline and after the +24th week post-­ +intervention (see figure  1, participant +flow chart based on the CONSORT guidelines for trans- +parent reporting of trials). To obtain sufficient numbers +of participants from each community association and +minimise loss to follow-­ +up, we will involve community +heads (CHs) for different communities. These CHs will +monitor, supervise and encourage the participants, and +hence, their involvement is critical. Researchers, together +with the clinical staff, will set up schedules to ensure the +availability of all participants during data collection or +supervision. Venipuncture will be done post a minimum +of 8-­ +hour fasting, and blood samples will be collected in +EDTA tubes. +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from +3 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access +Randomisation and blinding +An external statistician who is not directly involved in +implementation of the intervention will randomise +the participants during the baseline visit in a 1:1 ratio +(n=125, each arm) using a sequence randomiser. Only +one eligible member from each household would be +randomly selected to avoid any clustering effect (within-­ +family correlations). The allocation sequences will be +sealed, and immediately after baseline assessments, the +participants will be informed about the further process. +Owing to the nature of the intervention, complete double +blinding is not possible. However, to reduce the detection +Figure 1  Participant flow chart for parallel design, based on the Consolidated Standards of Reporting Trials guidelines for +transparent reporting of trials. MMSE, Mini-­ +Mental Status Examination. +Table 1  Inclusion and exclusion criteria +Inclusion criteria +Exclusion criteria +► +►Age ≥60–80 years +► +►Both the genders +► +►Interested and willing to participate in study +► +►Able to perform moderately strenuous yoga asanas +► +►Diagnosed with lifestyle disorders like diabetes mellitus, +obesity and hypertension +► +►Signed informed consent by the parent/legally acceptable +representative and assent by the patient appropriate to +the patient’s age, including willingness to participate in the +study +► +►Sedentary lifestyle, lack of physical exercise defined as +below the WHO norm of 30  +min of intermediate exercise, 5 +times a week +► +►Engagement in any regular structured exercise or yoga over +past 3 months +► +►History of any other chronic ailments like cancer, chronic +kidney disease or neurodegenerative and neurological +disorders like stroke, major depressive disorder, psychosis, +anxiety disorder, severe hearing and visual impairments +► +►Those who have undergone any recent surgery +► +►Concomitantly taking part in another research study +► +►Mini-­ +Mental Status Examination score <24 for prevalent +cognitive impairment +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from +4 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access +bias, investigators involved in the evaluation of outcome +measures would be blinded for the randomisation groups. +Interventions +The yHAP is a multifactorial intervention, aimed at +improving the outcomes across different dimensions of +ageing to be assessed through HAP markers. Details of the +intervention are given in the online supplemental table +1. Yoga sessions will include physical activity, relaxation, +regulated breathing, dietetic advice and counselling on +philosophical aspects and social support (described as a +sangha in ancient literature).24 Dietetic advice is drafted +based on the ancient yoga-­ +based concepts aligned with +the research-­ +based evidence for healthy nutrition aspects +in the older adults.25–28 Participants will be advised to +consume a diet that includes sprouted whole grains, fresh +fruits, land and sea vegetables, pure fruit juices, nut and +seed milk and cheese, legumes, nuts, seeds, sprouted +seeds, honey and herbal teas (please see online supple- +mental table for details). The integrated multifacto- +rial approach of yHAP is derived from the principles of +ancient texts which emphasise that yoga should promote +holistic health.29–31 The intervention will be given 1 hour +per day for 6 days a week, spread for 24 weeks, interrupted +by weekend breaks of 1 day. yHAP will be delivered by +certified and experienced yoga instructors who would be +trained for the intervention. Participants will be advised +to practise the same on their own on the off-­ +days. The +course will be given to a group of 15–20 patients at a time. +The yHAP will be uniform throughout the study to avoid +the risk of intervention variability. Daily attendance will be +taken for the participants. Those who will not attend the +sessions would be contacted personally by the research +team to understand the reason for their absence and cut +out any adverse effects of the intervention. Personal time +with the trainer will be given separately throughout the +intervention phase to all the participants, to make them +understand the practices more clearly. +Waitlist group +For the inactive control group, we chose a waitlist design +as we deemed it as an ethically appropriate alternative to +provide needed care to the inactive older adults following +the trial. While recruitment, they will be instructed to +continue their daily activities (without engaging in regular +structured exercise). After the completion of the 24-­ +week +study, these participants will receive the same yoga-­ +based +lifestyle intervention given to the intervention group post +their data collection and a secondary within-­ +group anal- +ysis will be conducted including these participants. +Measures to maintain adherence +Yoga classes will be given free of charge and will be +conducted near the radius of 1 km, instructions will be +made simple and less demanding; cognitive–motivational +factors such as self-­ +efficacy and health beliefs will also be +included in theory-­ +based motivations to maintain adher- +ence to the intervention.32 +Study outcomes +The panel of (bio)markers considered for the present +trial (table  2) is primarily influenced by the insights +presented by Lara et al,5 for the measurement of the +HAP in lifestyle-­ +based intervention studies. However, +given the complexity in statistical analysis owing to +multiplicity, we have selected few tools deemed as most +relevant under each domain. Further, based on the mech- +anistic and epidemiological correlates with the process of +Table 2  Primary outcome panel—HAP domains and the respective tools/assessments included +Domains +Tools adopted from the panel proposed by Lara et al5 +Physiological and metabolic health +   +Cardiovascular health metric +Glycated haemoglobin +Plasma concentrations of cholesterol fractions (LDL-­ +C) +Arterial systolic blood pressure (mm Hg) +Lung function +Forced expiratory volume +Cognitive function +   +Processing speed +Digit Symbol Substitution Test40 +Executive function +Trail Making Tests A and B41 +Physical capability +   +Strength +Hand grip strength +Locomotion +Gait speed42 +Psychological well-­ +being +   +Quality of life +WHOQOL-­ +Bref43 +Social well-­ +being +University of California, Los Angeles Loneliness Scale44 +As mentioned above, we have included five domains of HAP under the primary outcomes of the study: physiological and metabolic health, +cognitive function, physical capability, psychological well-­ +being and social well-­ +being. +HAP +, healthy ageing phenotype; LDL-­ +C, low-­ +density lipoprotein cholesterol; WHOQOL-­ +Bref, WHO Quality of Life Instrument-­ +Short Form. +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from +5 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access +biological ageing, we included a few additional secondary +biomarkers in the panel (table 3) such as Klotho and the +inflammatory cytokines (tumour necrosis factor-­ +alpha, +C reactive protein and interleukin 6).7 33 34 Over the last +20 years, Klotho has emerged as a biomarker for healthy +ageing,34 as an integrator of organ systems, making it +both a promising tool for advancing our understanding +of the biology of ageing and an intriguing target for inter- +ventional studies. +The secondary outcomes would be evaluated as the +difference between baseline and follow-­ +up values at the +24th week of the 10 individual markers related to phys- +iological and metabolic health: low-­ +density lipoprotein +cholesterol (LDL-­ +C), body mass index, systolic blood +pressure, forced expiratory volume in 1 s; cognition— +Digit Symbol Substitution Test, Trail Making Tests A and +B; physical capability gait speed and hand grip strength; +social-­ +well being loneliness and quality of life—WHO +Quality of Life Instrument-­ +Short Form. Further, all the +secondary variables will also be assessed, as the panel +presented in table 3. +Assessments +The schedule of enrolment, interventions and assess- +ments, according to Standard Protocol Items: Recom- +mendations for Interventional Trials 2013 guidelines, has +been reported in table 4. The baseline assessment will be +performed by trained research assistants before randomi- +sation. The assessment covers demographic characteris- +tics and collection of primary and secondary outcomes +including anthropometric measurements, question- +naires, and functional ability tests of physical health +and cognition. The detailed methods of assessments are +given in online supplemental appendix 1. Participants +will receive a prior appointment in Sri Jayadeva Institute +of Cardiovascular Sciences and Research for Biological +Sampling and will receive a scheduled time for follow-­ +up. +Data will be managed by the principal investigator and +study coordinator and they will be responsible for main- +taining the confidentiality of data. Information of partic- +ipants will be collected through study proforma and +collected information will be transferred to Excel sheet. +Each participant will be given a unique code for confiden- +tiality, and the data will be transferred for further statis- +tical analysis. +Statistical analyses +Sample size +Since we aim to capture a holistic effect of YBI across +the multiple domains of HAP, we propose to use the +global statistical test (GST) to assess the efficacy of the +intervention.35 36 However, in view of non-­ +availability of +preliminary data, unknown nature of correlations among +the outcome variables and their distribution, we prefer +to choose a sample size of n1−n2=100, which is in line +with the adequate sample size proposed for 10 multiple +outcomes (K), under the simulations reported for sample +size calculations with computation of the global treat- +ment effect under various possible settings by Huang +et al.35 Further, since the reported efficiency of GST to +summarise a treatment’s merit is not compromised with +small sample sizes, we could avoid the risk of being under- +powered.37 Further, keeping in view of the attrition rate +of 25% over 6 months, we derived a sample size of n=250 +for the present study. We will compare the baseline char- +acteristics of this sample with the intention-­ +to-­ +treat popu- +lation (all randomised subjects). Baseline characteristics +of participants will be summarised using mean and SD or +Table 3  Secondary outcome panel +Adiposity +Body mass index (kg/m2) +Auxiliary blood biochemistry +Complete haemogram +Differential count +Blood urea (kidney function marker) +Serum creatinine (kidney function) +Inflammatory markers (IL-6, TNF-­ +alpha and CRP) +A composite score for inflammageing would be created for the three markers CRP +, IL-6 +and TNF-alpha; for each inflammatory marker, a z-­ +score will be calculated (‍ +z = (x −x)/SD‍ + +where x is an individual marker value, ‍ +x‍ + is the mean marker value, and SD is the SD of +marker values). Further, a composite z-­ +score will be calculated for inflammageing using +the individual z-­ +scores, (ie, z-­ +score (inflammageing)=average (z-­ +CRP +, z-­ +IL-6, z-­ +TNF-alpha)). +Cut-­ +offs will be defined based on the 50th percentile of the population distribution of the +composite z-­ +score. +Systemic integrity +Z-­ +score will be calculated for the physiological serum Klotho concentrations. Scoring will +based on baseline z-­ +score distribution and appropriate quantiles will be generated, highest +quantile will be assigned the highest score and lowest will be assigned a score of 0. +Frailty Index for Elderly (FIFE) +FIFE is a 10-­ +item assessment instrument with scores ranging from 0 to 10. A score of 0 +indicates no frailty; a score of 1–3 indicates frailty risk; and a score of 4 or greater indicates +frailty.45 +Cardiovascular function +None=1, 1 factor=0.75, 2 factors=0.5, 3 factors=0.25, 4 factors=0 +CRP +, C reactive protein; IL-6, interleukin 6; TNF +, tumour necrosis factor. +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from +6 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access +median and IQR for continuous variables and frequency +and percentage for categorical variables. The analyses will +observe intention-­ +to-­ +treat, that is, participants will be anal- +ysed according to the group to which they were allocated. +Missing data will be replaced using multiple imputation +methods. Sensitivity analyses will be performed. Log bino- +mial models will be estimated by generalised estimating +equations. Mixed-­ +effects linear regression models will be +used. We will include outcomes at baseline and 12 weeks, +and include all participants with outcomes data available. +All analyses will be performed in IBM SPSS, V.26 and in +R (V.76). We will employ a statistical threshold of α=0.05. +Patient and public involvement +Participants in the study are not involved in the devel- +opment of this trial protocol as the study consists of a +non-­ +clinical sample. Study participants will be involved +only at the time of recruitment and once they meet the +eligibility criteria, research assistants will explain the whole +trial and their role in the study and clarify their queries if +any informed consent will be obtained. The intervention +will be free of cost and there would not be any burden to +participate in research. Results of biomarkers and pheno- +typical markers will be offered to individual participants +on completion of follow-­ +up data collection. +Assessment of harms +All eligible candidates will be screened by trained +research assistants to eliminate those with health-­ +related problems that might disturb their participa- +tion or increase their physical activity. Participants will +be instructed to inform the study coordinator of any +Table 4  Schedule of enrolment, interventions and assessments, according to SPIRIT 201343 guidelines +Study period +Time points +   +Enrolment +Baseline +Intervention +Endpoint +Week-1 +Week 0 +Week 1–24 +Week 24+2 +Eligibility screening +   +x +Informed consent +   +x +Allocation +   +x +Intervention +   +x +Yoga +   +x +Waitlist +   +x +x +Assessments +Methods +Demographics +Study proforma +x +x +Cardiovascular and +metabolic function +Systolic blood pressure +Blood lipid—LDL-­ +C +Haemoglobin +x +x +x +Lung function +Forced expiratory volume 1 +x +x +x +Body composition +Body mass index +x +x +x +Physiological function +(biomarkers) +Serum Klotho levels, an anti-­ +ageing +protein +x +x +x +Markers of inflammageing, IL-6, +TNF-­ +alpha, CRP +x +x +x +Complete haemogram +x +x +x +Differential count +x +x +x +Blood urea (auxiliary kidney function +marker) +x +x +x +Serum creatinine (kidney function) +x +x +x +Strength +Hand grip strength +x +x +x +Locomotion +Gait speed +x +x +x +Frailty +Frailty Index for Elderly +x +x +x +Processing speed +Digit Symbol Substitution Task +x +x +x +Executive function +Trail Making Tests A and B +x +x +x +Psychological well-­ +being +WHOQOL-­ +Bref +x +x +x +CRP +, C reactive protein; IL-6, interleukin 6; LDL-­ +C, low-­ +density lipoprotein cholesterol; SPIRIT, Standard Protocol Items: Recommendations +for Interventional Trials; TNF +, tumour necrosis factor; WHOQOL-­ +Bref, WHO Quality of Life Instrument-­ +Short Form. +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from +7 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access +experienced adverse events throughout the study and +there will be a personal meeting with a trainer after +each session to eliminate the harm if any. Decision of +the participant in the discontinuation of the study will +be taken by the principal investigator. +Ethics and dissemination +The study will be conducted in accordance with the +protocol, and in accordance with the requirement +from the institution’s ethical committee. The study +is approved by the Institutional Ethics Committee of +Swami Vivekananda Yoga Anusandhana Samsthana +University, Bangalore (RES/IEC-­ +SVYASA/143/2019). +The study is also registered in Clinical Trials Registry +India. Primary results and datasets will be avail- +able from the corresponding author on reasonable +request. The results of the study will be publicly avail- +able in scientific media through research articles and +conferences. +Consent to participate +Every potential participant will be informed about +the study aims and procedures by a research assistant +prior to participation, verbally and in writing. Confi- +dentiality, voluntariness and freedom to withdraw from +the study at any point will be stated. Written informed +consent will be obtained from all participants by a +research assistant. +Confidentiality +Study participants will be allocated unique study IDs at +inclusion. Data will be coded and stored in the partici- +pant proforma and will be converted in Microsoft Excel +2013. Collected data will be handled only by the principal +investigator. Trial randomisation codes will also be main- +tained confidential. +Data statement +As the paper relates to a study protocol, data sharing is +not applicable as no datasets generated and/or analysed +for this study. However, after completion of the study, +individual participant data that underlie the results will +be reported in a peer-­ +reviewed publication after de-­ +iden- +tification in the form of an appendix. Hence, we feel that +data sharing statement will be applicable in the manu- +script that will arise from the proposed study. We plan to +share the study protocol along with the main manuscript. +Researchers who provide a methodologically sound +proposal would be able to view the files, proposals should +be directed to email of the corresponding author. The +third-­ +party website will be provided in the main manu- +script. The data will be available to achieve aims in the +approved proposal and for individual participant data +meta-­ +analysis. +DISCUSSION +The present trial would be a pioneer yoga-­ +based lifestyle +trial envisaged to understand the measurable impact of +the YBI on HAP. The major strength of this trial is the +comprehensive approach including assessments on +the key domains of HAP, which are carefully selected, +aligning with the requisite of harnessing age-­ +associated +clinical comorbid events. Tracking of clinically morbid +events would otherwise require longer follow-­ +ups and +was deemed to be not feasible.5 Though a few recent trial +protocols have included the multidimensional outcomes +of yoga intervention on health in older individuals, they +have included single primary outcome measures, implic- +itly prioritising subjective well-­ +being over the other +dimensions of health.9 10 Analysis of multiple primary +outcomes is associated with concerns related to the multi- +plicity aspect, in particular, due to unknown correlations +between the study outcomes.35 36 Towards the same, +we propose to implement the GST, first proposed by +Huang et al and further extended by others, that seems +to provide a useful solution to assess the global impact +of multidimensional interventions with multiple primary +outcomes.35 GST could provide us an overall test of +multiple outcomes, with separate reports of individual +outcomes with an adaptation of the Bonferroni proce- +dure.36 There are several statistical advantages associated +with the use of GST. The interpretation of GST has been +reported to be unaffected by the outcomes of individual +items, even if they fail to achieve significance. Further, +GST offers a solution to combine outcomes to demon- +strate efficacy using fewer subjects, the sample size would +also not be a limiting factor to establish the efficacy of the +intervention. +The selected panel of primary outcomes adopted +from Lara et al5 aligns with the requisite of GST of a +careful selection of the essential outcomes used to +address the efficacy of an intervention.37 We hypoth- +esise that the trial findings will enhance the interpret- +ability of findings across different clinical trials with +varied interventions.5 Additionally, we have incorpo- +rated a few more cardinal biomarkers including Klotho +and inflammatory markers for the secondary outcomes. +Despite being reported to be the drivers of biological +ageing rather than just indicators,7 33 34 these markers +have not been systematically explored before for geri- +atric trials on healthy ageing using the YBI. Hence, the +outcomes on these markers will pave the foundation +for the development of yoga-­ +based therapeutic strat- +egies to counteract age-­ +related declines. Overall, the +proposed trial will be one of the few preliminary steps +for the foundation of large clinical trials and could +provide a concept of proof that biological ageing could +be targeted through interventions in humans. +The study design could be limited by waitlist +controlled design, as these studies report an inflated +effect size due to the inclusion of inactive controls.38 +However, our primary aim is to establish the efficacy of +yoga on multiple outcomes compared with an inactive +lifestyle. Yoga has been reported to be as effective as +stretching-­ +strengthening exercises in improving func- +tional fitness in older adults,39 with small-­ +to-­ +moderate +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from +8 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access +effects on several aspects of health. Hence, we did not +include an active control group, assuming a small effect +size in a study with multiple outcomes, and a chance of +missing the overall effect of the intervention. However, +for future intervention studies, we propose the inclu- +sion of an active control group to derive conclusions +concerning the effectiveness of yoga compared with +different exercise programmes. We also anticipate +challenges during data collection of the trial in the +community setting. Due to a lack of social support, +there is likely reduced participation in geriatric clin- +ical studies. Refusal to participate may also be due +to caste, gender, religion and other social attributes. +To address these challenges, data collectors will be +trained and retrained on how to build rapport with +participants and maintain privacy and confidentiality. +Further, as yoga being a popular healthcare strategy in +India, there could be a motivational bias for participa- +tion that could further influence the generalisability +of the findings. Despite an increasing trend observed +in older adult participation in yoga/pilates in western +countries, yoga participation rates remain low.19 The +findings of this trial could lead to the effective imple- +mentation of global health policies promoting yoga-­ +based physical activity for enhancing healthy ageing in +inactive older individuals. +Contributors  The study design and concept were conceived by VM and NKM. ASn +will conduct screening, data collection and analysis. VM and ASn prepared the first +draft of the manuscript. RN, RM, ASi, KSR and NHR provided edits and critiqued the +manuscript for intellectual content. +Funding  This research received institutional funding from SVYASA deemed to be a +university (grant number: N/A). +Competing interests  None declared. +Patient consent for publication  Not required. +Provenance and peer review  Not commissioned; externally peer reviewed. +Supplemental material  This content has been supplied by the author(s). It has +not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been +peer-­ +reviewed. Any opinions or recommendations discussed are solely those +of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and +responsibility arising from any reliance placed on the content. Where the content +includes any translated material, BMJ does not warrant the accuracy and reliability +of the translations (including but not limited to local regulations, clinical guidelines, +terminology, drug names and drug dosages), and is not responsible for any error +and/or omissions arising from translation and adaptation or otherwise. +Open access  This is an open access article distributed in accordance with the +Creative Commons Attribution Non Commercial (CC BY-­ +NC 4.0) license, which +permits others to distribute, remix, adapt, build upon this work non-­ +commercially, +and license their derivative works on different terms, provided the original work is +properly cited, appropriate credit is given, any changes made indicated, and the use +is non-­ +commercial. See: http://​ +creativecommons.​ +org/​ +licenses/​ +by-​ +nc/​ +4.​ +0/. +ORCID iDs +Vijaya Majumdar http://​ +orcid.​ +org/​ +0000-​ +0002-​ +8594-​ +5761 +Atmakur Snigdha http://​ +orcid.​ +org/​ +0000-​ +0001-​ +9949-​ +970X +REFERENCES + 1 Chang AY, Skirbekk VF +, Tyrovolas S, et al. Measuring population +ageing: an analysis of the global burden of disease study 2017. +Lancet Public Health 2019;4:e159–67. + 2 World Health Organization. Multisectoral action for a life course +approach to healthy aging: draft global strategy and plan of action +on aging and health. Geneva: WHO, 2016. http://​ +apps.​ +who.​ +int/​ +gb/​ +ebwha/​ +pdf_​ +files/​ +WHA69/​ +A69_​ +17-​ +en.​ +pdf?​ +ua=1 + 3 Brown GC. Living too long: the current focus of medical research on +increasing the quantity, rather than the quality, of life is damaging our +health and harming the economy. EMBO Rep 2015;16:137–41. + 4 Xie J, Matthews FE, Jagger C, et al. The oldest old in England and +Wales: a descriptive analysis based on the MRC cognitive function +and ageing study. Age Ageing 2008;37:396–402. + 5 Lara J, Godfrey A, Evans E, et al. Towards measurement of the +healthy ageing phenotype in lifestyle-­ +based intervention studies. +Maturitas 2013;76:189–99. + 6 Longo VD, Antebi A, Bartke A, et al. Interventions to slow aging in +humans: are we ready? Aging Cell 2015;14:497–510. + 7 Justice JN, Ferrucci L, Newman AB, et al. A framework for selection +of blood-­ +based biomarkers for geroscience-­ +guided clinical trials: +report from the TAME biomarkers Workgroup. Geroscience +2018;40:419–36. + 8 Franco OH, Karnik K, Osborne G, et al. Changing course in ageing +research: the healthy ageing phenotype. Maturitas 2009;63:13–19. + 9 Östh J, Diwan V, Jirwe M, et al. Effects of yoga on well-­ +being and +healthy ageing: study protocol for a randomised controlled trial +(FitForAge). BMJ Open 2019;9:e027386. + 10 Choudhary A, Pathak A, Manickam P +, et al. Effect of yoga versus light +exercise to improve well-­ +being and promote healthy aging among +older adults in central India: a study protocol for a randomized +controlled trial. Geriatrics 2019;4:64. + 11 Woodyard C. Exploring the therapeutic effects of yoga and its ability +to increase quality of life. Int J Yoga 2011;4:49–54. + 12 McPhee JS, French DP +, Jackson D, et al. Physical activity in older +age: perspectives for healthy ageing and frailty. Biogerontology +2016;17:567–80. + 13 Hallal PC, Andersen LB, Bull FC, et al. Global physical activity +levels: surveillance progress, pitfalls, and prospects. Lancet +2012;380:247–57. + 14 Williams K, Steinberg L, Petronis J. Therapeutic application of +iyengar yoga for healing chronic low back pain. Int J Yoga Therap +2003;13:55–67. + 15 Sivaramakrishnan D, Fitzsimons C, Kelly P +, et al. The effects of yoga +compared to active and inactive controls on physical function and +health related quality of life in older adults- systematic review and +meta-­ +analysis of randomised controlled trials. Int J Behav Nutr Phys +Act 2019;16:33. + 16 Tulloch A, Bombell H, Dean C, et al. Yoga-­ +based exercise improves +health-­ +related quality of life and mental well-­ +being in older people: +a systematic review of randomised controlled trials. Age Ageing +2018;47:537–44. + 17 Tew GA, Howsam J, Hardy M, et al. Adapted yoga to improve +physical function and health-­ +related quality of life in physically-­ +inactive older adults: a randomised controlled pilot trial. BMC Geriatr +2017;17:902–17. + 18 Oliveira JS, Sherrington C, Lord S, et al. Yoga-­ +based exercise +to prevent falls in community-­ +dwelling people aged 60 years +and over: study protocol for the successful ageing (SAGE) +yoga randomised controlled trial. BMJ Open Sport Exerc Med +2020;6:e000878. + 19 Sivaramakrishnan D, Fitzsimons C, Mutrie N. Perceptions of yoga +among older adults: a qualitative approach. Annals of Yoga and +Physical Therapy 2017;2. + 20 Begg C, Cho M, Eastwood S. Improving the quality of reporting of +randomized controlled trials. JAMA 1996;276:637–9. + 21 Martínez-­ +Mesa J, González-­ +Chica DA, Duquia RP +, et al. Sampling: +how to select participants in my research study? An Bras Dermatol +2016;91:326–30. + 22 Green J, Thorogood N. Qualitative methods for health research. 3rd +Edn. London: SAGE, 2014. + 23 Folstein MF +, Folstein SE, McHugh PR. "Mini-­ +mental state". A +practical method for grading the cognitive state of patients for the +clinician. J Psychiatr Res 1975;12:189–98. + 24 Rioux JG, Ritenbaugh C. Narrative review of yoga intervention +clinical trials including weight-­ +related outcomes. Altern Ther Health +Med 2013;19:32–46. + 25 Anderson AL, Harris TB, Tylavsky FA, et al. Dietary patterns and +survival of older adults. J Am Diet Assoc 2011;111:84–91. + 26 Loureiro LMR, Almeida LFF +, Machado CJ, et al. Food consumption +and characteristics associated in a Brazilian older adult population: a +cluster analysis. Front Nutr 2021;8:641263. + 27 Dhanya S, Ramesh N V, Mishra A. Traditional methods of food +habits and dietary preparations in Ayurveda—the Indian system of +medicine. J Ethn Food 2019;6. + 28 Agte VV, Chiplonkar SA. Linkage of concepts of good nutrition in +yoga and modern science. Curr Sci 2007;92:956–61. +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from +9 +Majumdar V, et al. BMJ Open 2021;11:e051209. doi:10.1136/bmjopen-2021-051209 +Open access + 29 Manjunath NK, Telles S. Influence of yoga and Ayurveda on self-­ +rated +sleep in a geriatric population. Indian J Med Res 2005;121:683–90. + 30 Gambhirananda S. Taittiriya Upanishad. Calcutta: Advaita Ashrama, +1986. + 31 Greendale GA, Kazadi L, Mazdyasni S, et al. Yoga Empowers seniors +study (YesS): design and Asana series. J Yoga Phys Ther 2012;2. + 32 Flegal KE, Kishiyama S, Zajdel D, et al. Adherence to yoga and +exercise interventions in a 6-­ +month clinical trial. BMC Complement +Altern Med 2007;7:37. + 33 Ferrucci L, Fabbri E. Inflammageing: chronic inflammation in +ageing, cardiovascular disease, and frailty. Nat Rev Cardiol +2018;15:505–22. + 34 Cheikhi A, Barchowsky A, Sahu A, et al. Klotho: an elephant in aging +research. J Gerontol A Biol Sci Med Sci 2019;74:1031–42. + 35 Huang P +, Woolson RF +, O'Brien PC. A rank-­ +based sample size method +for multiple outcomes in clinical trials. Stat Med 2008;27:3084–104. + 36 Hu J, Liu S, Liu W, et al. Establishing an evaluation mode with +multiple primary outcomes based on combination of diseases and +symptoms in TCM clinical trials. Ann Transl Med 2017;5:420. + 37 Huang P +, Goetz CG, Woolson RF +, et al. Using global statistical +tests in long-­ +term Parkinson's disease clinical trials. Mov Disord +2009;24:1732–9. + 38 Cunningham JA, Kypri K, McCambridge J. Exploratory randomized +controlled trial evaluating the impact of a waiting list control design. +BMC Med Res Methodol 2013;13:150. + 39 Gothe NP +, McAuley E. Yoga is as good as Stretching-­ +Strengthening +exercises in improving functional fitness outcomes: results from +a randomized controlled trial. J Gerontol A Biol Sci Med Sci +2016;71:406–11. + 40 Wechsler D. Adult intelligence Scale- revised. New York: +Psychological corporation, 1981. + 41 Spreen O, Strauss E. A compendium of neuropsychological tests: +administration, norms and commentary. 2nd edn. New York: Oxford +Publisher Trust, 1998: 8. + 42 Studenski S, Perera S, Patel K, et al. Gait speed and survival in older +adults. JAMA 2011;305:50–8. + 43 WHOQOL Group. Development of the world Health organization +WHOQOL-­ +BREF quality of life assessment. The WHOQOL group. +Psychol Med 1998;28:551–8. + 44 Hughes ME, Waite LJ, Hawkley LC, et al. A short scale for measuring +loneliness in large surveys: results from two population-­ +based +studies. Res Aging 2004;26:655–72. + 45 Tocchi C, Dixon J, Naylor M, et al. Development of a frailty +measure for older adults: the frailty index for elders. J Nurs Meas +2014;22:223–40. +copyright. + on June 6, 2022 at India:BMJ-PG Sponsored. Protected by +http://bmjopen.bmj.com/ +BMJ Open: first published as 10.1136/bmjopen-2021-051209 on 16 September 2021. Downloaded from diff --git a/subfolder_0/Reduced glycemic variability with yoga in patients with type 2 diabetes mellitus results of a pilot study.txt b/subfolder_0/Reduced glycemic variability with yoga in patients with type 2 diabetes mellitus results of a pilot study.txt new file mode 100644 index 0000000000000000000000000000000000000000..33addc5a81ccdc5fa954c22cde7e937293c8da33 --- /dev/null +++ b/subfolder_0/Reduced glycemic variability with yoga in patients with type 2 diabetes mellitus results of a pilot study.txt @@ -0,0 +1,177 @@ +https://doi.org/10.1177/1932296819852064 +Journal of Diabetes Science and Technology +2019, Vol. 13(4) 803­ +–804 +© 2019 Diabetes Technology Society +Article reuse guidelines: +sagepub.com/journals-permissions +DOI: 10.1177/1932296819852064 +journals.sagepub.com/home/dst +Letter to the Editor +Glycemic variability (GV) in type 2 diabetes mellitus +(T2DM) is associated with increased risk of complications, +especially macrovascular complications,1,2 by increasing +oxidative stress, proinflammatory markers, and advanced +glycation end products (AGE).3 Yoga is a widely used +complementary therapy in the management of T2DM and +has multiple benefits including reduction in fasting plasma +glucose, postprandial glucose, HbA1C, oxidative stress, +and proinflammatory markers.4 The objective of our study +is to understand the effect of yoga on glycemic variability +in T2DM. +Ten T2DM patients, 40-70 years of age, were recruited for +the study. Mean baseline HbA1C was 7.50% (±1.87) and +age 55 (±12.78). Continuous glucose monitoring was done +for 14-day using flash glucose monitoring system sensor, +Freestyle Libre Pro (Abbott Diabetes Care Ltd, Oxon, UK). +Participants were instructed to continue with same lifestyle +without any further modifications for the next 14 days. A +consultant endocrinologist ensured that medication dosages +of the patients are adequate and require no modification till +the end of the study period. Baseline glycemic variability +was established in the first 7 days, followed by 7 days of +yoga intervention. A validated conventional yoga module +involving asanas (physical postures), pranayama (breathing +practices), and dhyana (meditation) was taught. Statistical +analysis was performed using statistical package for social +sciences (SPSS version 22.0). Normality of distribution mea- +sured using the Shapiro-Wilk test, and the appropriate statis- +tical test for within-group analysis was performed using +paired sample t-test. +Results +Nine participants completed the study. One dropped out due +to personal reasons not relevant to the study. One patient was +on insulin and the rest were on oral glucose lowering agents. +A significant reduction in glycemic variability was observed +in all measures of GV. Continuous overlapping net glycemic +action (CONGA), mean of daily differences (MODD), and +standard deviation (SD) reduced significantly (Table 1). +Sustenance of the euglycemic target range, measured using +glycemic risk assessment in diabetes equation (GRADE), +average daily risk ratio (ADDR), and J Index, also signifi- +cantly increased. +Discussion +A significant reduction in GV and higher percentage of time +within the glycemic target was observed after one week of +yoga practice. To our knowledge this is the first ever study +exploring the effect of yoga on glycemic variability in +T2DM. In our study, short-term yoga practice (7 days) +showed a statistically significant reduction in GV. The pos- +sible mechanism of action might be through enhanced para- +sympathetic activity with yoga.5 A strong correlation was +observed between the baseline pre and post mean glucose +levels, and between baseline glucose level and measures of +GV. Our findings have a high translational value, as reducing +glycemic variability would possibly help reduce oxidative +stress, proinflammatory markers, and associated cardiovas- +cular complications of T2DM, in a more sustainable and +cost-effective manner. Likewise, reduction in blood glucose +levels observed on a “glucose-dependent manner” would +benefit patients at higher risk of hypoglycemia. The moder- +ate intensity of yoga would make it a more preferable and +safer mode of physical activity in the management of T2DM +with reduced risk of hypoglycemia. +852064 DSTXXX10.1177/1932296819852064Journal of Diabetes Science and TechnologyVijayakumar et al. +letter2019 +1Division of Yoga and Life Sciences, S-VYASA University, Bengaluru, India +2Government Yoga and Naturopathy Medical College, Chennai, India +3Narayana Health, Bommasandra, Bengaluru, India +Corresponding Author: +Venugopal Vijayakumar, PhD, BNYS, MSc Diabetes (Edin), Government +Yoga and Naturopathy Medical College, Anna Hospital Campus, +Arumbakkam, Chennai, India. +Email: dr.venu@yahoo.com +Reduced Glycemic Variability With +Yoga in Patients With Type 2 Diabetes +Mellitus: Results of a Pilot Study +Venugopal Vijayakumar, PhD, BNYS, MSc Diabetes (Edin)1,2, +Ramesh Mavathur, PhD1, Manjunath N. K. Sharma, PhD1, +and Subramanian Kannan, MD3 +Keywords +complications, exercise, glucose fluctuations, glycemic variability, type 2 diabetes, yoga +804 +Journal of Diabetes Science and Technology 13(4) +Abbreviations +ADDR, average daily risk ratio; CONGA, continuous overlapping +net glycemic action; GRADE, glycemic risk assessment in diabetes +equation; GV, glycemic variability, MODD, mean of daily differ- +ences; SD, standard deviation. +Authors’ Note +Trial registration number: Clinical Trial Registry of India— +CTRI/2017/11/010455 (www.ctri.in). +Declaration of Conflicting Interests +The author(s) declared no potential conflicts of interest with respect +to the research, authorship, and/or publication of this article. +Funding +The author(s) disclosed receipt of the following financial support +for the research, authorship, and/or publication of this article: The +study was funded under the CSR initiative of TVS motor company. +However, the company did not have any influence on the study +design or the results. +References +1. +Kovatchev BP. Metrics for glycaemic control—from HbA1c to +continuous glucose monitoring. Nat Rev Endocrinol. 2017;13:425. +2. Su G, Mi S, Tao H, et al. Association of glycemic variability and +the presence and severity of coronary artery disease in patients +with type 2 diabetes. Cardiovasc Diabetol. 2011;10:19. +3. Kohnert KD, Freyse EJ, Salzsieder E. Glycemic variability and +pancreatic β-cell dysfunction. Curr Diabetes Rev. 2012;8:345- +354. +4. Kumar V, Jagannathan A, Philip M, Thulasi A, Angadi P, +Raghuram N. Role of yoga for patients with type II diabetes +mellitus: a systematic review and meta-analysis. Complement +Ther Med. 2016;25:104-112. +5. Jyotsna VP, Ambekar S, Singla R, Joshi A, Dhawan A, Kumar +N, et al. Cardiac autonomic function in patients with diabetes +improves with practice of comprehensive yogic breathing pro- +gram. Indian J Endocrinol Metab. 2013;17:480. +Table 1.  Comparison of Changes in Ambulatory Glucose Profile Before and After Yoga. +Pre +Post +Difference +P value +Correlation coefficient (pre and post) r +Mean daily glucose (mmol/L) +8.35 ± 2.33 +7.67 ± 2.05 +0.68 ± 0.65 +.014* +.96 +SD +2.30 ± 0.86 +1.99 ± 0.66 +0.31 ± 0.36 +.036* +.92 +MODD +1.97 ± 0.71 +1.67 ± 0.56 +0.3 ± 0.38 +.048* +.85 +CONGA +7.38 ± 2.29 +6.74 ± 1.99 +0.64 ± 0.73 +.031* +.95 +GRADE +6.21 ± 5.85 +4.79 ± 4.92 +1.42 ± 1.74 +.04* +.96 +ADDR +19.73 ± 12.25 +15.33 ± 9.25 +4.4 ± 4.67 +.022* +.94 +J INDEX +39.44 ± 23.18 +32.23 ± 18.07 +7.21 ± 8.90 +.041* +.94 +*P < .05. diff --git a/subfolder_0/Regulation of autonomic functions following two high frequency yogic breathing techniques.txt b/subfolder_0/Regulation of autonomic functions following two high frequency yogic breathing techniques.txt new file mode 100644 index 0000000000000000000000000000000000000000..9f993af266a7ab41e3cc993d2bfd1e0c46ed4493 --- /dev/null +++ b/subfolder_0/Regulation of autonomic functions following two high frequency yogic breathing techniques.txt @@ -0,0 +1,513 @@ + + + +1 +TANG / www.e-tang.org + +2015 / Volume 5 / Issue 1 / e4 +Original Article + +Regulation of autonomic functions following two high frequency yogic breathing +techniques + +Joydeb Mondal1, Ragavendrasamy Balakrishnan2, Manjunath Nandi Krishnamurthy2,* + +1S-VYASA Yoga University, Bangalore, India; 2Department of Life Sciences, S-VYASA University, Bangalore, India + + +ABSTRACT +Yoga is an ancient Indian system of life, encompassing various practices including practices for self- +discipline and also for regulating the health states of the individual, being practiced for thousands of years. +The present study aims at understanding the effect of two high frequency breathing practices over +autonomic nervous system. Forty healthy male volunteers of age 21 ± 2 years with 9 ± 3 months of Yoga +practice experience were recruited. The two high frequency Yoga breathing practices, kapalabhati (KB) +and bhastrika (BH) were given as interventions randomly on either of the two days to minimise +laboratory bias. They were assessed before and immediately after the interventions for heart rate, +respiratory rate, heart rate variability (HRV), blood pressure and peripheral oxygen saturation. There was +a significant increase in heart rate (p < 0.01; p < 0.001), systolic blood pressure (p < 0.01; p < 0.001), +NN50 (p < 0.01; p < 0.001) component of HRV for both KB and BH groups respectively. There was a +significant reduction in respiratory rate in both the groups (p < 0.001, and p < 0.05, BH and KB +respectively) immediately following intervention. A significant increase in LF component of HRV and +reduction in Diastolic blood pressure and high frequency (HF) component following KB was also +observed (p < 0.05, for all comparisons). The Mean peripheral oxygen saturation remained unaltered in +both the groups (p > 0.05). The results suggest that high frequency yoga breathing practices induce +physiological arousal immediately as evidenced by increased blood pressure and heart rate. The +sympathetic arousal was more following KB session as evidenced by an increased diastolic blood +pressure, LF power and a decrease in HF power of HRV as compared to the BH session. + +Keywords pranayama, kapalbhathi, bhastrika, autonomic functions, heart rate variability + + + +INTRODUCTION + +Yoga is a way of life being practiced in India since thousands of +years in the form of physical postures (asana), breathing +practices (pranayama), and meditation (dhyana). Past decades +have encouraged rigorous scientific studies to understand the +science +behind +these +traditional +practices +towards +understanding their possible role in promoting health and +alleviate disease conditions. Recent studies in Yoga have +demonstrated beneficial effects in many cardio vascular +diseases and metabolic disorders like diabetes mellitus (Ren et +al., 2012). +Present day science has started recognizing the relationship +between the emotional regulation, breathing and metabolism +(Porges, 2001), which has been described in the hatha yoga +pradipika (Muktibodhananda, 2000). Also, respiratory patterns +and maneuvers have shown to provide striking influences on +the autonomic nervous system and may exacerbate or reduce +adverse responses to stressors. For example, increased +breathing rate is a typical response to stressful situations +(Grossman, 1983). This tendency can lead to breathing in +excess of metabolic needs (hyperventilation), which causes +reduction in blood carbon dioxide concentrations. The reduced +carbon dioxide causes psycho-physiological and psychological +effects that include (a) enhanced arousal and anxiety and (b) +decreased cerebral and coronary blood flow, which can lead to +a variety of clinical symptoms including dizziness, poor +performance, headache, chest pain, cardiac abnormalities, and +sleep disturbances (Brown, 1953; Fried, 1988; Grossman, 1983; +Lamb et al., 1958; Magarian, 1982). Certain other respiratory +patterns +that +modestly +elevate +blood +carbon +dioxide +concentration appear to promote the opposite effects, including +reduced anxiety and increased or well-maintained cerebral and +coronary blood flow (Grossman, 1983). Reduction of +hypertension (Irvine et al., 1986; Patel et al., 1981; Patel and +North, 1975) and dramatic improvement of heart disease have +resulted from integrated treatment programs that included yogic +breathing practices (Berman and Larson, 1994). +Pranayama, the science and art of breath regulation is more +than a simple breathing exercise. It is not merely breathe +control but one of the powerful yogic techniques used to +regulate the prana (defined as the force behind every action) in +the body to a higher frequency (Singh et al., 1990). Pranayama +techniques involve breathing through either of the nostrils or +through both the nostrils, and conscious regulation of rate and +depth of breathing (Niranjanananda, 2000). +Kapalabhati (KB) is mentioned as one of the six cleansing +procedures (Muktibodhananda, 2000) that involves rapid +breathing consisting of active expiration with the help of +abdominal muscles and passive spontaneous inspiration +*Correspondence: Manjunath Nandi Krishnamurthy +E-mail: nkmsharma@svyasa.org +Received April 7, 2014; Accepted February 12, 2015; Published +February 28, 2015 +doi: http://dx.doi.org/10.5667/tang.2014.0015 +©2015 by Association of Humanitas Medicine +This is an open access article under the CC BY-NC license. +(http://creativecommons.org/licenses/by-nc/3.0/) +Autonomic functions following two high frequency yogic breathing techniques + +2 +TANG / www.e-tang.org + +2015 / Volume 5 / Issue 1 / e4 +happening during relaxation (Raghuraj et al., 1998). Bhastrika +(BH) is another high frequency breathing practice similar to +that of KB except for the forceful inhalation unlike KB +(Muktibodhananda, 2000). +However, there being very subtle difference in the actual +procedure of the practice, these practices have been described +as voluntary breath regulation practices and cleansing +procedures thereby demanding closer observation into the +traditional literatures to unearth their significance and +understand their possible applications. +Experimental data shows that KB and BH practices have a +direct influence on physiological processes such as respiratory +and cardiovascular system, biochemical parameters (Desai and +Gharote, 1990) and central nervous activity (Stancák et al., +1991). An increase in the performance in a letter cancellation +task was observed immediately after practice of KB at a rate of +60 strokes (breaths) per minute (Telles et al., 2008). Whereas +the cognitive evoked potentials showed a reduction in latency +and increase in amplitude following practice of KB when +administered at the rate of 120 strokes (breaths) per minute +(Joshi and Telles, 2009). Earlier studies have reported that +slower +breathing +practices, +alternate +nostril +breathing +(nadishuddhi) increase parasympathetic activity whereas faster +breathing practices (KB) increase sympathetic activity (Pal et +al., 2004). +Heart Rate Variability (HRV) is an indicator of the +autonomic nervous system activity of an individual. Previous +studies conducted on the influence of kapalabhati on HRV +have shown increased sympathetic arousal (Raghuraj et al., +1998). However studies are lacking in understanding the +difference in autonomic changes following BH and KB. BH +and KB both being high frequency breathing practices it is a +mandate to understand the underlying difference in their +mechanism of action. This preliminary study is expected to aid +in understanding the commonalities and differences between +these two high frequency yoga breathing techniques on +components of autonomic functions. + + +Methodology + +Subjects +An advertisement mentioning ‘volunteers shall register for a +study to understand the autonomic regulations of two breathing +practices’ was made in a residential yoga institute campus. Of +the sixty registered volunteers, 40 volunteers of the age group +(21 ± 2 years), having an experience of 9 ± 3 months, who were +clinically healthy, not under medication from the date of start of +study, were recruited for the study following approval from the +Institutional Ethics Committee. A written informed consent was +obtained from all the subjects before recruitment. +Subjects +were +assessed +five +minutes +before +and +immediately after KB on one day and BH on another day, but at +the same time of the day with similar physical mental load +before coming to the laboratory. Alternate allocation of KB and +BH on day one of their visit to the lab was done to ensure 50% +of the subjects performing KB on Day one while the remaining +50% performed BH. +Immediately after reaching the laboratory, subjects were +made to sit in a sound attenuated, dim light room, allowing +them to relax for five minutes, following which baseline +recordings of blood pressure, heart rate, ECG, oxygen +saturation, and respiration were recorded. The intervention KB +and BH were randomly administered for duration of 1 min. + + +Assessments + +Heart Rate Variability +The ECG was recorded using a polygraph (BIOPAC MP100, +USA) at a sampling rate 1024 Hz and was analyzed offline. The +data were acquired using the standard limb lead II +configuration in five minutes epochs before and immediately +after the intervention. The data was visually inspected offline +and noise free data were included for analysis. The R data +waves were detected to obtain a point event series of successive +RR intervals, from which the beat to beat heart series were +computed. The data were analysed with an HRV analysis +program, ‘Kubios’, developed by the biomedical signal analysis +group (Finland). + +Respiration (R) +Respiration was as recorded using a stetho-graph fastened +approximately 1 cm below the margin of the rib cage while +subject was made to sit erect. Respiration was constantly +monitored before and immediately following the intervention +for 5 mins. + +Blood pressure (BP) +A digital sphygmomanometer device (Mindray, Hong Kong) +was used to monitor the blood pressure. The digital manometer +was tied in the left arm over the brachial artery and was inflated +to record the blood pressure immediately before the start and +after the completion of the intervention. + +Oxygen Saturation +Oxygen saturation was measured using Pulse oxymeter +(Mindray, Hong Kong). A photo plethysmograph comprising of +an infra-red diode was connected to the middle finger of the +right hand and continuous blood oxygen saturation was +recorded before and after the intervention for five minutes. + +Intervention +The participants were made to sit in a chair having their spine +straight and the hands resting on the knees. With their eyes +closed, they were asked to voluntarily relax the entire body. +Ag-AgCl electrodes were placed as per limb lead II and +respiration belt was applied on the chest 1 cm below the lower +margin of the rib cage. Sphygmomanometer cuff was tied to the +left arm and the Pulse Oximeter was fixed to the thumb of the +right +hand +to +avoid +any +interference +from +the +sphygmomanometer cuff. +KB and BH was administered as mentioned in Hatha Yoga +Pradipika (Mukthibodhananda, 2000). +KB: The participants were asked to sit in a chair having the +spine straight and the hands resting on the knees. The subjects +were instructed to relax the whole body. Inhaling deeply +through both nostrils, expanding the abdomen, the subject has +to exhale with a forceful contraction of the abdominal muscles. +Following forceful exhalation, voluntary relaxation of the +abdominal muscles promotes downward movement of the +diaphragm causing a negative pressure in the thoracic cavity, +facilitating rapid influx of air. The speed of the practice was +guided with the help of an electronic timer device. After +completion of 60 rapid breaths in succession, the participants +were asked to relax in the same position without voluntarily +manipulating their breath. (Muktibodhananda, 2000). +BH: The subjects were instructed to breathe in and out +forcefully through the nose without straining any part of the +body. Inhaling deeply through both the nostrils forcefully, the +subjects were instructed to exhale forcefully for 40 rounds in a +rhythmic fashion. The speed of the practice was guided with +Autonomic functions following two high frequency yogic breathing techniques + +3 +TANG / www.e-tang.org + +2015 / Volume 5 / Issue 1 / e4 +the help of an electronic timer device. (Muktibodhananda, +2000). + +Statistical analysis +Statistical analysis was performed using the SPSS version 19.0. +Following the normal distribution of the data as indicated +through Shapiro–wilk’s test, within group differences were +analyzed using paired ‘t’ test and between group effects were +analyzed using independent ‘t’ test. + + +RESULTS + +Paired ‘t’ test performed (Table 1) to understand the within +group differences showed a significant increase in heart rate (p +< 0.001), and a significant decrease in NN50 (p < 0.001) +immediately after the practice of BH and KB practices. A +significant increase in LF (p < 0.05) and significant decrease in +HF (p < 0.05) components of HRV was observed immediately +following the practice of KB. There were no significant +differences following intervention on both the days. +Respiratory rate was significantly reduced immediately +following both the practices KB (p < 0.05) and BH (p < 0.001) +(Table 1). There was no significant change observed in the +peripheral oxygen saturation levels. + + +DISCUSSION + +The purpose of this study was to understand the influence of +two High Frequency Yogic Breathing practices on the Heart +Rate Variability and Blood Pressure in healthy experienced +Yoga practitioners. Both KB and BH practices involve constant +forceful rapid exhalations; the difference in the two practices +being additional active forceful inhalation in BH practice, +which is thought to contribute to additional load over the +physiological reserve. However, there were no studies +comparing the role of KB and BH practices regulating the +Heart Rate Variability. +The findings of the present study are in accordance with the +earlier findings indicating an increase in Sympathetic Nervous +System activity immediately after both the practices. However, +the sympathetic arousal was non-significantly more following +the practice of BH as compared to KB, which can be attributed +to the increased effort required to perform the BH, requiring +more Cardiac output to suffice the needs of the exercising +respiratory musculature and the diaphragm. +High frequency breathing is known to cause a direct +influence on physiological processes through the cardio +respiratory system (Stancák et al., 1991). +Though KB was shown to be a stimulating practice, +reported to improve attention and concentration (Tells et al., +2008), there was a need to understand simpler breathing based +methods to increase sympathetic activity. It is clear from the +present study that high frequency breathing has a direct impact +on the autonomic nervous system. While BH showed more +influence on blood pressure and heart rate, KB had better +influence on heart rate variability as expected. BH practice +appears to influence the cardio Respiratory system more +mechanically than KB. +The thoraco-abdominal manoeuvring involved in BH +results in increased breath volume and greater contraction and +expansion of the thorax and abdominal wall. In comparison, +KB with more of diaphragmatic movement appears to exert less +mechanical pressure on the thorax and hence has less influence +on the blood pressure. No changes observed in oxygen +saturation levels can probably be attributed to the duration of +the practice. +The findings of the present study are in accordance with the +earlier findings of high frequency breathing practices directly +regulating the autonomic nervous system. The results suggest +that practice of Kapalabhathi and Bhastrika for 60 and 40 +strokes per minute respectively in experienced practitioners, +cause an increase in heart rate, blood pressure, LF component +of HRV and a significant decrease in NN50 component and +respiratory rate. Further follow up studies are required to +understand the long term autonomic regulation following +breathing practices. And evaluation of safety in hypertensive +patients is warranted. + + +Table 1. The group mean ± SD of HRV, SpO2, RR and BP recorded before and immediately after the practice of Kapalabhati and Bhastrika +Pranayama +VARIABLES +BHASTRIKA +KAPALABHATI +Pre +Post +Pre +Post +Mean HR (bpm) +80.05 ± 10.53 +83.28 ± 9.17*** +80.59 ± 14.78 +82.46 ± 14.52*** +NN50 (nu) +87.87 ± 42.73 +76.28 ± 66.60*** +88.49 ± 13.70 +80.05 ± 15.95*** +LF (nu) +54.20 ± 16.88 +57.98 ± 19.23 +50.27 ± 17.87 +57.75 ± 18.87* +HF (nu) +45.78 ± 16.89 +42.00 ± 19.23 +49.72 ± 17.87 +42.22 ± 18.87* +LF/HF RATIO (nu) +1.65 ± 1.43 +1.99 ± 1.55 +1.41 ± 1.35 +1.90 ± 1.78 +RR (bpm) +15.29 ± 2.40 +13.82 ± 2.20*** +15.56 ± 2.31 +14.85 ± 2.49* +SpO2 (%) +96.97 ± 0.75 +96.82 ± 4.75 +97.10 ± 0.97 +96.97 ± 0.95 +BP-SYS (mmHg) +107.66 ± 8.4 +110.35 ± 11.48*** +107.40 ± 8.70 +111.41 ± 10.88** +BP-DIA (mmHg) +72.56 ± 5.70 +72.42 ± 13.42 +73.23 ± 7.60 +76.09 ± 8.46* +Paired ‘t’ test indicating within group differences *p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001. Mean HR (bpm): mean heart rate in beats per minute, NN50 (nu): +number of successive RR intervals differing more than 50 ms represented in normalised units, LF (nu): low frequency in normalised units, HF (nu): +high frequency in normalised units, LF/HF Ratio (nu): ratio of low frequency and high frequency components in normalised units, RR (bpm): +respiratory rate in normalised units, SpO2 (%): percentage of oxygen in peripheral capillaries, BP-SYS: systolic blood pressure, BP-DIA: diastolic +blood pressure. +Autonomic functions following two high frequency yogic breathing techniques + +4 +TANG / www.e-tang.org + +2015 / Volume 5 / Issue 1 / e4 +ACKNOWLEDGEMENTS + +None. + + +CONFLICT OF INTEREST + +The authors have no conflicting financial interests. + + +REFERENCES + +Berman BM, Larson DB. Alternative medicine: Expanding +medical horizons. 1st ed. (Washington DC, North America: +Diane Publishing Company), 1994. + +Brown EB. Physiological effects of hyperventilation. Physiol +Rev. 1953;33: 445-471. + +Desai BP, Gharote ML. Effect of Kapalabhati on blood urea, +creatinine and tyrosine. Act Nerv Super (Praha). 1990;32:95-98. + +Fried R. The hyperventilation syndrome--research and clinical +treatment. J Neurol Neurosurg Psychiatry. 1988;51:1600-1601. + +Grossman P. Respiration, stress, and cardiovascular function. +Psychophysiology. 1983;20:284-300. + +Irvine MJ, Johnston DW, Jenner DA, Marie GV. Relaxation and +stress management in the treatment of essential hypertension. J +Psychosom Res. 1986;30:437-450. + +Joshi M, Telles S. A nonrandomized non-naive comparative +study of the effects of kapalabhati and breath awareness on +event-related potentials in trained yoga practitioners. J Altern +Complement Med. 2009;15:281-285. + +Lamb LE, Dermksian G, Sarnoff C. Significant cardiac +arrhythmias induced by common respiratory maneuvers. Am J +Cardiol. 1958;2:563-571. + +Magarian GJ. Hyperventilation Syndromes: infrequently +recognized common expressions of anxiety and stress. +Medicine (Baltimore). 1982;61:219-236. + +Muktibodhananda S. Hatha Yoga Pradipika. 2nd ed. (Bihar, +India: Nesma Books India), 2000. + +Niranjananda S. Prana, Pranayama Pranavidya. (Jharkhand, +India: Satyanandashram), 2000. + +Pal GK, Velkumary S, Madanmohan. Effect of short-term +practice of breathing exercises on autonomic functions in +normal human volunteers. Indian J Med Res. 2004;120:115- +121. + +Patel C, North WR. Randomised controlled trial of yoga and +bio-feedback +in +management +of +hypertension. +Lancet, +1975;2:93-95. + +Patel C, Marmot MG, Terry DJ. Controlled trial of +biofeedback-aided behavioural methods in reducing mild +hypertension. Br Med J (Clin Res Ed). 1981;282:2005-2008. + +Porges SW. The polyvagal theory: phylogenetic substrates of a +social nervous system. Int J Psychophysiol. 2001;42:123-146. + +Raghuraj P, Ramakrishnan AG, Nagendra HR, Telles S. Effect +of two selected yogic breathing techniques on heart rate +variability. Indian J Physiol Pharmacol. 1998;42:467-472. + +Ren P, Barreto A, Gao Y, Adjouadi M. Comparison of the use +of pupil diameter and galvanic skin response signals for +affective assessment of computer users. Biomed Sci Instrum. +2012;48:345-350. + +Singh V, Wisniewski A, Britton J, Tattersfield A. Effect of yoga +breathing exercises (pranayama) on airway reactivity in +subjects with asthma. Lancet, 1990;335:1381-1383. + +Stancák A, Kuna M, Srinivasan, Dostálek C, Vishnudevananda +S. Kapalabhati--yogic cleansing exercise. II. EEG topography +analysis. Homeost Health Dis. 1991;33:182-189. + +Telles S, Raghuraj P, Arankalle D, Naveen KV. Immediate +effect of high-frequency yoga breathing on attention. Indian J +Med Sci. 2008;62:20-22. + + + diff --git a/subfolder_0/Relation between Mindfulness and Depression among Adolescent Orphans.txt b/subfolder_0/Relation between Mindfulness and Depression among Adolescent Orphans.txt new file mode 100644 index 0000000000000000000000000000000000000000..ec5c5872ddb5b657234649753292d3e1d0923258 --- /dev/null +++ b/subfolder_0/Relation between Mindfulness and Depression among Adolescent Orphans.txt @@ -0,0 +1,500 @@ +Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): VC01-VC04 +1 +DOI: 10.7860/JCDR/2018/31785.12294 +Original Article +Psychiatry Section +Relation between Mindfulness and +Depression among Adolescent Orphans +Dayal Sharma Shambhu1, Sasidharan K Rajesh2, P Subramanya3 +Keywords: Cognitive, Negative affect, Positive affect, Psychological factors, Self-regulation +ABSTRACT +Introduction: Even though children in orphanages experience’s +multifaceted psychosocial problems, limited research has +focused on psychological protective factors that can lessen the +effect of orphanhood. +Aim: To examine associations between mindfulness and +psychological factors (i.e., depression, cognitive function, +positive emotion, and negative emotion) among adolescent +orphans. +Materials and Methods: This was a descriptive correlation +study and 140 orphan children living in three orphan homes, +Tamil Nadu, India were recruited. Study’s instruments included +Child and Adolescent Mindfulness Measure (CAMM), Cognitive +Functioning Scale (CFS), Short Mood and Feelings Questionnaire +(SMFQ) and Positive and Negative Affect Schedule for Children +(PANAS-C). +Results: There was significant correlation observed between +mindfulness and depression among orphan adolescents +(r=-0.53, +p<0.01). +Further, +mindfulness +had +significant +relationships  to cognitive function (r=0.30, p<0.01), positive +affect (r=0.33, p<0.01) and negative emotion (r=-0.38, p<0.01). +Regression analysis showed that depression accounted 39% +of variance in the model containing mindfulness, positive affect +and negative affect. +Conclusion: This study supports the emerging literature on +the benefits of mindfulness construct. Present findings will +encourage the mindfulness-based interventions targeting well- +being of an orphan adolescent. +INTRODUCTION +According to United Nations Children’s Fund (UNICEF), a child +below 18 years of age, who has lost one or both parents to any +reason of death is considered as an orphan [1]. The UNICEF +report 2012 has estimated 3,10,00,000 orphans in India [2]. In +an orphanage setup, the children suffer from multifaceted and +interconnected psychosocial issues [3]. Orphans in institutional +homes were found to suffer from behavioural and emotional +problems [4] paternal, maternal, and double orphans exhibited +more-severe distress than non orphaned, non vulnerable children. +Orphanhood remained associated with psychosocial distress after +we controlled for differences in more-proximate determinants. A +recent study reported a high prevalence of depression, anxiety, +and stress as well as low self-esteem among adolescents in +orphanages [5]. +Mindfulness is hypothesised as a state of attentiveness to +present events and experiences that is unmediated by discursive +or discriminating cognition [6]. Clinicians working in the area of +child and adolescent issues, the mindfulness-based programs +provides an innovative solution for enhancing the well-being +[7]. Mindfulness is associated positively with outcomes such +as quality of life and academic competence [8]. Further, it is +negatively related with the somatic complaints, internalising +symptoms, maladaptive processes of thought suppression +and psychological inflexibility [8]. Hence, the current study +was designed to achieve the following specific aims among +adolescents in orphanages: (1) to examine associations between +mindfulness and depression; (2) to examine associations of +mindfulness and psychological factors (i.e., cognitive function, +positive emotion, and negative emotion); and (3) to examine the +extent towhich mindfulness account for significant variance in +psychological well-being. To our information, this may be the first +survey that examined the relationship between mindfulness and +depression among orphans. +MATERIALS AND METHODS +Participants +One hundred and forty orphan children living in three orphan +homes (Karunai Illam Charitable Trust, Good Life Centre and +Reaching The Unreached), Tamil Nadu, India were included +in this descriptive correlation study. A priority sample size +computation was carried out based on an earlier study that +reported significant correlation (r=0.26) between mindfulness +and positive affect. From this, estimated sample size was +112 participants, with α=0.05 and (1-β)=0.80 [9]. Data collection +was done from February 2016 to March 2016. The inclusion +criteria of the current study were adolescents aged between 11 +and 15 years [10], with the ability to read, write and comprehend +information. The exclusion criteria were adolescents diagnosed +with severe psychiatric ailments (ongoing violence, evidence of +self-harming or suicidal ideations), developmental disability or +intellectual disability, and physical impairment. The exclusion +of severe psychiatric condition was based on participants +personal files. Participants received no financial return for their +participation. +Procedure +All recruitment and study procedures were approved by the +Institutional Ethical Committee of SVYASA Yoga University +(RES/IEC-SVYASA/47/2015). A prior informed consent was +obtained from the orphanage head and a signed inform assent +was obtained from the children after explaining in detail about +the nature of the study. The interviewers were trained in +psychological assessments. Participant’s demographic details +and psychological questionnaires were assessed individually. +The average completion time for assessments was 20 minutes. +Once participants had completed the questionnaire, they were +fully debriefed to the nature of the study. +Dayal Sharma Shambhu et al., Mindfulness and Depression among Orphans +www.jcdr.net +Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): VC01-VC04 +2 +Child and Adolescent Mindfulness Measure (CAMM) +[8,11] 413 +The 10-item CAMM measure was administered to evaluate the +mindfulness. The CAMM estimates the degree to which adolescents +perceive the internal experiences, act with awareness, and admits +the core experiences without judging them. It has a single factor +structure. Participant has to indicate how each item reflected +their experience using a 5-point scale from 0 (Never true) to 4 +(Always true). All items in this scale described actions contrary to +a mindfulness perspective. Therefore, each question was reverse +scored and added to create a total score. High scores indicate a +high degree of mindfulness. The reliability of the scale demonstrates +a good internal consistency of Cronbach’s alpha=0.87, while the +validity of the research using CAMM suggests that the measure has +good concurrent validity. +Cognitive Functioning Scale (CFS) [12] +The Cognitive Functioning Scale (six questions) asks questions +regarding memory and attention over the last month. The scale +was answered using a five-point Likert scale (0=never a problem; +1=almost never a problem; 2=sometimes a problem; 3=often a +problem; 4=almost always a problem). Items are reverse scored +and linearly transformed to a 0-100 scale (0=100, 1=75, 2=50, +3=25, 4=0). Higher scores indicate the better level of Cognitive +Functioning. Validation report shows a significant association +between CFS and Behaviour Rating Inventory of Executive +Function, a widely validated measure of executive functioning. +The CFS has demonstrated strong psychometric properties +across pediatric populations [13]. +Short Mood and Feelings Questionnaire (SMFQ) [14,15] +Children’s depression measured by 13 items in SMFQ, which +focuses on the affective, cognitive and somatic components of +depression. SMFQ is a unidimensional scale. The participants +rate each statement on 2 (true), 1 (sometimes true), or 0 (not +true) scale over the past two weeks. SMFQ correlates highly +with the standard measures of depression and discriminates +depressed from non depressed children in general population +samples. The scores on each item can then be summed to +produce a total score ranging from 0 to 26. Score 11 and above +are considered as high levels of depressive symptoms. The +SMFQ showed high internal reliability, with a Cronbach’s alpha +of 0.84 [16]. +Positive and Negative Affect Schedule for Children +(PANAS-C) [17-19] +The PANAS-C consist of 10-item scale desgined to measure +positive affect (PA) and negative affect (NA). Children rate on a +5-point Likert scale (1=very slightly or not at all, 5=extremely) +the extent to which they have felt PA (joyful, cheerful, happy, +lively, proud) and NA (miserable, mad, afraid, scared, sad). +Participants rated the degree to which they have experienced +each particular emotion during the previous two weeks. The +total score ranged from 5 to 25 for each of the domains, the +positive and negative affect. The PANAS-C differentiate youth +with associated clinical disorders apart from youth with non- +targeted emotional and behavioural problems. The PANAS-C +subscales have shown good internal consistency and modest +convergent and discriminant validity. +STATISTICAL ANALYSIS +All statistical analysis was performed using the computing +environment R (version 3.4.0). Pearson correlations were used +to examine the association between mindfulness, depression, +cognitive function, positive affect and negative affect. A multiple +regression was run to predict depression from mindfulness, positive +affect and negative affect. +RESULTS +The sample consisted of 42 boys and 98 girls. Mean age of the +subjects was 12.41 years (SD=1.18). Descriptive statistics for +all variables and the zero-order correlation between variables is +summarised in [Table/Fig-1]. Mindfulness was significantly and +negatively correlated with depression (r=-0.53, p<0.01) and +negative affect (r=-0.38, p<0.01). Further, the significant and positive +association observed with cognitive (r=0.30, p<0.01) and positive +affect (r=0.33, p<0.01). Correlations between cognitive function +with depression and negative affect were significant and negative. +Furthermore, positive affect was significantly and negatively +correlated with depression (r=-0.44, p<0.01) and negative affect +(r=-0.43, p<0.01). +Predictor +B +B 95% CI +(LL, UL) +Beta +Beta 95% CI +(LL, UL) +sr2 +sr2 95% CI +(LL, UL) +r +Fit +(Intercept) +14.02** +(9.18, 18.86) +Mindfulness +-0.21** +(-0.29, -0.12) +-0.36 +(-0.50, -0.22) +0.11 +(0.03, 0.19) +-0.53** +Positive Affect +-0.24** +(-0.41, -0.07) +-0.21 +(-0.35, -0.06) +0.03 +(-0.01, 0.08) +-0.44** +Negative Affect +0.28** +(0.12, 0.44) +0.26 +(0.11, 0.41) +0.05 +(-0.01, 0.11) +0.49** +R2=0.408** +95% CI +(0.27,0.50) +[Table/Fig-2]: Regression results using depression as the criterion. +Note. ** indicates p< .01. A significant b-weight indicates the beta-weight and semi-partial correlation are also significant. b represents unstandardized regression weights; beta indicates the standardized +regression weights; sr2 represents the semi-partial correlation squared; r represents the zero-order correlation. LL and UL indicate the lower and upper limits of a confidence interval, respectively. In-text the +adjusted R-squared is referred and reported, while in the table R-squared that has been adjusted for the number of predictors in the model. +Variable +M +SD +1 +2 +3 +4 +1. Mindfulness +20.70 +7.35 +2. Depression +9.54 +4.22 +-0.53** +3. Cognitive +301.43 +111.19 +0.30** +-0.27** +4. Positive affect +17.90 +3.64 +0.33** +-0.44** +0.35** +5. Negative affect +14.70 +3.95 +-0.38** +0.49** +-0.44** +-0.43** +[Table/Fig-1]: Means, standard deviations, and correlations. +Note.** indicates p<.01. M and SD are used to represent mean and standard deviation, respectively. +The multiple regression model statistically significantly predicted +depression, F(3, 136)=31.23, p<0.001, adj. R2=0.39. All three +variables added statistically significantly to the prediction, p<0.05. +Regression coefficients can be found in [Table/Fig-2]. +DISCUSSION +This study sets out to examine the connection between +mindfulness and depression among adolescents living in the +orphanages. Participants in this study had no formal training +in mindfulness techniques. The significant association between +dispositional mindfulness and depression confirmed our primary +hypothesis. Further, mindfulness had significant relationships +to positive and negative emotion. This study supports the +emerging literature on the benefits of mindfulness construct [6,7]. +www.jcdr.net +Dayal Sharma Shambhu et al., Mindfulness and Depression among Orphans +Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): VC01-VC04 +3 +Furthermore, correlation analysis showed that all the variables +in this study (mindfulness, cognitive, depression, positive affect +and negative affect) had a significant influence on each other +among orphan adolescents. This finding is consistent with a +previous research reporting on mindfulness and psychological +well-being [20]. +Further, adolescence is the most rapid phase of human +development and highly vulnerable to mental disorders, which in +turn cause a significant long-term disability [21]. Depression is +a significant contributor to the global burden of mental health in +adolescent’s [22]. Previous finding highlights, orphanage children +show more negative emotions and less positive emotions in +comparison with non-orphanage children [4,5]. Furthermore, +orphans had scored significantly higher level of depression than +non-orphans due to lack of extended family system, which is an +important source of solace and care giving [23]. +Research suggests that mindfulness, a positive dispositional +trait inherent to all of us can deliver lasting improvements +in self-awareness and emotional stability [7]. Further higher +level of mindfulness was associated with better dispositional +self-control and way to abstrain from maladaptive impulsive +behaviour [24,25]. Furthermore, relatively short mindfulness +based intervention showed enhancement of self-regulation +and prosocial behaviour in young children [26]. Further, the +majority of studies on mindfulness, emphasise mostly healthy +participants recruited from schools [27]. Few studies explore +the psychological protective factors that can mitigate the effect +of orphanhood and enhance psychological well-being. Current +study highlights the scope of mindfulness-based intervention for +the well-being of orphan children. +Potential mechanisms by which dispositional mindfulness enhance +well-being may be due to the present movement awareness +and non-reactivity which in turn enhance the self-regulated +behaviour and positive emotional states. Further, according +to the previous studies, dispositional mindfulness is positively +correlated with psychological well-being and emotional regulation +[28]. Furthermore, current results are in line with the previous +research that showed significant association of mindfulness +to better emotional intelligence, enhanced positive affect, +lesser levels of negative affect, and greater life satisfaction [29]. +Empirical evidence from mindfulness-based programs has shown +noteworthy enrichment of children’s psychological, physiological, +and social development [30-32]. +LIMITATION +There are some limitations to this study that needs to be +considered. The convenience sampling method and limited +sample size may limit the generalisation. However, the population +is very much hard to approach. Hence, convenience sample +may be the only possible way to study this population. Further, +lack of information concerning the reasons for orphaning, years +of the orphanhood, and the causes of parental demise may +be another limitation. Furthermore, the causal direction of this +relationship is uncertain in this study due to cross-sectional +design. Interventional study on mindfulness training may provide +causal relationships between mindfulness and well-being +among orphans. Data collection was done using a set of self- +rated questionnaires. Response biases may compromise self- +report measures. Future work should explore comprehensive +behavioural and physiological measures. +CONCLUSION +Despite these limitations, the present study confirmed our primary +hypothesis; dispositional mindfulness is negatively correlated +with depression. Mindfulness approaches can be taught to +orphan adolescents to improve self-regulation and cope with +the psychosocial stress of orphanhood. This study suggests +that enhancement of mindfulness in orphan populations and +understanding possible mechanisms linking mindfulness and well- +being may be a fruitful avenue for future research. Current findings +will aid the development of interventions targeting well-being in an +orphan adolescent. +ACKNOWLEDGEMENTS +We thank the participants and authority of the orphanages in Tamil +Nadu. We also thank Mr. R. Senthil Kumar and Mr. J. John Britto for +their assistance with data collection. +REFERENCES + Orphans | Press centre | UNICEF [Internet]. [cited 2017 Jul 9]. Available from: +[1] +https://www.unicef.org/media/media_45279.html + Unicef.org. Children in an Urban World. The State of the the World’s Children; +[2] +2012. Available from: https://www.unicef.org/sowc/. + Sebsibe T, Fekadu D, Molalign B. Psychosocial wellbeing of orphan and +[3] +vulnerable children at orphanages in Gondar Town, North West Ethiopia. J Public +Heal Epidemiol. 2014;6(10):293-301. + Kaur R, Vinnakota A, Panigrahi S, Manasa RV. A descriptive study on behavioural +[4] +and emotional problems in orphans and other vulnerable children staying in +institutional homes. Indian J Psychol Med. 2018;40(2):161. + Mohammadzadeh M, Awang H, Kadir Shahar H, Ismail S. Emotional health and +[5] +self-esteem among adolescents in Malaysian orphanages. Community Ment +Health J. 2017;18:1-9. + Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in +[6] +psychological well-being. J Pers Soc Psychol. 2003;84(4):822. + Thompson M, Gauntlett-Gilbert J. Mindfulness with children and adolescents: +[7] +Effective clinical application. Clin Child Psychol Psychiatry. 2008;13(3):395-407. + Greco LA, Baer RA, Smith GT. Assessing mindfulness in children and adolescents: +[8] +Development and validation of the Child and Adolescent Mindfulness Measure +(CAMM). Psychol Assess. 2011;23(3):606-14. + Bluth K, Blanton PW. Mindfulness and self-compassion: Exploring pathways to +[9] +adolescent emotional well-being. J Child Fam Stud. 2014;23(7):1298-309. + World Health Organization. (2018). Adolescent health. [online] Available at: http:// +[10] +www.who.int/topics/adolescent_health/en/ [Accessed 6 Aug. 2018]. + Sharma T, Sinha VK, Sayeed N. Role of mindfulness in dissociative disorders +[11] +among adolescents. Indian J Psychiatry. 2016;58(3):326. + Stephen MD, Varni JW, Limbers CA, Yafi M, Heptulla RA, Renukuntla VS, et al. +[12] +Health-related quality of life and cognitive functioning in pediatric short stature: +Comparison of growth-hormone-naïve, growth-hormone-treated, and healthy +samples. Eur J Pediatr. 2011;170(3):351-58. + Varni JW, Limbers CA, Sorensen LG, Neighbors K, Martz K, Bucuvalas +[13] +JC, et al. PedsQL Cognitive Functioning Scale in pediatric liver transplant +recipients:  feasibility, reliability, and validity. Qual Life Res [Internet]. +2011;20(6):913-21. + Thapar A, McGuffin P +. Validity of the shortened Mood and Feelings Questionnaire +[14] +in a community sample of children and adolescents: A preliminary research note. +Psychiatry Res. 1998;81(2):259-68. + Angold A, Costello EJ, Messer SC, Pickles A, Winder F, Silver D. The +[15] +development of a short questionnaire for use in epidemiological studies of +depression in children and adolescents. Int J Methods Psychiatr Res. 1995. +Pp. 237-49. + Rhew IC, Simpson K, Tracy M, Lymp J, McCauley E, Tsuang D, et al. Criterion +[16] +validity of the Short Mood and Feelings Questionnaire and one- and two-item +depression screens in young adolescents. Child Adolesc Psychiatry Ment Health. +2010;4:8. + Huebner ES, Dew T. Preliminary validation of the Positive and Negative Affect +[17] +Schedule with adolescents. J Psychoeduc Assess. 1995;13:286-93. + Kale D, Kumari S. Effect of 1-month yoga practice on positive-negative affect +[18] +and attitude toward violence in schoolchildren: A randomized control study. Int J +Educ Psychol Res. 2017;3(3):180. + Ebesutani C, Regan J, Smith A, Reise S, Higa-McMillan C, Chorpita BF. The +[19] +10-item Positive and Negative Affect Schedule for Children, Child and parent +shortened versions: Application of item response theory for more efficient +assessment. J Psychopathol Behav Assess. 2012;34(2):191-203. + Bränström R, Duncan LG, Moskowitz JT. The association between dispositional +[20] +mindfulness, psychological well-being, and perceived health in a Swedish +population-based sample. Br J Health Psychol. 2011;16(2):300-16. + Patel V, Flisher AJ, Hetrick S, McGorry P +. Mental health of young people: a global +[21] +public-health challenge. The Lancet. 2007;369(9569):1302-13. + WHO. Depression, a global public health concern. WHO Dep Ment Heal Subst +[22] +Abus [Internet]. 2012;1-8. Available from: http://www.who.int/mental_health/ +management/depression/who_paper_depression_wfmh_2012.pdf + Atwine B, Cantor-Graae E, Bajunirwe F. Psychological distress among AIDS +[23] +orphans in rural Uganda. Soc Sci Med. 2005;61(3):555-64. + Bowlin SL, Baer RA. Relationships between mindfulness, self-control, and +[24] +psychological functioning. Pers Individ Dif. 2012;52(3):411-15. +Dayal Sharma Shambhu et al., Mindfulness and Depression among Orphans +www.jcdr.net +Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): VC01-VC04 +4 +PARTICULARS OF CONTRIBUTORS: +1. PhD (Yoga) Research scholar, Department of Psychology, S-VYASA University, Bengaluru, Karnataka, India. +2. Assistant Professor, Department of Psychology, S-VYASA University, Bengaluru, Karnataka, India. +3. Associate Professor, Division of Yoga and Life Sciences, S-VYASA University, Bengaluru, Karnataka, India. +NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: +Dr. P Subramanya, +S-VYASA University, #19, Eknath Bhavan, Gavipuram Circle, Kempe Gowda Nagar, Bengaluru, Karnataka, India. +E-mail: pailoors@gmail.com +Financial OR OTHER COMPETING INTERESTS: None. +Date of Submission: Jul 24, 2018 +Date of Peer Review: Aug 16, 2018 +Date of Acceptance: Sep 15, 2018 +Date of Publishing: Nov 01, 2018 + Rajesh SK, Ilavarasu JV, Srinivasan TM. Dispositional mindfulness and its relation +[25] +to impulsivity in college students. Int J Yoga -PPP +. 2013;1(1):49. + Flook L, Goldberg SB, Pinger L, Davidson RJ. Promoting prosocial behaviour +[26] +and self-regulatory skills in preschool children through a mindfulness-based +kindness curriculum. Dev Psychol. 2015;51(1):44-51. + Zoogman S, Goldberg SB, Hoyt WT, Miller L. Mindfulness Interventions with +[27] +Youth: A Meta-Analysis. Mindfulness (N Y). 2015;6(2):290-302. + Hill CLM, Updegraff JA. Mindfulness and its relationship to emotional regulation. +[28] +Emotion. 2012;12(1):81-90. + Schutte NS, Malouff JM. Emotional intelligence mediates the relationship between +[29] +mindfulness and subjective well-being. Pers Individ Dif. 2011;50(7):1116-19. + Burke CA. Mindfulness-based approaches with children and adolescents: A +[30] +preliminary review of current research in an emergent field. J Child Fam Stud. +2010;19(2):133-44. + Semple RJ, Lee J, Rosa D, Miller LF. A randomized trial of mindfulness-based +[31] +cognitive therapy for children: Promoting mindful attention to enhance social- +emotional resiliency in children. J Child Fam Stud. 2010;19(2):218-29. + Schonert-Reichl KA, Oberle E, Lawlor MS, Abbott D, Thomson K, Oberlander +[32] +TF, Diamond A. Enhancing cognitive and social–emotional development +through a simple-to-administer mindfulness-based school program for +elementary school children: A randomized controlled trial. Dev Psychol. +2015;51(1):52. diff --git a/subfolder_0/SPATIAL AND VERBAL MEMORY TEST SCORES FOLLOWING YOGA AND FINE ARTS.txt b/subfolder_0/SPATIAL AND VERBAL MEMORY TEST SCORES FOLLOWING YOGA AND FINE ARTS.txt new file mode 100644 index 0000000000000000000000000000000000000000..30b472ee69f49462cdeacbd4e58583c3ff14cc29 --- /dev/null +++ b/subfolder_0/SPATIAL AND VERBAL MEMORY TEST SCORES FOLLOWING YOGA AND FINE ARTS.txt @@ -0,0 +1,13 @@ + + + + + + + + + + + + + diff --git a/subfolder_0/STANDARDIZATION OF SUSHRUTHA PRAKRITI INVENTORY.txt b/subfolder_0/STANDARDIZATION OF SUSHRUTHA PRAKRITI INVENTORY.txt new file mode 100644 index 0000000000000000000000000000000000000000..6a26eacdab48c7d251f760013e6ff015f0fae1d8 --- /dev/null +++ b/subfolder_0/STANDARDIZATION OF SUSHRUTHA PRAKRITI INVENTORY.txt @@ -0,0 +1,1081 @@ +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-IX + +1 + +STANDARDIZATION OF SUSHRUTHA PRAKRITI INVENTORY- SPI AN +AYURVEDA BASED PERSONALITY ASSESSMENT TOOL WITH SCIENTIFIC +METHODS + + + Ramakrishna B R1 Kishore K R2 Vaidya V3 Nagaratna R4 Nagendra H R5 + +INTRODUCTION: +Human being is a social animal and a product of social +circumstances. Society influences his life and he +influences the society. In the process of the interaction +between man and society, a kind of characteristics +emerge which can be considered as his way of behavior +and subsequently that becomes the pattern of his life +which is called personality / Prakriti. +There are many ways of understanding and interpreting +these characteristics and from time to time many +scholars have tried to define personality. Theories, have +been developed across the globe, defining and +assessing human behavior in terms of his unique traits +and types. According to Allport’s definition “personality +is the dynamic organization within the individual of +those psycho-physical systems that determine his +unique adjustments to his environment” (25). +Personality thus includes three aspects of an individual, +the psychological, biological and environmental aspects. +It encompasses the enduring characteristics that +differentiate people which make each one unique. It is +also the personality that leads us to act in a consistent +ABSTRACT: + + +Background: Our survey amongst practicing Ayurveda doctors had established the need for a standardized Prakriti +assessment tool. We have developed Sushrutha Prakriti Inventory (SPI) based on Ayurvedic concept of personality. The +pilot study has yielded a scientifically developed tool called SPI with two parts SPI- Q (questions) and SPI- C(check-list) to +assess the Prakriti of an individual. Objectives: To standardize Sushrutha Prakriti Inventory (SPI) based on Ayurvedic +concept of personality through scientific methods. Settings and design: The SPI tool that was developed through a pilot +study was administered to 1200 healthy volunteers of different age group of both male and female subjects from multi +centres. The data obtained was subjected to Test-retest for Reliability and Experts Cross validity test, Correlations study +between subjective and objective parameters by Cronbach’s alpha and Normality test by Kolmogorov Supernova for +standardization of the tool. Method: The data was collected and subjected to the tests of Reliability, Validity and +Normality. A total of 1200 subjects were taken for the test of validation and 120 subjects for Test – retest Reliability and +120 subjects for expert validation by experienced Ayurveda physicians. Results: Data analysis was done using SPSS-2006 +version and there was found to be a strong reliability of the Questionnaire with Pearson correlation score for Vata, Pitta +and Kapha being 0.990, 0.952 and 0.954 respectively; the Pearson correlation score for Vata, Pitta and Kapha for +Physical Check-list being 1.000, 0.996 and 0.999 respectively. With respect to Test – retest reliability scores for Vata, Pitta +and Kapha for Questionnaire is 0.994, 0.975 and 0.976 respectively and 1.000, 0.997 and 0.983 for Vata, Pitta and Kapha +respectively for physical Check-list giving a high rate of reliability. The SPI version with 90+60 quections that evolved after +Content / Consensual validity by 10 experts had Cronbach’s alpha between 0.61 to 0.80. Pearson’s correlations of +Subjective vs. Objective assessment was > 0.95 and Test-retest reliability was>0.95 for all three Prakriti. Conclusion: This +study has yielded a scientifically standardized tool SPI with two parts, SPI- Q with 90 objective questions and SPI- C with +60 subjective Physical questions. +Key Words: Prakriti, Vata, Pitta, Kapha, Personality, Sushrutha, Constitution. +1Ph.D.(Yoga) scholar, 4Medical Director, 5Chancellor. Swami +Vivekananda +Yoga +Anusandhana +Samsthana +(S-VYASA) +University, Bengaluru. +2Research officer, National Ayurveda Dietetics Research +Institute, Jayanagar, Bengaluru. +3Deputy medical superintendent, Sushrutha Ayurveda Medical +College and Hospital, Bengaluru. +Corresponding author email address: + brramakrishnasvyasa@gmail.com +Access this article online: www.jahm.in +Published by Atreya Ayurveda Publications under the license +CC-by-NC. +Received on: 01/11/14, Revised on: 04/01/15, Accepted on: +04/01/15 +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-IX + +2 + +and predictable manner both in different situations and +over extended periods of time. +The +biological +aspects +consisting +of +genetic, +neurophysiological, and neurochemical components +predispose the individual for a particular behavior that +he / she may exhibit. Thus, in interaction with socio- +cultural components such as learning, language, religion +and society as a whole influence the development of +personality. (26.) +Different cultures and schools of thoughts have put +forth their concepts of personality through scientific +and empherical studies. In the eastern concept, +traditional texts of Yoga and Ayurveda are rich sources +of psycho-physical and spiritual knowledge. +Ayurveda describes the personality as Prakriti, a +Sanskrit word. The word Prakriti means nature or +natural form of constitution of an individual. It consists +of +two +syllables +pra +and +krti. +Pra +means +commencement or source of origin, kriti means +performing and is derived from the root kr which means +to perform. Therefore they jointly mean natural form or +the natural status of ones performance or behavior. +In Ayurveda practice the first step is to recognize the +Prakriti state of a person before the examination of +diseased condition. Hither to Prakriti assessment has +been purely a subjective one and based on one’s own +traditional / personal experience. Prakriti is of seven +types namely Vataja, Pittaja, Kaphaja, VataPittaja, +VataKaphaja, +PittaKaphaja +and +VataPittaKaphaja +Prakriti /sama Prakriti. Prakriti is formed in the womb +of the mother at the time of conception. A study by +Bhushan and Kalpana has demonstrated a correlation +between the tissue type Human leukocyte antigens +(HLA) and Prakriti types to support this.[12] +The different variants of Prakriti are based on the +principles of Tridoshas viz., Vata (motion), Pitta +(metabolism) and Kapha (structure) (1). This concept had +so far remained elusive to modern day biomedical +scientists and was looked upon as esoteric. Of late +these theories stand the potential of satisfying modern +biological theories and findings of a couple of recent +studies. Patwardhan et.al. +(12) hypothesized and +demonstrated correlation between HLA alleles and +Prakriti type, thus opening new research avenues for +the concept of an association between HLA alleles and +the Ayurvedic Tridosha theory of individual Prakriti +types. +In another study the concept of Tridosha was found to +have a sound empirical basis in terms of accuracy of +estimation with statistical confidence level above 90% +that could be used for the scientific establishment of +Ayurveda in a new light(8). Further, there have been +preliminary attempts to develop a clinical tool to +diagnose physiological classifications of Prakriti. A few +such attempts are worth mentioning. Deepak Chopra +did publish one in his book called Ayurveda body-type +questionnaire having three sections each for Vata, Pitta +and Kapha (11) The data extractable from this tool seems +linear where as there is coupling seen in the +presentations of these Prakritis. The data extractable +from Kasture’s (21) questionnaire, though is non-linear +he does not seem to have sufficiently stressed on the +higher mental predispositions (34) and seems to have just +listed the attributes of Prakriti and cannot be effectively +used as a tool. A software that intends to measure +Prakriti +called +Ayu-Soft +(32) +seems +to +have +inconsistencies in terms of close ended and too many +questions thus compromising on the user friendliness of +the instrument. +Further, these tools have not been subjected to +standard tests of validity and reliability. In this regard +our study on need of a standardized Prakriti assessment +tool has affirmatively strongly confirmed[35] With this +background they have felt the need to standardize a +concise clinical instrument which is comprehensive, +user friendly, nonlinear and with open ended +questions.In order to fulfill this requirement the +scientifically developed SPI[36] was subjected for +scientific methods of tool standardization after +analyzing the results of pilot study. The developed SPI +which has 2 parts (part –A with 90 Questions and part – +B with 60 Physical Check-list) with total 150 questions +was administered to 1200 subjects after obtaining the +informed consent. +AIMS AND OBJECTIVES: +Standardization of SPI (Sushrutha Prakriti Inventory) +consisting of an objective self-rating Questionnaire (SPI- +Q) and subjective Check-list (SPI-C) based on Ayurvedic +concepts through scientific methods for clinical and +research purpose. +METHODS: +This study included the following steps; +1. Modification and correction of SPI based on Pilot +study results. +2. Assessment of Prakriti using SPI on 1200 subjects +(Main study) +3. Reliability study by Retest on 120 randomly +selected subjects from the same group after a lapse +of 10 days. +4. Study of Validity by correlation of clinical a with SPI +assessment on the same 120 subjects of Retest. +Design of the Study +Thus developed SPI was administered to 1200 subjects +after obtaining the informed consent. The subjects +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-IX + +3 + +were briefed about SPI-Q and they were informed to +select and tick the appropriate ones in the tool. All the +subjects were examined by the investigator / trained +personals to elicit the features of check -list found. The +scorings of SPI-Q and SPI-C were added on individual +basis to quantify the proportion of tridoshas in the +subjects. +Study Design: An Observational study with 1200 healthy +subjects was undertaken to study to assess the +validation of Prakriti scale and develop reference +interval for the PRAKRITI scale on sub-scale basis viz. +VATA, PITA and KAPHA. +Table 1: Number of subjects according to age group. +Age in years +Number +of +subjects +% +16-20 +320 +26.7 +21-30 +456 +38.0 +31-40 +136 +11.3 +41-50 +88 +7.3 +51-60 +124 +10.3 +61-70 +40 +3.3 +71-80 +36 +3.0 +Total +1200 +100.0 +Mean ± SD +31.43±15.62 +Gender +Number +of +subjects +% +Male +556 +46.3 +Female +644 +53.7 +Total +1200 +100.0 + +Test- Retest +In order to ascertain the reliability of SPI 10 percent of +the subjects +(120) were randomly selected for retest after a gap of +10 days. +Cross-Validation +The same 120 subjects who were subjected for test- +retest reliability were subjected for cross validation +with 5 Ayurvedic experts. +RESULTS: +The data collected were scored and subjected to both +descriptive and inferential statistics. The descriptive +statistics were calculated using percentage, mean and +standard deviation. +Cronbach’s coefficient alpha was used to calculate the +internal consistency to assess consistency of results +across items within the scale. +The reliability of the SPI was calculated by using the Chi- +square data through Split – half method and Spearman +brown test. +Pearson’s correlation coefficient (r) was calculated for +establishing cross validity. +Intra – Class correlation coefficient was used to assess +the consistency, conformity of measurements made by +multiple respondents’ measuring the same quantity. +Cronbach Alpha for consistency /Reliability of items in +VATA, PITTA and KAPHA after deleting item. +Cronbach classification + +0 ≤ α ≤ 0.40: Not reliable + +0.41 ≤ α ≤ 0.60: Moderate reliability + +0.61 ≤ α ≤ 0.80: Good reliable + +0.81 ≤ α ≤ 1.00: very High reliable +The scale as a whole proved good reliability with +Crohnbach’s alpha α between 0.61 - 0.80 +Norms for PITA, VATA and KAPHA for Male +Range of score was calculated on ±1SD +Table 2: Norms according to age* (Abstract) +Age in +years +VATA +PITA +KAPHA +Mal +e +Femal +e +Mal +e +Femal +e +Mal +e +Femal +e +16-20 +10 +15 +14 +11 +15 +16 +21-30 +10 +16 +13 +13 +16 +15 +31-40 +11 +15 +12 +13 +15 +18 +41-50 +11 +17 +12 +13 +17 +15 +51-60 +11 +15 +13 +14 +15 +16 +61-70 +9 +16 +13 +12 +16 +12 +71-80 +9 +15 +9 +10 +15 +15 +Averag +e +10 +16 +13 +12 +16 +15 +*Note: If the distribution is not normal, percentile +distribution is used to find the reference interval +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-IX + +4 + +Table 3: Norms according to age (Abstract) (30+20 +statements) +Table 4: Test –test reliability of Inventory of tridoshas + +Pearson +correlation +Test-retest +reliability +TRIDOSHAS +INVENTORY + + +VATA +0.990 +0.994 +PITA +0.952 +0.975 +KAPHA +0.954 +0.976 +TOTAL +0.968 +0.983 +PHYSICAL FEATURES + + +VATA +1.000 +1.000 +PITA +0.996 +0.997 +KAPHA +0.999 +0.999 +TOTAL +1.000 +1.000 +Table 5: Expert validation of VATA, PITA and KAPHA + +VATA +PITA +KAPHA +EXPERT1 +0.966** +0.947** +0.909** +EXPERT2 +0.959** +0.930** +0.895** +EXPERT3 +0.955** +0.919** +0.870** +EXPERT4 +1.000** +1.000** +1.000** +EXPERT5 +0.991** +0.995** +0.980** +Values are Pearson correlation, ** highly significant + +8 +9 +10 +11 +12 +13 +14 +15 +16 +0 +10 +20 +30 +40 +50 +60 +70 +80 +90 +100 +Age in years +VATA score +Male +Female + +Figure 1: Graph showing the scores for Vata against +age +The graph shows that as the age increase the scores for +Vata have decreased in males and in case of females +the scores for Vata have remained the same as age +advanced. + +Figure 2: Graph showing the scores for Pitta against +age +The graph shows that as the age increase the scores for +Pitta have decreased in males and in case of females +the scores for Pitta have increased as age advanced. +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +0 +10 +20 +30 +40 +50 +60 +70 +80 +90 +100 +Age in years +KAPHA score +Male +Female + +Figure 3: Graph showing the scores for Kapha against +age. +Age +in +years +VATA +PITTA +KAPHA +Male +Female +Male +Female +Male +Female +16-20 +14.0 +14.0 +18.0 +17.0 +25.0 +23.8 +21-30 +14.1 +14.1 +17.6 +17.0 +24.2 +23.0 +31-40 +15.0 +15.0 +17.0 +17.0 +22.9 +22.1 +41-50 +15.0 +15.0 +17.0 +17.0 +21.7 +21.3 +51-60 +15.0 +15.0 +16.7 +17.0 +20.6 +20.5 +61-70 +15.0 +15.0 +16.0 +17.0 +19.5 +19.7 +71-80 +15.5 +15.5 +16.0 +17.0 +18.3 +18.9 +Total +14.8 +15.9 +16.8 +17.0 +21.5 +21.1 +10 +11 +12 +13 +14 +15 +16 +0 +20 +40 +60 +80 +100 +Age in years +PITA score +Male +Female +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-IX + +5 + +The graph shows that as the age increase the scores for +Kapha have decreased in males and females as age +advanced. +Statistical Methods: Descriptive statistical analysis has +been carried out in the present study. Results on +continuous measurements are presented on Mean ± SD +(Min-Max) and results on categorical measurements are +presented in Number (%). Significance is assessed at 5 +% level of significance. Cronbach alpha has been +performed to assess the consistency and reliability of +response of the scale to measure the PRAKRITI and +confirm the scale is summative scale, Biserial +correlation has been used to assess the item-total +correlation to understand the items correlation. +Normality test has been performed for the VATA, PITA +and KAPHA score, Reference Interval has been +developed by either Normal method (if normal +distribution is accepted) or Percentile method (if +normal distribution is not accepted). Classification of +PRAKRITI SCALE was done with 27 combinations, one +category represents the completely Normal population, +and 26 variants of VATA, PITA and KAPHA were also +assessed. Pearson correlation ahs been done for expert +validation. +Norms were developed using the Mixed Model of PROC +MIXED of SAS 9.2, with random Intercept and age as +effect, using the following SAS code +odsrtf; +odsgraphicson; +procmixed data=datafemale; +Model k_total=age/cl; +Random intercept; +run; +odsgraphicsoff; +odsrtfclose; +1. t-test of a correlation coefficient +Objective: To investigate whether the difference +between the sample correlation co-efficient and zero is +statistically significant. +Limitations: It is assumed that the x & y values +originates from a bivariate normal distribution and that +relationship is linear. To test an assumed value of +population co-efficient other than zero, refer to the Z- +test for a correlation co-efficient. +∑ +∑ +∑ +− +− +− +− += +2 +2 +) +( +) +( +) +)( +( +y +y +x +x +y +y +x +x +r + +) +1 +( +) +2 +( +2 +r +n +r +t +− +− += +is calculated and follows student t +distribution with n-2 degrees of freedom. +2. Classification of Correlation Co-efficient (r ) +Up to 0.1 Trivial Correlations +0.1-0.3 +Small Correlation +0.3-0.5 Moderate Correlation +0.5-0.7 +Large Correlation +0.7-0.9 Large Correlation +0.9- 1.0 + Nearly Perfect correlation +1 + +Perfect correlation +3. Cronbach classification +0 ≤ α ≤ 0.40: Not reliable +0.41 ≤ α ≤ 0.60: Low reliability +0.61 ≤ α ≤ 0.80: Very reliable +0.81 ≤ α ≤ 1.00: High reliable + +4. Significant figures ++ Suggestive significance (P value: 0.05 5 +years’ experience as clinical practitioners and academic staff of ayurveda medical college. +3. Inclusion criteria for subjects for whom this protocol can be followed: + 3.1. Women and men between 30-60 years (married or single) who satisfy ADA criteria for +diagnosis of DM2. + 3.2. Those, who have not undergone ayurveda treatment in the past six months. +3.2 Exclusion criteria: +1. Patients with complications of DM2 such as CAD, nephropathy, proliferative retinopathy, cannot +undergo this treatment protocol. +2. Patients who are suffering from duodenal or peptic ulcers cannot undergo this treatment protocol. +3. Those who are diabetic from childhood and have low BMI (Dhatu kshaya madhumehi) are excluded +for this protocol. + +3.3 Steps: +Different acharyas in ayurveda talk about different ways for the treatment of madhumeha. Some talk about +samshodhana and samshamana, but some talk about only sanshamana. In the same way, the studies done in various +research institutes of ayurveda are either drug trials or on a single procedure of the treatment of madhumeha. +Therefore, to develop an overall protocol, we followed the following steps- +3.3.1 Step-1: Exhaustive literary search from the vedas, puranas, samhitas and research thesis available in ayurveda +was done for the concept of prameha, zooming into madhumeha as the most probable description of diabetes mellitus. +The vedas reviewed included the Kaushika sutra of Atharva Veda, the puranas included- Agni purana, apart from all +the Laghutrayis and Bruhatrayis of ayurveda. +All the features mentioned in the classical texts for madhumeha were used to develop a four phase residential +management protocol. The four phases of treatment are- +a. Sanshodhana (Purvakarma, Pradhana karma & Paschat karma) +b. Sanshamana +c. Ahara and +d. Vihara. +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +923 + +At the same time, exhaustive list of ayurvedic medications have been taken from the classical texts for the sanshamana +phase. This wide list of medications was further presented in front of the clinicians. And depending upon their clinical +experience and availability of drugs in the market, they were asked to give their inputs. This resulted in getting the list +of the most effective ayurveda medicines from the exhaustive list. +The ahara and vihara based on dinacharya was chosen. The special attention on ahara & vihara during the +sanshodhana karma was taken care. As nidana parivarjana is said to be the prime line of treatment, all do’s & don’ts +have been included in the protocol. The concept of complete health and arriving at total swasthya according to +Ayurveda. 21includes ‘prasanna atmendriya manah’ for which regular yoga practice is a necessary component. Now +there are several references on the beneficial effects of yoga 22,23,24,25 in the management of madhumeha. Hence, +simple restful practices of integrated approach of yoga therapy for diabetes developed and used in all studies of +diabetes at SVYASA has been added as a part under vihara and manah santulana. +3.3.2 Step-2: The compiled literature has been put together in a tabular form to get the common and unique features +described in each text. Then, the studies done on different phases of treatment of madhumeha in ayurvedic research +institutes were compared with the compiled matter. Starting from shodhana procedure (Table no. 6 & 7) described in +classical texts right up to the present day drug trials (Table no. 8) are included. In the same way the do’s and don’ts +mentioned in ahara has been developed into palatable recipes (Table no. 3) the details mentioned under vihara has +been modified for present day life style while tabulating the recommended daily physical activities (Table no. 4). +3.3.3 Step-3: A day wise treatment protocol is developed in the form of flow chart which is supported by classical +texts and research evidence. The flow chart shows the criteria for recruitment of patients under two channels i.e. +Sthula madhumehi & Krisha madhumehi. The chart further defines various assessments needed for the proceeding +towards treatment. Six assessment tools have been developed to define the eligibility at each of the four phases of +treatment. This starts from the day of arrival and continues for 30 days. +3.3.4 Step-4: This full module was presented for validation in front of ayurveda experts specialized in Kayachikitsa, +Panchakarma, Swastha vritta etc with clinical experience (>5years). There were 11 experts who were requested to +participate in the test of content validity for the proposed instrument. The check-list was divided into ten domains +(categories of questions): They are- Classical Reference, Classification, Ahara (Diet), Vihara (Daily Routine), +Principle of treatment, Deepana & Paachana, Sneha aushadha, Virechana aushadha, Sansarjana Krama and +Sanshamana aushadha. +Each expert was asked to rate each the content validity of each domain on a three point scale: "Essential", "Useful but +not essential", "Not necessary". The content validity was then calculated using the method of Lawshe (1975).26 If E +denotes the number of experts marking a domain as essential and N the total number of experts, then Lawshe’s CVR is +defined as the ratio of (E – N/2) and N/2. The critical values for this CVR statistic are given in Lawshe (1975)26 26. +3.4 Data analysis +A matrix of the validated results by 11 experts was prepared. Data was analyzed using software ‘R’ and the statistical +test Lawshe’s Content Validity Ratio (CVR) was used to check the content validity. + +4.0 Results +4.1 Step 1 and 2 +References of Prameha are found in “Kaushika sutra” of “Atharva veda” (5000 B.C to 1500 B.C), Agni purana, +Garuda purana, Kautilya artha shashtra and the epic Ramayana (4000 B.C to 1000 B.C)providing evidence for +description and existence of diabetes (Madhumeha) which has been recognized and documented by man in that era. +Information available in laghutrayis, bhruhatrayis, commentaries like- Dalhana etc, post graduate dissertations from +medical colleges were used for this compilation. Table 1 shows the literature from different texts. + + + + + +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +924 + + Table 1: Literature from different texts + +Vedas/ +puranas / +Samhitas/ +Studies +Introductio +n +Etiology Classificati +on +Clinical +features +Complicatio +n +Management +(Shodhana) +Managemen +t +(Shamana) +Ahara +/ +Vihar +a +Atharva veda +√ +- +- +- +- +- +√ +- +Agni purana +√ +- +- +√ +- +- +- +- +Ramayana +- +- +- +√ +- +- +- +- +Kautilya Artha- +Shastra +√ +- +- +- +- +- +- +- +Charaka +Samhita +√ +√ +√ +√ +√ +√ +√ +√ +Sushruta +Samhita +√ +√ +√ +√ +√ +√ +√ +√ +Astanga +Hrudaya +√ +√ +√ +√ +√ +√ +√ +√ +Astanga +Samgraha +√ +√ +√ +√ +√ +√ +√ +√ +Parashara +Samhita +√ +- +- +√ +- + + +√ +√ +Bhela Samhita +√ +- +√ + +- +√ +√ +√ +Harita Samhita +√ +- +√ +√ +√ +- +√ +√ +Kasyap Samhita +- +- + +√ +- +- + + +Sharangadhar +Samhita +- +- +√ +- +- +- +√ +√ +Rasendra sara +samgraha +- +- +- +- +- +- +√ + +Bhaisajya +Ratnavali +- +- +- +- +- +- +√ +√ +Sahastra Yoga +Samgraha +- +- +- +- +- +- +√ +- +Yogratnakar +- +- +- +- +- +- +√ +- +Madhavakara +- +√ +√ +- +- +- +- +- +Gayadasa +- +√ + +√ +- +- +- +- +Chakrapanidatta +√ +√ +√ +√ +√ +√ +√ +√ +Dalhana +√ +√ +√ +√ +√ +√ +√ +√ +Bhavamishra + +√ + + + + +√ +√ + +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +925 + +The introduction, etiology and clinical features responsible to correlate the disease with modern perspectives +were found in most the samhitas. When referring to the treatment or management of diabetes we found that +very few classical texts (Charaka Samhita, Sushruta Samhita, Bhel Samhita, Astanga Samgraha & Hrudyam) +provide detailed descriptions of the principles of management. Some texts (Rasendra sara samgraha, +Sahastra Yogam, yoga Ratnakar etc) recommend only Shamana with Ahara & Vihara or nidana parivarjana. +Thus, this compilation of the treatment protocol evolved after an exhaustive literature search from all +available samhitas, vedas & puranas. +Figure 1 shows the day wise flow chart of the treatment protocol. +As the patient arrives to the campus, he will be subjected to various assessments. An ayurveda physician +will document his case history and assess the subject‘s eligibility for sthaulya and karshya channel on the +basis of physical examination, BMI and shodhana yogya-ayogya criteria. +If the patient falls under karshya category, then he will be taken up for samshamana chikitsa.27 If the patient +fits into the criteria of sthula, then agni, ama & kostha will be assessed. This helps in fixing the duration & +dosage of deepana, pachana . The deepana & pachana will be completed within 3 to 7 days. In the same way +by assessing agni, ama & kostha, dosage of snehapana will also be calculated. 28,29 As sneha siddha +lakshanas are seen, abhyanga will be started for three consecutive days followed by atapa swedana. The +snehapana completes in 3 to 7 days (Approx. 10-12 days after admission) and abhyanga in 3 days +(Approx. 15-17 days after admission). For the assessment of sneha sidha lakshanas, a separate column of +sneha jeernamana assessment has been prepared (Table-2). +Just after the third day of abhyanga, the subject is taken up for virechana by administering virechanopaga +drugs. This will be done for one day and the assessment of shuddhi will be done by shuddhi assessment +chart provided in the case sheet (Table-2). Depending upon the result of shuddhi assessment, the number of +days necessary for sansarjana krama will be finalized. Sansarjana krama completes in 3 to 7 days (Approx. +22-25 days after admission). And this will be followed by samshamana chikitsa.27 +4.2 Step 3 +As the patient arrives to the campus, he will be subjected to various assessments. An ayurveda physician +will document his case history and assess the subject‘s eligibility for sthaulya and karshya channel on the +basis of physical examination, BMI and shodhana yogya-ayogya criteria. Figure 1 shows the day wise flow +chart of the treatment protocol. +If the patient falls under karshya category, then he will be taken up for samshamana chikitsa.27 If the patient +fits into the criteria of sthula, then agni, ama & kostha will be assessed. This helps in fixing the duration & +dosage of deepana, pachana . The deepana & pachana will be completed within 3 to 7 days. In the same way +by assessing agni, ama & kostha, dosage of snehapana will also be calculated. 28,29 As sneha siddha +lakshanas are seen, abhyanga will be started for three consecutive days followed by atapa swedana. The +snehapana completes in 3 to 7 days (Approx. 10-12 days after admission) and abhyanga in 3 days +(Approx. 15-17 days after admission). For the assessment of sneha sidha lakshanas, a separate column of +sneha jeernamana assessment has been prepared (Table-2). +Just after the third day of abhyanga, the subject is taken up for virechana by administering virechanopaga +drugs. This will be done for one day and the assessment of shuddhi will be done by shuddhi assessment +chart provided in the case sheet (Table-2). Depending upon the result of shuddhi assessment, the number of +days necessary for sansarjana krama will be finalized. Sansarjana krama completes in 3 to 7 days (Approx. +22-25 days after admission). And this will be followed by samshamana chikitsa.27 + + + + + +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +926 + + + + + +Figure 1: Stepwise Treatment/Management protocol for Madhumeha + + + + + + + + + + + + + + + + + + +Table 2: list of assessments to be satisfied before the patient moves on to the next step + +I +Assessment of agni for +Deepana drug dosage +Agni assessment Column in case sheet +II +Assessment of ama for +Pachana drug dosage +Ama assessment Column in case sheet +III +Assesment of Kostha +Kostha assessment Column in case sheet +IV +Assessment of Sneha & +Sneha lakshanas +Sneha Jeeranaman assessment column in case sheet. +V +Assessment of vegiki, +Lingiki & manaki +Shuddhi +Vega assessment column in case sheet. + + + + + + + + + + + + + + +ON THE DAY OF ARRIVAL +Assess prakruti, vikruti and fitness (Shodhana yogya/ayogya purusha) +for treatment + Sthaulya +Samshodhana + +Karshya +Assess agni, aama, +Kostha + +Samshamana +Chikitsa + +Deepana & Paachana +Max. up to 7th day + +Snehana; +1.Snehapana. 3-7 days +2.Abhyanga. 3 days + +Virechana. 1 day (Followed by +Samasarjan Krama (3-7 days). + +Samshamana +Chikitsa +Total days-7+7+3+1+7=25days +(Max) + +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +927 + +VI +Assessment of +Sthula/Karshya category +1. Physical Examination. +2. BMI. +3.Shodhana Yogya/Ayogya column in case sheet + + Table 3: Ahara table with palatable recepies by following Nidan Parivarjana +Ahara30,31, 32 + +Sunday +Monday +Tuesday +Wednesday +Thursday +Friday +Saturday +Break +fast +Broken +Wheat +(Dalia) +roasted. + Vegetable of - +Spinach, +Bottle guard +etc. +Barley saktu +mixed +with cows +Milk & +honey +Barley grain dipped +in triphala decoction +soaked overnight & +taken with honey. +Broken +Wheat +(Dalia) +roasted. +Vegetable of - +Spinach, +Bottle guard +etc. +Barley +saktu +mixed +with cows +Milk & +honey + +Diluted +milk +with +water +(1:2) +Malt +(Barleychur +ned drink) +Triphala +Juice, +Turmuric +with Honey +Diluted milk with +water +(1:2) +Malt +(Barley +churned +drink) +Diluted milk +with water +(1:2) +Triphala +rasa, +Turmuric +with +Honey + + + + + + + + +Lunch +soup of +Lentils +(Moong) +Soup of half +cooked rice +Boiled +Barley Soup +Lentils Soup +Soup of +half +cooked +rice +soup of Lentils +(Moong) +Boiled +Barley +Soup + +Bitter +gourd +vegetable +cooked +in +Taila of +Mustard +Patola +vegetable +cooked in +Taila of +Mustard +Bottle gourd +vegetable +cooked in +Taila of +Mustad +Jack fruit +vegetable +cooked in Taila of +Mustard +Bitter +gourd +vegetable +cooked in +Taila of + Mustard +Patola +vegetable +cooked in +Taila of +Mustad +Bottle +gourdvege +table +cooked in +Taila of +Mustard + +Red rice +(Rata +shali) +Broken wheat +Red rice +(Rata shali) +Broken wheat +Red rice +(Rata +shali) +Broken wheat +Red rice +(Rata +shali) + +Chapati +of Wheat +Chapati of +Barley +Chapati of +Wheat +Chapati of Barley +Chapati of +Wheat +Chapati of +Barley +Chapati of +Wheat + +Floor of +Barley- +mixed +with + water +and +cooked. +Floor of +Barley- mixed +with + water and +cooked. +Floor of +Barley- +mixed with + water and +cooked. +Floor of Barley- +mixed with + water and cooked. +Floor of +Barley- +mixed with + water and +cooked. +Floor of +Barley- mixed +with + water and +cooked. +Floor of +Barley- +mixed +with + water and +cooked. + + + + + + + + +Dinner +Lentils +Soup +Boiled Barley +Soup +Soup of +half cooked +rice +Lentils soup +Maize +Soup +Boiled Barley +Soup +Soup of +half +cooked +rice + +Jackfruit/ +ashgourd +vegetable +cooked +in Taila +of +Mustard +Kasheru/ +Lauki +vegetable +cooked in +Taila of +Mustard +Patola +vegetable +cooked in +Taila of +Mustard +Karela vegetable +cooked in Taila of +Mustard +Jackfruit/a +shgourd +vegetable +cooked in +Taila of +Mustard +Bottle gourd +vegetable +cooked in +Taila of +Mustard +Patola +vegetable +cooked in +Taila of +Mustard + +Broken +wheat +Red rice +(Rata shali) +Broken +wheat +Red rice +(Rata shali) +Broken +wheat +Red rice +(Rata shali) +Broken +wheat + +Chapati +of Barley +Chapati of +Wheat +Chapati of +Barley +Chapati of Wheat +Chapati of +Barley +Chapati of +Wheat +Chapati of +Barley +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +928 + + +Floor of +Barley- +mixed +with + water +and +cooked. +Floor of +Barley- mixed +with + water and +cooked. +Floor of +Barley- +mixed with + water and +cooked. +Floor of Barley- +mixed with + water and cooked. +Floor of +Barley- +mixed with + water and +cooked. +Floor of +Barley- mixed +with + water and +cooked. +Floor of +Barley- +mixed +with + water and +cooked. + + Table 4: Vihara table with accepted daily routine following Nidan Parivarjana + + + + + + + + + + + + + + + + + + + +4.3 Step 4 +Validation: +Our calculations show that the various domains have a CVR as shown in table-5. The average CVR was +0.85. For a total of eleven experts, the critical value of the CVR is 0.58. We conclude from table-5, that each +domain has satisfactory content validity and that the entire instrument too has satisfactory content validity. +Vihara 33 +Time +What to do +5.30am- 6.00am +Wake up and fresh +6.00am-7.15am +Purva karma/ morning walk /Special techniques of DM. +7.15am-8.00am +Maitri Milan +8.00am-8.30am +Breakfast (except during snehapana/ pradhana karma) +8.30am-9.30am +Bath & Wash +9.30am-11.30am +Library Reading/karma Yoga +11.30am-1.00pm +Pranayama & Special technique of DM (Not at Snehapana and +pradhana karma period- So MSRT at that time) +1.00pm-2.00pm +Lunch +2.00pm-2.30pm +Normal walking/DRT +2.30pm-4.30pm +TV Shows Like- Mahabharat/Ramayan/Vishnupuran etc. +4.30pm-6.00pm +Evening Walk/ Exercise after shodhana/ Tuning to the nature +6.00pm-7.00pm +Wash & Fresh +7.00pm-7.30pm +Bhajan +7.30pm-8.30pm +Dinner +8.30pm-9.30pm +Library Reading +9.30pm-10.00pm + Going back to room & lights off. + +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +929 + +Table 5: Lawshe’s Content Validity Ratio (CVR) for domains +Variables + +1 +2 +3 + 4 +5 +6 +7 +8 +9 +10 +11 + + +Dr +Aja +y +Dr +Rama +krish +na +Dr +Shara +da +Dr +Mam +ta +Dr +Vasud +ev +Dr +Sang +a +Mitr +a +Dr +Anit +a +Dr +Swet +a +Dr +Vasud +ha +Dr +Sriniv +as +Dr +Umes +h + +SUM + +CVR +Classica +l +referenc +e +U +E +E +E +E +E +E +E +E +E +E +10 +0.8 +Classifica +tion +E +E +E +E +E +E +E +E +E +E +E +11 +1.0 +Ahara +E +E +E +E +E +E +E +E +E +E +E +11 +1.0 +Vihara +E +E +E +U +E +E +E +E +E +E +E +10 +0.8 +Principl +e of +treatme +nt +E +E +E +E +E +E +E +E +E +E +U +10 +0.8 +Deepana +& +Paachan +a +E +E +E +E +E +E +E +E +E +E +U +10 +0.8 +Sneha +aushadh +a +E +E +E +E +E +E +U +E +E +E +U +9 +0.6 +Virecha +na +aushadh +a +E +E +E +E +E +E +E +E +E +E +U +10 +0.8 +Samsarj +ana +krama +E +E +E +E +E +E +E +E +E +E +E +11 +1.0 +Shaman +a +aushadh +a +E +E +E +E +E +E +E +E +E +E +U +10 +0.8 + +Avera +ge +0.8 +5 +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +930 + + +5.0 Discussion +This study provides a validated ayurveda treatment protocol for treatment of adult DM2 patients without +major complications (heart, kidney or the eyes). The detailed principle and protocol of treatment which are +scattered in different sections of Brhatrayis, Laghutrayis and others (18 texts) have been compiled. Not all +texts provide a comprehensive protocol for management of madhumeha.27, 34, 35 +5.1 Madhumeha vs Prameha +Table-6: Treatment/management of Prameha + +Prameha +Chi. +Sa. +Yog +Cha. +Sa. +Su. +Sa +Astan. +Sa +Ast. +Hru +Bhel. +Sa +Ha. +Sa +Bh. +Pr. +Sha.Sa +Yog. +Ra +Vamana +- +Chi.6/1 +5,16 +Chi. +11/5 +Chi.14/2 +,3,4 +12/1,2, +3 +- +- +38/44 +- +- +Virechana +- +Chi.6/1 +5,16 +Chi. +11/5 +Chi.14/2 +,3,4 +12/1,2, +3 +- +- +38/44 +- +- +Basti +- +- +Chi. +11/5 +Chi.14/2 +,3,4 +12/1,2, +3 +- +- +38/44 +- +- +Only +shansamana +Ka.pr +- +- +- +- +7/1,2 +(Teekshna +Dravyas) +28/6- +25 + +- +Utt.Pra +m.Chi +Others +- +- +- + +- +- +- +- +7/59-62 +Ganana +- + +Most of the texts (Table-6) describe the treatment protocol under the heading of prameha and not +madhumeha. 35, But it is known that madhumeha is very different from prameha. Madhumeha is considered +as one of vataja pramehas and when the prameha is not treated properly and becomes chronic then it takes +the form of madhumeha. Further this madhumeha condition leads to various complications such as- excess +medas, Pidikas etc. So the treatment of madhumeha is different from prameha. +Shusruta has said that patients suffering from madhumeha should be always treated by teevra virechana. +Mridu virechana cannot help them because of their body being pervaded by excessive meda.37 In the same +manner Harita samhita says that madhumeha is vataja prameha and this is very difficult to cure or +sometimes incurable. Hence the treatment should be done after giving a small virechana.38 Harita samhita +also describes the shaman aushadhis for chronic prameha which are- Haritaki, Jayapalaa churna as well as +making the lehya of triphala.38All these three are vatanulomaka and can lead to virechana. Astanga +Samgraha says similar to shusruta for the treatment of chronic pramehi. It says that chronic pramehis should +be treated by giving teevra virechana because they have excess of medas.39 Therefore it was concluded that +the treatment of madhumeha will be done by teevra virechana followed by shamana aushadis and Nidana +parivarjana (strict adherence to prescribed ahara and vihara). +Table 7 shows the treatment principle of madhumeha in classical texts +Table-7 Treatment/Management of Madhumeha + + +Madhumeha +Chikitsa +Bhe.Sa +Ha.Sa +Su.Sa +Astan.Sa +Vamana + - +- +- +- +Virechana +Chi.7/29 +Pram.28/16,17 +Chi.12/6 +Chi.14/21 +Basti + - +- +- +- +Only shansamana + - +- +- +- +others + - +- +- +- + +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +931 + +The shamana chikitsa described in all the classical texts are similar. There are some preparations which are +different but most of the herbs used in different preparations are the same. Those preparations which are +common in most of the classical texts, and are used by the clinicians frequently were given the top priority +in our protocol. Modern research studies carried out using some of these formulations have been referred +and thus a list of shamana drugs has been finalized. + +Table-8 Sanshamana formulations in classical texts with research studies + +Name of the Herbs/ +Preparation +Research contribution +Classical reference +Phalatrikadi ghan vati +Mani Raj singh et al, 1972 40 +Bh.Pra. 38/59 +Nisha Kathakadi Kasaya +Shardamani, K.R. et al – 1988 41 +S.Y.Kasaya yo. pra. +Kathaka Khadiradi Kasaya +Mohammad. N. P,. et al-199942 +S.Y.Kasaya yo. pra. +Nishamlaki +Yadav, R. K., et al-200143 +Ast.Hru. 12 +Shilajitwadi lauha +Mane Vijaya 199944 +Bh.Ra. Pra.Pa.3 +Shilajitwadi Vati +Shweta, M. K., 200845 +Bh.Ra. Pra.Pa.3 +Amrutadi churna +Rajalaxmii, K. et al – 201046 +S.Y.Churna yo.pra. +ChandraPrabha vati +Jamwal, V. D., 197847 +R.S.S. 3/21-25 +Vidangadi ghan vati +Patel Asha, J. – 200448 +S.Yo. Vati Yog. Pra. +Most of the ahara & vihara mentioned in classical texts are same. Therefore the ahara and vihara to be +avoided were listed and those which are permitted are used in the protocol considering the palatability and +acceptability. + +6.0 Limitations of the study +The validation was done by experts from one medical college in Bangalore. + +7.0 Strength of the study +First of this type of study using modern scientific methods for validating a protocol. This makes the module +acceptable and generalizable. + +8.0 Suggestions for future work +This may be refined by taking the opinion of different experts from different schools of ayurveda to make it +more acceptable as a protocol to be used in all ayurveda centers in the country and abroad. This validated +protocol has to be tested through randomized control studies to prove its efficacy. + +9.0 Acknowledgements +At this juncture of development of validated protocol, I express my sense of gratitude to SVYASA +University for providing me the opportunity. With heartful gratitude, I acknowledge the inestimable +guidance bestowed on me by the staff of Sushruta Ayurvedic Medical College, Bangalore including Dr. +Sharada, Dr. Mamta & Dr. Vasudev for their guidance & support rendered to me during the validation of +protocol. I also acknowledge Dr. Ravi Kulkarni for helping me in statistics to calculate the content validity +of the protocol. I thank Dr Amit and all my MD colleagues who helped me directly and indirectly in +developing and validating the protocol + +References: +1. Emslie M, Campbell M, Walker K. Family medicine complementary therapies in a local health care +setting. Part 1: is there real demands? Complement Ther Med 1996;4:39-42. +2. Kershaw E.E., Flier J.S. Adipose tissue as an endocrine organ. J Clin Endocrinol Metab 2004: +89(6):2548-5 +3. World Health Organization (WHO). World Health report 2004. Global prevalence of diabetes estimates +for year 2000 and projections for year 2030, Geneva 2004 +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +932 + +4. Wild S, Roglic G, Green A, Sicree R, King H. "Global prevalence of diabetes: estimates for 2000 and +projections for 2030". Diabetes Care 2004;2(7):1047–53 +5. American +Diabetes +Association +(2005). +"Total +Prevalence +of +Diabetes +& +Pre-diabetes". +http://www.diabetes.org/diabetes-statistics/prevalence.jsp. +6. Groop LC, Ratheiser K, Luzi L, et al. Effect of sulphonylureas on glucose-stimulated insulin secretion in +healthy and non-insulin-dependent diabetes subjects: a dose response study. Acta Diabetol 1991;28:162– +168. +7. Henry RR. Thiazolidinediones. Endocrinol Metab Clin North Am 1997;26:553–573. +8. Steyn NP, Mann J, Bennett PH, Temple N, Zimmet P, Tuomilehto J, Lindström J, Louheranta A. Diet, +nutrition and the prevention of type 2 diabetes. Public Health Nutr 2004; 7(1A):147-65 +9. Feinstein AR. Clinical biostatistics. VIII. An analytical appraisal of the University Group Diabetes +Program (UGDP) study. Clin Pharmacol Therapeut 1971;12:167–170 +10. Clarke BF, Duncan LJP. Comparison of chlorpropamide and metformin treatment on weight and blood +glucose response of uncontrolled obese diabetes. Lancet 1968;1:123–126. +11. DeFronzo RA, Ferrannini E, Hendler R, Felig P, Wahren J. Regulation of splanchnic and peripheral +glucose uptake by insulin and hyperglycemia in man. Diabetes 1983; 32:35–45. +12. Shastri KN, Chaturvedi GN. Charaka Samhita, Vidyotini commentary 1st ed., Chikitsasthana, Chapter +6th, 15th verse, Varanasi : Chaukhamba Sanskrit Series, 2004: 235. +13. Tripathi B. Sarangadhara Samhita of Sharangadharacharya, Chaper-7, shloka-62. Chaukhamba +surbharati Prakashana, Varanasi, 2010;101. +14. Murthy S. Madhav Nidan, Chapter- 10, shloka-1. Chawkhamba orientalia, Varanasi 2009; 43. +15. Dutta AS. Sushruta Samhita. In: Nidanasthana Chapter 6,5th verse 9th ed. Varanasi, India: Chaukhamba +Bharati Academy, 2007: 231-232. +16. Jaykar, TG. A clinical trial of an ayurvedic compound ad add in therapy to allopathic drugs in the +management of NIDDM, Dept. of Kayachikitsa, Govt. Ayurvedic college, Trivandrum 2000. +17. Mahanta, N. A clinical trial of Shilajitu Daruharidra in Madhumeha (Diabetes Mellitus). Dept of +Kayachikitsa,Govt. Ayurvedic callege, Puri 1986. +18. Sengar, MRS. Effect of Phaltrikadi kwatha in Madhumeha. Dept of Kayachikitsa, State Ayurvedic +College, Lucknow 1980. +19. Raval, AJ. An effect of Gokshuradi gugguluin Madhumeha. (Diabetes Mellitus). Dept. of Kayachikitsa, +Govt. Akhandananda Ayurvedic College, Ahemdabad 1994. +20. Katiyar, VC. Further studies on the phenomenon of Madhumeha and its management with Haridra- +amlaki churna and Devdarvadi Ghanvati, Dept. of Kayachikitsa, I.P.G.T. & R.A., Jamnagar 1984 +21. Jadhavji V, Trikamji A. Sushruta Samhita by sri Dalhanacharya, Chapter- 15, Shloka- 41. Chowkhamba +Krishnadas academy, Varanasi 2008. +22. Sahay BK. Yoga And Diabetes in Novo Nordisk Diabetes Update 94 Proceedings. Ed. Anil Kapur, Publ. +Health care Communications, Bombay, 1994;159-68. +23. Sahay BK. Role of yogic practices in the prevention of NIDDM in Abstracts of the 15th International +Diabetes Fedration Congress at Kobe 1994:95 +24. Sahay BK. Role of yoga in diabetes. J Assoc Physicians India 2007;55:121-6. +25. Nayak NN, Shankar K. Yoga : A therapeutic approach. Phys Med Rehabil Clin N Am 2004, 15(4):783- +798. +26. Lawshe, C. H.. A quantitative approach to content validity. Personnel Psychology 1975; 28(4),563-575. +27. Shukla V, Tripathi RV. Charaka Samhita by Agnivesha, chapter6, shloka-15, 16, 1st ed. Chowkhamba +Sanskrit Pratisthan, New Delhi 2004;118 +28. Vasant, CP. Further clinical study on standardization of Shodhanartha Snehapana, Jamnagar. 2006. +29. Badve, V.. A clinical study on standardization of Shodhanartha Abhyantara Snehapanam, Jamnagar. +2000. +30. Chandra L. Astanga Hrudayam, Chapter-12, Shlokas-10 to 14. Motilal Banarsidas publishers Ltd. New +Delhi 1963;716 +31. Shukla V, Tripathi RV. Charaka Samhita by Agnivesha, chapter-6, shloka-19 to 21, Chowkhamba +Sanskrit Pratisthan, New Delhi 2004;171. +Satyam Tripathi International journal of ayurvedic & herbal medicine 2(5) oct . 2012(921-934) + +933 + +32. Sitharam B. Bhavprakasha of Sri Bhavamishra, Chapter-38, Shlokas-41.Chaukhamba orientalia, +Varanasi 2010;420-427. +33. Chandra L. Banarsidas M. Astanga Hrudayam, Chapter-12, Shlokas-32- Motilal Banarsidas publishers +Ltd. New Delhi 1963;721. +34. Chandra L. Banarsidas M. Astanga Hrudayam, Chapter-Shlokas-12, 1,2,3, - Motilal Banarsidas +publishers Ltd. New Delhi 1963;715. +35. Vaidya Jadhavji, Trikamji Acharya Sushruta Samhita by Sri Dalhanacharya, Chapter- 11, Shloka- +5, Chowkhamba Krishnadas academy, Varanasi 2008;75. +36. Sitharam B. Bhavprakasha of Sri Bhavamishra, Chapter-38, Shlokas-44. Chaukhamba orientalia, +Varanasi 2010;420-427 +37. Vaidya Jadhavji, Trikamji. Sushruta Samhita by Sri Dalhanacharya, Chapter- 12, Shloka- +6.Chowkhamba Krishnadas academy, Varanasi 2008;79 +38. Vaidya Pandy J. Harita Samhita, Chapter-28 Shlokas-16. Chowkhamba Vishwabharathi, Varanasi +2010;402. +39. ShivPrasad. Astanga Samgraha of Vrddha Vagbhatta, Chapter-14, Shloka-21 Sanskrit, Commentary by +Indu, Chowkhamba Sanskrit series, Varanasi 2008; 126. +40. Sengar, M.R.S., Dube, C.B., Shukla, M.D. A clinical study of an indigenous compound on madhumeha +with special reference to Diabetes Mellitus. Dept. of Kaya Chikitsa- State ayurvedic college, Lucknow. +B.Y;1979:39.. +41. Arun N, Nalini N. Efficacy of turmeric on blood sugar and polyol pathway in diabetic albino rat. Plant +Foods Hum Nutr 2002;57(1):41-52. +42. Mohammad, NP, Lathiffa, MKM, Sirajudeen, S. Study of antipyretic and anti- inflammatory activity of +Kathaka Kadiradi Kashayam. The antiseptic Sep 1999;99(9):349-9. +43. Yadav, R.K., Mishra, R., Chippa, R.P., Audichya, K.C. Clinical trial of an indigenous compound drug +nishamlaki in the management if madhumeha vis-à-vis diabetes mellitus. Ancient science of life +2001;21(1)18-24. +44. Vijaya, M. Madhumeha mein Loha shilajiyu vati ka prayogik adhyan. Dept of kayachikitsa, K G M +Punarvasu Ayurvedic College 1999. +45. Shweta, M. K. Comparative study of the efficacy of triphaladi vati and shilajitwadi vati in the +management of prameha. Dept of Kayachikitsa, Ahemdabad 2008. +46. Rajalakshmi, K., Vani, G., Devaraj, N., Husain musthafa, M.K,. Dislipidemic effects of the ethanolic +extract of Tinospore Cardifolia on alloxon induces diabetic rats. Jounal of siddha 2010;2:18- +28. +47. Jamwal, VD. A study of antidiabetic effect of Chandraprabha Vati. Dept. ofKayaChikitsa, BHU +Varanasi 1978. +48. Patel AJ. Management of Madhumeha with shodhana and shamana chikitsa. GAAC, GAU, Gujrat 2004. + + + + + + diff --git a/subfolder_0/Voluntary heart rate reduction following yoga using different strategies.txt b/subfolder_0/Voluntary heart rate reduction following yoga using different strategies.txt new file mode 100644 index 0000000000000000000000000000000000000000..044bad2456079b644b8d1d8d3d7bdaac5fb347a0 --- /dev/null +++ b/subfolder_0/Voluntary heart rate reduction following yoga using different strategies.txt @@ -0,0 +1,203 @@ +8/11/2014 +Voluntary heart rate reduction following yoga using different strategies :[PAUTHORS], International Journal of Yoga (IJoY) +http://www.ijoy.org.in/printarticle.asp?issn=0973-6131;year=2013;volume=6;issue=1;spage=26;epage=30;aulast=Raghavendra +1/3 +ORIGINAL ARTICLE +Year : 2013 | Volume : 6 | Issue : 1 | Page : 26--30 +Voluntary heart rate reduction following yoga using different strategies +BR Raghavendra1, S Telles1, NK Manjunath1, KK Deepak2, KV Naveen1, P Subramanya1, +1 Department of Yoga and Biosciences, Sw ami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India +2 Department of Physiology, All India Institute of Medical Sciences, New Delhi, India +Correspondence Address: +S Telles +Patanjali Research Foundation, Patanjali Yogpeeth, Haridw ar, Uttarakhand 249408 +India +Abstract +Background/Aims: One month of yoga training has been shown to reduce the pulse rate voluntarily without using external cues. Hence, the present study was designed to +understand the strategies used by yoga practitioners and autonomic changes associated with voluntary heart rate reduction. Materials and Methods: Fifty volunteers (group mean +age ± S.D., 25.4 ± 4.8 years; 25 males) were assessed in two trials on separate days. Each trial was for 12 minutes, with a «SQ»pre«SQ» state and «SQ»during«SQ» state of 6 +minutes each. For both trials the «SQ»pre«SQ» state was relaxation with eyes closed. In the «SQ»during«SQ» state of Trial I, subjects were asked to voluntarily reduce their heart +rate using a strategy of their choice. From their responses to specific questions it was determined that 22 out of 50 persons used breath regulation as a strategy. Hence, in the +«SQ»during«SQ» state of Trial II, subjects were asked to voluntarily reduce their heart rate by breath regulation. Results: In the first trial, the heart rate was reduced by an average of +19.6 beats per minute and in the second trial (with breath regulation exclusively) an average decrease of 22.2 beats per minute was achieved. Conclusions: Hence, the strategy used +did not markedly alter the outcome. +How to cite this article: +Raghavendra B R, Telles S, Manjunath N K, Deepak K K, Naveen K V, Subramanya P. Voluntary heart rate reduction following yoga using different strategies.Int J Yoga 2013;6:26- +30 +How to cite this URL: +Raghavendra B R, Telles S, Manjunath N K, Deepak K K, Naveen K V, Subramanya P. Voluntary heart rate reduction following yoga using different strategies. Int J Yoga [serial +online] 2013 [cited 2014 Aug 11 ];6:26-30 +Available from: http://www.ijoy.org.in/text.asp?2013/6/1/26/105940 +Full Text + Introduction +There is an interest in understanding whether visceral and glandular functions can be voluntarily regulated. Many functions which were originally thought to be involuntary are now +known to be operantly conditioned. [1] There are several methods used to train an individual in voluntary regulation of these functions such as biofeedback which uses external cues. +In contrast, the ancient Indian science of yoga is believed to help in gaining mastery over the mind and body by awareness of internal sensations, breath regulation and directed +attention. [2] +Earlier studies investigated whether yoga practitioners are in fact able to control functions thought to be mainly, if not entirely, involuntary. For example, experienced yoga practitioners +claimed to be able to stop their heart beating at will. In some practitioners the amplitude of the QRS complex in the electrocardiogram was found to be lower, and was associated +with maintained inspiration and signs of raised intra thoracic pressure. [3] These findings suggested that the yoga practitioners used breath maneuvers to bring about the +cardiovascular changes seen in them. However, similar explanations did not apply to another yogi who remained in an underground pit for eight days, with an absence of electrical +activity in the EKG during the period. [4] The findings remained inexplicable to investigators. It was also difficult to explain the ability of practitioners of a Tibetan Buddhist meditation, +g-Tum-mo yoga, to increase the temperature of their digits by 5 to 15°C. [5] +In these reports the yoga practitioners were all experienced and committed to yoga practice. More recently a study was undertaken on novices to yoga practice, to determine whether +one month of yoga training would help them to reduce their pulse rate guided by external visual cues. [6] A group who practiced yoga were compared to a non-yoga control group. The +yoga group and the control group were able to achieve a pulse rate reduction of 7.1 beats per minute and 6.0 beats per minute on Day 1, respectively. While these values were not +significantly different, the pulse rate reduction achieved at the end of one month was a decrease of 23.1 beats per minute for the yoga group compared to a decrease of 5.2 beats per +minute recorded in the control group. Both groups were guided by external visual cues during each session. Hence, the results suggested that yoga practice could augment the +effect of feedback cues, within a month of learning yoga. +A subsequent study examined the effect of one month of yoga practice on the ability to voluntarily reduce the pulse rate without external cues. [7] At the start of the study, the lowest +pulse rates achieved during a six minute session, were comparable for yoga and control groups. At the end of one month, the yoga group was able to reduce their pulse rate +significantly by 6.8 beats per minute without external cues while the control group showed no change. However, the reduction of 6.8 beats per minute without using external cues +was considerably less than the reduction of 23 beats per minute observed when external cues were used. [6] +In the absence of the external cues individuals would have used their own strategies to reduce their pulse rate. Hence, the present study was designed to attempt to understand the +strategies used by yoga practitioners during voluntary heart rate reduction, and simultaneously recording changes in heart rate variability (HRV). + Materials and Methods +Participants +8/11/2014 +Voluntary heart rate reduction following yoga using different strategies :[PAUTHORS], International Journal of Yoga (IJoY) +http://www.ijoy.org.in/printarticle.asp?issn=0973-6131;year=2013;volume=6;issue=1;spage=26;epage=30;aulast=Raghavendra +2/3 +Fifty volunteers with ages ranging from 18 to 37 years (group mean age ± S.D. 25.4 ± 4.8 years; 25 males) participated in the study. All of them were residential trainees at different +stages of yoga training programs of two years duration. Their average experience of yoga was 16.3 ± 14.0 months. A routine clinical examination showed that they all had normal +health. An electrocardiogram (EKG) recording showed that none of them had extra systoles or any abnormality in the EKG. The project was approved by the Institutional Ethics +Committee. The study design was explained to the participants who gave their signed consent to participate in this study. +Design of the study +All participants were assessed in two trials on two separate days. Both trials were for 12 minutes. This duration was selected to be comparable with the assessment periods in two +earlier studies which examined voluntary pulse rate reduction following yoga. [6],[7] In the earlier studies the pulse rate was measured from the record of the peripheral pulse using a +photo electric transducer. For the first trial (Trial I), subjects were asked to sit at ease with their eyes closed, for six minutes. This was the 'pre' state. In the next six minutes subjects +were asked to attempt to voluntarily reduce their heart rate. They were not given any suggestion how to do so and were asked to use a strategy of their choice. This was the 'during' +state. At the end of Trial I the subjects were asked to tick (√) the option which described the strategy they used to reduce their heart rate voluntarily. The questionnaire had 7 choices +(and was multiple-choice and open ended). The options from which they had to select any one were: (i) mental imagery, (ii) muscle relaxation, (iii) mental repetition of a syllable, (iv) +internal awareness, (v) breath regulation, (vi) meditation, or (vii) any other strategy, which allowed participants to add any other strategy used by them, and hence, was open ended. +44 percent of the subjects (i.e., 22 out of 50) chose breath regulation as the strategy. Hence, for Trial II, the first six minutes (or 'pre' state) was the same as for Trial I. However, for the +'during' state, also of six minutes all subjects were asked to regulate their breath as a possible way to voluntarily reduce their heart rate. For breath regulation subjects were asked to +breathe slowly and deeply. Throughout the session both the Trial I and Trial II subjects were asked to sit at ease in a chair and to keep their eyes closed. +Assessments +The electrocardiogram (EKG) was acquired using Ag/AgCl adhesive pre-gelled electrodes (Bio Protech, Korea) and a standard limb lead I configuration. The EKG was recorded +using an ambulatory EKG system (Recorders and Medicare Systems ECG 101, Chandigarh, India). The sampling rate was 1024 Hz and data were stored offline for analysis, using a +software developed at the Department of Physiology, All India Institute of Medical Sciences, New Delhi, India. The data were visually inspected off-line and noise free data were +included for analysis. Data were acquired separately during the 'pre' and the 'during' states of both Trial I and Trial II. +Data extraction +The heart rate was obtained from the interbeat interval. Frequency domain analysis of heart rate variability data was carried out for six minute recordings of both 'pre' and 'during' +states. The heart rate variability power spectrum was obtained using Fast Fourier Transform (FFT) analysis. The energy in the heart rate variability series in the following frequency +bands was used for analysis., viz., the very low frequency band (VLF; 0.0 - 0.04 Hz), low frequency band (LF; 0.04 - 0.15 Hz), and high frequency band (HF; 0.15 - 0.40 Hz). The low +frequency and high frequency band values were expressed as normalized units. [8] The heart rate was obtained from the interbeat interval and the average heart rate recorded in two +six minute states ('pre' and 'during'), as well as the lowest heart rate reached in the 'during' state was noted. +Data analysis +Statistical analysis was done using SPSS (Version 10.0). Values obtained in the 'during' state were compared to the 'pre' state of a trial, using a t-test for paired data. This was done +separately for Trial I and for Trial II. The values compared were the average heart rate and the power of the heart rate variability components (i.e., LF, HF, and VLF, as well as the +LF/HF ratio). The least heart rate achieved in the 'during' state of Trial I was compared with the least heart rate achieved in the 'during' state of Trial II. + Results +Trial I +In the 'during' state of Trial I subjects attempted to voluntarily reduce their heart rate and did not use any specific strategy. The average heart rate was lower 'during' compared to 'pre' +(P> 0.01, paired t-test). There was a significant increase in the low frequency (LF) power 'during' compared to 'pre' (P> 0.05, paired t-test). The high frequency (HF) power was +significantly less 'during' compared to 'pre' (P> 0.05, paired t-test), and the LF/HF ratio was higher 'during' compared to 'pre' (P> 0.05, paired t-test). The very low frequency (VLF) +power was lower 'during' compared to 'pre' (P> 0.001, paired t-test). +Trial II +In the 'during' state of Trial II subjects attempted to voluntarily reduce their heart rate by breath regulation. In the 'during' state the following values were higher, the LF power of the +heart rate variability (P> 0.001), the LF/HF ratio (P> 0.001) and the VLF power (P> 0.001). In contrast, the HF power was significantly lower 'during' compared to 'pre' (P> 0.001). The +least heart rate achieved in the 'during' state of Trials I and II were not significantly different. Groups mean values ± S.D. are given in [Table 1].{Table 1} + Discussion +In the present study on fifty normal volunteers with sixteen months of experience in yoga, participants achieved a significantly lower heart rate during a period of attempting to reduce +the heart rate by breath regulation. The decrease was by 22.2 beats per minute (group mean 57.3 ± 7.4 beats per minute) compared to preceding rest periods. When subjects used +strategies of their own choice, their heart rate was lower by 19.6 beats per minute (group mean 60.1 ± 7.5) beats per minute. +The decrease in heart rate achieved when subjects used breath regulation as a strategy to voluntarily reduce their heart rate was comparable to the reduction achieved in an earlier +study when subjects used external visual cues and achieved a reduction of 23 beats per minute, [6] but was considerably more than the decrease of 7.1 beats per minute seen in +another group who attempted to decrease their heart rate without external cues. This difference may be related to the fact that the subjects of present study had longer experience of +yoga than those assessed earlier (i.e., an average of 16 months as compared to 1 month). Practicing yoga has been shown to improve the regularity of breathing, [9] reduce +physiological arousal, [10] and increase attention. [11] Hence, the practice of yoga may facilitate the conditioning of visceral responses by autosuggestion. In the present study +participants did use autosuggestion to reduce their heart rate. However, it is possible that though the participants did use their own strategy to reduce the heart rate since they were +trained in yoga, self-regulation may have added to the effects seen. +In the present study there was an increase in the LF power in the 'during' states of both Trial I and Trial II compared to the respective 'pre'. The LF band of heart rate variability is +chiefly related to sympathetic modulation when expressed as normalized units. [8] It is also reported that acute increase in the low frequency and total spectrum heart rate variability +and in vagal gain were corrected with slow breathing during biofeedback periods. [12] Also, it was shown that biofeedback training to increase the amplitude of respiratory sinus +arrhythmia maximally increases the amplitude of heart rate oscillations at 0.1 Hz, exclusively. [13] To achieve this, breathing is slowed to a point at which resonance occurs between +respiratory induced oscillations and oscillations that naturally occur at this rate. In the present study in both the 'during states' (i.e., of Trial I and Trial II), the subjects modified their +breathing, to breathe slower and deeper. For Trial I this was true for 22 out of 50 persons, whereas for Trial II all 50 persons were asked to breathe slowly and deeply. The data of +those participants who used breath techniques during both trial periods appeared to show no clear training effect as in Trial 1 the 22 participants showed an average heart rate +reduction of 3 beats per minute, from 81.5 (pre) to 78.1 (during). In Trial II there was no change, as the heart rate in 'pre' state was 78.4 and in 'during' state was 78.5. However, the +least heart rate achieved in Trial II (55.97) was marginally less than that achieved in Trial I (58.71), suggesting that there may have been some training effect, though the difference +8/11/2014 +Voluntary heart rate reduction following yoga using different strategies :[PAUTHORS], International Journal of Yoga (IJoY) +http://www.ijoy.org.in/printarticle.asp?issn=0973-6131;year=2013;volume=6;issue=1;spage=26;epage=30;aulast=Raghavendra +3/3 +was not statistically significant. +The increase in LF power was greater in the 'during' state of Trial II (52.6 percent increase) compared to 'during' state of Trial I (12.6 percent increase). The fact that respiration was +not simultaneously monitored is a drawback of the present study. In the absence of such an objective assessment, it is only possible to speculate that the increase in LF power may +have been related to slower breath rates. This suggests that the shift to greater LF activity in the 'during' phase of both trials resulted from a change in breath rate to the low frequency +range rather than from changes in autonomic balance. +In both 'during' states of the two trials the HF power decreased, compared to the 'pre' as did the LF/HF ratio. When expressed as normalized units efferent vagal activity is a major +contributor to the HF band. The LF/HF ratio is correlated with sympatho-vagal balance. [14] The present results are suggestive of a shift in the autonomic balance, with lower vagal +activity and possible sympathetic predominance in the 'during' states. However, in the 'during' states the heart rate was lower than the pre-state. This was not unexpected as subjects +were attempting to reduce their heart rates voluntarily. Hence, while the average heart rate in the 'during' states was lower than in the respective 'pre' states; and this did not appear to +be due to a change in the autonomic balance. This lack of clarity is due to the fact that the changes in heart rate variability may have been related to a change in breath frequency, and +in the absence of a record of respiration this remains unanswerable. +The VLF (very low frequency) power was also lower in the 'during' states of both trials. While the very low frequency power accounts for more than 90 percent of the total power in the +24 - h heart rate power spectrum, the physiological mechanisms underlying the very low frequency power have not been determined. [15] The VLF power partially reflects +thermoregulatory mechanisms, fluctuation in activity of the renin-angiotensin system, and the function of peripheral chemoreceptors. [14],[16] Also, both the respiratory pattern and +level of physical activity modulate very low frequency power. [17],[18] Hence, the physiological mechanisms for very low frequency power are not fully understood. For this reason +there has been no attempt to discuss the physiological significance of changes in very low frequency power in the present study. +In summary, the present study has shown that yoga practitioners with an average of 16 months of experience in yoga, were effectively able to reduce their heart rates by 19.6 beats +per minute when they used strategies of their choice, and were able to achieve a reduction of 22.2 beats per minute when all of them used breath regulation as a strategy for heart +rate reduction. The exact mechanisms underlying the change are not known. Further studies, with a simultaneous recording of variables regulated by the autonomic nervous system +along with recording the breath frequency would be expected to help in understanding the mechanisms involved. The possible mechanism of such changes in heart appears to be +due to enhance respiratory sinus arrhythmia. Yoga training includes variety of physical and psychic maneuver which have capability to enhance respiratory sinus arrhythmia. +The study has three main limitations. (i) there was no control group which used specific strategies to reduce their heart rate voluntarily, and (ii) despite the fact that biofeedback has +clinical possibilities in decreasing the blood pressure, [19] in the present study it was not possible to record the blood pressure, and (iii) participants were not asked whether they +used the Valsalva maneuver, which is known to alter the heart rate. [20] These limitations suggest directions for future studies. +References +1 +Leukel F. Introduction to physiological psychology. Indian ed. Delhi: CBS Publications. 1985. +2 +Taimini IK. The science of yoga. madras: The theosophical publishing house; 1986. +3 +Wenger MA, Bagchi BK, Anand BK. Experiments in India on 'voluntary' control of the heart and pulse. Circulation 1961;24:1319-25. +4 +Kothari LK, Bordia A, Gupta OP. The yogic claim of voluntary control over the heartbeat: An unusual demonstration. Am Heart J 1973;86:283-4. +5 +Benson H, Lehman JW, Malhotra MS, Goldman RF, Hopkins J, Epstein MD. Body temperature changes during the practice of g-Tum-mo yoga. Nature 1982;295:234-5. +6 +Telles S, Vani R. Increase in voluntary pulse rate reduction achieved following yoga training. Int J Stress Manag 2002;9:235-9. +7 +Telles S, Joshi M, Dash M, Raghuraj P, Naveen KV, Nagendra HR. An evaluation of the ability to voluntarily reduce the heart rate after a month of yoga practice. Integr Physiol +Behav Sci 2004;39:119-25. +8 +Task force of the european society of cardiology and the north american society of pacing and electrophysiology, heart rate variability: Standards of measurements, +physiological interpretation and clinical use. Circulation 1996;93:1043-65. +9 +Telles S, Srinivas RB. Autonomic and respiratory measures in children with impaired vision following yoga physical activity programs. Int J Rehabil Health 1999;4:117-22. +10 +Telles S, Narendran S, Raghuraj P, Nagarathna R, Nagendra HR. Comparison of changes in autonomic and respiratory parameters of girls after yoga and games at a +community home. Percept Mot Skills 1997;84:251-7. +11 +Telles S, Raghuraj P, Maharana S, Nagendra HR. Immediate effect of three yoga breathing techniques on performance on a letter cancellation task. Percept Mot Skills +2007;104:1289-96. +12 +Lehrer PM, Vaschillo E, Vaschillo B, Lu SE, Eckberg DL, Edelberg R, et al. Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosom +Med 2003;65:796-805. +13 +Lehrer PM, Vaschillo E, Vaschillo B. Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Appl Psychophysiol +Biofeedback 2000;25:177-91. +14 +Malliani A, Pagani M, Lombardi F, Cerutti S. Cardiovascular neural regulation explore in the frequency domain. Circulation 1991;84:482-92. +15 +Hadase M, Azuma A, Zen K, Asada S, Kawasaki T, Kamitani T, et al. Very low frequency power of heart rate variability is a powerful predictor of clinical prognosis in patients +with congestive heart failure. Circulation 2004;68:343-7. +16 +Parati G, Saul JP, Di Rienzo M, Mancia G. Spectral analysis of blood pressure and heart rate variability in evaluating cardiovascular regulation: A critical appraisal. +Hypertension 1995;25:1276-86. +17 +Bernadi L, Valle F, Coco M, Calciati A, Sleight P. Physical activity influences heart rate variability and very-low-frequency components in Holter electrocardograms. +Cardiovasc Res 1996;32:234-7. +18 +Mortara A, Sleight P, Pinna GD, Maestri R, Prpa A, La Rovere MT, et al. Abnormal awake respiratory patterns are common in chronic heart failure and may prevent evaluation +of autonomic tone by measures of heart rate variability. Circulation 1997;96:246-52. +19 +Patel C, North WR. Randomised controlled trial of yoga and biofeedback in management of hypertension. Lancet 1975;2:93-5. +20 +Looga R. The Valsalva manoeuvre-cardiovascular effects and performance technique: A critical review. Respir Physiol Neurobiol 2005;147:39-49. + + +Monday, August 11, 2014 + Site Map | Home | Contact Us | Feedback | Copyright and Disclaimer diff --git a/subfolder_0/YOGA BASED ISOMETRIC RELAXATION VERSUS SUPINE REST.txt b/subfolder_0/YOGA BASED ISOMETRIC RELAXATION VERSUS SUPINE REST.txt new file mode 100644 index 0000000000000000000000000000000000000000..d1a097381f8a6d139e19d82978bee8e00b8a24fd --- /dev/null +++ b/subfolder_0/YOGA BASED ISOMETRIC RELAXATION VERSUS SUPINE REST.txt @@ -0,0 +1,22 @@ + + + + + + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/YOGA FOR REHABILITATION - AN OVERVIEW.txt b/subfolder_0/YOGA FOR REHABILITATION - AN OVERVIEW.txt new file mode 100644 index 0000000000000000000000000000000000000000..6be30bcbb91a507f0e9b4e319dccd4c360090c99 --- /dev/null +++ b/subfolder_0/YOGA FOR REHABILITATION - AN OVERVIEW.txt @@ -0,0 +1,6 @@ + + + + + + diff --git a/subfolder_0/Yoga Reduces Symptoms of Distress In Tsunami Survivors.txt b/subfolder_0/Yoga Reduces Symptoms of Distress In Tsunami Survivors.txt new file mode 100644 index 0000000000000000000000000000000000000000..abcca4f0f520f8dbfe1e0800fa9a7c9bda99655c --- /dev/null +++ b/subfolder_0/Yoga Reduces Symptoms of Distress In Tsunami Survivors.txt @@ -0,0 +1,792 @@ +[Ver: A3B2-WIN8.07r/W-Standard] +[1.6.2007–5:06pm] +[1–7] +[Page No. 1] +FIRST PROOFS +K:/Journals/Inprocess/Oup/ecam/nem069.3d +(ECAM) +Paper: nem069 +OUP +eCAM 2007;Page 1 of 7 +doi:10.1093/ecam/nem069 +Original Article +Yoga Reduces Symptoms of Distress In Tsunami Survivors +5 in the Andaman Islands +Shirley Telles, K. V. Naveen and Manoj Dash +Swami Vivekananda Yoga Research Foundation (A Yoga University), Bangalore, India +A month after the December 2004 tsunami the effect of a 1 week yoga program was evaluated +10 +on self rated fear, anxiety, sadness and disturbed sleep in 47 survivors in the Andaman Islands. +Polygraph recordings of the heart rate, breath rate and skin resistance were also made. Among +the 47 people, 31 were settlers from the mainland (i.e. India, ML group) and 16 were +endogenous people (EP group). There was a significant decrease in self rated fear, anxiety, +sadness and disturbed sleep in both groups, and in the heart and breath rate in the ML group, +15 +and in the breath rate alone in the EP group, following yoga (P50.05, t-test). This suggests +that yoga practice may be useful in the management of stress following a natural disaster in +people with widely differing social, cultural and spiritual beliefs. +Keywords: Indian Ocean tsunami – stress management – yoga +20 +Introduction +The Indian Ocean tsunami which occurred in December +2004 affected various parts of South-East Asia including +the +Andaman +Islands. +These +islands +consist +of +an +25 +archipelago in the Bay of Bengal, inhabited by hunter- +gatherers who are believed to have originated from the +Paleolithic age and Neolithic colonies of South-East Asia +(1). The present population includes the endogenous +people (EP) as well as settlers from the mainland (ML), +30 +i.e. India. +A month after the tsunami there was an initiative to +introduce stress management techniques for the people +who were temporarily relocated in camps in the capital +(Port Blair), as their homes were destroyed. At that stage +35 +their immediate needs were provided. However, most of +them were anxious and distressed, this being related to +(i) the possible recurrence of the tsunami especially in +the presence of ‘after-shocks’, (ii) being displaced and +(iii) reconstructing their lives. Most of them also had +40 +to come to terms with losing their relatives, friends and +property. +As a part of this initiative a survey was conducted on +646 people of whom 328 were endogenous people and +318 were mainland settlers (2). The two populations +45 +differed in their: (i) social organization, as the EP group +form close communities under a ‘tribal leader’, whereas +the ML group has the family as the main unit and +(ii) religion, as most of the EP group follow Christianity, +whereas most of the ML group are Hindus. The ML +50 +group had higher levels for four indicators of distress +(i.e. anxiety, fear, sadness and disturbed sleep) which are +commonly reported by disaster survivors (3). The groups +also differed in their coping strategies with the EP group +choosing interpersonal contact while the ML group chose +55 +denial strategies especially alcohol. +Yoga is an ancient Indian science which includes the +practice of loosening exercises (sithilikarana vyayama), +specific postures (asanas), cleansing practices (kriyas), +voluntarily regulated breathing (pranayamas), yoga-based +60 +guided relaxation and meditation (dhyana) (4). Yoga +training has been reported to decrease heart rate and +breath rate, the signs of reduced psycho-physiological +arousal in normal volunteers (5). Significant reductions +were shown for depression, anger, anxiety, neurotic +For reprints and all correspondence: Shirley Telles PhD, Swami +Vivekananda Yoga Research Foundation (A Yoga University), # 19, +Eknath Bhavan, Gavipuram Circle, K.G. Nagar, Bangalore 560 019, +India. Tel: þ91-80-26612669; Fax: þ91-80-26608645; +E-mail: shirleytelles@gmail.com + 2007 The Author(s). +This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ +licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is +properly cited. +[Ver: A3B2-WIN8.07r/W-Standard] +[1.6.2007–5:06pm] +[1–7] +[Page No. 1] +FIRST PROOFS +K:/Journals/Inprocess/Oup/ecam/nem069.3d +(ECAM) +Paper: nem069 +OUP +symptoms and low frequency heart rate variability in +17 patients with depression following training in Iyengar +yoga (6). +The present study was designed to compare responses +5 +of the EP and ML groups to a 1 week yoga program, +based on psycho-physiological variables, as well as their +self rated indicators of distress. +Methods +Participants +10 +There were 47 persons, of whom 16 were (EP) and +31 were second-generation immigrants from the ML. +The groups were comparable with respect to education, +socio-economic status and age range (28–50 years), but +differed in their (i) social organization and (ii) religion. +15 +Both groups had lost their relatives and friends or their +homes as a result of the tsunami. All of them were in +normal health based on a routine clinical examination +and were able to perform the yoga practices. All particip- +ants gave their consent to take part in the study. +20 +The project was approved by the institutional ethics +committee. +Design +All 47 participants were assessed on day 1 and on day 8 +after receiving a 1 week program of ‘Vivekananda yoga’, +25 +detailed under ‘Interventions’ subsequently. +Assessments +Self rated Symptoms of Distress +The participants rated the intensity of their feelings with +respect to four symptoms, using a 10 cm visual analog +30 +scale (VAS). The four symptoms were fear, anxiety, +disturbed sleep and sadness. These four symptoms were +selected as they are commonly reported by disaster +survivors (3). +The electrocardiogram (EKG), breath rate and skin +35 +resistance +were +recorded +in +all +participants. +These +recordings were made simultaneously using a digital +four channel polygraph (Medicaid, Chandigarh, India), +with the participants seated in a quiet room which was +set aside for medical treatment of camp participants. +40 +After coming to the recording room the participants +were asked to be seated for 5 min followed by 10 min +of recording. +Assessment Procedure +Visual Analog Scales +45 +Emotional impact in terms of fear, anxiety, disturbed +sleep and sadness were calculated by measuring the +distance in millimeters from the left of the analog scale +(where the left end of the scale corresponded to ‘0’ and +the right end to ‘10’). All the analog scales were scored +50 +in one direction to make it easier to explain the method +to the participants. +Autonomic and Respiratory Measurements +Polygraph recordings were taken of the (i) ECG using +standard limb lead I, to obtain the heart rate by +55 +counting the number of QRS complexes in a minute, +(ii) respiration using a mechanical stethograph placed +below the costal margin, to get the breath rate and +(iii) the skin resistance using Ag/AgCl electrodes placed +in contact with the volar surfaces of the middle and ring +60 +fingers of the right hand, with a current of 15 mA passed +between the electrodes. +Intervention +Philosophy of Vivekananda Yoga +Yoga is an ancient Indian science and way of life which +65 +brings about relaxation and also induces a balanced +mental state. The participants were taught ‘Vivekananda +Yoga’ which is an integrated yoga program combining +practices intended to act at physical, emotional, intellec- +tual and even at spiritual levels. This yoga program is +70 +derived from principles in ancient texts (Patanjali’s Yoga +Sutras and Taittreya Upanisad) which emphasize that +yoga should promote health at all levels (4,5). Another +ancient Indian text (the Mandukya Upanisad) considers +the ‘body’ as three parts namely. the physical part (sthula +75 +sharira), a subtle or inner part (sukshma sharira) and the +causal body (kaarana sarira) (7). These three parts are +represented as five levels of existence (pancha koshas) (5). +These are the physical level (annamaya kosha), the level +of subtle life energy (pranayama kosha), the level of emo- +80 +tional thinking (manomaya kosha), the level of rational +thinking and judgment (vijnanamaya kosha) and the level +of complete health and happiness (anandamaya kosha). +In this description the physical level and physical part +(of the body) (sthula sharira) are the same. The levels of +85 +subtle energy, emotional and rational thinking form the +‘subtle inner part’ (sukshma sharira) and the level of +complete +health +and +happiness +is +the +causal +body +(kaarana sharira). A balance between these three parts +(shariras) is believed to be necessary for complete health. +90 +Swami +Vivekananda +Yoga +Research +Foundation, +Bangalore is an established yoga center specializing in +yoga education and using yoga as a therapy. The institute +has developed an integrated yoga program based on the +principles mentioned above and the ‘eight limbed yoga’ +95 +(astanga yoga) of Sage Patanjali which acts at different +levels of existence. These eight ‘limbs’ are: (i and ii) rules +for good conduct (yamas and niyamas), (iii) physical +2 of 7 +Yoga and tsunami survivors +[Ver: A3B2-WIN8.07r/W-Standard] +[1.6.2007–5:06pm] +[1–7] +[Page No. 1] +FIRST PROOFS +K:/Journals/Inprocess/Oup/ecam/nem069.3d +(ECAM) +Paper: nem069 +OUP +postures (asanas), (iv) voluntarily regulated breathing +(pranayama), +(v) +sensory +withdrawal +(prathyahara), +(vi) +focused +thinking +(dharana), +(vii) +meditation +(dhyana) and (viii) experience of transcendence (samadhi). +5 +The practices which act at different levels are as follows: +(i) and (ii) act at the level of rational thinking and +judgment; (iii) at the physical level; (iv) at the level of +subtle life energy; (v) and (vi) at the level of emotional +thinking (vii) and (viii) at the level of complete health +10 +and happiness. This traditional style of yoga has come to +be known as ‘Vivekananda Yoga’ (8). +Vivekananda Yoga Program +The yoga sessions were conducted in small groups with +one teacher for around ten participants. The teachers +15 +were trained in the ‘Vivekananda system’ with a 1-year +certificate course. The sessions were for 60 min daily, for +8 days and included: loosening exercises (shithilikarana +vyayama, 10 min), physical postures (asanas, 20 min), +voluntarily +regulated +breathing +(pranayama, +15 min), +20 +and yoga-based guided relaxation (15 min). +Loosening +exercises +(Sithilikarana +Vyayama, +in +Sanskrit) are a set of practices intended to increase +mobility of joints and to prepare for the practice of yoga +postures. The techniques involve repetitive movements of +25 +all the joints from the toes up to the neck. For example, +more complex joints such as the shoulder could have +movements such as rotation, flexion, extension, abduc- +tion and adduction. +For the practice of yoga postures (asanas) participants +30 +were asked to be in a posture as long as they could with +comfort and with normal breathing. The following yoga +postures +were +taught: +mountain +posture +(tadasana), +lateral +arc +posture +(ardhakatichakrasana), +hand-to- +foot +posture +(padahasthasana), +half +wheel +posture +35 +(ardhachakrasana), sitting with a sideways twist posture +(vakrasana), back-stretching posture (paschimothanasana), +half lotus posture (ardha-padmasana), diamond posture +(vajrasana), camel posture (ushtrasana), moon posture +(shashankasana), crocodile posture (makarasana), cobra +40 +posture (bhujangasana), locust posture (shalabhasana), +shoulder +stand +posture +(sarvangasana), +fish +posture +(matsyasana), and corpse posture (shavasana). These +postures are shown in Fig. 1. +While +seated +with +eyes +closed +keeping +the +neck +45 +and back as straight as possible, voluntarily regulated +breathing techniques (pranayamas) were practiced where +the nostrils were manipulated by adopting a specific hand +gesture (mudra) where the index finger and middle fingers +were flexed against the palm keeping the thumb and +50 +other fingers extended. The ring and little finger were +used to regulate the breathing through the left nostril +while the thumb was similarly used for the right nostril. +For right nostril yoga breathing (surya anuloma viloma) +and left nostril yoga breathing (chandra anuloma viloma) +Jogging +Jogging +Side twist +Resting state +Back-ward movement +Side-ways movement +Side-ways movement +1. Loosening exercises [Sithilikarana vyayama] +1.1 Standing series +1.2.1 Sitting series: Neck exercises +Figure 1. Illustration of selected loosening excercises [sithilikarana +vyayama] and yoga postures [asanas]. +eCAM 2007 +3 of 7 +[Ver: A3B2-WIN8.07r/W-Standard] +[1.6.2007–5:06pm] +[1–7] +[Page No. 1] +FIRST PROOFS +K:/Journals/Inprocess/Oup/ecam/nem069.3d +(ECAM) +Paper: nem069 +OUP +Wrist movements: upwards +Movements of the elbow joints +Exercises for fingers +Wrist movements: downwards +Vajrasana +Forward bending +Tiger stretch-1 +Tiger stretch-2 +Backward bending +Relaxation in makarasana +Straight leg raising-1 +Relaxation in shavasana +Straight leg raising-2 +Padahasthasana +Ardhachakrasana +Tadasana +ArdhaKatiChakrasana-Right ArdhaKatiChakrasana-Left +1.2.2 Sitting exercises: wrist exercises +1.3 Supine series +2. Yoga postures [Asanas] +1.2.3 Sitting series +Figure 1. Continued. +4 of 7 +Yoga and tsunami survivors +[Ver: A3B2-WIN8.07r/W-Standard] +[1.6.2007–5:06pm] +[1–7] +[Page No. 1] +FIRST PROOFS +K:/Journals/Inprocess/Oup/ecam/nem069.3d +(ECAM) +Paper: nem069 +OUP +inhalation and exhalation were exclusively through the +right +and +the +left +nostril +respectively. +These +were +practiced for nine rounds each. During alternate nostril +breathing (nadishudhi) the practice began with exhalation +5 +through the left nostril, inhalation through the same side +followed by exhalation and then inhalation on the right +side. This was considered as one round and practiced for +nine rounds. Bumble bee practice (brahmari) involved +Vakrasana-Right side +Paschimothanasana +Ardhapadmasana +Vajrasana +Vakrasana-Left side +Ustrasana +Shashankasana +Makarasana +Bhujanagasana +Sarvanagasana +Matsyasana +Relaxation in shavasana +Shalabhasana +Figure 1. Continued. +eCAM 2007 +5 of 7 +[Ver: A3B2-WIN8.07r/W-Standard] +[1.6.2007–5:06pm] +[1–7] +[Page No. 1] +FIRST PROOFS +K:/Journals/Inprocess/Oup/ecam/nem069.3d +(ECAM) +Paper: nem069 +OUP +exhalation with a humming sound with the mouth +closed and the index fingers on either side in the ears. +This practice was performed for five rounds. Guided +relaxation +involved +lying +in +the +corpse +posture +5 +(shavasana) and relaxing parts of the body beginning +with +the +toes +and +moving +upwards +according +to +instructions. +These techniques were selected either because previous +research showed that they reduced physiologic arousal +10 +(9,10) or based on our unpublished, clinical observations. +Data analysis +The data of the two groups (EP and MS) recorded before +and after the yoga intervention were compared for each +group separately, with a two-tailed t-test for paired data. +15 +The correlation between each of the self rated indicators +of distress (fear, anxiety, sadness and disturbed sleep) and +each of the psycho-physiologic variables (i.e. the heart +rate, breath rate and skin resistance) was assessed using +the Pearson correlation coefficient test. +20 Results +Visual Analog Scales +The self rated fear, anxiety, sadness and disturbed sleep +were significantly less in both EP and ML groups +following yoga compared to before (P50.05, for all +25 +comparisons). +Polygraph Data +The participants of both groups also showed a significant +decrease +in +breath +rate +(P50.05) +following +yoga. +The group average values (SD) are given in Table 1. +30 +Correlation between VAS and Polygraph Data +There was no significant correlation between the self +rated indicators of distress and the psycho-physiological +variables recorded using a polygraph. +Discussion +35 +Recapitulation of the Results +Self rated indicators of distress (namely fear, anxiety, +sadness and disturbed sleep) decreased significantly in all +participants after a 1 week yoga camp for tsunami survi- +vors. This was seen for both EP and ML. Also, the breath +40 +rate decreased significantly in both groups after yoga. +Use of Yoga for Post-Traumatic Stress Disorder (PTSD) +and Related Conditions +A yoga breathing technique has been used as a public +health intervention for survivors of mass disasters, to +45 +alleviate +post-traumatic +stress +disorder +(PTSD) +(11). +Apart from this report on the use of yoga breathing for +PTSD, +yoga +practices +have +been +shown +to +reduce +symptoms of emotional distress in different populations. +For example, Kundalini yoga (KY) meditation was shown +50 +to reduce fear in patients with cancer (12). +Yoga practice has also been shown to decrease the time +taken to fall asleep, increase the total number of hours +slept and the feeling of being rested in the morning, +in older persons (13). Improved sleep efficiency, total +55 +sleep time, decreased sleep onset latency and reduced +wake time after sleep onset in persons with chronic +insomnia were reported following yoga practice (14). +The Basis for the Present Findings +These effects of practicing yoga may explain the benefits +60 +of the yoga program in the tsunami survivors reported +here. The marginally greater decrease in fear, anxiety, +sleep disturbances and sadness in the EP as compared +with the MS may be related to differences in the sample +sizes of the groups as well as their coping strategies, +65 +previous +traumatization, +education +and +individual +vulnerability. However, of greater importance than the +difference between groups (which was not statistically +significant) +is +the +fact +that +both +groups +showed +a significant decrease in symptoms of distress following +70 +7 days of yoga training. However, the fact that the +Table 1. Self-rated indicators of distress and autonomic and respiratory variables in tsunami survivors after a week of yoga +Group +State +Self-rated indicators of distress +Autonomic and respiratory variables +Fear +Anxiety +Sadness +Disturbed sleep +Heart rate +(beats/min) +Breath rate +(breaths/min) +Skin Resistance +(in k) +Endogenous people +Pre-yoga +7.2  2.3 +7.4  2.2 +7.8  2.5 +6.8  2.7 +91.5  6.3 +26.5  7.0 +671.8  742.8 +n ¼ 16 +Post-yoga +3.5*** +4.7* +4.8*** +3.2*** +89.0 +20.9* +480.6 +2.2 +3.0 +3.1 +2.2 +12.7 +3.3 +520.6 +Mainland settlers +Pre-yoga +7.3  2.0 +7.6  1.7 +7.8  2.1 +7.2  2.2 +88.1  11.0 +24.0  7.1 +394.9  381.6 +n ¼ 31 +Post-yoga +5.3*** +5.3*** +6.2*** +5.1*** +84.9# +20.1*** +420.1 +2.2 +2.5 +2.6 +2.3 +9.6 +3.1 +383.9 +#P50.05, one tailed, *P50.05; ***P50.001 t-test for paired data, two tailed. +6 of 7 +Yoga and tsunami survivors +[Ver: A3B2-WIN8.07r/W-Standard] +[1.6.2007–5:06pm] +[1–7] +[Page No. 1] +FIRST PROOFS +K:/Journals/Inprocess/Oup/ecam/nem069.3d +(ECAM) +Paper: nem069 +OUP +VAS were used rather than validated questionnaires +is a limitation of the study. +A decrease in heart rate and breath rate following yoga +training has been reported in normal volunteers (15) and +5 +in those who have increased psycho-physiological arousal +due to their social circumstances, namely. adolescent girls in +a remand home (16). The breath rate reduced following +3 weeks of yoga in children with impaired vision (17). +The decrease in breath rate in the present study following +10 +yoga may be associated with a decrease in psycho- +physiologic arousal (18) though no correlation was found +between these variables and the self rated fear and anxiety. +Summary +The present results suggest the use of yoga to reduce +15 +stress and derive psycho-physiological benefits in survi- +vors of a major natural disaster. However, given the fact +that the study was conducted in a field setting it was +not possible to have conventional controls, which is +a definite limitation of the study. +20 Acknowledgements +The study formed part of a project funded by the +Government of the Andaman and Nicobar Islands and +the Government of Karnataka, India which is gratefully +acknowledged. +25 References +1. Thangaraj +K, +Singh +L, +Reddy +AG, +Rao +VR, +Sehgal +SC, +Underhill PA, et al. Genetic affinities of the Andaman Islanders, +a vanishing human population. Curr Biol 2003;13:86–93. +2. Telles S, Dash M, Naveen KV. Emotional impact following +30 +the tsunami in endogenous people and mainland settlers in the +Andaman Islands. Indian J Med Sci 2006;60:70–1. +3. Silver SM, Iacono CU. Factor-analytic support for DSM-III’s +post-traumatic stress disorder for Vietnam veterans. J Clin Psychol +1984;40:5–14. +35 +4. Taimini IK. The Science of Yoga. Madras: The Theosophical +Publishing House, 1986. +5. Swami Gambhirananda. Taittiriya Upanishad. Calcutta: Advaita +Ashrama, 1986. +6. Shapiro D, Cook IA, Davydov DM, Ottaviani C, Leuchter AF, +40 +Abrams M. Yoga as a complementary treatment of depression: +effects of traits and moods on treatment outcome. Evid. Based +Complement. Alternat. Med. 2007, [Advance Access published on +February 28, 2007; doi: doi:10.1093/ecam/nel114]. +7. Swami Gambhirananda. Mandukya Upanisad. Calcutta: Advaita +45 +Ashram, 2000. +8. Monro R, Nagarathna R, Nagendra HR, Ford-Kohne N. Yoga for +Common Ailments. New York: Simon & Schuster, 1991. +9. Tran MD, Holly RG, Lashbrook J, Amsterdam EA. Effects of +hatha yoga practice on the health-related aspects of physical fitness. +50 +Prev Cardio 2001;4:165–70. +10. Vempati RP, Telles S. Yoga based guided relaxation reduces +sympathetic activity judged from baseline levels. Psychol Rep +2002;90:487–94. +11. Brown RP, Gerbarg PL. Sudarshan Kriya Yogic breathing in the +55 +treatment +of +stress, +anxiety, +and +depression, +Part +II-clinical +applications +and +guidelines. +J +Altern +Complement +Med +2005;11:711–7. +12. Shannahoff-Khalsa +DS. +Patient +perspectives: +Kundalini +yoga +meditation +techniques +for +psycho-oncology +and +as +potential +60 +therapies for cancer. Integr Cancer Ther 2005;4:87–100. +13. Manjunath NK, Telles S. Influence of yoga and ayurveda on self +rated +sleep +in +a +geriatric +population. +Indian +J +Med +Res +2005;121:683–90. +14. Khalsa SB. Treatment of chronic insomnia with yoga: a preliminary +65 +study with sleep-wake diaries. Appl Psychophysiol Biofeedback +2004;29:269–78. +15. Telles S, Nagarathna R, Nagendra HR, Desiraju T. Physiological +changes in sports teachers following 3 months of training in yoga. +Indian J Med Sci 1993;47:235–8. +70 +16. Telles S, Narendran S, Raghuraj P, Nagarathna R, Nagendra HR. +Comparison of changes in autonomic and respiratory parameters of +girls after yoga and games at a community home. Percept Mot +Skills 1997;84:251–7. +17. Telles S, Srinivas RB. Autonomic and respiratory measures in +75 +children with impaired vision following yoga and physical activity +programs. Int J Rehab Health 1999;4:117–22. +18. Ax AF. The physiologic differentiation between fear and anger in +humans. Psychosomatic Med 1953;15:433–42. +Received January 1, 2007; accepted May 08, 2007 +eCAM 2007 +7 of 7 diff --git a/subfolder_0/Yoga for COVID-19.txt b/subfolder_0/Yoga for COVID-19.txt new file mode 100644 index 0000000000000000000000000000000000000000..f216e8582bdb26181d500eaf95561e157c2431de --- /dev/null +++ b/subfolder_0/Yoga for COVID-19.txt @@ -0,0 +1,122 @@ +Int J Yoga. 2020 May-Aug; 13(2): 87–88. +Published online 2020 May 1. doi: 10.4103/ijoy.IJOY_27_20 +PMCID: PMC7336947 +PMID: 32669761 +Yoga for COVID-19 +HR Nagendra +Editor-In-Chief, International Journal of Yoga, Chancellor, Swami Vivekananda Yoga Anusandha Samsthana, +Bengaluru, Karnataka, India E-mail: chancellor@svyasa.edu.in +Received 2020 Apr 4; Revised 2020 Apr 7; Accepted 2020 Apr 7. +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. +Yoga is welcomed world over for its health promoting and wellness creating aspects. Research over +three decades both at this university and elsewhere has shown the efficacy of yoga practices including +meditation in establishing homeostasis in noncommunicable diseases by reducing stress levels and +promoting healthy life style. Interconnectedness of the mind and body and correcting the imbalances +have been intensively investigated to provide a holistic framework for the health of individuals. +The pandemic global spread of coronavirus disease-19 (COVID-19) infection caused by severe acute +respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to profound global health crisis with the +recently analyzed estimate of the overall case fatality ratio in China of 1·38% (95% CI 1·23–1·53).[1] +The spread of COVID-19 and the tragedy we are all facing today makes us search for answers and +course corrections urgently needed for the very survival of humans. This has raised many questions on +our knowledge base along with the attendant social and individual ways of life. +Immunity of the host is an essential requisite to facilitate the eradication of infections. Disturbed +immune systems seen as lymphopenia and elevated C-reactive protein levels are recognized to be the +characteristic features in severely affected cases of COVID-19 infection. +While the corona viruses (0.06–0.14 μ) are the biggest among viruses so far found (0.005–0.05 μ), we +have much bigger white blood cells (WBCs) (15 μ) which constitute our defense system. Furthermore, +the number of WBCs in one drop (one ml) of blood varies from 5000 to 7000/ml amounting to millions +of WBCs in our body, while the number of COVID-19 viruses are much smaller in number. The WBCs +serve as the first line of defense against the invading viruses limiting their spread and subsequent tissue +damage. Hence, we have a very good chance of winning over the virus attack if our immune system is +normal and strong. Thus, the outcome of this infection could be either a welcome result of an effective +immune response that combats COVID-19 as observed in recovering patients with mild symptoms or a +state of immune suppression that debilitates the system leading to progression to severe damage. +Extensive work, both at this university and elsewhere, has shown that systematic special tailor-made +asana practices, dedicated pranayamas, meditation, and mantras could provide a broad-spectrum +immune build up in the body so that viral infection could be averted and/or its virulence reduced. We +published the efficacy of integrated yoga (IY) that included asanas, relaxation techniques, breathing +practices, and meditation in achieving earlier (P < 0.05) sputum negativity in the yoga group as +compared to control group as an add-on to antituberculosis treatment in sputum-positive cases of +pulmonary tuberculosis in a sanatorium in Bangalore.[2] One month of IY in patients suffering from +HIV-1 infection has reported a significant reduction in their viral load with an increase in the number of +CD4 immune cells and improvement in their psychological states.[3] A study on healthy individuals +doing transcendental meditation showed higher (P < 0.01) blood levels of B-lymphocyte series as well +as natural killer (NK) cells, as compared to nonmeditators.[4] Kamei et al.[5] reported a significant +correlation between alpha brain wave activation in the frontal lobe as seen in electroencephalogram +(indicating restful awareness) and an increase in NK activity during yoga practices pointing to the +relationship between a calm mind and better cellular immunity. +The upper respiratory tract being the portal of entry for the SARS-CoV-2 virus infection, the health of +the respiratory system is very important in preventing fatality. There are several reports of clinical trials +that suggest an overall effect of yoga training toward improved pulmonary function in patients with +chronic obstructive pulmonary disease. +A 4-min video of very simple breathing practices was sent for helping patients with acute respiratory +distress hospitalized for COVID-19 infection in Milano, Italy, as a pilot study. This has been visited by +1000 people between March 17, 2020, and March, 20, 2020, with request for more such modules. An e- +mail report by a renowned cardiac surgeon in Italy who was also affected, stayed in an intensive care +unit with an oxygen mask, and practiced this very simple module while in the and has come out of the +hospital after two negative tests says, “we have reached scientific evidence that this simplified protocol +sent by you is effective and we intend to disseminate to the overall Scientific Community.” Considering +the limitations posed by the highly contagious nature of COVID-19 that poses a great risk of +nosocomial infections among health-care workers and caregivers, we planned to deliver tele-yoga- +based intervention that would be administered through mobile yoga apps a noncontact and +nonobtrusive mode of intervention. +Thus, apart from maintaining the new norms of social distancing, frequent handwashing, and isolation +of infected persons and their contacts, we should build immunity both in the body and in minds of +people. We have seen that there is some degree of evidence presently to say that yoga practices could +provide much needed body immunity and could assure a disease-free homeostatic state for the body. +This is based on three basic concepts of yoga as highlighted in the traditional texts: +1. The total and the right understanding of five aspects of our human system and the entire creation +in general: The physical as the grossest (annamaya) with the bioenergy (Pranamaya kosha), mind +(Manomaya kosha), and the intellect (Vignanamaya kosha) as the subtle layers with the causal +state of consciousness that constitutes the bliss layer called the Anandamaya kosha, a state of all +pervasive silence at the base +2. The wrong and distorted knowledge (Viparyaya, e.g., a Jaundiced person thinking that the whole +world has become yellow) at the mind and intellect level can percolate through the brain and +hypothalamic–pituitary–adrenal axis down to bring distortions in our immune responses. The +remedy is to correct this Viparyaya and reverse the downward process of damage to the tissues +3. Several yoga techniques are available to develop mastery over the mind by enhancing the +willpower that keeps the immune system strong. These include asana, pranayama, meditation +with or without using Mantras, and detoxification through kyiyas. Along with these practices, a +mental attitude known as Pratipaksha Bhavana (contrary attitude) is recommended in the yoga +literature. Yoga recognizes the emotionally charged state of stress response, wherein the mind is +in a state of violent spinning speed of thoughts and hence, becomes unmanageable. The +techniques train the mind to let go of all violent reactions and replace them by positive thoughts +of love and acceptance (prashamana). Such an attitude of love and trust sends signals between +the brain and the heart which start working in unison, not letting the stress destabilize the +person's biochemistry. +All yoga practices utilize deep relaxation which could release all tensions and stresses to prevent +immune suppression that would otherwise have weakened the responses to the onslaught of infectious +bacteria and viruses. We need to practice antidote for stress – at work or even at home – at the time of +experiencing the stress, not 5 h later when we can cloister ourselves in a room for a short time! +Any holistic therapy should address the entire spectrum of body-mind-consciousness of an individual +so that the totality of human personality is ready for the next evolution in human consciousness. The +five sheaths of body, prana, mind and emotions, knowledge, and bliss are addressed in the modules +developed here with the understanding that an imbalance in any one could bring disorder in all sheaths. +The disorder is perceived only when it percolates to mind or body level and mending them in isolation +will only bring transitory relief. For a complete cure, all the above sheaths must be addressed and set +right so that the person is not only symptoms free but also ready to explore the depths of consciousness +moving beyond the frail human condition. +We await more publications to understand the precise role of yoga therapy in conditions like COVID- +19. Till such times, the well understood underlying mechanisms for the use of yoga for stress reduction +and immune modulation shall be considered as the basis for its complimentary role in the management +of an infectious condition like COVID-19. This editorial is offered in all sincerity and love and +dedication to all so that we can overcome this threat successfully and without much trauma. +References +1. Ruan S. Likelihood of survival of coronavirus disease 2019. Lancet infect Dis. 2020 doi: +101016/S1473-3099(20)30257-7. [PMC free article] [PubMed] [Google Scholar] +2. Visweswaraiah NK, Telles S. Randomized trial of yoga as a complementary therapy for pulmonary +tuberculosis. Respirology. 2004;9:96–101. [PubMed] [Google Scholar] +3. Naoroibam R, Metri KG, Bhargav H, Nagaratna R, Nagendra HR. Effect of integrated yoga (IY) on +psychological states and CD4 counts of HIV-1 infected patients: A randomized controlled pilot study. +Int J Yoga. 2016;9:57–61. [PMC free article] [PubMed] [Google Scholar] +4. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 +novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7:228–9. [PMC free article] +[PubMed] [Google Scholar] +5. Kamei T, Toriumi Y, Kimura H, Kimura K. Correlation between alpha rhythms and natural killer cell +activity during yogic respiratory exercise. Stress Health. 2001;17:141–5. [Google Scholar] +Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow +Publications diff --git a/subfolder_0/Yoga for academic performance A brain wave coherence analysis.txt b/subfolder_0/Yoga for academic performance A brain wave coherence analysis.txt new file mode 100644 index 0000000000000000000000000000000000000000..23ebdd41c91d1ce5ed320f5f178654a7ff20a952 --- /dev/null +++ b/subfolder_0/Yoga for academic performance A brain wave coherence analysis.txt @@ -0,0 +1,834 @@ +European Journal of Psychology & Educational Studies, Vol 1 / Issue 1 / Oct-Dec-2014 +10 +and deteriorating academic performance.[1,2] Academic +performance is essential to provide opportunities +for students to work together in improving their +understanding of concepts in their academic health +core. Academic performance helps students to +teach problem‑solving and collaborative learning +strategies.[3] Educational institutions play an important +role in encouraging student engagement, and engagement +has been shown to be one of the many factors that +is positively involved in academic achievements of +university students.[4] More specifically, it was reported +that encouraging student’s engagement in yoga activities +Introduction +Optimal stress brings out a student’s best; however, +extremes of stress can result in stress‑induced disorders +Yoga for academic performance: A brain wave +coherence analysis +Hanish Sankhla, Tikhe Sham Ganpat, Subramanyam Pailoor, Kalpesh Zala, + Parameshwar Some, Manish Ranjan, Manish Agarwal +Department of Yoga and Management, S-VYASA University, Bangalore, Karnataka, India +ABSTRACT +Background: Optimal stress brings out a student’s best; however, extremes of stress can result in stress‑induced disorders +and deteriorating performance. Yoga is known to bring positive effect on personality development in students. Can yoga be +beneficial in enhancing orderliness of brain functioning leading to increased academic performance in university students? +Objective: To assess immediate effect of Nadi Shuddhi Pranayama (NSP), Bhramari Pranayama (BP), Om Meditation (OM), +Pranic Energization Technique (PET), and Mind Sound Resonance Technique (MSRT) on brain wave coherence (BWC) +in university students. Materials and Methods: Two hundred and thirty‑four students in the range of 18–30 years of age +and 21.63 ± 3.60 (mean ± SD) years of mean age were selected for the present study from a university at Bangalore, India. +They were divided in two groups, 117 subjects in each group: yoga group (NSP = 15, BP = 30, OM = 29, PET = 27, and +MSRT = 16) and control group (NSP = 15, BP = 30, OM = 29, PET = 27, and MSRT = 16). Brain wave coherence (BWC) +data were collected immediately before and after the intervention (pre recorded session of 24 minutes in NSP, BP, OM, +PET and MSRT to yoga group and sitting quietly with the eyes closed for the same duration in control group) using Brain +Master 2 Channel EEG version 2.0 for clinical from Bio Medical Instruments, Inc., Warren, Michigan, USA. Results: The +significant increase in delta was observed in BP, OM, PET, and MSRT. Similarly, significant increase in theta was also +observed in BP and PET. Moreover, significant increase in alpha was found in BP and OM whereas significant increase +in beta was noted in BP. It was also recorded that there was significant increase in gamma in NSP, BP and MSRT. There +was no significant change observed in control group of yogic practices. Conclusion: The immediate effect NSP, BP, OM, +PET, and MSRT on BWC compared with controls shows that these yogic practices are related with increased orderliness of +brain functioning, which is essential for good academic performance. Additional well‑designed studies are needed before +a strong recommendation can be made. +Key words: Academic performance, brain wave coherence, orderliness of brain functioning, university students, +Yogic practices +Address for correspondence: +Dr. Tikhe Sham Ganpat, Swami Vivekananda Yoga Anusandhana Samsthana University, Prashanti Kutiram, 19, Eknath Bhavan, Gavipuram Circle, +Kempegowda Nagar, Bangalore ‑ 560 019, Karnataka, India. E‑mail: rudranath29@gmail.com +Original Article +Access this article online +Quick Response Code: +Website: www.ejpes.org +DOI: *** +[Downloaded free from http://www.ejpes.org on Wednesday, February 3, 2021, IP: 136.232.192.146] +Sankhla, et al.: Yogic education for academic performance +11 +European Journal of Psychology & Educational Studies, Vol 1 / Issue 1 / Oct-Dec-2014 +enhances their overall personality development.[5] Yoga, +which is a way of life, has been found to be an effective +tool in reducing stress levels.[6,7] Yogic practices are +characterized by balance, health, harmony, and bliss,[8] +which consists of Kriya (yogic purification processes), +Sukshma Vyayama (loosening and stretching practices), +Asanas  (physical postures), Pranayama  (breathing +techniques) such as Nadi Shuddhi Pranayama (NSP), +Bhramari Pranayama (BP), etc., Krida Yoga (yogic games), +Bhajan (devotional sessions), meditation practices +such as Om Meditation  (OM), Pranic Energization +Technique  (PET), and Mind Sound Resonance +Technique (MSRT) to bring about an overall personality +transformation at physical, mental, emotional, social, +and spiritual levels.[9] +Coherence is the condition of synchrony between +the waves generated in the hemispheres of the brain, +whereas brain wave coherence (BWC) is the recording +of electrical activity of different brain waves from +the surface of the skull.[10] BWC is associated with +different cognitive processes and plays both critical +and useful roles in yoga, with a wide range of functional +significance including stress reduction[6] and enhanced +academic performance.[11‑20] Similarly, it was reported +that alpha waves were higher in persons performing +meditation with good coherence, which suggested good +homogeneity, uniformity, and increased orderliness +of brain mediators, as compared to that in control +group.[21] As mentioned earlier, a student under optimal +stress does bring out his or her best; however extremes +of stress can result in stress‑induced disorders and +deteriorating performance. Can yoga be beneficial in +enhancing orderliness of brain functioning leading +to increased academic performance in university +students? The present study examines whether there +is an immediate effect of yoga‑based NSP, BP, OM, PET, +and MSRT on BWC in university students. +Objective +To assess immediate effect of NSP, BP, OM, PET, and +MSRT on academic performance in university students +undergoing BWC recordings +Materials and Methods +Subjects +Two hundred and thirty‑four students in the range +of 18–30 years of age with 21.63 ± 3.60 (mean ± SD) +years of mean age were selected for the present +study from S‑VYASA University, Bangalore. They were +divided in two groups: 117 subjects in each group: +Yoga group (NSP = 15, BP = 30, OM = 29, PET = 27, +and MSRT = 16) and control group (NSP = 15, BP = 30, +OM = 29, PET = 27, and MSRT = 16). +Inclusion Criteria: Healthy students with exposure to +yogic practices and willing to participate +Exclusion Criteria: Students taking medication, +psychiatric drugs, alcohol, or tobacco in any form or +using any other wellness strategy +Design +Two groups (yoga and control) pre‑post: Randomized +control trial +Intervention +NSP: It is an alternate nostril breathing technique[22,23] +in a pre‑recorded format was practiced in sitting on the +chair by yoga group (NSP) participants for 24 minutes, +whereas control group were asked to sit quietly with +their eyes closed for the same duration. +BP: It is a technique in which one inhales through both +nostrils and while exhaling, produces sound of female +humming bee.[24] The instructions in a pre‑recorded +format were practiced in sitting on the chair by yoga +group (BP) participants for 24 minutes, whereas control +group were asked to sit quietly with their eyes closed +for the same duration. +OM: The technique of meditating and mental chanting +of OM[25,26] in a pre‑recorded format was practiced in +sitting on the chair by yoga group (OM) participants +for 24 minutes, whereas control group were asked to +sit quietly with their eyes closed for the same duration. +PET: PET is a novel method of meditation based on the +Vedic tradition, which uses techniques of breathing and +visualization for calming the mind and for capturing and +intentionally directing Prana (“vital energy”) wherever +necessary.[27] The PET technique in a pre‑recorded +format was practiced in sitting on the chair by yoga +group  (PET) participants for 24  minutes, whereas +control group were asked to sit quietly with their eyes +closed for the same duration. +MSRT: The practice of MSRT[28,29] in a pre‑recorded +format was given to the MSRT group. MSRT works +on the principle of resonance, which is created by +repetition of mental sounds throughout the body. The +Mahamrutyunjaya Mantra and Pranav (Om or AUM) +and its components  (A, U, M) were used in MSRT. +The resonance of the body occurs when the chanting +frequency coincides with the natural frequency of the +body. The control group participants were asked to sit +[Downloaded free from http://www.ejpes.org on Wednesday, February 3, 2021, IP: 136.232.192.146] +Sankhla, et al.: Yogic education for academic performance +European Journal of Psychology & Educational Studies, Vol 1 / Issue 1 / Oct-Dec-2014 +12 +quietly with their eyes closed for the same duration as +MSRT session (24 minutes). This MSRT [Table 1] was +developed using 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).[30] MSRT opens +up the secret of traditional chants called Mantras.[29] +Assessments +In this study, we used BrainMaster two‑Channel +EEG version 2.0 from Bio‑Medical Instruments, Inc., +Warren, Michigan for BWC recording,[31,32] which records +brain waves and through an inbuilt software, gives +the coherence values of delta (δ), theta (θ), alpha (α), +beta (β), and gamma (γ) waves. We collected BWC data +using electrode locations C3 and C4 referenced to linked +earlobes, with the ground at the forehead. We kept the +electrode impedances below 10 KΩ to ensure noise‑free, +accurate, and good brain wave recordings.[13,14] The +sampling frequency was 256 Hz. Protocol of setting file +was brain wave pro 2 channel alpha synchrony. Run of +length was 10.0 minutes. We studied BWC immediately +before and after the intervention for both yoga (NSP, +BP, OM, PET, and MSRT) and control subjects. During +BWC recording, all subjects were resting on the chair +with their eyes closed for 24 minutes in the research +laboratory of S‑VYASA University. +Data collection +BrainMaster calculates and displays coherence for +different components as delta, theta, alpha, beta, and +gamma. In addition, we can set a threshold between +0.01 and 0.99 for training. The operator can select any +or all of the components for sound feedback; hence, +coherence training was easy. In addition, we can show +the coherence on the summary screen, and read it from +the Excel spreadsheet containing the minute‑by‑minute +statistics. Coherence between 0.0 and 0.4 in brain wave +is not significant, because random signals can have a +small amount of coherence. However, coherent values +above 0.5 and especially exceeding 0.6 are significant +for brain wave training.[33] +Statistical analysis +All statistical analyses were carried out using the +version  16.0 of the Statistical Package for Social +Sciences (SPSS) software. Tests of Normality using +Kolmogorov‑Smirnov Test showed that the data +were normally distributed (P > 0.05). Further, Paired +Samples Test was used for analyzing the data. Results +were presented as Mean ± SD. P value less than 0.05 +was considered statistically significant with different +significance levels expressed as ***P < 0.001, **P < 0.01, +and *P < 0.05). +Results +After comparing pre‑  and post‑measurements in +yoga (NSP, BP, OM, PET, and MSRT) and control groups, +a complete statistical analysis of BWC using Paired +Samples Test showed following results: +NSP: Overall 57.96% significant increase (P = 0.001) +in gamma waves. Similarly, there was an increase in all +other brain wave rhythms, which was not significant, +whereas in the control group, there was no significant +change was found in BWC [Table 1]. +BP: Overall 40.86% significant increase +(P  <  0.001) in delta waves, 32.19% significant +increase (P  <  0.001) in theta waves, 20.09% +significant increase (P = 0.010) in alpha waves, 24.97% +significant increase (P = 0.007) in beta waves, and +41.32% significant increase (P < 0.001) in gamma BWC. +In control, there was no significant change [Table 2]. +OM: About 24.50% significant increase (P = 0.028) in delta +and 35.48% significant increase (P = 0.004) in alpha BWC. +There was no significant change in other BWC rhythms of +OM group as well as in its control group [Table 3]. +PET: About 25.77% significant increase (P = 0.001) in +delta and 17.47% significant increase (P = 0.033) in +theta BWC. There was no significant change in other +BWC rhythms of PET group as well as in its control +group [Table 4]. +Table 1: Nadi Shuddhi Pranayama +Brain waves +coherence +(HZ) +Mean±standard deviation +Experimental group (NSP) +% increase +(↑) +P +Mean±standard deviation +Control group (NSP) +% decrease +(↓) +P +Before (pre) +After (post) +Before (pre) +After (post) +Delta (δ) (1-3) +84.20±27.65 +85.95±22.29 +18.67 +0.703 +96.58±2.59 +93.83±4.92 +2.85 +0.022* +Theta (θ) (4-7) +68.42±29.68 +73.49±21.49 +24.48 +0.242 +79.53±13.32 +73.93±12.47 +6.14 +0.064 +Alpha (α) (8-12 +63.48±30.59 +73.54±24.85 +65.61 +0.273 +75.53±16.82 +67.48±20.08 +8.50 +0.140 +Beta (β) (13-39) +59.61±17.28 +66.22±22.37 +13.73 +0.139 +69.35±27.22 +58.06±27.04 +7.81 +0.089 +Gamma (γ) (40-45) +43.84±21.78 +62.67±23.56 +57.96 + 0.001** +61.83±28.06 +49.86±29.46 +5.39 +0.105 +**P<0.01, *P<0.05, (paired samples test), NSP: Nadi Shuddhi Pranayama +[Downloaded free from http://www.ejpes.org on Wednesday, February 3, 2021, IP: 136.232.192.146] +Sankhla, et al.: Yogic education for academic performance +13 +European Journal of Psychology & Educational Studies, Vol 1 / Issue 1 / Oct-Dec-2014 +MSRT: The Wilcoxon’s Signed Rank Tests showed +significant increase in delta BWC (P = 0.002) in MSRT +group compared to control group (P = 0.501). Similarly, +the Paired Samples Test showed significant increase in +gamma BWC (P = 0.012) in MSRT group compared to +control group (P = 0.686). There were no significant +changes observed in other BWC rhythms in MSRT group +as well as in its control group [Table 5]. +Discussion +Brain activity is associated with different cognitive +processes and plays a critical role in different yogic +practices.[6,34,35] BWC analysis is a technique that +investigates the pair wise correlations of power spectra +obtained from different electrodes. It measures the +functional interaction between cortical areas in different +frequency bands. A high level of coherence between two +Table 2: Bhramari Pranayama +Brain waves +coherence (HZ) +Mean±standard deviation +Experimental group (BP) +% increase +(↑) +P +Mean±standard deviation +Control group (BP) +% increase (↑) +% decrease (↓) +P +Before (pre) +After (post) +Before (pre) +After (post) +Delta (δ) (1-3) +53.65±33.40 +75.57±29.95 +40.86 +<0.001*** +52.73±38.30 +59.96±28.29 +13.72 +0.295 +Theta (θ) (4-7) +44.91±23.92 +59.26±23.91 +32.19 +<0.001*** +45.54±29.22 +54.59±26.29 +19.89 +0.091 +Alpha (α) (8-12) +51.19±26.16 +61.47±23.35 +20.09 +0.010* +48.93±26.01 +53.90±22.09 +10.14 +0.380 +Beta (β) (13-39) +47.80±29.27 +59.74±26.98 +24.97 +0.007** +49.08±25.60 +48.31±24.39 +1.57 +0.880 +Gamma (γ) (40-45) +34.06±20.02 +48.13±20.62 +41.32 +<0.001*** +36.84±21.72 +76.83±29.95 +7.57 +0.345 +***P<0.001, **P<0.01,*P<0.05 (paired samples test), BP: Bhramari Pranayama +Table 3: Om Meditation +Brain waves +coherence (Hz) +Mean±standard deviation +Experimental group (OM) +% increase +(↑) +P +Mean±standard deviation +Control group (OM) +% increase (↑) +% decrease (↓) +P +Before (pre) +After (post) +Before (pre) +After (post) +Delta (δ) (1-3) +43.42±23.53 +54.06±28.46 +24.50 +0.028* +51.53±25.25 +54.69±21.15 +6.14 +0.410 +Theta (θ) (4-7) +50.69±33.48 +63.48±35.62 +25.88 +0.074 +45.27±17.31 +49.76±18.18 +9.92 +0.156 +Alpha (α) (8-12) +38.25±23.49 +51.82±27.72 +35.48 +0.004** +46.13±21.09 +51.98±25.57 +12.67 +0.346 +Beta (β) (13-39) +48.22±23.65 +50.46±22.98 +4.66 +0.686 +39.63±22.35 +39.55±22.08 +0.21 +0.986 +Gamma (γ) (40-45) +37.69±21.24 +46.10±22.62 +22.30 +0.064 +32.46±12.68 +34.66±17.75 +6.78 +0.547 +**P<0.01,*P<0.05, (paired samples test), OM: Om Meditation +Table 4: Pranic Energization technique +Brain Waves +Coherence (Hz) +Mean±standard deviation +Experimental group (PET) +% increase +(↑) +P +Mean±standard deviation +Control group (PET) +% increase (↑) +% decrease (↓) +P +Before (pre) +After (post) +Before (pre) +After (post) +Delta (δ) (1-3) +72.11±31.11 +90.68±17.37 +25.77 +0.001** +57.79±30.51 +52.64±35.98 +8.91 + 0.438 +Theta (θ) (4-7) +59.60±26.20 +70.01±20.94 +17.47 +0.033* +49.76±24.11 +51.26±24.83 +3.13 + 0.735 +Alpha (α) (8-12) +56.20±27.74 +61.80±24.02 +9.96 +0.284 +50.75±26.87 +55.80±24.22 +9.95 + 0.246 +Beta (β) (13-39) +54.72±22.63 +58.56±19.60 +7.02 +0.344 +61.42±23.03 +60.30±23.47 +1.83 + 0.812 +Gamma (γ) (40-45) +39.85±21.78 +46.15±21.74 +15.81 +0.172 +36.39±18.61 +35.52±20.30 +2.41 + 0.804 +**P<0.01,*P<0.05, (paired samples test), PET: Pranic Energization Technique +Table 5: Mind sound resonance technique +Brain waves +coherence +Mean±standard deviation +Experimental group (MSRT) +% increase (↑) +% decrease (↓) +P +Mean±standard deviation +Control group (MSRT) +% increase (↑) +% decrease (↓) +P +Before (pre) +After (post) +Before (pre) +After (post) +Delta (δ) (1-3) +80.26±25.50 +90.75±23.13 +16.19 +0.002** +86.69±24.63 +84.32±25.18 +0.66 +0.501 +Theta (θ) (4-7) +60.33±36.30 +54.33±34.25 +1.36 +0.121 +72.44±25.88 +67.35±24.78 +10.69 +0.464 +Alpha (α) (8-12) +59.24±28.10 +55.02±24.21 +3.75 +0.424 +66.77±23.31 +63.45±29.75 +20.17 +0.709 +Beta (β) (13-39) +51.04±19.54 +56.85±22.44 +17.30 +0.165 +60.51±20.92 +64.53±18.56 +12.86 +0.325 +Gamma (γ) (40-45) +44.27±22.33 +49.01±25.38 +19.05 +0.012* +52.37±20.42 +49.78±25.77 +8.87 +0.686 +**P<0.01,*P<0.05, (paired samples test), MSRT: Mind sound resonance technique +[Downloaded free from http://www.ejpes.org on Wednesday, February 3, 2021, IP: 136.232.192.146] +Sankhla, et al.: Yogic education for academic performance +European Journal of Psychology & Educational Studies, Vol 1 / Issue 1 / Oct-Dec-2014 +14 +signals indicates a co‑activation of neuronal populations +and provides information on functional coupling +between these areas.[35] Previous report on BWC +showed significant increase in alpha BWC suggesting +that yoga‑based Self Management of Excessive Tension +program develops the ability to heal and manage stress in +corporate executives.[10] Similarly, there was significant +increase in both delta and alpha BWC in university +students reporting that Integrated Yoga Module can +result in improvement of coherent and integrated brain +functioning among university students, thus paving the +way for their better mental health performance.[36] Yoga +is the best lifestyle modification, which aims to attain the +unity of mind, body, and spirit through Asana (exercise), +Pranayama  (breathing), and meditation.[37] While +practicing Pranayama one concentrates on the act +of breathing, which removes focus from worries and +“de‑stresses” them. This stress‑free state of mind evokes +relaxed responses, in which parasympathetic nerve +activity overrides sympathetic activity.[38] +The emergence of the slow frequency waves in BP and +PET strongly supports the existing claims of frontal theta +in producing meditative state along with trait effects in +attention processing.[34] Interestingly, predominance of +slow wave potentials (delta) is associated with voluntary +pain control.[39,40] Therefore, yogic practices such as BP, +OM, PET, and MSRT, in which delta BWC was increased, +can induce the state of deeper relation of body and mind, +demonstrating the capacity of voluntary pain control. +Similarly, it was reported that alpha waves were higher +in persons performing meditation with good coherence, +which suggested good homogeneity, uniformity, and +increased orderliness of brain mediators as compared +to that in control group.[21] Hence, BP and OM are best +yogic practices to induce balanced mental activity. In the +present study, the practice of NSP, BP, and MSRT generate +controlled high‑frequency gamma waves consistent +with the previous reports induces parasympathetic +dominance signifying relaxed state of mind.[41,42] The +increase in beta and alpha observed in the present study +during BP and OM practices compared to control has a +balancing effect on the functional activity of the left and +right hemisphere.[43] +Conclusion +The immediate effect of yogic practices (NSP, BP, OM, +PET, and MSRT) on BWC when compared with controls +suggests that yogic practices may be associated with +increased orderliness of brain functioning, which may +enhance academic performance in university students. +Although this preliminary research is promising, +well‑designed studies are needed before a strong +recommendation can be made. +References +1. +Malathi A, Damodaran A. Stress due to exams in medical +students‑ Role of yoga. Indian J Physiol Pharmacol 1999;43:218‑24. +2. +Kauts A, Sharma N. Effect of yoga on academic performance in relation +to stress. Int J Yoga 2009;2:39‑43. +3. +Tikhe SG, Nagendra HR, Tripathi N. Ancient science of yogic life for +academic excellence in university students. Anc Sci Life 2012;31:80‑3. +4. +Casuso‑Holgado MJ, Cuesta‑Vargas AI, Moreno‑Morales N, +Labajos‑Manzanares MT, Barón‑López FJ, Vega‑Cuesta M. The +association between academic engagement and achievement in health +sciences students. BMC Med Educ 2013;13:33. +5. +Udupa KN. Stress and its management by yoga 2nd ed. Delhi: Narendra +Prakash Jain; 1985. +6. +Michaels RR, Huber MJ, McCann DS. Evaluation of transcendental +meditation as a method of reducing stress. Science 1976;192:1242‑4. +7. +Vempati RP, Telles S. Yoga‑based guided relaxation reduces +sympathetic activity judged from baseline levels. Psychol Rep +2002;90:487‑94. +8. +Nagendra HR. Beyond quantum physics. Int J Yoga 2009;2:1. +9. +Kumar S, Nagendra HR, Manjunath NK, Naveen KV, Telles S. +Meditation on OM: Relevance from ancient texts and contemporary +science. Int J Yoga 2010;3:2‑5. +10. +Ganpat TS, Nagendra HR, Muralidhar K. Effects of yoga on brain wave +coherence in executives. Indian J Physiol Pharmacol 2011;55:304‑8. +11. +Miskiman DE. The effect of Transcendental Meditation Program on +the organization of thinking and recall (secondary organization). +Graduate department of Psychology. Collected Papers V1. 58 +Edmonton, Alberta. Canada: University of Alberta; 1973. +12. +Schecter H. The Transcendental Meditation program in the classroom. +A psychological evaluation. Doctoral thesis (summary), graduate +department of psychology, York university North York, Ontario, +Canada. Dis Abstr Int 1977;38:3372B. +13. +Alexander CN, Kurth SS, Travis F, Warner T, Alexander VK. Cognitive +stage of development in children practicing the Transcendental +Meditation program: Acquisition and consolidation of conservation +Department of Psychology and Social Relations, Harvard University, +Cambridge, Massachusetts USA, Hampshire College, Amherst, +Massachusetts, USA, Department of Psychology and Department of +Management and Public Affairs, Maharishi International University, +Fairfield, Iowa, USA, and Department of Psychology, York University, +Toronto, Ontario, Canada. 1979. +14. +Wallace RK, Orme‑Johnson DW, Mills PJ, Dillibeck MC, Jacobe E. +The relationship between the paired Hoffman reflex and academic +achievement in participants of the Transcendental Meditation (TM) +program. Department of Biology and Psychology. Fairfield, Iowa: +Maharishi International University; 1980. +15. +Wallace RK, Mills PJ, Orme‑Johnson DW, Dillibeck MC, Jacobe E. The +paired H reflex and its correlation with EEG coherence and academic +performance in normal subjects practicing meditation. Soc Neurosci +Abstr 1982;8:537. +16. +Kember P. The Transcendental Meditation technique and postgraduate +academic performance: A shot report on controlled and longitudinal +pilot study. Br J Educ Psychol 1985;55:164‑6. +17. +Warner TQ. Transcendental meditation and development +advancement: Mediating abilities and conservation performance. Diss +Abstr Int 1986;47:3558B. +18. +Nidich SI, Schneider RH, Nidich RJ, Rainforth M, Salerno J, Scharf D, +et al. Maharishi Vedic vibration technology on chronic disorders and +associated quality of life. Front Biosci 2001;6:H1-6. +19. +Schneider RH, Nidich SI, Salerno JW, Sharma HM, Robinson CE, +Nidich RJ, et al. Lower lipid peroxide levels in practitioners of the +Transcendental Meditation program. Psychosom Med 1998;60:38-41. +20. +Muehlman JM, Nidich SI, Reilly B, Cole C. Relationship of the practice +of the Transcendental Meditation Technique to academic achievement. +Paper presented at the Annual meeting of the Mid‑Western +Educational Research Association, Chicago: Illinois; 1988. +21. +Khare KC, Nigam SK. A study of electroencephalogram in meditators. +Indian J Physiol Pharmacol 2000;44:173‑8. +[Downloaded free from http://www.ejpes.org on Wednesday, February 3, 2021, IP: 136.232.192.146] +Sankhla, et al.: Yogic education for academic performance +15 +European Journal of Psychology & Educational Studies, Vol 1 / Issue 1 / Oct-Dec-2014 +22. +Upadhyay Dhungel K, Malhotra V, Sarkar D, Prajapati R. Effect of +alternate nostril breathing exercise on cardiorespiratory functions. +Nepal Med Coll J 2008;10:25‑7. +23. +Subbalakshmi NK, Saxena SK, Urmimala, Urban JA. Immediate +effect of nadishodhana pranayama on some selected parameters +of cardiovascular, pulmonary and higher functions of brain. Thai J +Physiol Sci 2005;18:10‑6. +24. +Saxena T, Saxena M. The effect of various breathing exercises +(pranayama) in patients with bronchial asthma of mild to moderate +severity. Int J Yoga 2009;2:22‑5. +25. +Gururaja D, Harano K, Toyotake I, Kobayashi H. Effect of yoga on +mental health: Comparative study between young and senior subjects +in Japan. Int J Yoga 2011;4:7‑12. +26. +Oswal P, Nagarathna R, Ebnezar J, Nagendra HR. The effect of +add‑on yogic prana energization technique (YPET) on healing of +fresh fractures: A randomized control study. J Altern Complement +Med 2011;17:253‑8. +27. +Fernandes CA, Nóbrega YK, Tosta CE. Pranic meditation affects +phagocyte functions and hormonal levels of recent practitioners. +J Altern Complement Med 2012;18:761‑8. +28. +Nagendra HR. Mind sound resonance technique. Bangalore: Swami +Vivekananda Yoga Prakashana; 2001. +29. +Yogitha B, Nagarathna R, John E, Nagendra H. Complimentary +effect of yogic sound resonance relaxation technique in patients with +common neck pain. Int J Yoga 2010;3:18‑25. +30. +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. +31. +Collura TF. History and evolution of computerized +electroencephalography. J Clin Neurophysiol 1995;12:214‑29. +32. +Collura TF. Real‑time filtering for the estimation of steady‑state visual +evoked brain potentials. IEEE Trans Biomed Eng 1990;37:650‑2. +33. +Collura TF. Conclusion: QEEG‑guided neurofeedback in context and +in practice. Appl Psychophysiol Biofeedback 2010;35:37‑8. +34. +Baijal S, Srinivasan N. Theta activity and meditative states: Spectral +changes during concentrative meditation. Cogn Process 2010;11:31‑8. +35. +Franken IH, Stam CJ, Hendriks VM, van den Brink W. +Electroencephalographic power and coherence analysis suggest +altered brain function in bstinent male heroin‑dependent patients. +Neuropsychobiology 2004;49:105‑10. +36. +Ganpat TS, Nagendra HR, Selvi V. Efficacy of yoga for mental +performance in university students. Indian J Psychiatry 2013;55:349‑52. +37. +Iyengar BK. Light on yoga. 7th  ed. New  Delhi: Harpercollins +Publishers; 2002. p. 21. +38. +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. +39. +Peper E, Wilson VE, Gunkelman J, Kawakami M, Sata M, +Barton W, et al. Tongue piercing by a Yogi: QEEG observations. Appl +Psychophysiol Biofeedback 2006;31:331‑8. +40. +Kakigi R, Nakata H, Inui K, Hiroe N, Nagata O, Honda M, et al. +Intracerebral pain processing in a Yoga Master who claims not to feel +pain during meditation. Eur J Pain 2005;9:581‑9. +41. +Vialatte FB, Bakardjian H, Prasad R, Cichocki A. EEG paroxysmal +gamma waves during Bhramari Pranayama: A  yoga breathing +technique. Conscious Cogn 2009;18:977‑88. +42. +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. +43. +Stancák A Jr, Kuna M. EEG changes during forced alternate nostril +breathing. Int J Psychophysiol 1994;18:75‑9. +How to cite this article: Sankhla H, Ganpat TS, Pailoor S, Zala K, +Some P, Ranjan M, et al. Yoga for academic performance: A brain wave +coherence analysis. Eur J Psychol Educ Studies 2014;1:10-5. +Source of Support: Nil, Conflict of Interest: None declared. +[Downloaded free from http://www.ejpes.org on Wednesday, February 3, 2021, IP: 136.232.192.146] +Editorial + +Special message of Professor Philip Zimbardo, one of the most famous +psychologists of century, former president of American Psychological +Association to Alireza Memarian, Global Representative at International +Positive Education Network(IPEN): + + + +I wish to send my fondest greetings to all the readers of this new and exciting +European journal of Psychology (positive psychology). I hope it will become a +central marketplace for sharing research and conceptual ideas that can help +inform and inspire educators, business leaders, politicians, parents and youth +to work in harmony to transform Iranian society for the good of all people. + +Among the many Iranians I met during my recent visit to academic +institutions, arts and crafts centers, holy places, ancient cities, and dinners in +private homes, I was very impressed by the editor of this new journal, Alireza +Memarian. His enthusiasm for promoting positive psychology throughout his +nation was boundless and his vision well focused. I have agreed to be an +honorary member of his board of directors in his new Iranian Positive +Psychology program (Foundation). + + + Professor Philip Zimbardo, Ph.D. + Stanford University, Emeritus + President & Founder, Heroic Imagination Project + diff --git a/subfolder_0/Yoga-based lifestyle treatment and composite treatment goals in type 2 Diabetes in a rural South Indian setup-a retrospective study.txt b/subfolder_0/Yoga-based lifestyle treatment and composite treatment goals in type 2 Diabetes in a rural South Indian setup-a retrospective study.txt new file mode 100644 index 0000000000000000000000000000000000000000..ad10595533daa4029f71563d0d6e0d94b082bd0a --- /dev/null +++ b/subfolder_0/Yoga-based lifestyle treatment and composite treatment goals in type 2 Diabetes in a rural South Indian setup-a retrospective study.txt @@ -0,0 +1,1026 @@ +1 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +Yoga-based lifestyle treatment and +composite treatment goals in Type +2 Diabetes in a rural South Indian +setup- a retrospective study +Geetharani Arumugam1, Raghuram Nagarathna1, Vijaya Majumdar1*, Mandeep Singh2, +Rambabu Srinivasalu2, Rajagopal Sanjival2, Venkat S. Ram3 & +Hongasandra Ramarao Nagendra1 +This multicentre retrospective study examined the effects of adjunct yoga-treatment in achieving +composite cardiovascular goals for type 2 diabetes (T2D), set forth by the American Diabetes +Association (ADA) in rural Indian settings. Records were extracted for 146 T2D patients, aged ≥20–70 +years, and treated under the “Apollo Total Health Programme” for rural diabetes management, +for the period April 2016 to November 2016. The study cohort comprised of two treatment groups +(n = 73 each); non-yoga group (standard of care) and yoga group (adjunct yoga-treatment). +Propensity score matching was applied between the study groups to define the cohort. Composite +cardiovascular scores were based on the combination of individual ADA goals; A1c < 7%, blood +pressure (BP) < 140/90 mmHg, stringent BP (<130/80 mmHg) and lipid, LDL-C < 100 mg/dl [risk +factor for atherosclerotic cardiovascular disease]. Logistic regression was used to compare between +the two treatment groups. Compared to standard of care, adjunct yoga-treatment was found to +significantly facilitate the attainment of ADA composite score by 8-fold; A1c, ~2-fold; LDL-C, ~2-fold; +BP < 140/90 mmHg and <130/80 mmHg by ~8-and ~6-fold respectively. This study provides the first +evidence for significant efficacy of adjunct yoga-treatment for the attainment of favourable treatment +goals for T2D in rural Indian settings. Clinical Trial Registration Number: CTRI/2020/02/0232790 +Type 2 Diabetes (T2D) is a chronic progressive metabolic disease, pathophysiologically hallmarked by insulin +resistance and hyperglycemia, and clinically underlined by associated severe macrovascular and microvascular +ramifications1. According to the current estimates of the 8th edition of the atlas, International Diabetes Federation +(IDF), 425 million people are afflicted by T2D across the globe2. As well-reflected in the current IDF estimates +of 2018, with 72.95 million resident T2D populations, India is one of the most severely afflicted countries with +the epidemic. Urbanization and change of lifestyle are attributed as the major underlying causes of this rising +epidemic1,3,4. +Efficient diabetes care is a crucial aspect of the disease owing to its progressive nature5–7. Intensive glycemic +control delays development and aids in prevention of late T2D complications5,8. However, glycemic control is +not a stand-alone measure for efficient T2D care6,7. The compound pathophysiology of T2D is associated with +many other deranged metabolic indices contributing to the development of cardiovascular comorbidities1,9. The +most effective approach towards reduced mortality and morbidity in T2D appears to be comprehensive risk fac- +tor reduction targeting glycemic control, management of blood pressure and dyslipidemia9,10. These factors also +underlie the guidelines for Standards of Medical Care issued towards efficient cardiovascular control in T2D +by American Diabetes Association (ADA) which are updated annually in the month of January7. ADA guide- +lines recommend a combined target for [A1c < 7% and blood pressure (BP) < 140/90 mmHg (older cut off for +BP < 130/80 mmHg) for diabetes care. Though the recent guidelines of lipid management do not specify LDL-C +targets, the guidelines recommended LDL-C cut-off as <100 mg/dl for effective cardiovascular control against +1Division of Life sciences, Swami Vivekananda Yoga Anusandhana Samsathana, Bengaluru, 560106, Karnataka, +India. 2Health Programme-Apollo Hospitals Ardhagiri road, Aragonda village, Tavanampalle mandal, Chittoor +district, 517129, Andhrapradesh, India. 3Apollo Hospitals, Hyderabad, Telengana, India. *email: majumdar.vijaya@ +gmail.com +OPEN +2 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ +atherosclerotic cardiovascular disease7. Despite of these guidelines, at least one-third of patients with T2DM fail +to achieve their ADA goals11–13. The ultimate success of treatment algorithms of T2D is strongly associated with +concomitant synergistic lifestyle changes along with pharmacotherapy14. According to current ADA guidelines, +lifestyle management, with medical nutrition therapy and physical activity, is a fundamental component of dia- +betes care6. These guidelines also recommend incorporation of yoga, the ancient skillset of Indian origin, into the +regimen of physical activity based on individual preferences5. Yoga is an ancient Indian practice that emphasizes +balancing of various aspects (like physical, mental, emotional, and spiritual) of an individual. +South Asian ethnicity including Indians has been characterized as one of the most challenging population for +diabetes care with suboptimal status3,14. Though initially considered a “disease of opulence” +, the recent trends sug- +gest that diabetes has significantly impacted rural India, characterized by inadequate health care, and poverty15,16. +The recent visibility of T2D epidemic in rural India notifies an increasing trend in the prevalence estimates; esca- +lated from 1% to 4–10% in the year and reaching as high as 13.2% in an earlier report16. India is an agricultural +nation, with 72.2% of the population residing in its rural sector, hence the trending high prevalence of the rural +diabetes epidemic are highly alarming16. Several distinct cultural and socioeconomic factors define the epidemic +of T2D in rural India17. Response and efficacy of lifestyle interventions are governed by cultural practices as well +as genetic/ethnic makeup18. India is a vast country and an amalgamation of various social, cultural and sub-ethnic +groups. In view of the reported high receptivity of yoga on diabetes management in Asians Indians3, we aimed +to evaluate the effectiveness of this cost-effective lifestyle treatment in the marginalized rural clinical settings of +Southern India. +Results +Baseline Characteristics.  +Records of a total of 146 T2D patients were retrieved. The mean age of the study +cohort was 55.61 ± 10.90 years, the majority were female 64.40% (n = 94) , and 76.03% (n = 111) belonged to +low socioeconomic status. The recruited study cohort had an average duration of diabetes of ~6 years. According +to the ADA criteria, 54.79% (n = 80) of the total study cohort was found to be above recommended A1c targets +(≥7.0%, 53 mmol/ml), 81.51% (n = 119) above BP1 targets (≥130/80 mmHg), 47.26% (n = 69), above BP2 tar- +gets (≥140/90 mmHg) and 47.94% (n = 70) above lipid targets (LDL ≥ 100 mg/dl)19. Overall, at baseline, 93.83% +(n = 137) and 85.62% (n = 125) of the study cohort was found to be above combined ADA composite scores 1 and +2, respectively. The cohort was also observed to have generalized obesity with a mean BMI of 26.69 ± 4.58 Kg/ +m2. Importantly, 85.62% (n = 125) of the study cohort was found to be overweight/obese according to the Asian +cut off for BMI (≥23 kg/m2)20. At baseline, subjects in the yoga group had significantly lower DBP levels than the +non-yoga group (yoga, 80.66 ± 9.30 mmHg vs. 84.52 ± 10.12 mmHg; P = 0.032) but were similar to the control +group with respect to other parameters (Table 1). +Effect of Yoga treatment on the attainment of ADA-laid goals.  +Yoga treatment was found to have a +significant beneficial effect on attainment of the composite ADA goal, reflected by an increase of 2.74% [baseline, +6.85% (n = 5) to follow-up, 9.59% (n = 7)] in the number of subjects meeting the composite score 1, whereas +the control group exhibited a pronounced deterioration by 4.11% [baseline (5.48%), n = 4) to follow-up (1.37%, +n = 1) (Table 2)]. Similarly, there was an increase of 12.33% [baseline, 15.07% (n = 11) to follow-up, 27.40% +(n = 20)] in the number of subjects meeting the composite score 2, whereas the control group exhibited a pro- +nounced deterioration by 8.22% [baseline 13.70%, (n = 10) to follow-up 5.48%, (n = 4) (Table 2)]. When analysed +by multiple regression, yoga treatment was found to be 10-fold (OR = 10.20, 95% CI = 0.69–174.19) borderline +significant (P = 0.060) and ~8-fold (OR = 8.22, 95% CI = 2.02–33.49), statistically significant (P = 0.003), effective +towards attaining the favourable composite ADA score 1 and 2, respectively (Table 2). +With respect to the status of A1C goals of ADA (<7%), 46.58% (n = 34) subjects were found to meet criteria +for in the yoga group at baseline, however, the percentage increased to 54.79% (n = 40) at follow-up (Table 2). +In the non-yoga group, the percentage of subjects with A1c criteria decreased from 43.84% (n = 32) to 36.99% +(n = 27) (Table 2). The difference in the distribution between the patients meeting ADA criteria for A1c was +statistically significant between yoga and non-yoga treatment groups at the follow-up (P = 0.046). When ana- +lysed by multiple logistic regression, modelled by covariates, age, sex, duration of diabetes, socioeconomic status, +baseline A1c values, yoga treatment was found to be significantly associated with the ~2-fold (OR = 2.44, 95% +CI = 1.19–5.00, P = 0.015) higher chances of attainment of favourable A1c cut off (<7%) as compared to standard +of care (Table 2). +The percentage of subjects who met the ADA-criteria with respect to favourable LDL-C, < 100 mg/dl, +increased from 52.05% (n = 38) to 54.79% (n = 40) in the yoga group (Table 2). However, in the non-yoga group, +there was a decrease from 52.05% (n = 38) to 38.36% (n = 28) in the number of subjects who met the LDL-C cri- +teria (Table 2). The distribution of patients with favourable LDL-C values was not significant between yoga and +non-yoga groups at the follow-up (Table 2). However, when analysed by logistic regression, adjusted for covariates +and, baseline lipid status, yoga treatment was found to be significantly associated with the ~2-fold (OR = 2.22, +95% CI = 1.06–4.68, P = 0.035) increased chances for the attainment of favourable LDL-C outcome (<100 mg/dl) +as compared to standard of care alone (Table 2). +We assessed the BP outcomes with old and revised favourable cut-offs recommended by ADA (Table 3). When +analysed with old cut-off (<130/80 mm Hg), we could observe a pronounced increase in the percentage of sub- +jects meeting the favourable BP outcome from 21.92% (n = 16) to 34.25% (n = 25) in the yoga group (Table 2). +On the contrary, in the non-yoga group, the number of T2D patients who met BP criteria of <130/80 mm +Hg decreased from 15.07% (n = 11) to 8.22% (n = 6) (Table 2). When analysed by logistic regression, yoga treat- +ment was found to be associated with ~6.4-fold (OR = 6.37, 95% CI = 2.24–18.08, P = 0.001) increase the chances +of favourable BP cut-offs (<130/80) at follow-up. When analysed with revised new BP cut-off (<140/90 mm Hg), +we could observe a pronounced increase in the percentage of subjects meeting the favourable BP outcome from +3 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ +60.27% (n = 44) to 84.93% (n = 62) in the yoga group (Table 2), yoga treatment was also found to be associated +with 8.28-fold (95% CI, 3.52–19.48, P < 0.0001) increased chances for the revised favourable BP cut-offs,. In the +non-yoga group, the number of T2D patients who met BP criteria decreased from 45.21% (n = 33) to 39.73% +(n = 29) (Table 2). +We also analysed the status of cardiovascular control for the subgroup of study cohort with uncontrolled dia- +betes (A1c ≥ 8.0%), n = 44. We could observe 63.16% success towards attainment of lipid goal (LDL < 100 mg/dl) +and 26.32% for BP targets (130/80 mmHg) 89.47% for BP target (140/90) by 6-months of yoga treatment (data not +shown). However, the controls exhibited deterioration with respect to these goals (data not shown). +Effect of yoga treatment as compared to standard of care was demonstrated with respect to the attainment of +favourable BMI cut-off (<23 Kg/m2) for Asians (Table 2). When analysed by logistic regression, yoga treatment +Variable +Groups +P value +Yoga (n = 73) +Non-yoga (n = 73) +Age, Years +≤ 45 +14 (19.18) +19 (26.03) +0.429 +> 45 +59 (80.82) +54 (73.97) +Sex, n (%) +Men +28 (38.36) +24 (32.88) +0.604 +Women +45 (61.64) +49 (67.12) +Socio-economic status, n (%) +High +4 (5.48) +3 (4.11) +0.109 +Medium +9 (12.33) +19 (26.03) +Low +60 (82.19) +51 (69.86) +Hypertension, n (%) +Yes +25 (34.25) +29 (39.73) +0.607 +No +48 (65.75) +44 (60.27) +Obesity +BMI ≤ 25Kg/m2 +32 (43.84) +38 (52.05) +0.740 +BMI > 25 Kg/m2 +41 (56.16) +35 (47.95) +Known diabetes, n (%) +Yes +44 (60.27) +41 (56.16) +0.737 +No +29 (39.73) +32 (43.84) +Duration of diabetes, n (%) +≤5 years +28 (38.36) +27 (36.99) +1.000 +>5 years, n (%) +45 (61.64) +46 (63.01) +Body mass index, BMI (kg/m2) +27.18 ± 4.07 +26.16 ± 5.06 +0.139 +Medication for T2DM, n (%) +Yes +34 (46.58) +38 (52.05) +0.508 +No +39 (53.42) +35 (47.95) +Anti-hypertensive drugs, n (%) +0.604 +Yes +24 (32.88) +28 (38.36) +No +49 (67.12) +45 (61.64) +Lipid-lowering drugs +0.001 +Yes +3 (4.11) +17 (23.29) +No +70 (95.89) +56 (76.71) +Biochemical variables +A1c (%) +7.4 ± 2.3 +7.7 ± 2.3 +0.605 +FBS, mg/Dl +100.27 ± 24.72 +114.66 ± 45.042 +0.189 +PPBS, mg/dL +175.21 ± 46.87 +197.26 ± 67.76 +0.088 +SBP, mm Hg +126.07 ± 13.78 +130.44 ± 16.05 +0.060 +DBP, mm Hg +80.66 ± 9.30 +84.52 ± 10.12 +0.032 +Total Cholesterol, mg/dl +177.71 ± 27.94 +176.36 ± 34.11 +0.437 +Triglyceride, mg/dl +144.59 ± 28.68 +143.69 ± 44.27 +0.120 +LDL-c, mg/dL +103.55 ± 26.53 +102.16 ± 32.90 +0.557 +HDL-c. mg/dL +45.24 ± 1.72 +45.30 ± 2.66 +0.120 +Table 1.  Baseline characteristics of theT2DM cohort with and without yoga treatment. Test statistics, Pearson’s +chi-square for categorical variables & Mann-Whitney U tests for continuous variables; FBS, fasting blood +glucose; PPBS, postprandial blood glucose; SBP, systolic blood pressure; DBP, diastolic blood pressure; LDL-c +low density lipoprotein cholesterol, continuous values are presented as meand ± SD. +4 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ +was found to be associated with 62-fold (OR = 61.73, 95% CI = 3.19–1193) increased chances of attainment of the +favourable BMI cut-off over a period of 6 months (Table 2). +Outcomes in continuous measures.  +Over the study period of around 6-months, the yoga-group exhib- +ited significant within-group beneficial mean changes and percent changes in A1c, −0.50%, (−5.03%); FBS, +−11.27 mg/dL (−8.00%); PPBS, −25.51 (−−11.44%); Wt., −2.91 (-4.18%); BMI, −1.14 Kg/m2 (−4.04%); SBP, +−5.30 (−3.02%); DBP, −4.57 (−4.60%); TC, −2.94 mg/dl (−1.49%), HDL-c, −0.70 mg/dl (−1.49%) (Table 3). +With respect to triglyceride (TG), we could observe an unexpected increase in the mean TG levels in the yoga +group, 11.74 ± 3.72 mg/dl (31.94%) (Table 3). We observed pronounced worsening of the metabolic variables in +the non-yoga group (Table 3). We could observe a deteriorating trend in the mean difference of these variables +from baseline in the non-yoga group (Table 3). Significant within-group differences were also observed in the +non-yoga group for FBS, 11.14 mg/dl (18.31%); BMI, 0.76 Kg/m2 (4.06%); HDL-c, −2.51 mg/dl (−4.72%), and +TG, 67.70 mg/dl (59.01%). Between-study group differences between yoga group and non-yoga group very sig- +nificant with respect to all the studied parameters (Table 3). +Discussion +Type 2 diabetes is associated with vascular complications and enhanced risk of cardiovascular events. Therefore, +ADA has suggested a multifactorial targeted approach towards efficient management of T2D [glycemic, lipid, +and blood pressure]5,7. Use of such composite endpoints in clinical studies also help in the better understanding +of the net effect of an intervention or a therapy rather than individual endpoints21,22. Further, studies targeting +composite endpoints have been reported to have higher statistical efficiency as compared to those with individual +endpoints22. We hereby highlight the grim status of diabetes management with respect to the attainment of the +ADA laid primary treatment goals, in rural Indian settings. At baseline of the study, 54.79% was found to be above +ADA laid A1c targets (≥7.0%), 47.26% was found to be above lipid targets (LDL-C > 100 mg/dl) and 81.51% were +found to be above BP cut-offs of>130/80 mmHg, and 47.26% were found to be above the revised BP cut-offs +(<140/90 mmHg)5. Overall, only 6.16% (n = 9) of the total study cohort was found to be meeting the composite +Outcome +Baseline +Follow up +Logistic Regression analysis +Yoga, n (%) +Non-Yoga, n (%) +P Value +Yoga, n (%) +Non-Yoga, n (%) +P Value +Adjusted OR +Adjusted CI +P Value +A1c target +<7% +34(46.58) +32(43.84) +0.868 +40(54.79) +27(36.99) +0.046 +2.44 +1.19–5.00 +0.015 +≥7% +39(53.42) +41(56.16) +33(45.21) +46(63.01) +1(ref) +BP1 +<130/80 mm Hg +16(21.92) +11(15.07) +0.286 +25(34.25) +6 (8.22) +<0.0001 +6.37 +2.24–18.08 +0.001 +≥ 130/80 mm Hg +57(78.08) +62(84.93) +48(65.75) +67(91.78) +1(ref) +BP2 +<140/90 mmHg +44 (60.27) +33(45.21) +0.097 +62(84.93) +29(39.73) +<0.0001 +8.28 +3.52–19.48 +<0.0001 +≥140/90 mm Hg +29 (39.73) +40(54.79) +11(15.07) +44(60.27) +1(ref) +LDL-c target +<100 mg/dl +38(52.05) +38(52.05) +1.000 +40(54.79) +28(38.36) +0.068 +2.22 +1.06–4.68 +0.035 +≥ 100 mg/dl) +35(47.95) +35(47.95) +33(45.21) +45(61.64) +1(ref) +Composite Score 1 +Favourable +5(6.85) +4(5.48) +0.712 +7(9.59) +1(1.37) +0.013 +10.20 +0.69–174.19 +0.060 +Unfavourable +68(93.15) +69(94.52) +66(90.41) +72(98.63) +1(ref) +Composite Score 2 +Favourable +11(15.07) +10(13.70) +1.000 +20(27.40) +4(5.48) +0.001 +8.22 +2.02–33.49 +0.003 +Unfavourable +62(84.93) +63(86.30) +53(72.60) +69(94.52) +1(ref) +BMI +<23 Kg/m2 +6(8.22) +15(20.55) +0.057 +11(15.07) +5(6.85) +0.184 +61.73 +3.19–1193 +0.006 +≥23 Kg/m2 +67(91.78) +58(79.45) +62(84.93) +68(93.15) +1(ref) +Table 2.  Association of yoga-treatment versus non-yoga treatment with ADA cut-offs and Logistic regression +at follow-up. OR, Odds ratio; OR (A1c target) for yoga vs. non-yoga groups, adjusted for age, sex, occupation, +BMI at baseline, duration of diabetes, glycaemic indices, (FBS, PPBS and A1c) at baseline and intake of oral +hypoglycaemic drug, BP, Blood pressure OR(BP targets) for yoga vs. non-yoga groups adjusted for age, sex, +duration of diabetes, socioeconomic status, SBP and DBP at baseline; and medication for blood pressure. +OR(LDL-c target) for yoga vs. non-yoga groups adjusted for age, sex, occupation, duration of diabetes, +BMI, LDL-c, TG, TC and HDL-c at baseline, * additionally adjusted for lipid lowering drugs. OR(BMI) for +yoga vs. non-yoga groups adjusted for age, sex, duration of diabetes, education, smoking status and alcohol +consumption, and BMI Values at baseline Ref: Reference group, non-yoga treatment group Composite score +1(favourable): A1c < 7.0%, BP1 < 130/80 mm Hg, LDL-c < 100 mg/dl, additionally adjusted for baseline glucose, +lipid values and BMI values, and medications. Composite Score 2 (favourable): A1c < 7.0%, BP2 < 140/90 mm +Hg, LDL-c < 100 mg/dl. +5 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ +score of all the three treatment targets at the baseline. However, a prior report by Menon et al.15, indicated only +1–3% of Indian T2D population achieving the combined treatment goals of ADA in an urban clinical setup. The +pathophysiological link between obesity and T2D was also evident in the study cohort, wherein, 62.33% (n = 91) +of the cohort sample was found to be obese. As majority of the cohort sample (~80%), belonged to low socio- +economic status23, this poor status of cardiovascular risk control could be attributed to lack of pharmacologic +management, governed by poor awareness and socioeconomic status in the rural Indian settings. +Lifestyle management plays an essential role in the efficient control of diabetes status6,24. Yoga, as a lifestyle +intervention has been reported to lead to beneficial health outcomes related to cardiovascular and metabolic +disorders including T2D25,26. Based on its high reported receptivity and cost-effectiveness, yoga holds a strong +potential as a lifestyle management skill in Indian scenario3. This is the first report wherein the efficacy of yoga +treatment was assessed in aiding the cardiovascular fitness with respect to achievement of ADA laid primary +treatment goals of T2D in rural Indian settings. Our findings reflect a magnitude of success of 10.96% attained by +6-months of yoga treatment on overweight/obese T2D Indian rural cohort. However, Ikramuddin et al. reported +Variables +Group +Baseline values, +mean ± SE (95% +CI) +Follow up values. +mean ± SE (95% +CI) +Mean change +from baseline +mean ± SE (95% +CI) +Within +study +groups +Between study groups +Percentage change +from baseline (95% +CI) +Test +statistics +Test statistics +Partial +eta +squared +P value +F +P value +A1c (%) +Yoga-group +7.40 ± 1.30 +(7.03–7.77) +6.90 ± 1.29 +(6.53–7.27) +−0.50 ± 1.49 +(−0.15 to −0.85) +−5.03 (−9.64 to +−0.42) +0.002 +19.18 +≤0.001 +0.120 +Non-yoga group +7.75 ± 1.88 +8.05 ± 1.94 +0.30 ± 2.99 +10.66 (1.26 to 20.1) +0.396 +Fasting plasma glucose, +mg/dl +Yoga-group +100.27 ± 24.72 +(93.02–107.52) +89.00 ± 10.14 +(81.75–96.25) +−11.27 ± 22.91 +(−16.62 to −5.93) +−8.00 (−11.7 to +−4.29) +<0.0001 +48.69 +≤0.001 +0.259 +Non-yoga group +114.66 ± 45.04 +(107.41–121.91) +126.33 ± 41.03 +(115.66–130.91) +11.15 ± 56.53 +(−3.62 to 25.89) +18.31(5.91 to 30.7) +0.019 +Postprandial plasma +glucose, mg/dl +Yoga-group +175.20 ± 46.87 +(162.25–188.16) +149.70 ± 30.46 +(136.74–162.66) +−25.51 ± 40.01 +(−34.84 to −16.17) +−11.44 (−15.7 to +−7.2) +<0.0001 +49.25 +≤0.001 +0.262 +Non-yoga group +197.26 ± 67.76 +212.53 ± 73.44 +14.63 ± 117.23 +19.82 (4.02 to 35.6) +0.249 +Weight, Kg +Yoga-group +68.82 ± 27.18 +(66.33–71.29) +65.90 ± 10.28 +(63.50–68.30) +−2.90 ± 2.37 +(−3.46 to −2.36) +−4.18 (−4.96 to +−3.39) +<0.0001 +29.96 +≤0.001 +0.176 +Non-yoga group +65.82 ± 12.36 +67.33 ± 11.82 +1.51 ± 6.07 +2.30 (−0.23 to 4.83) +<0.0001 +BMI, Kg/m2 +Yoga-group +27.18 ± 4.07 +(26.25–28.27) +26.02 ± 0.51 +(25.02–27.02) +−1.14 ± 1.20 +(−1.44 to −0.92) +−4.04 (−5.01 to +−3.05) +<0.0001 +29.01 +≤0.001 +0.172 +Non-yoga group +26.16 ± 5.06 +(25.12–27.13) +26.92 ± 4.33 +(25.79–27.88) +0.76 ± 2.67 (0.04 +to 1.39) +4.06 (1.15 to 6.97) +0.002 +Systolic blood pressure, +mmHg +Yoga-group +126.07 ± 13.78 +(119.65–125.12) +120.77 ± 10.55 +(118.03 − 123.50) +−5.30 ± 17.97 +(−9.50 to −1.11) +−−3.02 (−6.22 to +0.18) +0.026 +57.94 +≤0.001 +0.293 +Non-yoga group +130.44 ± 16.05 +(128.39 − 133.86) +135.11 ± 11.88 +(132.34-138.05) +4.67 ± 18.86 +5.19 (1.38 to 9) +0.083 +Diastolic blood +pressure, mmHg +Yoga-group +80.66 ± 9.30 +(78.54-82.77) +76.08 ± 7.28 +(73.97-78.20) +4.57 ± 10.51 +−4.60 (−7.59 to +−1.61) +0.001 +40.76 +≤0.001 +0.225 +Non-yoga group +84.52 ± 10.11 +(82.40 −86.64) +86.23 ± 9.86 +(83.72-88.13) +1.71 ± 13.33 (−2.17 +to 4.46) +2.94 (−0.93 to 6.81) +Total Cholesterol, +mg/dl +Yoga-group +177.71 ± 27.94 +(170.60-184.82) +174.77 ± 26.87 +(167.66-181.88) +−2.94 ± 33.88 +(−10.85 to 4.96) +−1.49 (−2.27 to +−0.708) +0.439 +6.40 +0.012 +0.044 +Non-yoga group +176.36 ± 34.11 +(169.25-183.47) +185.26 ± 28.88 +(181.31-196.26) +8.90 ± 43.30 (−0.63 +to 25.69) +5.05 (2.76 to 7.34) +0.055 +LDL Cholesterol, mg/dl +Yoga-group +103.55 ± 26.53 +(96.74-110.36) +98.96 ± 25.42 +(92.15-105.77) +−4.59 ± 33.22 +(−12.34 to 3.16) +−1.03 (7.42 to 9.48) +0.312 +4.56 +0.035 +0.032 +Non-yoga group +102.15 ± 32.69 +(95.30-109.01) +108.54 ± 32.09 +(102.01-116.22) +6.22 ± 48.55 (−4.44 +to 20.24) +18.81 (5.71 to 31.9) +0.141 +HDL Cholesterol, +mg/dl +Yoga-group +45.24 ± 1.72 +(44.62-45.86) +44.54 ± 1.92 +(43.92-45.16) +−0.70 ± 1.91 +(−1.15 to −0.26) +−1.49 (−2.44 to +−0.536) +0.013 +11.11 +0.001 +0.074 +Non-yoga group +45.30 ± 0.32 +42.79 ± 3.96 +−2.51 ± 5.11 +−4.72 (−7.33 to +−2.11) +<0.0001 +Triglycerides, mg/dl +Yoga-group +144.59 ± 28.68 +(134.25-154.93) +156.33 ± 32.05 +(145.99 −166.66) +11.74 ± 31.79 (4.32 +to 19.16) +31.94 (23.1 to 40.8) +0.010 +27.08 +≤0.001 +0.016 +Non-yoga group +143.69 ± 43.96 +(133.29-154.10) +211.39 ± 83.81 +(174.36-195.94) +67.70 ± 93.95 +(20.38 to +62.86) +59.01 +(41 to +77) +<0.0001 +Table 3.  Distribution of continuous variables between yoga and non-yoga treatment groups at baseline and +follow up. Data are represented as mean ± SE (95% confidence interval) P-value of < 0.05 was set as significant +between baseline and follow-up on within group and between group comparisons; CI, confidence interval, A1c; +P value- Within study groups, Test statistics t-test; P value-Between study groups test statistic- ANCOVA. +6 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ +a success rate of 19% with respect to ADA composite endpoint over a period of 12 months on patients with +uncontrolled T2D27. Further, compared to usual care, 6-months of yoga treatment was also found to be associated +with 8-fold higher (OR = 8.22, 95% CI = 2.02–33.49) success towards the attainment of ADA composite scores +(with revised BP cut-off of 140/90 mmHg) in rural Indian settings. With respect to individual composite goals, 6 +months of yoga treatment was found to have a higher likelihood of attainment of A1c goal by ~2-fold (OR = 2.44, +95% CI = 1.19–5.00); LDL-C by ~2-fold (OR = 2.22, 95% CI = 1.06–4.68); blood pressure<140/90 mmHg by +~8-fold [OR = 8.28, 95% CI, 3.52–19.48)] in rural T2D population compared to standard of care. The observed +2-fold higher potential of yoga-treatment as compared to standard of care towards attainment of LDL-c tar- +gets in the rural Indian T2DM cohort deserves clinical attention. Control of dyslipidemia in Indian T2DM +patients has been reported to be very poor; with almost half of them not reaching their LDL-C goal28. These +findings are important as Coronary Artery Disease (CAD) mortality remains high in the Indian patients with +T2DM. Similarly, the observed 8-fold increased impact of yoga on BP control as compared to standard of care +is an important clinical outcome. Hypertension is a prevalent co-morbidity in T2D patients associated with an +increased risk of cardiovascular events and mortality29,30. This coexistence has been reported to enhance the risks +of nephropathy and retinopathy31,32. +As previously reported by Ikramuddin et al., intense lifestyle intervention could aid in 31% success towards +attainment of glycemic, 70% for lipid and 70% for BP targets (130/80 mmHg) over a period of 12 months in a +mixed ethnic population of uncontrolled T2D (HbA1c ≥ 8.0%)27. Interestingly, in the present subgroup of patients +with uncontrolled T2D, HbA1c ≥ 8.0% yoga treatment of 6 months duration was found to be effective with +26.32% success in attainment of glycaemic control, 63.16% for lipid, and 26.32% for BP goals (130/80 mmHg). +These findings indicate that if assessed for long-term effects, yoga treatment could match the magnitude of the +potential of intense lifestyle-interventions as described for overweight/obese uncontrolled T2D patients27. +Glycemic control is the primary target of diabetes management strategies towards prevention of the devas- +tating complications such as blindness, kidney failure and amputations7,9. We could observe significant absolute +decrease in mean A1c% by 0.5 in the yoga group over a period of 6 months. The magnitude of reduction by 0.5% +in A1c holds strong clinical significance, based on the reported epidemiological association between 1% reduction +in the A1c value with 14% reduction in myocardial infarction (MI), 21% reduction in diabetes-related mortality +and 37% reduction in microvascular complications33. Further significant and beneficial yoga treatment-induced +mean percentage reductions in SBP (4.33%); DBP (5.66%); and TC (1.65%) could also be observed in the present +study. These findings support earlier reported beneficial cardiovascular effects of yoga25,26. +Weight loss remains a major challenge in diabetes due to the complex interplay between metabolic, neu- +roendocrine and psychological factors34. In a prior study intensive lifestyle intervention of 1 year was reported +to achieve an average 8.6% weight loss along with significant reduction of A1C, and CVD risk factors, with sus- +tained effects up to 4 years24. In the present study, we could observe a 4.18% reduction in weight over a period +of 6 months under yoga-treatment. Our results highlight the equivalent potential of yoga to intense weight-loss +intended lifestyle interventions in overweight/obese T2D patients. A favourable and differential effect of 61-fold +(OR = 61.73, 95% CI = 3.19–1193) was also observed for BMI outcome of <23 kg/m2 in the yoga group against +standard of care. The observed significant impact of yoga-treatment on BMI outcome in diabetes bears strong +clinical relevance as weight management is an important component of efficient diabetes care7. Further, weight +loss through lifestyle changes remains the first-line therapy for T2DM34. Available observational evidence suggest +various clinical benefits of weight loss in diabetes including improvement in glycemic control, reduced risk of +cardiovascular events alongwith improvements in quality of life, mobility, and physical function35,36. However, +we could not assess the sustenance of weight-related effects of yoga in this short-duration study. Based on the +proposed self-regulation modality of yoga, wherein yoga could lead to repatterning of hedonic neurocircuitries, +we speculate sustained weight-loss effects with long-term yoga-treatment37. +The study is limited by its observational nature. The difference-in-means method used to establish the equiv- +alence between the study groups could be limited in its capacity to control the confounding by baseline variables. +To this end, we conducted propensity score matching with “nearest neighbour” method for matching of the treat- +ment groups for key covariates. Further, logistic regression was also done to adjust for the effect of the covariates +to assess the study outcomes. The observed poor outcome in the standard of care group deserves attention of phy- +sicians and clinicians working in the rural sector of India. The poor outcome could possibly be attributed to poor +adherence to medication and prescribed physical activity in the rural T2D population suggesting that there is a +need to explore strategies to facilitate adherence with the patients/caregivers17. Since Indian patients were found +to be receptive to yoga, yoga-based treatment could be a pragmatic solution for effective diabetes management. +Based on the epidemic proportions of T2DM in India, there is an urgent need to conduct a large, prospective, +long-term study of the efficacy of yoga on attaining all of the ADA goals in the rapidly increasing T2DM popula- +tion. Early initiation of yoga treatment to target adequate diabetes care has the potential to prevent the devastating +complications including not just the microvascular but also loss of time from work and quality of life. +Methods +Cohort identification.  +The study was part of an ongoing service activity defined as the “Total Health +Programme” (THP) India’s first integrated rural healthcare service delivery network, initiated by the Apollo +Group (https://www.apollohospitals.com/corporate/initiatives/csr-at-apollo/total-health-programme). THP +aimed at patients for various diseases across the adopted villages for effective disease management in collab- +oration with Swami Vivekananda Yoga Anusandhana Samsathana (S-VYASA) (http://svyasa.edu.in/). During +the month of April/May 2016, 324 adults diagnosed with T2D, aged ≥20 years to 70 years, from 12 nearby vil- +lages of the Chittoor district, Andhra Pradesh, India, were originally referred to the Apollo health scheme for +diabetes management. T2D was defined as per the American Diabetes Association criteria19. When the records +were screened, out of 277 initially referred patients, only 150 were found to complete regular supervised yoga +7 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ +treatment, and amongst them 73 only had sufficient laboratory data until November 2016. Figure 1 details the +steps involved in cohort selection. Medical records of these 73 patients were retrieved for the study. Patients +undergoing insulin treatment, pregnant or breastfeeding, or who had severe vascular, hepatic, renal diseases or +cancer were excluded from the study. Patients with atherosclerotic cardiovascular disease (ASCVD)7 were also +excluded. Records of an equal number of T2D patients were retrieved as a non-yoga group who opted for only +standard of care treatment at the rural Apollo clinics during the same period of time. Difference-in-means of the +age, the proportion of sex and blood A1c levels were matched between yoga and non-yoga groups before finaliz- +ing the selection of the cohort sub-groups (n = 73 each). This was followed by matching the sub-groups through +propensity score matching. Thus, we defined a cohort of 146 T2D patients, diagnosed with T2D as per ADA cri- +teria19. Both yoga and non-yoga groups were followed from the (index date; date of first check up with prescribed +treatment) until the end of 6 months. Parameters of interest were included at the time of admission/index date +(baseline) and at an average of 6 months of follow-up. Written consent was obtained from the study subjects +and the study was approved by the Institutional Ethics Committee of Swami Vivekananda Yoga Anusandhana +Samsathana, Bengaluru, India. Informed consent was obtained from all the study subjects. All methods were per- +formed in accordance with the relevant guidelines and regulations. The study was registered with ClinicalTrials. +gov (NCT01212133); registration number: (CTRI/2020/02/0232790). +Measures.  +The duration of yoga- treatment was approximately six months. Primary parameters of inter- +est were the follow-up status of revised ADA laid treatment goals of diabetes;A1C < 7.0% (<53 mmol/mol), +and BP cut- offs (<140/90 mmHg). Additionally based on ADA definition of risk factors of Atherosclerotic +Cardiovascular Disease (ASCVD)7, the treatment goals also included <100 mg/dl of LDL-C, and stringent BP +goals (<130/80 mmHg). Composite score was defined based on the meeting of all the target goals. Secondary +outcomes were continuous measures of A1c, FBS (fasting blood glucose), PPBS (postprandial blood glucose), +LDL-Cholesterol (LDL-C), SBP, DBP, weight, total cholesterol (TC), triglyceride (TG) diastolic blood pressure +(DBP), and body mass index (BMI). Patient demographic and anthropometric information including age, sex, +Figure 1.  Flowchart of the study design. +8 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ +socioeconomic status, duration of diabetes, medication, weight, blood pressure, height was also extracted. BMI +was calculated as weight in kilograms divided by the square of height in meters. Asian cut-off for BMI (≥25 kg/m2) +was used to define obesity20. +Intervention.  +The administration of yoga was carried out at Apollo rural and satellite clinics (https://www. +apollohospitals.com/corporate/initiatives/csr-at-apollo/total-health-programme) for T2D patients from nearby +villages. Non-yoga group, the T2D patients received the standard of care for diabetes as per ADA guidelines +from a physician-coordinated team5. The patients were also referred for diabetes self-management education +and support for strengthening and empowering their diabetes knowledge and self-care behaviors as per ADA +guidelines. The yoga treatment given to the patients was derived from a validated integrated yoga module devel- +oped by Angadi et al.38. The treatment protocol included daily supervised administration of yoga sessions for +one hour. The yoga module was comprised of loosening practices, asanas, pranayama, relaxation techniques, and +meditation; (detailed protocol has been appended as a supplement table no. 1). Only certified yoga therapists +were involved in the administration of the yoga-treatment. Both the yoga and non-yoga treatment groups were +followed from the date of admission into the clinics, till November 2016. +Statistical analyses.  +Missing data were minimal. Continuous variables were tested for normality with the +Shapiro-Wilk test. We used descriptive statistics with mean and 95% confidence intervals [CIs]), and standard, +or percentages (numbers) for representation of T2D patient’s baseline characteristics. Categorical variables were +described using frequencies. Socioeconomic status was determined by using Kuppuswamy’s scale22. Outcome +measures were compared using Analysis of covariance (ANCOVA) to adjust for baseline measures and to provide +an unbiased estimate of the mean group differences. A General linear model (GLM) for multivariate analysis +was developed with covariates of baseline values of the outcome variables, age, medication and duration of dia- +betes. P-value of < 0.05 was set as significant and < 0.0001 was set as highly significant. Statistical analysis was +performed using SPSS version 21.0, Microsoft Excel-2013 and R studio version 1.1.423. For comparisons within +treatment groups from baseline to follow-up, a Wilcoxon signed rank test was performed. Propensity scores were +calculated for each subject based on primary baseline covariates known to be associated with diabetes treatment +and/or the study outcomes, including age, sex, socioeconomic status, disease duration, medication, and biochem- +ical parameters using the “nearest neighbour” method (Appendix, supplementary material). Logistic regression +was then used to identify predictors of successful achievement of the favourable ADA and BMI outcomes. Models +of the relationships were created with independent variable including age, sex, duration of diabetes, yoga treat- +ment vs. non-yoga treatment, baseline values of variables of biological relevance. +Data availability +The datasets generated during and/or analysed during the current study are available from the corresponding +author on reasonable request. +Received: 4 July 2019; Accepted: 20 March 2020; +Published: xx xx xxxx +References + 1. Kahn, S. E. et al. Pathophysiology and treatment of type 2 diabetes: perspectives on thepast, present, and future. Lancet. 383, +1068–83 (2014). + 2. International Diabetes Federation. IDF diabetes atlas.8th ed. IDF, www.diabetesatlas.org (2017). + 3. Bhurji, N. et al. Improving management of type 2 diabetes in South Asian patients: a systematic review of intervention studies. BMJ +Open. 6, e008986z (2016). + 4. Hills, A. P. et al. Epidemiology and determinants of type 2 diabetes in south Asia. Lancet Diabetes Endocrinol. 6, 966–978 (2018). + 5. American Diabetes Association. Standards of Medical Care in Diabetes—2017 Abridged for Primary Care Providers. Clin Diabetes. +35, 5–26 (2017). + 6. American Diabetes Association. Lifestyle Management: Standards of Medical Care in Diabetes—2019. Diabetes Care. 42(Supplement +1), S46–S60 (2019). + 7. American Diabetes Association. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2018. +Diabetes Care. 41(Supplement 1), S86–S104 (2018). + 8. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl +J Med. 358, 2560–2572 (2008). + 9. American Diabetes Association. Foundations of Care and Comprehensive Medical Evaluation. Diabetes Care. 39(Suppl 1), S23–35 +(2016). + +10. Janssen, P. G. et al. Randomised controlled trial of intensive multifactorial treatment for cardiovascular risk in patients with screen- +detected type 2 diabetes: 1-year data from the ADDITION Netherlands study. Br J Gen Pract. 59, 43–8 (2009). + +11. López-Simarro, F. et al. Inertia and treatment compliance in patients with type 2 diabetes in primary care. Med Clin (Barc). 138, +377–384 (2012). + +12. Stark Casagrande S, et al. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010. +Diabetes Care. 201z 36, 2271–9. + +13. Menon, A. S. & Ahluwalia, A. I. The ABC of diabetes. How many patients are able to achieve the goal laid down by American +Diabetes Association? Med J Armed Forces India. 71, 132–4 (2015). + +14. Stolar MW. Defining and achieving treatment success in patients with type 2 diabetes mellitus. Mayo Clin Proc. 2010; 85(12 Suppl): +S50–9. + +15. Anjana, R. M. et al. Prevalence of diabetes and prediabetes (impaired fasting glucose or/and impaired glucose tolerance) in rural and +urban India: Phase 1 results of the Indian Council of Medical Research-INdiaDIABetes (INDIAB) study. Diabetologia. 54, +3022–3027 (2011). + +16. Misra, P. et al. A review of the epidemiology of diabetes in rural India. Diabetes Research and Clinical Practice. 92, 303–311 (2011). + +17. Little, M. et al. Decoding the Type 2 Diabetes Epidemic in Rural India. Med Anthropol. 36, 96–110 (2017). + +18. Haughton, C. F. et al. Racial/ethnic representation in lifestyle weight loss intervention studies in the United States: A systematic +review. Prev Med Rep. 9, 131–137 (2018). +9 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ + +19. American Diabetes Association. Standards of Medical Care in Diabetes—2015 Abridged for Primary Care Providers. Clinical +Diabetes. 33, 97–111 (2015). + +20. Misra, A. Ethnic-Specific Criteria for Classification of Body Mass Index: A Perspective for Asian Indians and American Diabetes +Association Position Statement. Diabetes Technol Ther. 17, 667–71 (2015). + +21. Unnikrishnan, A. G. et al. Importance of achieving the composite endpoints in diabetes. Indian J Endocrinol Metab. 17(5), 835–843 +(2013). + +22. Leslie, D. B. et al. Efficacy of the Roux-en-Y gastric bypass compared to medically managed controls in meeting the American +Diabetes Association composite end point goals for management of type 2 diabetes mellitus. Obes Surg. 22, 367–74 (2012). + +23. Kumar, B. P. R., Dudala, S. R. & Rao, A. R. Kuppuswamy’s socio-economic status scale’s revision of economic parameter for. Int J of +Res Dev Health. 1, 2–4 (2012). + +24. The Look AHEAD Research Group. Long Term Effects of a Lifestyle Intervention on Weight and Cardiovascular Risk Factors in +Individuals with Type 2 Diabetes: Four Year Results of the Look AHEAD Trial. Arch Intern Med. 170, 1566–1575 (2010). + +25. Thind, H. et al. The effects of yoga among adults with type 2 diabetes: A systematic review and meta-analysis. Prev Med. 105, +116–126 (2017). + +26. Innes, K. E. & Selfe, T. K. Yoga for Adults with Type 2 Diabetes: A Systematic Review of Controlled Trials. J Diabetes Res. 2016, +6979370 (2016). + +27. Ikramuddin, S. et al. Durability of Addition of Roux-en-Y Gastric Bypass to Lifestyle Intervention and Medical Management in +Achieving Primary Treatment Goals for Uncontrolled Type 2 Diabetes in Mild to Moderate Obesity: A Randomized Control Trial. +Diabetes Care. 39, 1510–8 (2016). + +28. Mithal, A. et al. Prevalence of dyslipidemia in adult Indian diabetic patients: A cross sectional study (SOLID). Indian J Endocrinol +Metab. 18, 642–7 (2014). + +29. Passarella, P., Kiseleva, T. A., Valeeva, F. V. & Gosmanov, A. R. Hypertension Management in Diabetes: 2018 Update. Diabetes Spectr. +31, 218–224, https://doi.org/10.2337/ds17-0085 (2018). + +30. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK +Prospective Diabetes Study Group. Bmj. 317, 703–13 (1998). + +31. Adler, A. I. et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes +(UKPDS 36): prospective observational study. BMJ. 321(7258), 412–419 (2000). + +32. Gosmanov, A. R. et al. Synergistic association of combined glycemic and blood pressure level with risk of complications in US +veterans with diabetes. J Hypertens. 34, 907–913 (2016). + +33. Stratton, I. M. et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): +prospective observational study. BMJ 321, 405–412 (2000). + +34. Pi-Sunyer, F. X. Weight loss in type 2 diabetic patients. Diabetes Care. 28, 1526–1527 (2005). + +35. Pi-Sunyer, X. et al. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results +of the Look AHEAD trial. Diabetes Care. 30, 1374–83 (2007). + +36. Wing, R. R. et al. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with +type 2 diabetes. Diabetes Care 34, 1481–1486 (2011). + +37. Gard, T. et al. Potential self-regulatory mechanisms of yoga for psychological health. Front. Hum. Neurosci. 8, 770 (2014). + +38. Angadi, P. et al. Adherence to yoga and its resultant effects on blood glucose in Type 2 diabetes: A community-based follow-up study. +Int J Yoga 10, 29–36 (2017). +Acknowledgements +We are thankful to the “Apollo Total Health Group’ for the financial support provided to conduct the study. We +acknowledge the support and continued involvement of the chairman, doctors, researchers and field workers +of ‘Apollo Total Health Group’ and yoga therapists of S-VYASA University in the study. The funding sponsor +contributed in design of the study, data collection and data analysis. A special thanks to Sai Lakshmi Prasanna +M, senior yoga therapist. We have not paid to write this article to any pharmaceutical company or other agency. +We also thank the USV (PVT) Ltd for the generous donation of digital BP measurement machines which were +utilized in this study. +Author contributions +G.A. contributed to the study design, planned the cohort, data collection and analysis. N.R. revised the +experiment design, and reviewed the manuscript. V.M. analysed the data and wrote the manuscript. S.M. is the +chief advisor of Total Health-A CSR initiative of Apollo Hospitals enterprise limited. R.S. and R.S. are the project +and deputy medical directors of Total Health, respectively. S. M., R.S., and R.S. planned the cohort, designed the +study and contributed to the data collection. V.S. R reviewed the manuscript. N.H.R. contributed to the discussion +section and reviewed the manuscript. We also declare Dr. Nagarathana R as the guarantor of the entire study. The +corresponding author had full access to all the data in the study and had final responsibility for the decision to +submit for publication. +Competing interests +The authors declare no competing interests. +Additional information +Supplementary information is available for this paper at https://doi.org/10.1038/s41598-020-63133-1. +Correspondence and requests for materials should be addressed to V.M. +Reprints and permissions information is available at www.nature.com/reprints. +Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and +institutional affiliations. +10 +Scientific Reports | (2020) 10:6402 | https://doi.org/10.1038/s41598-020-63133-1 +www.nature.com/scientificreports +www.nature.com/scientificreports/ +Open Access This article is licensed under a Creative Commons Attribution 4.0 International +License, which permits use, sharing, adaptation, distribution and reproduction in any medium or +format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Cre- +ative Commons license, and indicate if changes were made. The images or other third party material in this +article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the +material. If material is not included in the article’s Creative Commons license and your intended use is not per- +mitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the +copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/. + +© The Author(s) 2020 diff --git a/subfolder_0/Yoga_ A Strategy to Cope up Stress and Enhance Wellbeing Among Medical Students.txt b/subfolder_0/Yoga_ A Strategy to Cope up Stress and Enhance Wellbeing Among Medical Students.txt new file mode 100644 index 0000000000000000000000000000000000000000..cc6b10f85885bcb717e403270b4352d935d68753 --- /dev/null +++ b/subfolder_0/Yoga_ A Strategy to Cope up Stress and Enhance Wellbeing Among Medical Students.txt @@ -0,0 +1,245 @@ +3/1/2017 +Yoga: A Strategy to Cope up Stress and Enhance Wellbeing Among Medical Students +https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866479/?report=printable +1/4 +N Am J Med Sci. 2016 Apr; 8(4): 200–202. +doi:  10.4103/1947­2714.179962 +PMCID: PMC4866479 +Yoga: A Strategy to Cope up Stress and Enhance Wellbeing Among +Medical Students +Apar Avinash Saoji +Assistant Professor, The School of Yoga and Naturopathic Medicine, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana +Samsthana, Bengaluru, Karnataka, India, E­mail: aparsaoji@gmail.com +Copyright notice +This is an open access article distributed under the terms of the Creative Commons Attribution­NonCommercial­ShareAlike 3.0 License, which +allows others to remix, tweak, and build upon the work non­commercially, as long as the author is credited and the new creations are licensed +under the identical terms. +Dear Editor, +Stress, burnout, and coping strategies in preclinical medical students by Fares et al.[1] made for an interesting +read. I would like to compliment the authors for the commanding effort to put together a burning issue of +psychological and physical stress and burnout among the medical students. The issue is often neglected both +by the vulnerable population of students as well as the health­care community itself. The article definitely +brings attention on the need for coping strategies and also puts together various methods for the physical and +psychological wellbeing of the doctors­in­making. +Yoga, a mind­body practice of ancient Indian origin has gained significance in recent times due to its health +benefits. Various practices of yoga have been found beneficial to attenuate stress and enhance functionality +among medical students. Despite an array of coping strategies, yoga practices are found to reduce perceived +stress,[2,3,4,5] anxiety,[4,6,7,8] markers of stress such as cortisol,[9] improved general health and well­ +being,[5,10,11] physical and physiological health,[6,12,13] improve cognition[14] as well as cultivation of +positive emotions[2,3,7] such as empathy, compassion, and self­regulation. There is evidence of a reduction +in work­related stress and better autonomic balance with the practice of yoga in health professionals.[15] The +studies indicate not just the psychological benefits of yoga, but the physical benefits such as better autonomic +balance, enhanced respiratory endurance, auditory and visual reaction times as well as muscle strength.[13] +Few research studies showing the beneficial effects of yoga among medical students are listed in Table 1. +One of the most important stressors among medical students is the examination. Malathi and Damodaran and +Malathi et al.[8,12] have found yoga to be beneficial in modulating the response to stress during the +examination. In addition, studies indicate that yoga could enhance the examination performance and reduce +anxiety.[16] Another important area of concern brought out by Fares et al. is the lack of self­care behavior +among medical students.[1] Yoga and mindfulness­based practices have demonstrated beneficial impact on +the self­care behavior in counselors, who encounter similar health issues of that of medical students.[17] +From the review of existing scientific literature on the application of yoga in medical students, it is evident +that yoga is a self­practiced, low cost, safe, efficacious as well as acceptable tool benefitting the target +population. There are positive outcomes for the medical students in their physical, psychosocial, and +emotional health. The practices that are safely used in the wellbeing of student community include asana +(physical postures), pranayama (breathing practices), dhyana (meditation), mindfulness­based stress +relaxation, and mind sound resonance technique (MSRT).[2,3,4,5,6,7,8,9,10,11,12,13,14,18] These +techniques were used either as standalone modality in a combination or even as an adjunct program within +the frame of medical curricula. The possible mechanisms involved with the beneficial effects of yoga among +medical students include autonomic balance, relaxation, better emotional status, and self­care behavior. There +is scope to evaluate the effects of yoga further among the medical students through rigorous clinical studies, +wherein these mechanisms could be tested. +3/1/2017 +Yoga: A Strategy to Cope up Stress and Enhance Wellbeing Among Medical Students +https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866479/?report=printable +2/4 +Considering the current evidence in the field, which indicates the beneficial effects of yoga on the physical, +psychological, emotional, spiritual, and overall well­being of medical students, it could be recommended to +incorporate yoga into the medical curricula for the health benefits of the doctors­in­making, medical +fraternity, and community at large. The possible inclusions in such program could be the practice of simple +asana, pranayama, meditation, and mindfulness­based relaxation. The following module is proposed to be +incorporated for medical students keeping in mind the existing literature on yoga for medical students: +Shithilikarana vyayama (loosening exercises) ­ 5 min +Suryanamaskara (sun salutation) ­ 5 min +Asana (physical postures) ­ 15 min. +Ardhakatichakrasana (lateral bend pose) +Ardhachakrasana (backward bend pose) +Padahastasana (standing forward bend pose) +Sarvangasana (shoulder stand pose) +Matsyasana (fish pose) +Bhujangasana (serpent pose) +Padmasana (lotus pose) +Savasana (corpse pose). +Pranayama (breathing practices) – 10 min +Kapalabhati (illuminating forehead breath) +Nadisuddhi (alternate nostril breath) +Ujjayi (the psychic breath) +Bhramari (humming bee breath) +Meditation/relaxation – 10 min +Mindfulness­based relaxation/yoga nidra (psychic sleep) +MSRT or cyclic meditation – once a week. +Financial support and sponsorship +Nil. +Conflicts of interest +There are no conflicts of interest. +References +1. Fares J, Al Tabosh H, Saadeddin Z, El Mouhayyar C, Aridi H. Stress, burnout and coping strategies in +preclinical medical students. N Am J Med Sci. 2016;8:75–81. [PMCID: PMC4791902] +[PubMed: 27042604] +2. Bond AR, Mason HF, Lemaster CM, Shaw SE, Mullin CS, Holick EA, et al. Embodied health: The +effects of a mind­body course for medical students. Med Educ Online. 2013;18:1–8. +[PMCID: PMC3643075] [PubMed: 23639275] +3. Erogul M, Singer G, McIntyre T, Stefanov DG. Abridged mindfulness intervention to support wellness in +first­year medical students. Teach Learn Med. 2014;26:350–6. [PubMed: 25318029] +4. Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomised controlled trial of the effects of +mindfulness practice on medical student stress levels. Med Educ. 2011;45:381–8. [PubMed: 21401686] +5. Simard AA, Henry M. Impact of a short yoga intervention on medical students’ health: A pilot study. Med +Teach. 2009;31:950–2. [PubMed: 19877871] +6. Chen Y, Yang X, Wang L, Zhang X. A randomized controlled trial of the effects of brief mindfulness +meditation on anxiety symptoms and systolic blood pressure in Chinese nursing students. Nurse Educ Today. +2013;33:1166–72. [PubMed: 23260618] +7. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness­based stress reduction on medical and +premedical students. J Behav Med. 1998;21:581–99. [PubMed: 9891256] +3/1/2017 +Yoga: A Strategy to Cope up Stress and Enhance Wellbeing Among Medical Students +https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866479/?report=printable +3/4 +8. Malathi A, Damodaran A. Stress due to exams in medical students – Role of yoga. Indian J Physiol +Pharmacol. 1999;43:218–24. [PubMed: 10365315] +9. Turakitwanakan W, Mekseepralard C, Busarakumtragul P. Effects of mindfulness meditation on serum +cortisol of medical students. J Med Assoc Thai. 2013;96(Suppl 1):S90–5. [PubMed: 23724462] +10. Bansal R, Gupta M, Agarwal B, Sharma S. Impact of short term yoga intervention on mental well being +of medical students posted in community medicine: A pilot study. Indian J Community Med. 2013;38:105–8. +[PMCID: PMC3714937] [PubMed: 23878424] +11. Yazdani M, Esmaeilzadeh M, Pahlavanzadeh S, Khaledi F. The effect of laughter yoga on general health +among nursing students. Iran J Nurs Midwifery Res. 2014;19:36–40. [PMCID: PMC3917183] +[PubMed: 24554958] +12. Malathi A, Damodaran A, Shah N, Krishnamurthy G, Namjoshi P, Ghodke S. Psychophysiological +changes at the time of examination in medical students before and after the practice of yoga and relaxation. +Indian J Psychiatry. 1998;40:35–40. [PMCID: PMC2964815] [PubMed: 21494440] +13. Madanmohan, Thombre DP, Balakumar B, Nambinarayanan TK, Thakur S, Krishnamurthy N, et al. +Effect of yoga training on reaction time, respiratory endurance and muscle strength. Indian J Physiol +Pharmacol. 1992;36:229–33. [PubMed: 1291472] +14. Saoji A, Mohanty S, Vinchurkar SA. Effect of a single session of a yogic meditation technique on +cognitive performance in medical students: A randomized crossover trial. [Accessed March 25, 2016];J Relig +Health. 2016 at http://link.springer.com/article/10.1007%2Fs10943­016­0195­x . +15. Lin SL, Huang CY, Shiu SP, Yeh SH. Effects of yoga on stress, stress adaption, and heart rate variability +among mental health professionals ­ A randomized controlled trial. Worldviews Evid Based Nurs. +2015;12:236–45. [PubMed: 26220020] +16. Nemati A. The effect of pranayama on test anxiety and test performance. Int J Yoga. 2013;6:55–60. +[PMCID: PMC3573544] [PubMed: 23439436] +17. Christopher JC, Christopher SE, Dunnagan T, Schure M. Teaching self­care through mindfulness +practices: The application of yoga, meditation, and qigong to counselor training. J Humanist Psychol. +2006;46:494–509. +18. Parshad O, Richards A, Asnani M. Impact of yoga on haemodynamic function in healthy medical +students. West Indian Med J. 2011;60:148–52. [PubMed: 21942118] +Figures and Tables +Table 1 +Findings of research studies on yoga for medical students +Authors +Year Sample +size +Intervention +Findings +Bond et al.[2] +2013 +27 +Yoga and meditation +11­week yoga­based program increased self­regulation, self­ +compassion, and empathy and reduction in perceived stress +Erogul et al.[3] +2014 +58 +MBSR for 8 weeks +MBSR intervention improves perceived stress and self­ +compassion +Warnecke et al. +[4] +2011 +66 +8 weeks practice of +mindfulness +meditation +Mindfulness practice reduced stress and anxiety in senior +medical students +Simard and +Henry[5] +2009 +14 +16­week yoga +Improvements in overall health, perceived stress, and +depressive symptoms +3/1/2017 +Yoga: A Strategy to Cope up Stress and Enhance Wellbeing Among Medical Students +https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866479/?report=printable +4/4 +Authors +Year Sample +size +Intervention +Findings +Chen et al.[6] +2013 +60 +Mindfulness +meditation 30 min +daily for 7 consecutive +days +A brief course of mindfulness meditation was found to be +beneficial to reduce anxiety and lowering blood pressure +Shapiro et al. +[7] +1998 +NA +8 weeks practice of +mindfulness +meditation +Reduction in self­reported state and trait anxiety, overall +psychological distress and depression, an increase in overall +empathy, and spiritual experiences +Malathi and +Damodaran[8] +1999 +50 +Yoga +Yoga reduced basal anxiety as well as prior to examination +Turakitwanakan +et al.[9] +2013 +30 +Mindfulness +meditation +Mindfulness meditation reduces serum cortisol levels and +statistically nonsignificant improvement in GHQ scores +Bansal et al. +[10] +2013 +82 +45 min of integrative +practice for 1 month +Improvement in general and mental wellbeing following the +intervention +Malathi et al. +[12] +1998 +75 +Yoga and relaxation +Yoga and relaxation attenuated heart rate, blood pressure, and +galvanic skin resistance in response to the stress of +examination and enhanced reaction time +Madanmohan et +al.[13] +1992 +27 +Yoga for 12 weeks +Yoga improves visual and auditory reaction time, respiratory +endurance, and muscle strength +Saoji et al.[14] +2016 +42 +Mind sound resonance +technique +Single session of meditation improves performance in the +cognitive tasks +MBSR = Mindfulness­based stress reduction, GHQ = General Health Questionnaire +Articles from North American Journal of Medical Sciences are provided here courtesy of Medknow +Publications diff --git a/subfolder_0/Yoga_ Managing overweight in mid-life T2DM.txt b/subfolder_0/Yoga_ Managing overweight in mid-life T2DM.txt new file mode 100644 index 0000000000000000000000000000000000000000..ca68c001d206579d882282ef0724cff787d8db8d --- /dev/null +++ b/subfolder_0/Yoga_ Managing overweight in mid-life T2DM.txt @@ -0,0 +1,244 @@ +J Midlife Health. 2015 Apr-Jun; 6(2): 81–84. +doi: 10.4103/0976-7800.158959 +PMCID: PMC4481745 +PMID: 26167059 +Yoga: Managing overweight in mid-life T2DM +Ashwini Sham Tikhe, Subramanya Pailoor, Kashinath Metri, Tikhe Sham Ganpat, and +Nagendra Hongasandra Ramarao +Swami Vivekananda Yoga Anusandhana Samsthana University, Bangalore, Karnataka, India +Assistant Professor, Department of Yoga and Management, S-VYASA University, Bangalore, Karnataka, India +Project Coordinator, Morarji Desai National Institute of Yoga, New Delhi, India +Chancellor, Swami Vivekananda Yoga Anusandhana Samsthana University, Bangalore, Karnataka, India +Address for Correspondence: Dr. Sham Ganpat Tikhe, Project Coordinator, WHO-CC (Yoga), Morarji Desai +National Institute of Yoga, No. 68, Ashok Road, Near Gole Dak Khana, Opposite to Gurudwara Bangla Sahib, +New Delhi - 110 001, India. E-mail: rudranath29@gmail.com +Copyright : © Journal of Mid-life Health +This is an open access article distributed under the terms of the Creative Commons Attribution- +NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non- +commercially, as long as the author is credited and the new creations are licensed under the identical terms. +Abstract +Background: +The dramatic rise in the prevalence of obesity and type 2 diabetes mellitus (T2DM) is associated with +increased mortality, morbidity as well as public health care expenses worldwide. Previous research +suggests that yoga holds promise for obesity and T2DM management. +Objective: +The objective of the present study was to assess the effect of intensive integrated approach of yoga +therapy (IAYT) on body fat and body mass index (BMI) and resting metabolism in mid-life overweight +patients with T2DM (BMI, Mean ± SD, 27.05 ± 4.51). +Materials and Methods: +Twenty-four mid-life patients (6 females) with T2DM (Age, Mean ± SD, 55.38 ± 7.96 years) +participated in the study and practiced IAYT for 7 days. The IAYT works at five layers of human +existence (physical, vital, mental, intellectual and bliss) to bring positive health. The body fat and BMI +and resting metabolism were recorded before and after IAYT using Karada Scan body composition +monitor HBF-375 from Omron Healthcare Singapore PTE LTD. +Statistical Analysis: +SPSS-16 was used to analyze the data. Shapiro-Wilk test showed that the data was not normally +distributed. Further, the Wilcoxon signed-ranks test was used to analyze the change in means of pre- +and post-measurements. +Results: +Data analysis showed that there was a significant decrease in body fat and BMI and resting metabolism +(in all assessments, P < 0.001). +1 +2 +2 +3 +4 +1 +2 +3 +4 +Conclusion: +The present study suggests that 7 days practice of IAYT has a great promise for the management of +overweight in mid-life patients with T2DM. Additional well-designed studies are needed before a +strong recommendation can be made. +Keywords: Body composition, mid-life, overweight, type 2 diabetes mellitus, yoga +INTRODUCTION +In spite of all new drugs that are now available, type 2 diabetes (T2DM), which is a lifestyle-related +disease and a major health and socioeconomic problem worldwide[1,2] has drawn attention to the +research on effects of yoga in diabetes prevention and treatment.[3] The rapid increase in T2DM can be +attributed to adverse lifestyle such as physical inactivity and obesity, which are also key components +for development of insulin resistance.[4] This condition of insulin resistance or pre-diabetes can be +detected,[5] and if managed with dietary,[2] lifestyle modification practices[6] like yoga[7] can delay if +not prevent the onset of T2DM. This low level of insulin in T2DM causes decreased utilization of +glucose by body cells, increased mobilization of fats from fat storage cells and depletion of proteins in +the tissues of the body, keeping the body in crisis.[2] Therefore, a maneuver to prevent increase of +T2DM holds great significance. T2DM and overweight are closely associated.[8] In the process of +assessing overweight severity, the body mass index (BMI) is useful to categorize under and over- +nutrition. It is the weight in kilograms divided by the height in meters, squared.[9] Two related markers +of physical well-being in adults are BMI and medication use.[10] Overweight (BMI 25.0 to 29.9 +kg/m ) and obesity (BMI ≥ 30.0 kg/m ) are associated with increased all-cause mortality.[11] Mid-life +women are particularly vulnerable to overweight and obesity. Patients with T2DM are usually obese +and there are an estimated 51 million people with diabetes in India, and this number is projected to +increase to 80 million by 2030.[12] Impaired fasting glucose along with deranged waist hip ratio and +BMI play a significant role in predicting potential diabetics.[3] It was reported that yoga offers a +promising lifestyle intervention for decreasing weight-related T2DM risk factors and potentially +increasing psychological well-being.[7] Similarly, yogic lifestyle modification can make an appreciable +contribution to primary prevention as well as management of lifestyle diseases.[13] There was no +previous study that has reported systematically the effect of intensive IAYT on body weight, body fat +and BMI in mid-life overweight patients with T2DM. +Objectives +The study was designed to assess the effect of IAYT on body weight, body fat and BMI in mid-life +overweight patients with T2DM. +MATERIALS AND METHODS +Subjects +Twenty-four mid-life patients (6 females) with T2DM (Age, Mean ± SD, 55.38 ± 7.96 years) were +participated in the study and practiced IAYT for 7 days. [Table 1] Data derived from the previous study +with similar design on yoga[14] has been used to calculate the effect size. The power analysis (Alpha = +0.05, Power = 0.5, Effect Size = 0.51) had yielded sample size of total 24 subjects. +2 +2 +Inclusion criteria +Exclusion criteria +Source of subjects +Ethical consideration +Design +Table 1 +Details of the subjects +Mid-life patients (age ranging from 43 to 68 years) with T2DM, both males and +females, non-smokers +Those with orthopedic, with complications (like unstable angina, proliferative +retinopathy, severe peripheral vascular disease), those who have regularly been practicing yoga and/or +on Ayurveda treatment from prior three months who may carry over effect of such previous therapies. +The subjects for the present study were selected from the health home of Swami +Vivekananda Yoga Anusandhana Samsthana (S-VYASA) University, Bangalore. +An informed consent was obtained from all the participants to take part in the +study and this study was approved by the institutional review board of S-VYASA University, +Bangalore +Single group pre-post study. Pre-----7 days IAYT -----Post +Intervention +The IAYT program[15] of 7 days duration was administered to mid-life patients with T2DM who were +participated in the study. Sukma Vyayama (loosening and stretching practices), Yogasanas (physical +postures), Pranayama (breathing techniques), Dhyana (meditation), Kriyas (cleansing techniques), +devotional session, Sattvic diet (high-fiber low-fat vegetarian and balanced diet), yogic games and +lectures from the experts were the key essence of this IAYT program. This IAYT program, conducted +in a serene and peaceful atmosphere of S-VYASA University's health home was a residential setup +with a daily schedule starting from 5 AM to 10 PM. +Assessment +The Karada Scan body composition monitor HBF-375 from OMRON HEALTHCARE SINGAPORE +PTE LTD was used to collect data of different body compositions: Weight, fat, visceral fat, resting +metabolism, BMI, body age, subcutaneous whole body, subcutaneous trunk, subcutaneous arms, +subcutaneous legs, skeletal whole body, skeletal trunk, skeletal arms and skeletal legs. This machine is +useful for a more accurate and precise body composition measurement.[16,17] +Data extraction and analysis +The data for different body compositions were taken before and after the 7 days IAYT program for +mid-life patients with T2DM. The Statistical Package for the Social Sciences (SPSS) software version +16 was used to analyze data. Shapiro-Wilk test showed that the data is not normally distributed. +Further, the Wilcoxon signed-ranks test was used to analyze the change in means of pre- and post- +measurements. +RESULTS +The data analysis of 7 days IAYT program showed that there was a significant decrease (P < 0.001) in +all the variables of body compositions.[Table 2] It was noted that there was 1.06% decrease (P < 0.001) +in weight, 4.20% decrease (P < 0.001) in fat, 2.78% decrease (P < 0.001) in visceral fat, 1.08% +decrease (P < 0.001) in resting metabolism, 1.10% decrease (P < 0.001) in BMI, 1.58% decrease (P = +0.005) in body age, 3.20% decrease (P = 0.036) in subcutaneous whole body, 2.54% decrease (P = +0.036) in subcutaneous trunk, 2.84% decrease (P = 0.036) in subcutaneous arms, 2.78% decrease (P = +0.036) in subcutaneous legs, 1.60% decrease (P = 0.036) in skeletal whole body, 3.71% decrease (P = +0.036) in skeletal trunk, 1.54% decrease (P = 0.036) in skeletal arms, and 1.32% decrease (P = 0.036) +in skeletal legs. +Table 2 +Data analysis +DISCUSSION +A typical yoga program usually consisting of Asana, Pranayama, Kriya, deep relaxation and +meditation has a combined effect of relaxation of body, slowing of breath and calming of mind. This +effect in turn leads to reduction in oxygen consumption and metabolism thereby balancing the +homeostasis.[18,19] An understanding of metabolism at different times of the day has significant +implications due to its link to sleep, health, stress and fatigue, ultimately determining the quality of life. +The earliest study on metabolism by Anand et al.,[20] has demonstrated that a yogi could reduce +oxygen consumption while sealed in an airtight box for nearly 10 hours, thus changing metabolism at +will. Wallace et al., have reported the effect of acute practices resulting in the reduction in metabolic +rate in meditation as compared to sleep.[21,22] The reduced body weight in the present study suggests +greater metabolic efficiency, which is consistent with the previous studies.[14,18] The high-intensity +exercises increase the basal metabolic rate in subjects aged from 59 to 77[23] years, whereas low and +moderate intensity exercises do not have any effect on these rates.[24,25] All these exercises are +mainly related to central or sympathetic activation,[26] whereas yoga reduces sympathetic activity. +[27,28] It is believed that all these changes must have some positive and permanent effect on +metabolism when practiced over a period of time, leading to efficiency and relief from stress, thereby +resulting in certain changes in the diurnal metabolism, basal metabolic rate and sleep. The present +study endorses this view and adds that IAYT can bring significant decrease in resting metabolism, BMI +and body fat after 7 days. This may be due to reduced sympathetic activity and/or stabilized nervous +system.[29] +CONCLUSION +The IAYT has a great promise for management of overweight in mid-life patients with T2DM. +Additional well-designed studies are needed before a strong recommendation can be made. +Acknowledgement +Authors acknowledge chancellor and registrar of S-VYASA University, Bangalore for supporting and +granting permission to carry out this work. +Financial support and sponsorship +Nil. +Conflict of interest +There are no conflicts of interest. +REFERENCES +1. Pawar K, Thompkinson DK. Multiple functional ingredient approach in formulating dietary +supplement for management of diabetes: A review. Crit Rev Food Sci Nutr. 2014;54:957–73. +[PubMed] [Google Scholar] +2. Pathak M. Diabetes mellitus type 2 and functional foods of plant origin. Recent Pat Biotechnol. +2014;8:160–4. [PubMed] [Google Scholar] +3. Kaur S, Mahajan M, Bal BS. Prevalence of insulin resistance in siblings of type 2 diabetics of north +west punjabi population. J Clin Diagn Res. 2014;8:CC14–8. [PMC free article] [PubMed] +[Google Scholar] +4. Hamburg NM, McMackin CJ, Huang AL, Shenouda SM, Widlansky ME, Schulz E, et al. Physical +inactivity rapidly induces insulin resistance and microvascular dysfunction in healthy volunteers. +Arterioscler Thromb Vasc Biol. 2007;27:2650–6. [PMC free article] [PubMed] [Google Scholar] +5. Martinez FJ, Villa E, Serrano J, Garcia-Rodes R. Diagnosis of insulin resistance. Drugs. +1993;46:165–71. [PubMed] [Google Scholar] +6. McAuley KA, Williams SM, Mann JI, Goulding A, Chisholm A, Wilson N, et al. Intensive lifestyle +changes are necessary to improve insulin sensitivity: A randomized controlled trial. Diabetes Care. +2002;25:445–52. [PubMed] [Google Scholar] +7. McDermott KA, Rao MR, Nagarathna R, Murphy EJ, Burke A, Nagendra RH, et al. A yoga +intervention for type 2 diabetes risk reduction: A pilot randomized controlled trial. BMC Complement +Altern Med. 2014;14:212. [PMC free article] [PubMed] [Google Scholar] +8. Sarvottam K, Yadav RK. Obesity-related inflammation and cardiovascular disease: Efficacy of a +yoga-based lifestyle intervention. Indian J Med Res. 2014;139:822–34. [PMC free article] [PubMed] +[Google Scholar] +9. Walker BR, Colledge NR, Ralston SH, Penman I. Davidson's principles and practice of medicine. +Elsevier Health Sciences; 2013. p. 278. [Google Scholar] +10. Jarrett B, Bloch GJ, Bennett D, Bleazard B, Hedges D. The influence of body mass index, age and +gender on current illness: A cross-sectional study. Int J Obes (Lond) 2010;34:429–36. [PubMed] +[Google Scholar] +11. Berrington de Gonzalez A, Hartge P, Cerhan JR, Flint AJ, Hannan L, MacInnis RJ, et al. Body- +mass index and mortality among 1.46 million White adults. N Engl J Med. 2010;363:2211–9. +[PMC free article] [PubMed] [Google Scholar] +12. Atlas D. International Diabetes Federation. In: Imprimerie L, Vanmelle SA, editors. 2nd edition. +Gent/Mariakerke, Belgium: 2000. p. 159. Hallado en: http://www.idf.org/diabetesatlas/5e/es/prologo . +[Google Scholar] +13. Sharma R, Gupta N, Bijlani RL. Effect of yoga based lifestyle intervention on subjective well- +being. Indian J Physiol Pharmacol. 2008;52:123–31. [PubMed] [Google Scholar] +14. Chaya MS, Nagendra HR. Long-term effect of yogic practices on diurnal metabolic rates of healthy +subjects. Int J Yoga. 2008;1:27–32. [PMC free article] [PubMed] [Google Scholar] +15. Nagendra HR, Nagaratna R. Yoga for Diabetes. Bangalore: Swami Vivekananda Yoga Prakashana; +2011. pp. 39–54. [Google Scholar] +16. Kesavachandran C, Bihari V, Mathur N. Can physical activity maintain normal grades of body mass +index and body fat percentage? Int J Yoga. 2009;2:26–9. [PMC free article] [PubMed] +[Google Scholar] +17. Shaikh WA, Patel M, Singh S. Sleep deprivation predisposes gujarati Indian adolescents to obesity. +Indian J Community Med. 2009;34:192–4. [PMC free article] [PubMed] [Google Scholar] +18. Chaya MS, Kurpad AV, Nagendra HR, Nagarathna R. The effect of long term combined yoga +practice on the basal metabolic rate of healthy adults. BMC Complement Altern Med. 2006;6:28. +[PMC free article] [PubMed] [Google Scholar] +19. Nagendra HR, Nagaratna R. New perspective in stress management. Bangalore: Vivekananda +Kendra Prakashana; 1977. pp. 34–79. [Google Scholar] +20. Anand BK, Chhina GS, Singh B. Studies on Shri Ramanada Yogi during his stay in an air-tight +box.1961. Indian J Med Res. 2012;136:688. [PubMed] [Google Scholar] +21. Wallace RK, Benson H. Readings from scientific American. San Francisco: WH Freeman and Co; +1972. The physiology of meditation. Altered States of awareness; pp. 2–3. [Google Scholar] +22. Wallace RK, Benson H, Wilson AF. A wakeful hypometabolic physiologic state. Am J Physiol. +1971;221:795–9. [PubMed] [Google Scholar] +23. Williamson DL, Kirwan JP. A single bout of concentric resistance exercise increases basal +metabolic rate in 48 hours after exercise in healthy 59-77-year-old men. J Gerontol A Biol Sci Med Sci. +1997;52:M352–5. [PubMed] [Google Scholar] +24. Gilliat-Wimberly M, Manore MM, Wooly K, Swan PD, Carrrol SS. Effects of habitual physical +activity on resting metabolic rates and body composition of women aged 35 to 50 years. J Am Diet +Assoc. 2001;101:1181–8. [PubMed] [Google Scholar] +25. Ribeyre J, Fellmann N, Montaurier C, Delaitre M, Vernet J, Coudert J, et al. Daily energy +expenditure and its main components as measured by whole-body indirect calorimetry in athletes and +non-athletic adolescents. Br J Nutr. 2000;83:355–62. [PubMed] [Google Scholar] +26. McArdle WD, Katch FI, Katch VL. 9th ed. Lippincott Williams & Wilkins; 2010. Exercise +physiology: nutrition, energy, and human performance; pp. 349–65. [Google Scholar] +27. Sugi Y, Akutsu K. Studies on respiration and energy metabolism during sitting in Za Zen. Res J +Physiol Educ. 1968;12:190–206. [Google Scholar] +28. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration following two Yoga based +relaxation techniques. Appl Psychophysiol Biofeedback. 2000;25:221–7. [PubMed] [Google Scholar] +29. Orme-Johnson DW. Autonomic stability and Transcendental Meditation. Psychosom Med. +1973;35:341–9. [PubMed] [Google Scholar] +Articles from Journal of Mid-Life Health are provided here courtesy of Wolters Kluwer -- Medknow +Publications diff --git a/subfolder_0/Yogic breathing practices improve lung functions of competitive young swimmers.txt b/subfolder_0/Yogic breathing practices improve lung functions of competitive young swimmers.txt new file mode 100644 index 0000000000000000000000000000000000000000..7758a9958dd729596e1ef5273b728b8cf0947eb7 --- /dev/null +++ b/subfolder_0/Yogic breathing practices improve lung functions of competitive young swimmers.txt @@ -0,0 +1,651 @@ +Original Research Article (Clinical) +Yogic breathing practices improve lung functions of competitive +young swimmers +Chirag Sunil Hakked, Ragavendrasamy Balakrishnan*, Manjunath Nandi Krishnamurthy +Division of Life Sciences, SVYASA University, 19, Gavipuram Circle, K G Nagar, Bangalore, 19, India +a r t i c l e i n f o +Article history: +Received 12 May 2016 +Received in revised form +6 September 2016 +Accepted 10 December 2016 +Available online 8 June 2017 +Keywords: +Pranayama +Breathing practices +Competitive swimming +Pulmonary function +a b s t r a c t +Background: Resistive breathing practices are known to improve endurance and performance in +competitive swimmers. However, the effect of Pranayama or Yogic Breathing Practices (YBP) in improving +respiratory endurance and performance of competitive swimmers remains un-investigated. +Objectives: To study effects of yogic breathing practices on lung functions of swimmers. +Material and methods: Twenty seven national and international competitive swimmers of the age range +13e20 years, with 8.29 ± 2.9 years of competitive swimming experience and practicing swimming for +9.58 ± 1.81 km everyday, were assigned randomly to either an experimental (YBP) or to wait list control +group (no intervention). Outcome measures were taken on day 1 and day 30 and included (1) spirometry +to measure lung function, (2) Sport Anxiety Scale-2 (SAS-2) to measure the antecedents and conse- +quences of cognitive and somatic trait anxiety of sport performance and (3) number of strokes per breath +to measure performance. The YBP group practiced a prescribed set of Yogic Breathing Practices e +Sectional Breathing (Vibhagiya Pranayama), Yogic Bellows Breathing (Bhastrika Pranayama) and Alternate +Nostril Breathing with Voluntary Internal Breath Holding (Nadi Shodhana with Anthar kumbhaka) for half +an hour, five days a week for one month. +Results: There was a significant improvement in the YBP group as compared to control group in maximal +voluntary ventilation (p ¼ 0.038), forced vital capacity (p ¼ 0.026) and number of strokes per breath +(p ¼ 0.001). +Conclusion: The findings suggest that YBP helps to enhance respiratory endurance in competitive +swimmers. +© 2016 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by +Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ +licenses/by-nc-nd/4.0/). +1. Introduction +Swimming as a competitive sport involves propelling one's body +in water by pushing against it. The water, because of its greater +density, offers more resistance to the swimmers than air in land +based sports [1]. Competitive swimmers are expected to have spe- +cific anthropometrical features compared to other athletes [2]. +Swimming being an activity that requires physical strength and +endurance, is often associated with large lung volumes and rela- +tively reduced flow, which may represent a physiological variant of +normal pulmonary functions but also can signify an obstructive +abnormality [3]. Increased respiratory work in competitive swim- +ming induces respiratory muscle fatigue and in turn reduces +swimming endurance, performance and breathing frequency [4,5]. +Evidence suggests that serum lactate, a metabolic by product of the +glycolytic pathway increases in swimming and contributes to stiff- +ness and soreness [6]. Increased serum lactate levels have been +shown to influence stroke rate and distance covered per stroke +while swimming [7]. +The conventional method used for competitive swimming is +inhaling through the mouth in a short time and exhaling the air +from the nose while underwater [8,9], thereby reducing the resis- +tance caused by turning the head [10]. However, due to an increase +in exhalation, which helps in overcoming the resistance of water, +there is a resultant increase in the fatigue of the respiratory muscles +[11] and reduction in blood flow and oxygen supply to other exer- +cising muscles [3]. +In competitive swimming, strict regulation of breathing is +essential [12] to ensure maximum levels of oxygen in a relatively +available short time span [13]. Techniques evolved to enhance +performance and to overcome the associated complications of +* Corresponding author. +E-mail address: ragavendrasamy.b@svyasa.org (R. Balakrishnan). +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 +http://dx.doi.org/10.1016/j.jaim.2016.12.005 +0975-9476/© 2016 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by Elsevier B.V. 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 8 (2017) 99e104 +swimming +had +focused +on +keeping +well-conditioned +lungs, +increasing the vital capacity, regulating breathing pattern and +strengthening respiratory musculature [4]. +Research has indicated the influence of somatic and cognitive +anxiety on outcome measures in sports. The process of competitive +stress involves the perception of a substantial imbalance between +the environmental demand and one's response capabilities. This +imbalance is perceived as having important consequences on the +outcome [14]. Elevation in sympathetic tone as marked by anxiety +and reduced Heart Rate Variability patterns have been shown to be +regulated by regulation of breathing [15]. Also, Cognitive Behavioral +Therapy (CBT) aimed towards reducing anxiety has been docu- +mented to increase performance [16]. The ability to overcome +pressure and anxiety is an integral part of sports, particularly +among elite athletes [17,18]. +Pranayama is more than a simple breathing exercise. It is not +merely breath control but is one of the powerful yogic techniques +used to regulate the flow of energy, ‘prana’ in the body to a higher +frequency [19]. Traditional yogic literature suggest four important +aspects of breathing utilized in Pranayama. They are Puraka or +inhalation, Rechaka or exhalation, Anthar kumbhaka or Internal +Breath Retention and Bahir kumbhaka or External Breath Retention +[20]. In the current study three pranayama or Yogic Breathing +Practices (YBP) have been utilized: Sectional Breathing (Vibhagiya +Pranayama), Yogic Bellows Breathing (Bhastrika Pranayama) and +Alternate Nostril Breathing with Voluntary Internal Breath Reten- +tion (Nadi Shodhana Pranayama with Anthar kumbhaka). +In healthy individuals, Alternate Nostril Breathing has been +shown to be effective in improving vital capacity of the lungs as +well as cardio-pulmonary functioning [11]. Alternate Nostril +Breathing when practiced along with Yogic Bellows Breathing has +been shown to improve Maximum Ventilatory Volume along with +Vital Capacity of the lungs [21], whereas the same when practiced +with Voluntary Internal Breath Retention ensures better oxygen +availability to the tissues [21]. Yogic Bellows Breathing when +practiced along with other breathing practices showed a better +reduction in basal heart rate and respiratory rate suggesting a +better cardiac autonomic reactivity and parasympathetic activity +[22]. Sectional Breathing practices increased thoraco-pulmonary +compliances by more efficient use of diaphragmatic and abdom- +inal muscles, thereby emptying and filling the respiratory appa- +ratus +more +efficiently +and +completely. +Sectional +Breathing +involving individual's awareness helps correct the inefficient +breathing pattern and increase Vital Capacity of lungs [23]. Hav- +ing studied individually, the effects of the Yogic Breathing Practices +in healthy volunteers, this study aims to utilize these practices to +enhance pulmonary function and endurance of the respiratory +muscles in competitive swimmers. +Based on the findings from the earlier studies, we hypothesized +Alternate Nostril Breathing with Voluntary Internal Breath Reten- +tion; Yogic Bellows Breathing and Sectional Breathing are expected +to alleviate sport anxiety through reduction of sympathetic +arousal, enhance endurance of the respiratory muscles and vital +capacity of the lungs thereby reducing fatigue and acute respira- +tory symptoms. +2. Methodology +2.1. Participants +Twenty seven competitive swimmers from a swimming acad- +emy, (thirteen males and fourteen females) of the age range 13e20 +years, with 8.29 ± 2.9 years of competitive swimming experience, +practicing swimming for 9.58 ± 1.81 km everyday, participated in +the study. The project was approved by the Institutional Ethics +Committee. A written informed consent was obtained from all the +participants above 18 years and for minors below the age of 18 +years an informed consent was obtained from the parents or +guardians. +The sample size was estimated from a previous study conducted +with an effect size of 0.9 and an estimated sample size of 24. +Considering drop outs more swimmers (n¼30) were included in +the study. +2.2. Experimental design: randomized matched control clinical +study +Participants were first stratified according to their age and +gender and randomly assigned into one of two, Yogic Breathing +Practices (YBP) and wait-list control groups based on a computer- +ized random number generator. Baseline characteristics of the +participants in each group are described in Table 1. +2.3. Experimental protocol +The YBP group was administered with Sectional Breathing +(Vibhagiya Pranayama), Yogic Bellows Breathing (Bhastrika Pra- +nayama) and Alternate Nostril Breathing (Nadi Shodhana) with +Voluntary Internal Breath Retention (Anthar kumbhaka) for thirty +minutes, five days a week for a period of one month along with +their regular practice of swimming and physical training. The +control group underwent only physical training practices (Table 2). +The practice was administered in a sound attenuated hall as a pre- +recorded audio to avoid instructor bias. However, the instructor +was available throughout the practice session to clarify the doubts +if any. The waitlist control group practiced their regular swimming +and physical training protocol. +2.3.1. Description of intervention +2.3.1.1. Sectional Breathing (Vibhagiya Pranayama). Sectional Breath- +ing is a preparatory breathing practice for pranayama, which helps to +correct the incorrect breathing pattern such as habitual over +breathing, breath holding or shallow breathing. Participants were +Table 1 +Demographic data of the initially randomized sample. +Sl No +Baseline characteristics +YBP group +n ¼ 14 +(Mean ± SD) +Control group +n ¼ 15 +(Mean ± SD) +1. +Age (in years) +15.23 ± 1.59 +15.08 ± 1.26 +2. +Height (in cm) +165.69 ± 10.38 +163.31 ± 10.28 +3. +Weight (in kg) +55 ± 9.66 +52.77 ± 10.39 +4. +Experience (in years) +8.15 ± 2.96 +8.42 ± 2.83 +5. +Swimming per day (in km) +9.62 ± 1.89 +9.53 ± 1.81 +6. +Swimming per week (in km) +48.08 ± 9.47 +47.69 ± 9.04 +Table 2 +List of Yoga practices +Practice +Duration +Regular physical training undertaken by both the groups +Running and stretching exercises +20 min +Endurance building exercises +20 min +Swimming drills +6 kick & 3 pull +Practices specific to yoga group +Sectional Breathing +10 min +Yogic Bellows Breathing (Bhastrika Pranayama) +10 min +Alternate Nostril Breathing with Voluntary Internal +Breath Retention +10 min +C.S. Hakked et al. / Journal of Ayurveda and Integrative Medicine 8 (2017) 99e104 +100 +asked to sit in a comfortable posture e sukhasana, padmasana or +vajarasana with the spine erect (Fig. 1). +Abdominal breathing: Instructions were given to inhale by +bulging out the abdominal muscles and exhale by drawing back the +abdomen inward. Thoracic breathing: Instructions were given to +inhale by expanding the chest muscles and exhale by returning the +chest to its normal position. This was repeated for 10 rounds. +Upper lobar breathing: Instructions were given to inhale raising +the collar bones and shoulders upwards and backwards and exhale +by dropping the shoulders into a resting position. This was repeated +for 10 rounds. +Full yogic breathing: Instructions were given to inhale in the +following sequence e Abdominal breathing, Thoracic breathing and +Upper lobar breathing and exhale in the same sequence. This was +practiced at a frequency of 4 breaths/min [20]. +The steps mentioned above were repeated with awareness for +10 rounds. The entire practice was completed in a duration of +10 min. +2.3.1.2. Yogic +Bellows +Breathing +(Bhastrika +Pranayama). +Instructions were given to breathe in and out forcefully through the +nose without straining any part of the body. They were asked to +expand and contract abdomen rhythmically with the breath. This +was done through the left nostril, then the right nostril and both +the nostrils, which was repeated for ten rounds making one set. +After each set there was retention of the breath for a twenty sec- +onds. Then the participants were asked to breathe out slowly and +return to normal breathing. This made one round of Yogic Bellows +Breathing. The same procedure was repeated for 2 rounds followed +by relaxation for 10 min in total [20]. +2.3.1.3. Alternate Nostril Breathing with Voluntary Internal Breath +Retention (Nadi Shodhana with Anthar kumbhaka). Instructions +were given to adopt nasika mudra (Fig. 2). Following complete +exhalation, participants were instructed to inhale through the left +nostril closing the right nostril and hold the breath by closing both +the nostrils and placing the chin close to the jugular notch. +Following breath holding, raising the head, instruction was given to +exhale through the right nostril while closing the left. Inhalation +was then done through right nostril and exhalation through left +nostril following breath holding to complete one round of Nadi +Shodhana Pranayama with Kumbhaka. Inhalation, breath holding +and exhalation were performed for a duration of 8 s each (ratio +1:1:1) amounting the respiratory rate to be 2.5 breaths/minute +[24,25]. Practice was repeated for a duration of 10 min. +2.3.1.4. Outcome measures. The spirometery test was done as per +the standardization protocol prescribed by the American Thoracic +Society (ATS) [26]. Slow Vital Capacity (SVC), Inspiratory Reserve +Fig. 1.. Representation of postures in which the pranayama practices were administered to Yoga group +Fig. 2. Representation of Alternate Nostril Breathing performed with nasika mudra. +C.S. Hakked et al. / Journal of Ayurveda and Integrative Medicine 8 (2017) 99e104 +101 +Volume (IRV), Forced Vital Capacity (FVC), Maximum Voluntary +Ventilation (MVV) and Minute Ventilation (MV), and Peak Expira- +tory Flow (PEF) were determined for assessing lung functions in all +participants on day 1 and day 30. +Sport Anxiety Scale e 2 (SAS-2) is an anxiety scale, measuring +the antecedents and consequences of cognitive and somatic trait +anxiety in children and adults in sport performance settings [27]. +The SAS-2 has 30-items which measures individual differences in +somatic anxiety and two aspects of cognitive anxiety, namely, +worry and concentration disruption responded on a 4-point extent- +of-experience scale containing the following scales: 1 (not at all), 2 +(a little bit), 3 (pretty much) and 4 (very much). The participants +were asked to fill the SAS-2 questionnaire on the day 1 and day 30. +The capacity of the competitive swimmer to efficiently prolong +the breath and perform more strokes per breath shall play a sig- +nificant role in increasing the speed of swimming. The participants +were asked about their subjective observation of swimming strokes +per breath on the day 1 and day 30 to assess their performance. This +was done to understand the participant's subjective experience to +their specific experimental conditions. +2.4. Data analysis +Data were analyzed using SPSS version 16.0 (SPSS Inc, Chicago, +Ill). Descriptive statistics were used to assess normality and ho- +mogeneity. Following normal distribution of the data, paired +sample t test was used to assess the within group changes, and +analysis of covariance (ANCOVA) for between group changes were +performed. Principal Component Analysis was performed for +height, weight, duration of practice per week and experience of +swimming. The component obtained and baseline values of the +variables were used as covariates to determine the between-group +changes following intervention. +3. Results +The mean age of the participants was 15.23 ± 1.59 in YBP group +and 15.08 ± 1.26 in the waitlist control group. Attendance was +maintained to estimate adherence. 90% adherence was considered +as eligibility for the participants to be included in the study. +However, in the study the adherence was 100% Participants in both +the groups were comparable with respect to the socio-demographic +characteristics. +3.1. Pulmonary functions +ANCOVA test showed a significant improvement in Maximum +Voluntary Ventilation (MVV) (F(1,22) ¼ 6.06, p ¼ 0.02) and Forced +Vital Capacity (FVC) (F(1,22) ¼ 5.68. p ¼ 0.026) between the groups +following intervention. There were no significant differences +observed in the Slow Vital Capacity (SVC), Inspiratory Reserve +Volume (IRV), Minute Ventilation (MV) and Peak Expiratory Flow +(PEF) (Table 3). +3.2. Sport Anxiety Scale +Paired t test done to assess within group changes show a sig- +nificant reduction in self-reported Total Sport Anxiety (t ¼ 2.45, +p ¼ 0.031), Concentration Disruption (t ¼ 2.635, p ¼ 0.022) and +Somatic Complaints (t ¼ 2.343, p ¼ 0.037) in the YBP group. No +significant change was observed between the groups (Table 4). +3.3. Number of strokes +Paired t test done to assess the within group changes showed a +significant increase in the number of strokes per breath in the YBP +group (t ¼ 7.98, p  0.001). Analysis of Variance on post-inter- +vention measures showed a significant increase in the number of +strokes per breath in the YBP group compared with controls +(F(1,22) ¼ 13.06, p ¼ 0.002) (Table 5). +4. Discussion +Thirty competitive swimmers of age range 15.27 ± 1.66 yrs, were +randomly allocated to YBP or waitlist control groups. A significant +change in Maximal Voluntary Ventilation, Forced vital capacity as +well as in swimming performance based on number of strokes per +breath were observed in YBP as compared to the controls following +one month of intervention. There were 3 dropouts, 1 from the YBP +group and 2 from the control group as the participants were not +Table 3 +Comparison of pulmonary function +Sl No +Descriptive +YBP Group (Mean ± SD) n ¼ 14 +Control Group (Mean ± SD) n ¼ 13 +np +2 +Pre +Post +Pre +Post +1. +SVC +3.13 ± 0.52 +3.01 ± 0.59 +2.95 ± 1.07 +2.63 ± 0.71 +0.112 +2. +IRV +1.19 ± 0.43 +1.45 ± 0.76a +1.01 ± 0.45 +1.12 ± 0.46 +0.044 +3. +FVC +2.91 ± 0.42 +3.14 ± 1.03b +2.52 ± 0.65 +2.39 ± 0.75 +0.205 +4. +MVV +106.5 ± 30.61 +115.45 ± 31.44b +102.98 ± 23.52 +97.65 ± 20.37 +0.216 +5. +MV +27.35 ± 11.95 +23.04 ± 14.15 +24.93 ± 21.03 +17.78 ± 9.82 +0.037 +6. +PEF +6.34 ± 1.13 +6.84 ± 1.61 +5.67 ± 1.47 +5.45 ± 1.80 +0.148 +a p  0.05 for within group analysis using paired t test. +b p  0.05 for between group analysis using Analysis of Covariance. +Table 4 +Comparison of Sport Anxiety. +S No +Description +YBP Group (Mean ± SD) n ¼ 14 +Waitlist Control Group (Mean ± SD) n ¼ 13 +Pre +Post +Pre +Post +1. +Concentration disruption +9.38 ± 2.18 +8.0 ± 2.0a +9.46 ± 2.63 +9.15 ± 2.54 +2. +Somatic complaints +10.15 ± 3.62 +8.62 ± 3.28a +10.31 ± 2.46 +10.08 ± 2.88 +3. +Anxiety +10.0 ± 2.71 +8.85 ± 2.54 +9.77 ± 2.49 +9.46 ± 2.44 +4. +Total score in SAS-2b +29.54 ± 7.15 +25.46 ± 6.73a +29.54 ± 6.30 +28.69 ± 6.64 +a p  0.05 for within group analysis using paired t test. +b SAS-2 e Sport Anxiety Questionnaire -2. +C.S. Hakked et al. / Journal of Ayurveda and Integrative Medicine 8 (2017) 99e104 +102 +available for their post recordings. Posthoc analysis showed the +effect size of the present study to be 0.69 indicating the findings of +the study to have medium to large effect size. +These findings are in accordance with earlier findings suggestive +of resistive breathing training improving the pulmonary functions +[4]. +The purpose of the study was to assess the role of the voluntary +breath regulation practices in improving lung volumes, respiratory +muscle endurance and decreasing sport anxiety. It is well estab- +lished through previous studies that, following swimming prac- +tices, lung function of swimmers is reduced due to the pressure of +water on thorax causing restriction [28], gradually leading to a state +of end-organ fatigue at the level of diaphragm caused by reduced +oxygen supply, increased anaerobic metabolism and accumulated +lactic acid. In the present study, an observed increase in Maximal +Voluntary Ventilation and Forced Vital Capacity can be attributed to +the increased strength of the respiratory musculature [29]. +The increase in number of strokes per breath in YBP group +suggests an increase in breath holding time. However, this measure +was used as a tool to understand the possible impact of YBP in +improving the performance. Practice of voluntary breath retention +involves voluntary cessation of breathing and slowing down the +speed of breathing [4], aiding a practitioner to gain control over the +pneumotaxic center and influencing the pontine areas on the brain +stem. Control over these areas facilitates the practitioner to prolong +the breath holding time following inspiration [30]. Also, YBP have +shown beneficial effects in improving oxygen carrying capacity of +RBCs [31], which is reduced with increasing stress and anxiety. +Pranayama practices cleanses airway secretions and acts as a major +physiological stimulus for release of lung surfactant and prosta- +glandins into alveolar spaces and promote lung compliance [32]. +Even though, breath holding induces transient phases of hypoxia +[33], Pranayama practices are expected to deliver the results +through promoting the production of lung surfactants [32], reduce +the surface tension and promote exchange of gases in alveolar +membrane and enhancing the oxygen carrying capacity of the RBCs +[31]. +An increase in MVV and FVC is associated with decreased +resistance of airways and increased strength of the respiratory +musculature [34,35]. However, the present study has not made +attempts to understand the role of YBP in maintaining the airway +patency. The present results are suggestive of increased endurance +of the pulmonary musculature, better oxygen availability and +possible reduction in end organ fatigue through increased MVV and +reduction in concentration disruption, somatic stress and worry as +indicated by the Sport Anxiety Scale-2. +However earlier studies on exercise training suggest that, there +occurs no change to the Basal Metabolic Rate irrespective of the +pulmonary capacity [36] but, Yoga practices have shown reduction +in Basal Metabolic Rate [37], which might be of importance to be +explored as a reason for increased efficiency. +No significant differences were observed between the genders +in both the groups. Age-based comparison of outcomes were not +performed owing to the less sample size. The present study has not +been designed to monitor progressive improvement in the lung +capacities. The limitation of this study is that it does not give us an +understanding of the duration or the point of time at which, the +beneficial effects become observable. Further research is required +to understand the physiological adaptations that might have taken +place in the respiratory musculature and the group that is most +benefitted by the Yogic Breathing Practices. +5. Conclusion +The findings of the present study are in accordance with earlier +findings suggestive of resistive breathing training enhancing pul- +monary capacities. The results suggest that YBP for 30 min a day +along with routine physical exercises for five days a week, de- +creases airway resistance, increases respiratory muscle endurance, +and number of strokes per breath, possibly, through better auto- +nomic reactivity, oxygen diffusion and reduced anxiety in com- +petetive swimmers . Future studies are required to understand the +actual adaptations in the respiratory muscles and improvements in +performance. +Conflict of interest +None declared. +References +[1] Romer LE, Polkey MI. Exercise-induced respiratory muscle fatigue: implica- +tions for performance. J Appl Physiol 2008;104(3):879e88. +[2] Aspenes ST, Karlsen T. Exercise-training intervention studies in competitive +swimming. Sports Med 2012;42(6):527e43. +[3] Silvestri M, Crimi E, Oliva S, Senarega D, Tosca MA, Rossi GA, et al. Pulmonary +function and airway responsiveness in young competitive swimmers. Pediatr +Pulmonol 2013;48(1):74e80. +[4] Lindholm P, Wylegala J, Pendergast DR, Lundgren CEG. Resistive respiratory +muscle training improves and maintains endurance swimming performance +in divers. Undersea Hyperb Med 2007;34(3):169e80. +[5] Lomax M, Castle S. Inspiratory muscle fatigue significantly affects breathing +frequency, stroke rate, and stroke length during 200-m front-crawl swim- +ming. J Strength Cond Res 2011;25(10):2691e5. +[6] Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment +strategies and performance factors. Sports Med 2003;33(2):145e64. +[7] Oliveira MF, Caputo F, Dekerle J, Denadai B, Greco C. Stroking parameters +during continuous and intermittent exercise in regional-level competitive +swimmers. Int J Sports Med 2012;33(9):696e701. +[8] Hong SK, Cerretelli P, Cruz JC, et al. Mechanics of respiration during sub- +mersion in water. J Appl Physiol 1969;27(4):535e8. +[9] Palmer J. Greaing up. Simple swimming guide. 2010. p. 22. +[10] Maglischo EW. Reducing resistance. Swimming fastest: the essential reference +on technique, training, and program design. 2003. p. 130e41. +[11] Singh S, Gaurav V, Parkash V. Effects of a 6-week nadi-shodhana pranayama +training on cardio-pulmonary parameters. J Phys Educ Sport Manag 2010;2(4): +44e7. +[12] Kilding AE, Brown S, McConnell AK. Inspiratory muscle training improves 100 +and 200 m swimming performance. Eur J Appl Physiol 2010;108(3):505e611. +[13] Jorgic B, Puletic M, Okicic T, Me +skovska N. Importance of maximal oxygen +consumption during swimming. Phys Educ Sport 2011;9(2):183e219. +[14] Martens R, Vealey RS, Burton D. Competitive anxiety in sport. Human Kinetics; +1990. +[15] Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing in the treatment of +stress, anxiety, and depression: part I-neurophysiologic model. J Altern +Complement Med 2005;11(1):189e201. +[16] Miguel-Humara MA. The relationship between anxiety and performance: a +cognitive-behavioral perspective. Online J Sport Psychol 1999;1(2). +[17] Hardy L, Jones G, Gould D. Understanding psychological preparation for sport: +theory and practice of elite performers. Chichester, UK: Wiley; 1996. +[18] Orlick T, Partington J. Mental links to excellence. Sport Psychol 1988;2: +105e30. +[19] Muktibodhananda S, Saraswati SS. Hatha yoga pradipika. Munger, Bihar: Yoga +publication trust; 2009. +[20] Saraswati SS. Asana pranayama mudra bandha. Munger, Bihar: Yoga publi- +cation trust; 2002. +[21] Bal BS. Effect of anulom vilom and bhastrika pranayama on the vital capacity +and maximal ventilatory volume. J Phys Educ Sport Manag 2010;1(1):11e5. +[22] Veerabhadrappa SG, Herur A, Patil S, Ankad RB, Chinagudi S, Baljoshi VS. +Effect of yogic bellows on cardiovascular autonomic reactivity. J Cardiovasc +Dis Res 2011;2(4):223e7. +Table 5 +Comparison of total strokes per breath. +S No +Description +YBP (Mean ± SD) n ¼ 14 +Control (Mean ± SD) n ¼ 13 +Pre +Post +Pre +Post +1. +Total Strokes +2.08 ± 0.76 +3.54 ± 0.88a,b +2.85 ± 0.9 +3.08 ± 0.86 +a p values  0.001 for within group changes using paired t test. +b p values  0.001 for between group changes using analysis of covariance. +C.S. Hakked et al. / Journal of Ayurveda and Integrative Medicine 8 (2017) 99e104 +103 +[23] Nagarathana R, Nagendra HR. Yoga for promotion of positive health. Banga- +lore: Swami Vivekananda Yoga Prakashana; 2010. +[24] Iyengar BKS. Light on pranayama. 1st ed. Pune: Element; 2005. p. 118. +[25] Telles S, Desiraju T. Oxygen consumption during pranayamic type of very +slow-rate breathing. Indian J Med Res 1991;94:357e63. +[26] Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, et al. +Standardisation of spirometry. Eur Respir J 2005;26:319e38. +[27] Smith RE, Smoll FL, Cumming SP, Grossbard JR. Measurement of multidi- +mensional sport performance anxiety in children and adults: the sport anxiety +scale-2. J Sport Exerc Psychol 2006;28:479e501. +[28] Zauner CW, Benson NY. Physiological alterations in young swimmers dur- +ing three years of intensive training. J Sports Med Phys Fitness 1981;21: +179e85. +[29] Kesavachandran C, Nair HR, Shashidhar S. Lung volumes in swimmers per- +forming different styles of swimming. Indian J Med Sci 2001;55:669e76. +[30] Ganong WF. Pulmonary function. Review of medical physiology. 21st ed. +Boston: McGraw Hill; 2003. p. 649e66. +[31] Parshad O, Richards A, Asnani M. Impact of yoga on haemodynamic function +in healthy medical students. West Indian Med J 2011;60(2):148e52. +[32] Joshi LN, Joshi VD, Gokhale LV. Effect of short term pranayama on breathing +rate +and +ventilatory +functions +of +lungs. +Indian +J +Physiol +Pharmacol +1992;36(2):105e8. +[33] Krick S, Eul BG, Hanze J, Savai R, Grimminger F, Seeger W, et al. Role of +hypoxia-inducible factor-1a in hypoxia-induced apoptosis of primary alveolar +epithelial type II cells. Am J Respir Cell Mol Biol 2005;32(5):395e403. +[34] Lakhera S, Mathew L, Rastogi SK. Pulmonary function of Indian athletes and +sportsman: comparison with American athletes. Indian J Physiol Pharmacol +1984;28:187e94. +[35] Swinmane WE. Cardio-respiratory changes in college women to competitive +basketball players. J Appl Physiol 1968;25(6):720e4. +[36] Olufeyi A, Adegoke O, Arogundade. The effect of chronic exercise on lung +function and basal metabolic rate in some Nigerian athletes. Afr J Biomed Sci +2002;5:9e11. +[37] Chaya MS, Kurpad AV, Nagendra HR, Nagarathna R. The effect of long term +combined yoga practice on the basal metabolic rate of healthy adults. BMC +Complement Altern Med 2006;6:28. +C.S. Hakked et al. / Journal of Ayurveda and Integrative Medicine 8 (2017) 99e104 +104 diff --git a/subfolder_0/immediate effect of two yoga based relaxation techniques on performance in a letter cancellation task.txt b/subfolder_0/immediate effect of two yoga based relaxation techniques on performance in a letter cancellation task.txt new file mode 100644 index 0000000000000000000000000000000000000000..4647a9396541aee822a1e0b0e614a28f23a90885 --- /dev/null +++ b/subfolder_0/immediate effect of two yoga based relaxation techniques on performance in a letter cancellation task.txt @@ -0,0 +1,16 @@ + + + + + + + + + + + + + + + + diff --git a/subfolder_0/s the Indian Dietary Pattern Associated WithType 2 Diabetes A Pan-India Randomized Cluster Sample Study.txt b/subfolder_0/s the Indian Dietary Pattern Associated WithType 2 Diabetes A Pan-India Randomized Cluster Sample Study.txt new file mode 100644 index 0000000000000000000000000000000000000000..f1d4614537c83272abbe1940db43f208192aad0b --- /dev/null +++ b/subfolder_0/s the Indian Dietary Pattern Associated WithType 2 Diabetes A Pan-India Randomized Cluster Sample Study.txt @@ -0,0 +1,866 @@ +https://doi.org/10.1177/09727531211005226 +Annals of Neurosciences +27(3-4) 175­ +–182, 2020 +© The Author(s) 2021 +Reprints and permissions: +in.sagepub.com/journals-permissions-india +DOI: 10.1177/09727531211005226 +journals.sagepub.com/home/aon +Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- +NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and +distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https:// +us.sagepub.com/en-us/nam/open-access-at-sage). +Original Article +Is the Indian Dietary Pattern Associated With +Type 2 Diabetes? A Pan-India Randomized +Cluster Sample Study +Raghuram Nagarathna1, Akshay Anand2,3,4, + Sapna Nanda3, Suchitra S. Patil1, +Amit Singh1, S. K. Rajesh5 and H. R. Nagendra1 +Abstract +Background: +Diabetes is associated strongly with many neurodegenerative diseases and is also a lifestyle disorder. A good glycemic status +depends on diet management and physical activity. There are several studies available on the relationship between diet habits +and impact on diabetes. +Purpose: +The objective of this study was to check the association of different dietary factors with glucose levels and lipid values in type +2 diabetes from a part of a large nationwide trial. +Methods: +This was the data fromapan-India multicentered cluster randomized controlled study covering 60 states and 4 union +territories; 17,285 individuals were surveyed for dietary factors. Amongst them, data of 12,500 individuals were analyzed. +Males were 54% and 60% individuals were from urban areas. +Results: +The analysis of the results showed that consumption (usual/often) of milk(odds ratio, OR = 7.180), meat (OR = 6.81), +less fiber (OR = 17.77), and less fruits (OR = 14.71) was strongly and positively associated with fasting blood glucose +(P<.001). The postprandial blood glucose (PPBG) in diabetes individuals also had a strong positive association (P<.001) with +consumption (usual/often) of meat (OR = 22.82) and milk (OR = 17.19). In prediabetes individuals, milk was significantly +(P<.001) associated with fasting blood glucose (OR = 2.74). In nondiabetes individuals also, milk was significantly associated +with postprandial blood glucose (OR = 2.56). Consumption of meat was associated with high cholesterol (OR = 1.465). +Consumption of junk food was associated significantly (P <.001)with the status of known diabetes (OR = 1.345) and known +hypertension (OR = 1.247). +Conclusion: +Consumption of milk, meat, less vegetables, less fruits, and junk food has a significant effect on the glycemic status and +cholesterol levels, and also on the status of known diabetes and hypertension. +Keywords +Diabetes, Milk, Meat, Junk food, Indian population +Received 2 October 2020; revised 7 October 2020; accepted 7 October 2020 +4 Panjab University, Chandigarh, India +2 Neuroscience Research Lab, Postgraduate Institute of Medical Education +and Research (PGIMER), Chandigarh, India +3 Centre for Mind Body Medicine, PGIMER, Chandigarh, India +1 Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), +Kempegowda Nagar, Bengaluru, Karnataka, India +Corresponding author: +Raghuram Nagarathna, Director, Arogyadhama, VYASA, 19, Eknath Bhavan, +Gavipuram Circle, Kempegowda Nagar, Bengaluru, Karnataka 560019, India. +E-mail: rnagaratna@gmail.com +Introduction +Diabetes mellitus is a metabolic disorder, and lifestyle +behaviors including dietary patterns, physical activity, bad +habits, and stress are the known etiological factors. Its +increasing prevalence in developing countries such as India is +closely associated with the structure of the population, age +factors, and urbanized lifestyle.1,2 +The accurate etiology of diabetes mellitus has remained +uncertain in spite of the advancement in research and +5 Department of Yoga and Physical Science, SVYASA Yoga University, +Bangalore, India +176 +Annals of Neurosciences 27(3-4) +treatment facilities around the globe. Genetics, age, exercise, +physical fitness, dietary patterns, medications, obesity, and +waist circumference are the high-risk factors contributing to +the development of causes of diabetes—reduced insulin +absorption and beta-cell destruction.3 +In a review study,4 it is reported that the quality of the diet +was the important factor for reduced insulin absorption rather +than the components of the diet. In general, a greater intake +of milk products is not associated with reduced absorption of +insulin. This is in contrast to the traditional belief that milk +products, which are associated with higher levels of +cholesterol, saturated fat, and protein, are the risk factors for +cardio-vascular diseases (CVD). However, the fact that a +more protein intake increases the risk of ischemic heart +disease has not been established.5 +But the evidence of the study was not conclusive. The +study also suggested that several factors related to components +in milk products and constitutional variation, genetic +variability in populations may have an impact on insulin +absorption. For example, the type of milk products they +consume and the amount of fat and mineral may influence the +absorption of insulin. +Another study performed in Sweden, observed the +relationship between diet habits and risk of metabolic +syndrome, including a diet rich in milk fat compared to +regular milk and cheese. It revealed that excessive +consumption of glucose, bakery products, and alcohol was +associated with the risk of metabolic syndrome. However, in +women, consumption of excessive milk products was found +to be having a guarding effect with respect to type 2 diabetes. +Further, a diet with excessive milk fat was associated with a +reduced risk of hyperinsulinemia in women, but not in case of +men. The authors also noted that there may be a gender +difference in how different foods affect the metabolic +consequences with respect to diabetes.6 +In a prospective analysis of 7,731 men and women over 15 +years of follow-up, Brunner et al.7 found that a “healthy” +eating pattern characterized by a diet richin fruits, vegetables, +wholemeal bread, and breakfast cereals, low-fat dairy, and +little alcohol reduced the risk of diabetes and coronary death +or nonfatal myocardial infarction as compared to an +“unhealthy” eating pattern (white bread, processed meat, +fries, and full-cream milk). Compared with the “unhealthy” +pattern, the “healthy pattern” was almost two-fold higher in +fruit and vegetable intake and three-fold higher in bakery +product and milk product intake. +Numerous studies on milk products have shown negative +associations with the risk of type 2 diabetes.8 This study +examined the different facts that (a) milk products were +suggested to have an insulinotropic effect in single meals, (b) +fatty acids were found to improve insulin sensitivity, and (c) +diets rich in protein, calcium, and other minerals were found +to reduce blood pressure and body weight/fat and also found +to have an effect on blood cholesterol. +An earlier systematic review study which observed +outcomes related to glucose homeostasis concluded that less +amount of vitamin D and calcium may lead to hyperglycemia, +while intakes of a diet containing vitamin D and calcium may +regularize glucose metabolism.9 Various observational studies +have been carried out on the relation of the intake of milk +products and insulin absorption, and most of them have +revealed an opposite relation.10,11 +A prospective study established that excessive consumption +of red meat was associated with an increased risk of +developing type 2 diabetes in middle-aged and older people. +Also it was observed that there were significantly positive +associations of cholesterol-, protein-, and iron-rich diet foods, +for example red meat, with a risk of developing diabetes.11,12 +A study on personalized diet habits and counseling on +exercise hypothesized thatthese result in improving the +function of the nervous system and reduction in pain.13 +Globally, various studies are available on single dietary +factors (e.g., milk, meat, or fiber diet), but no comprehensive +study had been conducted in India including all dietary +factors. Hence, the present study has been conducted to check +the effect of different diet components on blood sugar and +lipid values in type 2 diabetes all over India. +Methodology +Study Design +This study is part of a pan-India multicentred cluster +randomized controlled trial covering all populous states and +union territories.14 Details of the methodology have been +published earlier.In brief, the study was planned in two phases +with the goal of preventing further development of prediabetes +into diabetes. In step 1 of phase I, screening was done on Indian +Diabetes Risk Score (IDRS) to identify high-diabetes-risk and +known diabetes individuals. In step 2 of phase I,detailed data +including blood test data were acquired for fasting blood +glucose (FBG), postprandial blood glucose (PPBG), and +glycated hemoglobin (HbA1c) only in those subjects who had +attained high IDRS scores (IDRS >60). Phase II was a two- +armed translational randomized controlled trial on yoga-based +lifestyle changes. Figure 1 provides the structure of the project. +In step 1, samples from seven geographical zones, i.e., +Jammu & Kashmir, Northeast, North, West, Central, East, and +South were included. A stratified, multistage cluster sampling +design was adopted. In rural areas, a two-stage village– +household design, and in urban areas, a four-stage town/city– +ward–block–household design wereadopted. Both rural and +urban areas were stratified at three levels based on the +geographical distribution and population size (Figure 1).15,16 +Assessments +The assessments in step 1 for all participants included four +factors: IDRS, sociodemographic variables, blood pressure, +and self-reported diabetes. Further assessments of known +diabetes and high-diabetes-risk groups (IDRS>60) included +HbA1c, FBG, PPBG, and lipid profiles (in venous blood). +Nagarathna et al. +177 +Details of dietary patterns were documented for the high-risk +group (Table 1). +Statistical Analysis +Data were uploaded via mobile apps by trained yoga +volunteers for diabetes mellitus (YVDMs) under supervision +of senior research fellows. Uploaded data from screening +forms (about 4, <0.001 per district), registration forms, and +laboratory data (about 50, <0.001) were checked for perfect +matching of coding. After cleaning on Excel, the dataset was +analyzed using R software for biostatistical analyses. Linear +regression and binomial regression were adopted for checking +the association between dietary factors and sugar levels and +status of diabetes. +Results +The survey was conducted on 17,285 individuals for dietary +factors. Sample data of 12,500 individuals were analyzed. In +those, males were 54%, and 60% individuals were from +urban areas. +Table 2 shows the regression values for the association +between different dietary factors and the blood glucose values +(FBG and PPBG) in individuals with diabetes, prediabetes, +and normoglycemia. As seen from the table, usual/often +intake of meat, milk, less fiber, and less fruits was significantly +associated with raised PPBG and FBG in the diabetes group. +Figure 1. Four-Level Sampling Design. +Source: Nagendra et al.16 +Table 1. Questions Asked in the Survey. +Skip breakfast? +Usually/Often 1 +Sometimes 2 +Rarely/Never 3 +Eat less than two servings of fruit +a day? +Serving = ½cup or 1 medium-sized +fruit or ¾ cup 100% fruit juice. +Usually/Often 1 +Sometimes 2 +Rarely/Never 3 +Eat less than two servings of veg- +etables a day? +Serving = ½ cup vegetables, or 1 +cup leafy raw vegetables. +Usually/Often 1 +Sometimes 2 +Rarely/Never 3 +Eat or drink two servings of milk, +yogurt, or cheese a day? Serving = +1 cup milk or yogurt; 60 g cheese. +Usually/Often 1 +Sometimes 2 +Rarely/Never 3 +Eat more than 250 g (see sizes +below) of meat, chicken, turkey, or +fish per day? +Note: 100 g of meat or chicken is +the size of a deck of cards or one of +the following: 1 regular hamburger, +1 chicken breast or leg (thigh and +drumstick), or 1 pork chop. +Usually/Often 1 +Sometimes 2 +Rarely/Never 3 +Burger/Chips +How many times in a week? +Fried items, e.g., Samosa/Kachori/ +Bonda, etc. +How many times in a week? +Pizza +How many times in a week? +Cake/Pastry +How many times in a week? +Fizzy cold drinks +How many times in a week? +Chat/Masala puri +How many times in a week? +178 +Annals of Neurosciences 27(3-4) +However, among the prediabetes group, these were +significantly associated with FBG only, except for the less +fruit group which has a significant association with both FBG +and PPBG. The normoglycemia group also revealed +significant associations of PPBG with usual milk intake and +FBG with meat, and less fiber, less fruit intake with raised +PPBG and FBG. In the diabetes group, no significant +association was noticed for either FBG or PPBG with skipping +of breakfast, whereas in the normal group FBG and PPBG +showed a significant association with skipping of breakfast. +Furthermore, in the prediabetic group, a significant association +was observed only for FBG. +Table 3 reveals the odds ratio of the association between +various junk foods and self-reported known diabetes. It was +found that consumption of cake and fizzy drinks per week +was significantly associated with the status of known +diabetes mellitus. +Table 4 depicts the odds ratio of various dietary factors for +the incidence of prehypertension, hypertension stage 1, and +hypertension stage 2. It was found that an increased +consumption of pizza and fizzy per week was associated with +prehypertension. Increased consumption of pizza, fizzy, and +cake per week was associated with hypertension stage 1. +Increased consumption of burger, cake, and fizzy per week +was associated with hypertension stage 2. +Table 5 reveals the odds ratio of the association between +various dietary factors consumed usually and peripheral +neuropathy in diabetes individuals. It was found that usual +consumption of meat was significantly associated with +peripheral neuropathy in diabetes individuals. +Table 6 shows the odds ratio of the association between +various dietary factors consumed usually and cholesterol. It +was found that usual/often consumption of meat and less +vegetables was significantly associated with high cholesterol. +Discussion +The present study has been conducted across seven zones of +India. In this study, an association of dietary factors such as +milk products, meat, and junk foods with FBG and PPBG +was appraised. +The findings of the present study revealed that regular +ingestion of excessive milk, meat, and junk foods has a +substantiated effect on the blood glucose levels of the +individuals, particularly in case of diabetes mellitus. These +Table 2. Association Between Dietary Factors With Diabetes Categories of Diabetes, Prediabetes, and Normoglycemia (Regression +Analysis). +Dietary Factor +Consumes usually/Often +Blood Variables +Diabetes Odds Ratio +Prediabetes Odds Ratio +Normoglycemia Odds Ratio +Milk +PPBG +17.19* +3.44 +2.56* +FBG +7.18* +2.74* +2.31 +Meat +PPBG +22.82* +3.90 +1.64 +FBG +6.81* +2.63* +1.51* +Less fiber +PPBG +17.77* +2.78 +2.80* +FBG +9.17* +2.87* +1.95* +Less fruit +PPBG +14.71* +3.51* +1.21* +FBG +8.99* +1.95* +1.18* +Skipping of breakfast +PPBG +5.63 +1.33 +1.72* +FBG +4.14 +1.69* +1.45* +Abbreviations: FBG, fasting blood glucose; PPBG, postprandial blood glucose. +Notes: There was a highly significant association between blood glucose (FBG and PPBG) values and consumption of milk, meat, less fruits, and less fiber, +but not with skipping of breakfast in diabetes individuals.*significance P< .001. +Table 3. Association Between Self-Reported Diabetes and Different Junk Foods (Regression Analysis). +Junk Foods +Sig. +Odds Ratio +95% Confidence Interval +Lower Bound +Upper Bound +Burger/Week +.165 +1.234 +0.917 +1.660 +Fried food/Week +.662 +1.053 +0.835 +1.329 +Cake/Week +.044 +1.345 +1.009 +1.795 +Fizzy drinks/Week +.008 +1.344 +1.079 +1.674 +Chats/Week +.331 +0.909 +0.749 +1.102 +Fish/Week +.754 +0.984 +0.888 +1.090 +Note: There is a significant association between diabetes and consumption of cake and fizzy drinks. +Nagarathna et al. +179 +Table 4. Association Between Different Categories of Hypertension and Different Junk Foods (Regression Analysis). +Hypertension Factor +Sig. +Odds Ratio +95% Confidence Interval +Lower Bound +Upper Bound +Prehypertension +Burger/Week +.413 +0.968 +0.413 +1.046 +Pizza/Week +.006 +1.233 +0.006 +1.432 +Cake/Week +.803 +1.018 +0.803 +1.176 +Fizzy drinks/Week +.000 +1.335 +0.000 +1.452 +Chats/Week +.786 +0.991 +0.786 +1.056 +Hypertension stage +1 +Burger +.429 +0.957 +0.429 +1.067 +Pizza +.026 +1.207 +0.026 +1.426 +Cake +.005 +1.236 +0.005 +1.433 +Fizzy drinks +.002 +1.181 +0.002 +1.310 +Chat +.991 +1.000 +0.991 +1.069 +Hypertension stage +2 +Burger +.044 +0.756 +0.044 +0.992 +Pizza +.755 +1.048 +0.755 +1.410 +Cake +.043 +1.247 +0.043 +1.543 +Fizzy drinks +.009 +1.215 +0.009 +1.406 +Chat +.854 +0.989 +0.854 +1.113 +Table 5. Association Between Peripheral Neuropathy in Diabetes and Consumption of Different Foods (Regression Analysis). +Dietary Factors +Sig. + Odds Ratio +95% Confidence Interval +Lower Bound +Upper Bound +Milk usually +.088 +1.143 +0.980 +1.332 +Milk sometimes +.598 +1.037 +0.905 +1.128 +Meat usually +.031 +1.198 +1.016 +1.412 +Meat sometimes +.157 +1.124 +0.956 +1.323 +Less vegetable usually +.569 +0.953 +0.807 +1.125 +Less vegetable sometimes +.778 +1.019 +0.895 +1.161 +Less fruit usually +.498 +0.943 +0.797 +1.117 +Less fruit sometimes +.850 +0.986 +0.857 +1.136 +Skip breakfast usually +.544 +1.042 +0.913 +1.188 +Skip breakfast sometimes +.736 +0.977 +0.855 +1.117 +results establish the role of the frequency and the type of +food an individual consumes in healthy and unhealthy +conditions. Ayurveda recommends avoiding milk products +to control diabetes.17 +Findings of another study also suggested that excessive +consumption of milk products reduces the insulin sensitivity +as compared to red meat in overweight and obese subjects +with glucose intolerance. Another study is also in line with +the findings of the present study signifying the positive +association between intakes of red meat and poultry with a +risk of developing diabetes.18 +Gittelsohn et al. have shown that excessive consumption +of junk foods and bakery products was associated with a +substantial increase in the risk of developing diabetes and +impaired glucose tolerance. These foods tend to be high in +simple glucose, low in fiber, and high in fat. The +authorsobserved a close relationship between dietary patterns +and the incidence of diabetes mellitus.17 +180 +Annals of Neurosciences 27(3-4) +Table 6. Association Between High Cholesterol and Different +Dietary Factors (Regression Analysis). +DietaryFactors +Sig. +Odds +Ratio +95% Confidence Interval +Lower +Bound +Upper +Bound +milk usually +.221 +0.871 +0.699 +1.086 +Milk sometimes +.076 +0.840 +0.692 +1.019 +Meat usually +.002 +1.465 +1.156 +1.858 +Meat sometimes +.194 +1.172 +0.922 +1.489 +Less vegetable +usually +.037 +0.769 +0.602 +0.984 +Less vegetable +sometimes +.124 +0.864 +0.717 +1.041 +Less fruit usually +.902 +0.985 +0.776 +1.251 +Less fruit +sometimes +.428 +0.922 +0.755 +1.127 +Skip breakfast +usually +.918 +0.990 +0.818 +1.199 +Skip breakfast +sometimes +.884 +1.014 +0.836 +1.231 +Note: High cholesterol was associated significantly with usual consumption +of meat and less vegetables. +On the contrary, a number of studies have shown the +negative association with milk consumption. A lipid and +glucose study conducted in Tehran, involving 827 subjects, +showed that a number of factors were found to be associated +favorably with dairy consumption, including the metabolic +syndrome in newly diagnosed diabetes, but significant +associations were not found.19 +The CARDIA study,20 which is a prospective study over +10 years, demonstrated a negative association between milk +consumption and the development of the disease. In contrast, +the present study has depicted a significant association +between milk intake and glucose levels in diabetes. +A prospective study conducted in Finland proposed that +the association between processed meat and diabetes was +mostly because of sodium.21 Another study by Alsabieh etal. +proposed an affirmative association between packed food +products and hypertension.22 +With consumption of usually less fiber and fruits showing +a significant association with PPBG and FBG in the diabetes, +prediabetes, and normoglycemia groups in the present study, +a study suggested the presence of heterogeneity in the +associations between the ingestion of fruits and risk of type 2 +diabetes. However, consumption of blueberries, grapes, and +apples was significantly associated with a lower risk of type 2 +diabetes. But excessive consumption of fruit juice was found +to be associated with a higher risk of diabetes.23 +Moreover, skipping of breakfast showed a nonsignificant +association with PPBG and FBG in the diabetes group,only +PPBG in the prediabetes group, and a significant association +in the normoglycemia group. A meta-analysis of studies +revealed that skipping of breakfast was found to be associated +with an increased risk of type 2 diabetes. A regular habit of +breakfast eating may help lower the risk of type 2 diabetes.24 +Thus, skipping of breakfast is associated withan increased +risk of type 2 diabetes. +In this study, association of dietary factors was also +analyzed with peripheral neuropathy, which revealed that +subjects who consumed meat usually had a significant +association with peripheral neuropathy, with symptoms of +pain and numbness from nerve damage in hands and feet, +majorly in diabetes individuals. +However, studies reveal that there are treatments in other +practices. In general, a healthy lifestyle involving maintaining +the body weight, eluding contact with toxins, practicing +physician-supervised exercise program, consuming a +balanced diet, rectifying vitamin deficiencies, and evading +alcohol and smoking can reduce the symptoms of peripheral +neuropathy.25  +However, the Foundation for Peripheral Neuropathy +endorses increasing omega-3 fatty acids for reducing the risk +of diabetes. It also suggests consuming one to two tablespoons +of flaxseed oil a day oreating fatty fish, salmon, or three +ounces of walnuts a day.26 +The association between nutritional status and optic or +peripheral neuropathies is well established with tobacco, +ethanol, deficiencies in thiamine, vitamin A, B12, B3, and +B6, and protein–energy malnutrition, all being causative.27 +The present study also revealed the association of dietary +factors with the cholesterol level that mainly revealed +nonsignificant results, whereas only subjects who consumed +usually meat and less vegetables showed a significant +association with the cholesterol level. After consumption of a +meat diet, the plasma cholesterol concentration fell by 8.6% +and low-density-lipoprotein cholesterol by 11%.  But the +present study showed a low significant association between +high cholesterol and meat consumption with odds ratio [OR +1.274 (1.018, 1.515)].28 Researchers found that consuming +excessive amounts of saturated fat and meat protein was +associated with an upsurge in blood cholesterol than the +meat-free diets. +A meta-analysis of studies postulates that both fresh red +meat and processed meat may upsurge the risk of stroke. This +is a significant finding because the excessive consumption of +red meat and the high morbidity and mortality have been +associated with stroke.29 In this study, we found the association +between meat and sugar levels. +The major asset of the study is that it was the first study to +analyze the association between different food groups and +glucose levels across seven zones of India. Sample size was +also good. +A limitation of the study is that the sample was not +distributed normally in all zones. Moreover, the data about +the exact quantity offoods was not obtained, and alsoit is +difficult to cull out the effects of physical activity. Furthermore, +data about diet information was retrospectively obtained, and +this is not a prospective supervised monitored diet study. +Nagarathna et al. +181 +Conclusion +Milk, meat, less vegetables, less fruits, and junk foods have a +significant effect on the glycemic status and cholesterol levels +and on the status of known diabetes and hypertension as well +as peripheral neuropathy. +Acknowledgments +We are thankful to (a) the funding by the Ministry of Health +and Family Welfare and Ministry of AYUSH routed through +Central Council for Research in Yoga and Naturopathy, +Government of India for their timely support for this project; +(b) the executive committee of Indian Yoga Association for +conducting Niyantrita Madhumeha Bharatha (NMB); (c) Art +of Living Institute, Vethathiri Maharishi College of Yoga, +Patanjali Yogpeeth, PGIMER Chandigarh, and SVYASA for +providing more than 1,200 volunteers; and (d) the members +of the research advisory board of NMB for their inputs at all +stages of the study. +Authors Contribution +Raghuram Nagarathna is the primary investigator of the +study, is the guarantor of this study and as such has full access +to all data in the study, and takes responsibility for the +integrity of the data and its analysis. Akshay Anand was +involved in overall management of study at the local zonal +level. Sapna Nanda wrote the manuscript. Suchitra Patil +performed the sample analysis. Amit Singh and Rajesh SK +were involved in the overall management of the study, data +collection, and participant supervision at the study sites. +Hongasandra Nagendra conceptualized the study and +monitored its execution. +Declaration of Conflicting Interests +The authors declared no potential conflicts of interest with respect to +the research, authorship, and/or publication of this article. +Ethical Statement +Ethical clearance was obtained by the Ethics Committee of +the Indian Yoga Association. The study was registered on +CTRI (Registration Number – Trial REF/2018/02/017724). +This article complies with International Committee of +Medical Journal Editors’ (ICMJE) uniform requirements for +the manuscript. +Funding +Funding for the study was provided by the Ministry of Health +and Family Welfare and Ministry of AYUSH routed through +Central Council for Research in Yoga and Naturopathy, +Government of India. +ORCID iD +Akshay Anand + https://orcid.org/0000-0001-7947-5209 +References +1. Ramachandran A, Snehalatha C, Kapur A, et al. High prevalence +of diabetes and impaired glucose tolerance in India: National +Urban Diabetes Survey. Diabetologia 2001;44(9):1094–1101. +2. King H, Aubert RE, Herman WH., Global burden of diabetes, +1995–2025: Prevalence, numerical estimates, and projections. +Diabetes Care 1998;21: 1414–1431. +3. Kahn SE, The relative contributions of insulin resistance and +beta-cell dysfunction to the pathophysiology of Type 2 diabe- +tes. Diabetologia 2003;46: 1707. +4. Marshall JA, Hamman RF, Baxter J., High-fat, low-carbohy- +drate diet and the etiology of non-insulin-dependent diabetes +mellitus: The San Luis Valley Diabetes Study. Am J Epidemiol +1991;134: 590–603. +5. Sonestedt E, Wirfält E, Wallström P, et al. Dairy products and its +association with incidence of cardiovascular disease: The Malmö +diet and cancer cohort. Eur J Epidemiol 2011;26: 609–618. +6. Brunner EJ, Mosdøl A, Witte DR, et al. Dietary patterns and +15-y risks of major coronary events, diabetes, and mortality. Am +J Clin Nutr 2008;87(5):1414–1421. doi:10.1093/ajcn/87.5.1414 +7. Mensink RP., Dairy products and the risk to develop type 2 +diabetes or cardiovascular disease. Int Dairy J 2006;16: 1001– +1004. +8. Kuroda M and Sakaue H. Role of vitamin D and calcium in +obesity and type 2 diabetes. Clin calcium 2016;26: 349–354. +9. Lawlor DA, Ebrahim S, Timpson N, et al. Avoiding milk is +associated with a reduced risk of insulin resistance and the met- +abolic syndrome: Findings from the British Women’s Heart and +Health Study. Diabet Med 2005;22:808–811. +10. Snijder MB, Van Dam RM, Stehouwer CDA, et al. A prospec- +tive study of dairy consumption in relation to changes in meta- +bolic risk factors: The Hoorn Study. Obesity 2008;16: 706–709. +11. Song Y, Manson JE, Buring JE, et al. A prospective study of +red meat consumption and type 2 diabetes in middle-aged and +elderly women: The women’s health study. Diabetes Care +2004;27: 2108–2115. +12. Fung TT, Schulze M, Manson JE, Willett WC, & Hu FB. +Dietary patterns, meat intake, and the risk of type 2 diabetes in +women. Arch Intern Med 2004; 164(20): 2235–2240. https:// +doi.org/10.1001/archinte.164.20.2235 +13. Brain K, Burrows TL, Rollo ME, Hayes C, Hodson FJ, & +Collins CE. The Effect of a pilot dietary intervention on pain +outcomes in patients attending a tertiary pain service. Nutrients +2019;11(1): 181. https://doi.org/10.3390/nu11010181 +14. Census of India 2011. New Delhi: Registrar General and Census +Commissioner of India; 2011. http://censusindia"from:http:// +censusindia. +15. Anand A., Narendra Modi’ s citizen centered Yoga-Diabetes +Management Program: Will Indian state install integrative med- +icine in premier institutes? Ann Neurosci 2019;26(2):47–48. +16. Nagendra H, Nagarathna R, Rajesh S, et al. Niyantrita +Madhumeha Bharata 2017, methodology for a nationwide dia- +betes prevalence estimate: Part 1. Int J Yoga 2019;12: 179. +17. Turner KM, Keogh JB, Clifton PM., Red meat, dairy, and insu- +lin sensitivity: A randomized crossover intervention study. Am +J Clin Nutr 2015;101: 1173–1179. +182 +Annals of Neurosciences 27(3-4) +18. Gittelsohn J, Wolever TMS, Harris SB, et al. Specific pat- +terns of food consumption and preparation are associated with +diabetes and obesity in a Native Canadian community. J Nutr +1998;128: 541–547. +19. Elwood PC, Pickering JE, Fehily AM., Milk and dairy con- +sumption, diabetes and the metabolic syndrome: The Caerphilly +prospective study. J Epidemiol Community Health 2007;61: +695–698. +20. Friedman GD, Cutter GR, Donahue RP, CARDIA:, et al. Study +design, recruitment, and some characteristics of the examined +subjects. J Clin Epidemiol 1988;41: 1105–1116. +21. Pan A, Sun Q, Bernstein AM, al. et, Red meat consumption and +risk of type 2 diabetes: 3 cohorts of US adults and an updated +meta-analysis. Am J Clin Nutr 2011;94: 1088–1096. +22. Alsabieh, M, Alqahtani, M, Altamimi, A, et al. Fast food con- +sumption and its associations with heart rate, blood pressure, +cognitive function and quality of life. Pilot study. Heliyon + +2019; 5(5): e01566. https://doi.org/10.1016/j.heliyon.2019. +e01566 +23. Du H, Li L, Bennett D, Guo Y, Turnbull I, Yang L, et al. Fresh +fruit consumption in relation to incident diabetes and diabetic +vascular complications: A 7-y prospective study of 0.5 million +Chinese adults. PLoS Med 2017;14(4): e1002279. https://doi. +org/10.1371/journal.pmed.1002279 +24. Ballon A, Neuenschwander M, Schlesinger S. Breakfast skip- +ping is associated with increased risk of type 2 diabetes among +adults: A systematic review and meta-analysis of prospective +cohort studies J Nutr January 2019; 149(1): 106–113. https:// +doi.org/10.1093/jn/nxy194 +25. National institute of neurological disorders, stroke. Peripheral +neuropathy information page | National Institute of Neurological +Disorders and Stroke. https://www.ninds.nih.gov/Disorders/ +All-Disorders/Peripheral-Neuropathy-Information-Page +(accessed May 12, 2021). +26. Dansinger M., Peripheral neuropathy and diabetes. 2019. + +https://www.webmd.com/diabetes/peripheral-neuropathy-risk- +factors-symptoms (accessed May 12, 2021). +27. Nightingale LM, Paviour DC., Nutritional optic and peripheral +neuropathy: A case report. Cases J 2009;2(6):10–13. +28. Watts GF, Ahmed W, Quiney J, et al. Effective lipid lowering +diets including lean meat. Br Med J (Clin Res Ed) 1988;296: +235–237. +29. Larsson SC, Virtamo J, Wolk A., Red meat consumption and +risk of stroke in Swedish women. Stroke 2011;42; 324–329. diff --git a/subfolder_0/yoga-based-lifestyle-for-prevention-of-medical-emergencies.txt b/subfolder_0/yoga-based-lifestyle-for-prevention-of-medical-emergencies.txt new file mode 100644 index 0000000000000000000000000000000000000000..733618a4a90d1070802b66bc5c74b414802363f1 --- /dev/null +++ b/subfolder_0/yoga-based-lifestyle-for-prevention-of-medical-emergencies.txt @@ -0,0 +1,660 @@ +International Journal of Emergency Mental Health and Human Resilience, Vol. 17, No.3, pp. 661-663, ISSN 1522-4821 +IJEMHHR • Vol. 17, No. 3 • 2015 661 +INTRODUCTION +A medical emergency is an acute morbidity that poses an immediate +risk to life as well as long-term health. WHO predicts noticeable rise +in emergency morbidity load in next few decades (McQueen, 2009). +A significant burden of diseases in developing countries is caused by +time-sensitive illnesses and injuries, such as severe infections, hypoxia +caused by respiratory infections, dehydration caused by diarrhea, +intentional and unintentional injuries, postpartum bleeding, and acute +myocardial infarction (Razzak & Kellermann, 2002). The conditions +with which a patient will approach the emergency department vary +from the rural to urban setup. (Gupta, 2009) Most common medical +emergencies may be categorized into following major categories: +1) Acute complications of chronic non-communicable diseases +(NCDs), 2) Injuries due to accidents and assaults, 3) Complications +of infections, 4) Pregnancy related complications and 5) those due to +poisoning and drug over-dosage (Razzak & Kellermann, 2002; Garg, +2013; Saddichha, Saxena, Pandey & Methuku, 2009). +Yoga Based Lifestyle +Yoga based lifestyle (YBL) involves life style modification +based on the concepts of right living from Indian yoga psychology. +Accordingly, the four components of life style namely diet, lack +of exercise, bad habits (alcohol, smoking, uncontrolled desires) +and emotional stress are all traceable to the mind (Nagarathna & +Nagendra, 2002). YBL includes simple and safe practices at physical, +mental, emotional, intellectual levels to reach a state of mastery +over the modifications of the mind through effortless blissful inner +awareness during all practices (Nagarathna & Nagendra, 2002; +Nagendra & Nagarathna, 2002). +Role of Psychological Stress in Various Medical +Emergencies +Emergencies due to complications of NCDs +Among those due to complications of NCDs, most +common emergencies are hypertension, acute asthma attack, +convulsions, hypoglycemia, myocardial infarction, shock, +stroke and psychiatric emergencies (Garg, 2013; Saddichha, +Saxena, Pandey & Methuku, 2009). In a survey in the emergency +department of a tertiary care teaching hospital in India, Garg et +al found that in 2013, nearly half of emergency subjects were +males and a great majority was in the age group of 15–40 years. +They also found that diseases related to the cardiovascular +system topped the list, of which hypertension was noted in +most cases (Garg, 2013). Majority of these NCDs are lifestyle +related and their progression towards acute complications are +often triggered by lifestyle changes (Yusuf, 2004; Mittleman, +1995). Psychological stress has been shown to contribute +significantly towards lifestyle disorders (Mittleman, 1995). +Emergencies due to accidents, assaults and violence +For those emergencies which involve accidents and assaults, +it was observed that males, in the 19-30 year age group, were +more often involved in risk and violence. Violence, especially +interpersonal violence, has been noted to be maximum in the age +group of 15-29 years and among males in earlier studies also (Baruah +& Baruha, 2007). The age between 15-29 years is the period when +young people face the realities of living and strive to make their own +existence. Such experiences result in increased risk of being involved +in accidents or assaults. An increased prevalence of assaults in this +age group is also highly concerning since this can result in a serious +*Correspondence regarding this article should be directed to: +hrn@vyasa.org +ABSTRACT: Most common medical emergencies may be categorized into following major +categories: 1) Acute complications of chronic non-communicable diseases (NCDs), 2) Injuries due +to accidents and assaults, 3) Complications of infections, 4) Pregnancy related complications and 5) +those due to poisoning and drug over-dosage. Lifestyle factors such as diet, physical activity, sleep, +substance abuse and psychological stress, are important direct or indirect contributors towards +these emergencies. We performed a integrative literature review consulting databases of ‘pubmed’ +and ‘google scholar’ from the year 2000 to 2015 using following key words: ‘medical emergency’, +lifestyle’, ‘yoga’, ‘meditation’, ‘prevention’ and ‘complications’. Randomized controlled trials, +controlled trials, uncontrolled trials, systematic reviews and metanalyses were included in this +integrative literature review. We also classified these emergencies into four categories depending +on their prevalence and usefulness of yoga based lifestyle: 1) Yoga based lifestyle to manage +common NCDs and Prevent Complications; 2) Yoga based lifestyle to reduce Stress, Aggression and +Substance Abuse in Youth; 3) Yoga Based lifestyle for Prevention and Management of Infections; +4) Yoga based lifestyle for preventing pregnancy related complications. We found that Yoga based +lifestyle (YBL) has been effectively used for prevention and management of various chronic medical +illnesses. Yoga techniques that include physical postures, regulated breathing, meditation and +relaxation help manage the life style better have the potential of bringing down the prevalence of +medical emergencies through various direct and indirect mechanisms. +Keywords: Medical emergency, lifestyle, yoga, meditation, prevention, complication +Yoga Based Lifestyle for Prevention of Medical Emergencies +Bhargav H, Nagarathna R, Nagendra HR* +Swami Vivekananda Yoga Anusnadhana Samsthana (S-VYASA) Yoga University, Bangalore, India +662 Bhargav, Nagarathna, Nagendra • Yoga Based Lifestyle +loss of bread-winners to the family. Programs designed to educate +on means of coping with stress may reduce some occurrence of +interpersonal violence. It would also be necessary to curb substance +use, since a high level of alcohol consumption of has been noted in +this population and which can prove disastrous (Medhi, Hazarika & +Mahanta, 2006). +Emergencies due to complications of infections +Among infections, viral infections are most common cause for +medical emergencies. Especially in developing countries, one of the +common causes of pain abdomen is rota virus diarrhea, seen mainly +in children (Phukan, Patgiri & Mahanta, 2003). Cholera outbreaks +also occur commonly in developing countries, these viruses are +sometimes resistant to commonly used antimicrobials (Phukan, +Borah, Biswas & Mahanta, 2004). Other prevalent infections are +respiratory infections which may be viral or bacterial in origin. Apart +from viral infections, infections due to bacteria’s are frequently +known cause for medical emergencies (Razzak & Kellermann, 2002). +Immunity and lifestyle factors are closely interlinked. Inhibiting or +holding back one's thoughts, feelings, and behaviors is associated +with long-term stress and disease. A meta-analysis of 300 studies +concludes that chronic stressors reduce both cell mediated and +humoral immunity of the host (Segerstrom & Miller, 2004). There +is also evidence that chronic stress impaires the immune system's +response to anti-inflammatory signals. The capacity of a synthetic +glucocorticoid hormone to suppress in vitro production of the pro- +inflammatory cytokine interleukin-6 was found diminished among +parents of cancer patients (Miller, Cohen & Ritchey, 2002). Thus, an +intervention which reduces psychological stress may have important +role to play in strengthening the immune system there by reducing +spread of infections and preventing complications. +Pregnancy related emergencies +Pregnancy remains as one of the top causes of medical +emergencies especially in developing countries (Garg, 2013; +Saddichha, Saxena, Pandey & Methuku, 2009). Previous studies +have noted a similar trend with most pregnancies occurring +in the age group of 20-30 years (Gogoi & Ahmed, 2007). +Therefore, targeting ante-natal care especially in the age +group of 20-30 years (Saddichha, Saxena, Pandey & Methuku, +2009) could reduce morbidity and mortality. Pregnancy is +a unique state of physiological stress, which necessitates +physical, mental and social adaptation. +Stressors during pregnancy vary from life events (e.g. divorce, +serious illness or death of a relative or friend) to daily trials and +tribulations (e.g. domestic affairs, financial or social problems). +During exposure to a stressor, the whole system of stress regulation, +ie: the hypothalamus–pituitary–adrenal cortex system (HPA axis) +and the sympathetic nervous system– adrenal medulla system, +is activated (Mulder et al., 2002). In addition, normal pregnancy +is associated with - 4 - physical alterations, hormonal changes +(often associated with rapid changes in mood), anxiety regarding +labor and fetal outcome, all of which potentially worsen the stress +response. These factors contribute significantly towards occurrence +of emergency situations during pregnancy (Sulochana & Samsthana, +2005). +Poisoning, substance abuse and drug over-dosage +Poisoning and over-dosage of drugs are another frequent cause +for medical emergencies. Acute pesticide poisoning is a major +public health problem. According to World Health Organization +(WHO 1990) estimates, around 3 million poisoning cases with 220 +000 deaths occur annually. About 99% of these deaths occur in +developing countries. In several agricultural districts, it precedes all +other causes of death in government hospitals. Organophosphorus +(OP) compounds cause most self-poisoning deaths in southern and +central India (Batra, Keoliya & Jadhav, 2003). Most of the acute +poisoning cases are intentional (suicide) and occur among young +adults, mainly males (Van Der Hoek, Konradsen, Athukorala & +Wanigadewa, 1998). Poisoning due to occupational exposure is also +common, but less well documented. Several psychopathologic risk +factors are identified for adolescent suicide and suicidal behavior, +namely, affective, disruptive, substance abuse, psychotic, and +personality disorders. The role of family environmental risk factors +in suicide and suicidal behavior is also important (Brent, 1995). All +these factors can be ultimately traced down to inability of the youth +and family to handle emotional distress (Brent, 1995). Thus, we +decided to perform a literature survey to understand preventive value +of yoga based lifestyle in various common medical emergencies. +METHODOLOGY +We performed a integrative literature review consulting +databases of ‘pubmed’ and ‘google scholar’ from the year 2000 to +2015 using following key words: ‘medical emergency’, lifestyle’, +‘yoga’, ‘meditation’, ‘prevention’ and ‘complications’. Randomized +controlled trials, controlled trials, uncontrolled trials, systematic +reviews and metanalyses were included in this integrative literature +review. We also classified these emergencies into four categories +depending on their prevalence and usefulness of yoga based +lifestyle: 1) Yoga based lifestyle to manage common NCDs and +Prevent Complications; 2) Yoga based lifestyle to reduce Stress, +Aggression and Substance Abuse in Youth; 3) Yoga Based lifestyle +for Prevention and Management of Infections; 4) Yoga based +lifestyle for preventing pregnancy related complications. +RESULTS +In category 1, i.e. where yoga based lifestyle has been utilized +to prevent complications and manage common non-communicable +diseases (NCDs), we found that 9 studies satisfied the criteria out +of these 9 studies, 8 were randomized controlled studies and 1 was +a non-randomized controlled trial. All the studies pointed towards +favorable effect of yoga based lifestyle or yoga techniques towards +prevention and management of NCDs and their complications. +In category 2, where efficacy of Yoga based lifestyle was +assesses to reduce stress, aggression and substance abuse in youth, +it was observed that there were total of 8 studies assessing the same, +6 were randomized controlled studies and 2 were non-randomized +controlled trials. All studies found beneficial effects of yoga on +stress, aggression and substance abuse in youth. +In category 3, which tested usefulness of yoga based lifestyle for +prevention and management of infections, it was observed that only +two RCTs tested yoga based lifestyle in management of infections +but other 10 studies (4 RCTs, 3 Non-randomized controlled studies +and 3 reviews) pointed towards indirect beneficial effects of yoga in +managing infections. +Category 4 dealt with application of Yoga based lifestyle for +preventing pregnancy related complications. Three RCTs satisfied +these criteria. All three RCTs found beneficial effects Yoga based +lifestyle in preventing pregnancy related complications. +Detailed discussion on these studies under respective categories +is provided below: +DISCUSSION +Yoga Based Lifestyle to Manage Common NCDs and +Prevent Complications +Transcendental Meditation (TM) program has been found to +decrease CAD risk factors, cardiovascular morbidity (Schneider et +al., 1995; Alexander et al., 1996), carotid atherosclerosis (Castillo- +Richmond et al., 2000), and mortality (Schneider et al., 1996; +Alexander et al., 1994). Intensive yoga based life style modification +program have been shown to retard coronary atherosclerosis +(Mahajan, Reddy & Sachdeva, 1991; Manchanda, 2000). We found a +IJEMHHR • Vol. 17, No. 3 • 2015 663 +reduction in various risk factors and enhancement of left ventricular +rejection fraction in patients of coronary artery disease who +underwent CABG (coronary artery bypass grafting), after one year +of yoga based lifestyle intervention (Raghuram, 2014). Similarly, in +a randomized controlled study on 277 type 2 diabetic patients, it was +observed that nine month of YBL intervention led to better reduction +in oral hypoglycemic medication requirement and LDL,with better + +increase of HDL than exercise based life style; yoga based life style +modification program was similar in efficacy to exercise-based life +style modification in reducing blood glucose, HbA1c, triglycerides, +total cholesterol and VLDL (Nagarathna et al., 2012). +Yoga Based Lifestyle to Reduce Stress, Aggression +and Substance Abuse in Youth +A randomized controlled trial showed that integrated yoga +intervention of 8 weeks lead to significant reduction in verbal +aggression of young adults (Deshpande, Nagendra & Raghuram, +2008).Studies have reported significant improvements in negative +emotions including tension-anxiety, depression-dejection, anger- +hostility, fatigue-inertia, and confusion-bewilderment. (Michalsen +et al., 2005; Lavey et al., 2005) Another study compared African +dance and Hatha yoga and found reduction in perceived stress and +negative affect with both these practices but reduced cortisol levels +in the hatha yoga group.(West et al., 2004) Yoga also helps reduced +impulsive behavior and brings better control over anger (Jensen & +Kenny, 2004; Noggle, Steiner, Minami & Khalsa, 2012). Yoga +based training has also shown promise in the treatment for smoking +cessations and substance use disorders (Bowen et al., 2009; Brewer +et al., 2011).  +Yoga Based lifestyle for Prevention and Management +of Infections +Consistent practice of yogic breathing techniques (pranayama) +increases the lung's airflow, air capacity, stamina and efficiency. +A randomized controlled trial tested the effect of 2 month of yoga +intervention on symptom scores, bodyweight, FVC, FEV(1), +FEV(1)/FVC%, sputum microscopy, sputum culture, and postero- +anterior view of the chest x ray. It was observed that yoga group +showed significant improvement in level of infection, radiographic +picture, FVC, weight gain and reduced symptoms Significantly +more patients in the yoga group showed sputum conversion based +on microscopy on days 30 and 45 compared to the control (breath +awareness) group (Visweswaraiah & Telles, 2004). A study (Gupta, +Telles & Balkrishna, 2011) assessed blood oxygen saturation before, +during and after two yoga breathing techniques; high frequency +yoga breathing (Kapalabhati) and breath awareness in 29 healthy +male volunteers with ages ranging between 17 and 32 years. They +observed a significant increase (P<0.01) in oxygen saturation during +the 33 min session of high frequency yoga breathing. Another +study compared oxygen consumption during the short kumbhaka +(timed breath holding, 22.2 % of the respiratory cycle) variety of +Ujjayi pranayama, and the other the long kumbhaka (50.4 % of +the respiratory cycle ) variety of Ujjayi in ten healthy volunteers +between 28-59 years of age. It was observed that short kumbhaka +ujjayi caused a statistically significant increase (52%) in the oxygen +consumption (and metabolic rate) while the long kumbhaka ujjayi + +caused lowering of the oxygen consumption (by 19%) and metabolic +rate (Telles & Desiraju, 1991). Yoga practices have been also been +shown to improve the redox status. Another study, was conducted +on healthy male volunteers divided into two groups viz. yoga (n = +34) and control group (n = 08). In addition to their routine activities, +the yoga group practiced yogasanas, pranayama and meditation for +3 months and control group followed the usual routine. Reduced +glutathione and total antioxidant status increased significantly +(P<0.001) where as glutathione peroxidase activity (P<0.001), +plasma concentration level of malondialdehyde (P<0.01) and +oxidized glutathione (P<0.01) decreased significantly in yoga group +after completion of 3 months; peripheral arterial oxygen saturation +also increased in the yoga group at the same time (Pal, Singh & +Saha, 2011). Another yogic breathing technique called Sudarshana +kriya (SK), which involves breathing in three different rhythms, has +been shown to lower blood lactate levels and offer better antioxidant +defense (Sharma et al., 2003). In another study, the effect of SK +was studied at the transcriptional level of the antioxidant enzymes +(Singh et al., 2008). There was a significant increase in expression +of glutathione-S-transferase in practitioners of SK as compared to +the normal controls along with significant increase in anti-apoptotic +Cox-2 and HSP-70. A non-significant increase was observed in +the expression of anti-oxidant Cu-Zn SOD, Mn SOD, Glutathione +peroxidase and Catalase genes in practitioners. Although the aging- +related hTERT and anti-apoptotic Bcl-2 also showed increasing +trends in SK practitioners, it was not statistically significant. +Yoga-derived breathing has been reported to improve gas +exchange in patients with chronic heart failure and in participants +exposed to high-altitude hypoxia, it has also been used for increasing +oxygenation in patients suffering from chronic obstructive +pulmonary diseases (Pomidori et al., 2009). Another study found +that oscillating airflow produced by humming bee breath (Bhramari +pranayama) enhanced sinus ventilation and thereby increase nasal +nitric oxide (NO) levels in ten healthy subjects. NO increased 15- +fold during humming compared with quiet exhalation (Weitzberg +& Lundberg, 2002). Minvaleeva et al, studied changes in hepatic +arterial inflow and venous outflow in 33 subjects during plough +posture (Halasana). They found that, during this position, the +minute blood filling of the liver through the hepatic artery and +portal vein remained unchanged while there occurred monophase +nonpulsatory or pulsatory two-phase hepatic vein outflow instead +of the usual triphase outflow with a partial return of blood to the +liver. After the plough position , the common triphase hepatic vein +outflow was fully restored; a therapeutic effect of this exercise was +recorded when the initially changed monophase hepatic outflow +(in a female patient with hepatitis in her case history) became +triphase immediately after exercise (Minvaleev, Kuznetsov & +Nozdrachev, 1998). +We assessed the changes in blood oxygen saturation levels during +two high frequency yoga breathing techniques called Bhastrika and +Kapalabhati on 10 healthy male volunteers in the age range of 18-30 +yrs (group mean ± S.D., 24.4 ± 2.8 years) who were divided into +two groups (five in each) to perform the two breathing techniques +respectively. They had experience of performing these breathing +practices for at least 3 months. Their oxygen saturation levels were +assessed for 1minute before and 1 minute during the practice using +Mindray MEC-1200 (Shenzhen Mindray Bio-Medical Electronics +Co., Ltd. China). We observed a significant increase in oxygen +saturation during the practices of both Bhastrika (p= 0.009) and +Kapalabhati (p=0.012) as compared to the baseline values (Bhargav, +Kashinath, Nagarathna & Nagendra, 2012). In another recent study, +we demonstrated significant increase in oxy-hemoglobin levels in the +pre-frontal cortices of 18 healthy volunteers during a high frequency +yoga breathing called Kapalabhati using functional near infrared +spectroscopy (Bhargav, Nagendra, Gangadhar & Nagarathna, 2014). +Pranic Energization Technique (PET) is another technique, +where the mind is focused and made sensitive to appreciate subtle +nerve impulse of touch sensation and then prāna (subtle energy) +is systematically moved and balanced throughout the body. This +technique of PET is also proposed to be beneficial in reducing +radiation induced side effects such as DNA damage by reducing +oxidative stress in cancer patients (Pandey, 2012; Ram et al., 2013). +Based on above mentioned evidence base, following yogic +breathing practices (done for ~25 minutes three times in a day +until infection is controlled) can be recommended for increasing +oxygenation to combat acute infections. +664 Bhargav, Nagarathna, Nagendra • Yoga Based Lifestyle +Yoga Based Lifestyle for Preventing Pregnancy +Related Complications +In a randomized controlled study, sixty-eight high-risk pregnant +women were recruited from two maternity hospitals in Bengaluru, +India and were randomized into yoga and control groups. The yoga +group (n = 30) received standard care plus one-hour yoga sessions, +three times a week, from the 12th to the 28th week of gestation. +The control group (n = 38) received standard care plus conventional +antenatal exercises (walking) during the same period. Significantly +fewer pregnancy induced hypertension (PIH), preeclampsia, +gestational diabetes (GDM) and intrauterine growth restriction +(IUGR) cases were observed in the yoga group. Significantly fewer +Small for Gestational Age (SGA) babies and newborns with low +APGAR scores were born in the yoga group. Authors concluded +that yoga can potentially be an effective therapy in reducing +hypertensive related complications of pregnancy and improving fetal +outcomes (Rakhshani et al., 2012). Another study on 122 healthy +women recruited between the 18th and 20th week of pregnancy at +prenatal clinics in Bangalore, India, found that 1 hour-daily practice +of yoga were randomized to practicing yoga and deep relaxation +or standard prenatal exercises 1-hour daily. It was observed that +there was reduction in perceived stress along with increase in +the high-frequency band of the heart rate variability spectrum +(parasympathetic), and reduction in both the low-frequency band +(sympathetic), and the low-frequency to high-frequency ratio were +in yoga group as compared to the control (Satyapriya, Nagendra, +Nagarathna & Padmalatha, 2009). Another randomized trial was +conducted on seventy four primigravida Thai women who were +equally divided into two groups (experimental and control). The yoga +program involved six, 1-h sessions at prescribed weeks of gestation. +The experimental group was found to have higher levels of maternal +comfort during labor and 2h post-labor, and experienced less subject +evaluated labor pain than the control group, in yoga group there was +shorter duration of the first stage of labor, as well as the total time of +labor (Chuntharapat, Petpichetchian & Hatthakit, 2008). +Yoga Module for Prevention of Common Medical +Emergencies +Basic understanding behind yoga based lifestyle is that all +distressful responses to demanding situations of life (short term or +long standing suppressed), are nothing but heightened emotions such +as depression, anxiety or anger. All emotions trigger the same stress +adaptation reflex pathway. It is known that chronic stresses at the +back of most of the life style disorders and acute stresses could trigger +emergencies. Yoga looks at all emotions as uncontrolled speeded up +rewinding of thoughts in the mind. Hence the entire concept of YBL +is based on calming down the mind; this in turn offers deep rest to +each and every cell in the body to promote normalcy by utilizing +simple mind-body techniques of physical postures, regulated +breathing, relaxation and meditations. +Based on the discussions made above, following yoga module +(performed daily for 60 minutes) should be useful in reducing +psychological stress, improving immunity and preventing medical +emergencies. This Yoga module was derived by selecting the most +common and most feasible practices that were found in our literature +survey. +(1) +Breathing techniques (Prānāyāma, total ~ 20-minute +session) +i. +Kapalabhati Breathing: 80-120 strokes per minute for 2 +minutes followed by gap of 1 minute and repeat the cycle +one more time ~ 6 minutes. +ii. +Bhastrika Breathing: 20 strokes followed by gap of 1 +minute and repeat the cycle 3 times ~ 6 minutes. +iii. +Alternate nostril breathing: 12 rounds 1 cycle ~ 5 +minutes. +iv. +Ujjayi breathing: 12 rounds one cycle ~ 3 minutes. +v. +Humming bee breath (bhramari): 12 rounds 1 cycle ~ 3 +minutes. +(2) Physical postures (Āsanas;1 minute each, total ~ 15-minute +session)—to be performed as follows: +i. Standing āsanas— Whole joint loosening followed by +Surya Namaskāra (Sun Salutation) in slow mode with +maintenance of each posture for 10 breaths; hand-to- +foot pose (Pādahastāsana); and half-waist-rotation pose +(Ardha Kati Chakrāsana; 1 minute each side) +ii. Sitting +āsanas—half-spinal-twist +pose +(Ardha- +matsyendrāsana), twisted pose (Vakrāsana), hare +pose (Shashānkāsana), and back-stretching pose +(Paschimottānāsana) +iii. Prone āsanas—crocodile pose (Makarāsana) and cobra +pose (Bhujangāsana) +iv. Supine +āsanas—shoulder +stand +pose +(Sarvāngāsana); plough pose (Halāsana); knees- +to-ear pose (Karnapidāsana); wind relieving pose +(Pawanmuktāsana); and bridge pose (Setubandhāsana) +(3) +Meditations—Kundalini Yoga, Om Meditation, Pranic +Energization Technique and cyclic meditation for 15 minutes, once +per day +(4) +Guided relaxation (Savāsana) and YogaNidra for 10 +minutes at the end of āsanas and prānāyamas. +CONCLUSION +Yoga based lifestyle has the potential to prevent common +medical emergencies. +REFERENCES +Alexander, C.N., Robinson, P., Orme-Johnson, D.W., Schneider, +R.H., & Walton, K.G. (1994). “Effects of Transcendental +Meditation compared to other methods of relaxation and +meditation in reducing risk factors, morbidity and mortality,” +Homeostasis in health & disease, 35, 243-264. +Alexander, C.N., Schneider, R., Claybourne, M., Sheppard, W., +Clayborne, B.M., Rainforth, M., et al. (1996). “A trial of stress +reduction for hypertension in older African Americans, II: sex +and risk factor subgroup analysis,” Hypertension, 28, 228-237. +Baruah, A., & Baruha, A. (2007). Epidemiological study of violence +study from North East India. Indian Journal of Community +Medicine, 32, 137-138. +Batra, Y.K., Keoliya, A.N., & Jadhav, G.U. (2003) Poisoning: an +unnatural cause of morbidity and mortality in rural india. Journal +of the Association of Physicians of India, 51, 955-959. +Bhargav, H., Kashinath, M., Nagarathna, R., & Nagendra, H.R. +(2012). Enhancement of Cancer Stem Cell Susceptibility to +Conventional Treatments through Complementary Yoga Therapy: +Possible Cellular and Molecular Mechanisms. Journal of stem +cells, 7(4), 261. +Bhargav, H., Nagendra, H.R., Gangadhar, B.N., & Nagarathna, +R. (2014). Frontal hemodynamic responses to high frequency +yoga breathing in schizophrenia: a functional near-infrared +spectroscopy study. Frontiers in psychiatry, 5. +Bowen, S., Chawla, N., Collins, S.E., Witkiewitz, K., Hsu, S., +Grow, J.,  et al. (2009). Mindfulness-based relapse prevention +for substance use disorders: A pilot efficacy trial. Journal of +Substance Abuse, 30, 295-305. +IJEMHHR • Vol. 17, No. 3 • 2015 665 +Brent, D.A. (1995). Risk factors for adolescent suicide and +suicidal behavior: mental and substance abuse disorders, +family environmental factors, and life stress. Suicide and Life- +Threatening Behavior, 25(s1), 52-63. +Brewer, J.A., Mallik, S., Babuscio, T.A., Nich, C., Johnson, H.E., +Deleone, C.M., et al. (2011). Mindfulness training for smoking +cessation: Results from a randomized controlled trial. Drug +Alcohol Dependence, 119, 72-80.  +Castillo-Richmond, A., Schneider, R.H., Alexander, C.N., Cook, R., +Myers, H., Nidich, S., et al. (2000). “Effects of stress reduction +on carotid atherosclerosis in hypertensive African Americans,” +Stroke, 313, 568-573. +Chuntharapat, S., Petpichetchian, W., & Hatthakit, U. (2008). +Yoga during pregnancy: effects on maternal comfort, labor +pain and birth outcomes.Complementary therapies in clinical +practice, 14(2), 105-115. +Deshpande, S., Nagendra, H.R., & Raghuram, N. (2008). A +randomized control trial of the effect of yoga on verbal +aggressiveness in normal healthy volunteers. International +journal of yoga, 1(2), 76. +Garg, R., Aggarwal, S., Singh, H., Kajal, K.S., Garg, R., & Pal, R. +(2013). Study of the relation of clinical and demographic factors +with morbidity in a tertiary care teaching hospital in India. +International journal of critical illness and injury science, 3(1), 12. +Gogoi, G., & Ahmed, F.U. (2007). Effect of maternal nutritional +status on the birth weight among women of tea tribe in Dibrugarh +district. Indian Journal of Community Medicine, 32, 120-122. +Gupta, R.K., Telles, S., & Balkrishna, A. (2011). Effect of Two Yogic +Breathing Techniques on Oxygen Saturation. Indian Journal of +Physiology and Pharmacology, 55(5). Supplement. http://www. +appicon2011.org/Documents/Page%2041%20-%20336. Pdf +Gupta, S. (2009). Laboratory Approach to the Management of +Clinical Emergencies: A Diagnostic Series. Journal of laboratory +physicians, 1, 27-30. +Jensen, P.S., & Kenny, D.T. (2004). The effects of yoga on the +attention and behavior of boys with attention-deficit/hyperactivity +disorder (ADHD). Journal of Attention Disorders, 7(4), 205-216. +Lavey, R., Sherman, T., Mueser, K.T., Osborne, D.D., Currier, M., +& Wolfe, R. (2005). The effects of yoga on mood in psychiatric +inpatients. Psychiatric Rehabilitation Journal, 28, 399-402.  +Mahajan, A.S., Reddy, K.S., & Sachdeva, U. (1991). “Lipid profile +of coronary risk subjects following yogic lifestyle intervention,” +Indian heart journal, 51(1), 37-40. +Manchanda, S.C., Narang, R., Reddy, K.S., Sachdeva, U., + +Prabhakaran, D., Dharmanand, S., et al. (2000). “Retardation of +coronary atherosclerosis with yoga lifestyle intervention,” The +Journal of the Association of Physicians of India, 48(7), 687-694. +McQueen, K.A., Parmar, P., Kene, M., Broaddus, S., Casey, K., Chu, +K., et al. (2009). Burden of surgical disease: Strategies to manage +an existing public health emergency. Prehospital and Disaster +Medicine, 24(2), S228-231. +Medhi, G.K., Hazarika, N.C., & Mahanta, J. (2006). Tobacco and +alcohol use among the youth of the agricultural tea industry in +Assam, India. Southeast Asian Journal of Tropical Medicine and +Public Health, 37, 581-586. +Michalsen, A., Grossman, P., Acil, A., Langhorst, J., Ludtke, R., +Esch, T., et al. (2005). Rapid stress reduction and anxiolysis +among distressed women as a consequence of a three-month +intensive yoga program. Medical Science Monitor, 11, 555-561. +Miller, G.E., Cohen, S., & Ritchey, A.K. (2002). Chronic +psychological stress and the regulation of pro-inflammatory +cytokines: a glucocorticoid-resistance model. Health Psychology, +21(6), 531. +Minvaleev, R.S., Kuznetsov, A.A., & Nozdrachev, A.D. (1998). +Human Physiology, 24(4), 475-480. Translated from Fiziologiya +Cheloveka. 24(4), 101-107. +Mittleman, M.A., Maclure, M., Sherwood, J.B., Mulry, R.P., Tofler, +G.H., Jacobs, S.C., et al. (1995). Triggering of acute myocardial +infarction onset by episodes of anger. Circulation, 92(7), 1720-1725. +Mulder, E.J., Robles de Medina, P.G., Huizink, A.C., Van den Bergh, +B.R., Buitelaar, J.K., & Visser, G.H. (2002). Prenatal maternal +stress: effects on pregnancy and the (unborn) child. Early Human +Development, 70(1-2), 3-14. +Nagarathna, R., & Nagendra, H.R. (2002). Promotion of Positive +Health., 1st Edn. Bangalore: Swami Vivekananda Yoga +Prakashan, 33-86. +Nagarathna, R., Usharani, M.R., Rao, A.R., Chaku, R., Kulkarni, +R., & Nagendra, H.R. (2012). Efficacy of yoga based life style +modification program on medication score and lipid profile in +type 2 diabetes-a randomized control study. International Journal +of Diabetes in Developing Countries, 32(3), 122-130. +Nagendra, H.R., & Nagaratna, R. (2002). Promotion of Positive +Health. Published by Swami Vivekananda Yoga Prakashana, +Bangalore. +Noggle, J.J., Steiner, N.J., Minami, T., & Khalsa, S.B.S. (2012). +Benefits of yoga for psychosocial well-being in a US high school +curriculum: a preliminary randomized controlled trial. Journal of +Developmental & Behavioral Pediatrics, 33(3), 193-201. +Pal, R., Singh, S.N., & Saha, M. (2011). Improvement of Redox Status +through Yoga. Indian Journal of Physiology and Pharmacology, +55(5). Supplement. http://www.appicon2011.org/Documents/ +Page%2041%20-%20336. Pdf +Pandey, A.N. (2012). Response 2. International Journal of Yoga, +5(1), 76-77. +Phukan, A.C., Borah, P.K., Biswas, D., & Mahanta J. (2004). A +cholera epidemic in a rural area of northeast India. Transactions +of the Royal Society of Tropical Medicine and Hygien, 98, 563-566. +Phukan, A.C., Patgiri, D.K., & Mahanta, J. (2003). Rotavirus +associated +acute +diarrhoea +in +hospitalized +children +in +Dibrugarh, north-east India.  Indian Journal of Pathology and +Microbiology, 46, 274-278. +Pomidori, L., Campigotto, F., Amatya, T.M., Bernardi, L., & Cogo, +A. (2009). Efficacy and tolerability of yoga breathing in patients +with chronic obstructive pulmonary disease: a pilot study. +Journal of cardiopulmonary rehabilitation and prevention, 29(2), +133-137. +Raghuram, N., Parachuri, V.R., Swarnagowri, M.V., Babu, S., Chaku, +R., Kulkarni, R., et al. (2014). Yoga based cardiac rehabilitation +after coronary artery bypass surgery: One-year results on LVEF, +lipid profile and psychological states–A randomized controlled +study. Indian heart journal, 66(5), 490-502. +Rakhshani, A., Nagarathna, R., Mhaskar, R., Mhaskar, A., Thomas, +A., & Gunasheela, S. (2012). The effects of yoga in prevention of +pregnancy complications in high-risk pregnancies: a randomized +controlled trial. Preventive medicine, 55(4), 333-340. +Ram, A., Banerjee, B., Hosakote, V.S., Rao, R.M., & Nagarathna, +R. (2013). Comparison of lymphocyte apoptotic index and +qualitative DNA damage in yoga practitioners and breast cancer +patients: A pilot study. International Journal of Yoga, 6(1), 20-25. +Razzak, J.A., & Kellermann, A.L. (2002). Emergency medical care +in developing countries: Is it worthwhile? Bulletin of the World +Health Organization, 80, 900-905. +666 Bhargav, Nagarathna, Nagendra • Yoga Based Lifestyle +Saddichha, S., Saxena, M.K., Pandey, V., & Methuku, M. (2009). +Emergency medical epidemiology in Assam, India. Journal of +Emergencies, Trauma and Shock, 2(3), 170. +Satyapriya, M., Nagendra, H.R., Nagarathna, R., & Padmalatha, V. +(2009). Effect of integrated yoga on stress and heart rate variability +in pregnant women. International Journal of Gynecology & +Obstetrics, 104(3), 218-222. +Schneider, H.N., Alexander, C.N., Staggers, F., Orme-Johnson, +W.D., Rainforth, M., Salerno, J.W., et al. (1996). “A randomized +controlled trial of stress reduction on cardiovascular and all-cause +mortality in the elderly: results of 8 and 15 year follow-ups,” +Circulation, 93, 629. +Schneider, R.H., Staggers, F., Alexander, C., Sheppard, W., Rainforth, +M., Kondwani, K., et al. (1995). “A randomized controlled trial +of stress reduction for hypertension in older African Americans,” +Hypertension, 26, 820-827. +Segerstrom, S.C., & Miller, G.E. (2004). Psychological stress and +the human immune system: a meta-analytic study of 30 years of +inquiry. Psychological bulletin, 130(4), 601. +Sharma, H., Sen, S., Singh, A., Bhardwaj, N.K., Kochupillai, V., & +Singh, N. (2003). Sudarshan Kriya practitioners exhibit better +antioxidant status and lower blood lactate levels. Biological +Psychology, 63, 281-291. +Singh, N., Sharma, H., Datta, P., Singh, A., Sen, S., Bhardwaj, +N.K., et al. (2008). Gene Expression Profiling in Practitioners of +Sudarshan Kriya. Journal of Psychosomatic research, 50-53. +Sulochana Gunasheela, M.D., & Samsthana, S.V.Y.A. (2005). +Efficacy of yoga in pregnant women with abnormal Doppler +study of umbilical and uterine arteries.  Journal of the Indian +Medical Association, 103(1), 12-4. +Telles, S., & Desiraju, T. (1991). Oxygen consumption during +pranayamic type of very slow-rate breathing. Indian Journal of +Medical Research, 94, 357-363. +Van Der Hoek, W., Konradsen, F., Athukorala, K., & Wanigadewa, +T. (1998). Pesticide poisoning: a major health problem in Sri +Lanka. Social science & medicine, 46(4), 495-504. +Visweswaraiah, N.K., & Telles, S. (2004). Randomized trial of +yoga as a complementary therapy for pulmonary tuberculosis. +Respirology, 9(1), 96-101. +Weitzberg, E., & Lundberg, J.O. (2002). Humming greatly increases +nasal nitric oxide. American journal of respiratory and critical +care medicine, 166(2), 144-145. +West, J., Otte, C., Geher, K., Johnson, J., & Mohr, D.C. (2004). +Effects of Hatha Yoga and African dance on affect, perceived +stress, and salivary cortisol. Annals of Behavioral Medicine. 28, +114-118. +Yusuf, S., Hawken, S., Ôunpuu, S., Dans, T., Avezum, A., Lanas, F., et +al. (2004). Effect of potentially modifiable risk factors associated +with myocardial infarction in 52 countries (the INTERHEART +study): case-control study. The Lancet, 364(9438), 937-952.