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+Volume 5 • Issue 3 • 1000185
+J Psychol Psychother
+ISSN: 2161-0487 JPPT, an open access journal 
+Research Article
+Open Access
+Telles et al., J Psychol Psychother 2014, 5:3
+http://dx.doi.org/10.4172/2161-0487.1000185
+Research Article
+Open Access
+Psychology & Psychotherapy
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+ISSN: 2161-0487
+A FMRI Study of Stages of Yoga Meditation Described in Traditional Text
+Shirley Telles1,2*, Nilkamal Singh1, K.V. Naveen2, Singh Deepeshwar2, Subramanya Pailoor2, N.K. Manjunath2, Lija George 2,3, Rose Dawn3 
+and Acharya Balkrishna1
+1PatanjaliResearch Foundation, Haridwar, India
+2ICMR Center for Advanced Research in Yoga and Neurophysiology, S-VYASA, Bengaluru, India
+3Department of Neuro-imaging and Interventional Radiology, NIMHANS, Bengaluru, India
+Abstract
+Objectives: .Meditation is described in traditional yoga texts as three stages, which follow each other in 
+sequence: (i) Focused attention (FA), (ii) Focused attention on the object of meditation (MF), and (iii) Meditation with 
+one-pointed focused attention without effort (ME). When not in meditation the mind is considered to be in a state of 
+normal consciousness characterized by random thinking (RT). The objective of the present study was to determine 
+the brain areas activated during the three stages of meditation compared to the control state using fMRI.
+Methods: Functional magnetic resonance images were acquired from twenty-six right handed meditators during 
+MF, ME and random thinking (RT) for comparison. Ten of them were experienced (average age ± SD, 37.7 ± 13.4 
+years; 9 males) with 6048 hours of meditation, whereas 16 (group average age ± SD, 23.5 ± 2.3 years; all males) 
+were less experienced, with 288 hours of meditation. During the fMRI recordings the participants practiced RT, 
+non-meditative focused thinking (FA), MF and ME, each lasting for 2 minutes. Brain areas activated during the 
+intervention were scanned using a 3.0-Tesla Philips-MRI scanner. 
+Results: During the third phase of meditation (ME) the experienced meditators alone showed significant 
+activation in the right middle temporal cortex (rMTC), right inferior frontal cortex (rIFC) and left lateral orbital gyrus 
+(LOG) (p < 0.05), Bonferroni adjusted t-tests for unpaired data, comparing ME and random thinking. 
+Conclusions: These changes suggest that ME is associated with sustained attention, memory, semantic 
+cognition, creativity and an increased ability to detach mentally.
+Keywords: Meditation; Yoga; Traditional texts; Random thinking; 
+fMRI; Focused attention; Effortless focused attention
+Introduction
+Meditation can be considered to be a training in awareness which 
+produces definite changes in perception, attention, and cognition [1]. 
+Meditation is also recognized as a specific consciousness state in which 
+deep relaxation and increased internalized attention co-exist [2]. Perhaps 
+related to this is the concept that directing and regulating attention are 
+considered an inherent part of different meditation techniques [3].
+Multiple neuroimaging studies on meditation have attempted to 
+describe the cognitive processes involved. The most common examples 
+are of focused attention and open monitoring meditation [4,5]. There 
+appears to be no neuroimaging study which has categorized the process 
+of meditation based on traditional texts whether Buddhist, Yoga, Chinese 
+or any others. The present study aimed to compare three stages of yoga 
+meditation described in Indian yoga texts with the mental state that is 
+described to exist when not in meditation. This non-meditative state is 
+characterized by both mind-wandering and switching of attention at 
+random. It has been described in traditional texts as the characteristic 
+mental state when the mind is not directed or instructed (Cancalata in 
+Sanskrit; Bhagavad Gita, Circa 500 B.C.; Chapter 6, Verse 34; simplified 
+here as random thinking or RT) [6]. This was considered as the control 
+state against which the stages of meditation were compared. In an 
+attempt to describe this mental state with contemporary descriptions it 
+can be considered as normal consciousness [7]. 
+Traditionally it is mentioned that in order to reach a meditative 
+state attention should be focused and maintained. In order to do this 
+different meditation techniques use varied objects, mantras as well as 
+interoception [8].
+As a practitioner attempts to meditate there are three successive 
+*Corresponding author: Shirley Telles, Patanjali Research Foundation, 
+PatanjaliYogpeeth, Haridwar, Uttarakhand 249405, India. Tel: +91 01334 244805; 
+Telefax: +91-1334-24008, E-mail: [email protected]
+Received April 07, 2014; Accepted May 26, 2015; Published June 02, 2015
+Citation: Telles S, Singh N, Naveen KV, Deepeshwar S, Pailoor S, et al. (2015) A 
+FMRI Study of Stages of Yoga Meditation Described in Traditional Text. J Psychol 
+Psychother 5: 185. doi: 10.4172/2161-0487.1000185
+Copyright: © 2015 Telles S, et al. This is an open-access article distributed under 
+the terms of the Creative Commons Attribution License, which permits unrestricted 
+use, distribution, and reproduction in any medium, provided the original author and 
+source are credited.
+stages, these are: (i) Focused attention (FA), (ii) Meditative focusing 
+(MF) and (iii) Pure meditation (ME). In FA the practitioner attempts 
+to return to focus when the mind wanders and attention is directed 
+to several thoughts about the same subject (in the present study the 
+thoughts were on the concepts of meditation). During Meditative 
+focusing (MF) focusing of attention is directed to a single thought 
+(in the present case the Sanskrit syllable ‘Om’), with the exclusion of 
+all distractions, which requires effort. Pure meditation (ME) occurs 
+as the practitioner continues with the second stage the stage of pure 
+meditation is spontaneously reached, where attention is on a single 
+thought (in this case the syllable ‘Om) but there is no effort involved.
+The descriptions of each stage of meditation in the traditional texts 
+give greater clarity about the processes involved. The first stage (FA) 
+is called ekagrata in Sanskrit (Bhagavad Gita, Chapter 6, Verse 12), 
+during which attention is directed to a series of associated thoughts. 
+As mentioned above if the thoughts are related to meditation, 
+the person would then be able to progress to the next two stages, 
+dharana (MF) and dhyana (ME). Dharana (or focusing with effort), is 
+described as ‘confining the mind within a limited mental area’ (‘desha-
+bandhashchittasya dharana’, Patanjali’s Yoga Sutras, the sage Patanjali 
+Citation: Telles S, Singh N, Naveen KV, Deepeshwar S, Pailoor S, et al. (2015) A FMRI Study of Stages of Yoga Meditation Described in 
+Traditional Text. J Psychol Psychother 5: 185. doi: 10.4172/2161-0487.1000185
+Page 2 of 6
+Volume 5 • Issue 3 • 1000185
+J Psychol Psychother
+ISSN: 2161-0487 JPPT, an open access journal 
+Circa 900 B.C.; Chapter 3, Verse 1) [9]. The next state is dhyana or 
+effortless expansion called pure meditation This state is described as 
+‘the uninterrupted flow of the mind towards the object chosen for 
+meditation’(‘tatra pratyayaikatanata dhyanam’, Patanjali’s Yoga Sutras, 
+the sage Patanjali Circa 900 B.C.; Chapter 3, Verse 2).
+The difference between dharana and dhyana in using effort to 
+direct attention is supported by data which show a shift towards vagal 
+dominance during dhyana [10]. Apart from the autonomic variables 
+there have been electrophysiological recordings of short [11], middle 
+[12] and long latency [13] auditory evoked potentials during FA, MF, 
+ME as well as during the control state (RT) of random thinking. The 
+changes were both in the time taken for information transmission (i.e., 
+the latency) as well as in the number of neurons recruited (indicated by 
+the amplitude). However auditory evoked potentials were specific for 
+the auditory pathway and the neural generators were correspondingly 
+specific to that pathway. Also evoked potential recordings do not 
+give spatial and temporal resolution which fMRI provides to localize 
+changes in brain functions. 
+Hence the present study was designed to compare the parts of the 
+brain involved in three successive stages of traditionally described yoga 
+meditation (i.e., FA, MF and ME) each with the mind wandering state 
+(RT) using fMRI.
+Methods
+Participants
+The participants were twenty-six right handed trained meditators. 
+Ten of them (9 males; group average age ± SD; 37.7 ± 13.4 years) 
+had 7 years of experience of meditation {(7 years × 12 months × 24 
+days × 180 minutes)/60} = 6048 hours), practiced as the two stages, 
+meditative focusing (ME) leading to pure meditation (ME). The other 
+sixteen meditators had 18 months experience of the same meditation. 
+They were all males and had an average age of 23.5 ± 2.3 years with 
+experience of 288 hours {(18 month × 24 days × 40 minutes)/60} = 288 
+hours). The two groups significantly differed with respect to age (t = 
+4.11 ; df = 24 ; p = 0.0003). Baseline characteristics of the experienced 
+and less experienced meditators are given in Table 1. Participants were 
+recruited for the trial by notices on the notice boards of the institution, 
+the Indian Council of Medical Research Center for Advanced Research 
+(ICMR-CAR), located in Bangalore, south India. This center is attached 
+to a residential yoga training center where meditators receive training 
+in meditation and come for advanced retreats. There was no incentive 
+to take part in the study and while the study design was explained to 
+the participants, the research question was not. To be included in the 
+trial participants had to meet the following criteria (i) normal health 
+based on a routine physical and mental health examination, (ii) right 
+hand dominance based on a routine hand dominance inventory [14], 
+and (iii) regularity in their practice of meditation, where regularity 
+meant practicing for at least 40 minutes a day for six days in a week. 
+The experienced meditators practiced for 180 minutes in a day while 
+the inexperienced meditators practiced for 40 minutes each day. 
+Pre-determined exclusion criteria were: (i) if they were not able to 
+be scanned due to claustrophobia, metal implants, a pacemaker, or 
+pregnancy, and (ii) inability to meditate in the scanner environment. 
+None of the participants had to be excluded for these reasons. The 
+study was approved by the Institutions’ ethics committees of the (i) 
+Indian Council of Medical Research Center for Advanced Research 
+(ICMR-CAR), and (ii) the National Institute of Mental Health and 
+Neurosciences (NIMHANS), both located in Bangalore in south 
+India. Signed informed consent was obtained from all the participants 
+following the guidelines of the Indian Council of Medical Research.
+Intervention
+During the fMRI recordings, the participants were asked to practice 
+the control and the three meditation sessions in the following order 
+i.e., random thinking, non-meditative focused thinking, meditative 
+focusing, and effortless meditation or pure meditation, each lasting for 
+2 min. The oral instructions were given from the control room through 
+noise-canceling electrostatic headphones.
+Random thinking
+Participants were asked to keep their eyes closed and 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 diverse topics recorded from a local radio 
+station transmission. These conversations were not connected and 
+hence it was thought that listening to them could induce a state of 
+random thinking.
+Non-meditative focused thinking (FT)
+Participants were asked to keep their eyes closed and listened to a 
+pre-recorded lecture on concepts of meditation. This was intended to 
+induce a state of non-meditative focusing.
+Meditative focusing (MF)
+During training participants were asked to open their eyes and 
+gaze at the Sanskrit syllable ‘Om’ as it is written in Sanskrit. However 
+in the scanner they were asked to keep their eyes closed. During this 
+time guided instructions through a pre-recorded audio tape required 
+them to direct their thoughts to physical attributes of the syllable, i.e., 
+the shape, the size and the color. The main emphasis during meditative 
+focusing was that thoughts are consciously brought back if they wander 
+to the single thought of ‘Om’.
+Effortless meditation or pure meditation (ME)
+During this session participants were instructed to keep their eyes 
+closed and dwell on thoughts of ‘Om’
+, particularly on the subtle (rather 
+than physical) attributes and connotations of the syllable. This would 
+gradually allow the participants to experience brief periods of silence, 
+which they reported after the session.
+Variables
+Experienced meditators (n = 10)
+Less experienced meditators (n = 16)
+Education 
+A minimum of 17 years
+A minimum of 17 years
+Age (mean ± S.D)
+37.7 ± 13.4 years
+23.5 ± 2.3 years
+Gender (M/F)
+9 /1 
+16/0
+Meditation practice (minutes/day)
+180 
+40 
+Meditation practice (total number of months)
+84 
+18 
+Hours of meditation (total hours)
+6084 
+288 
+Table 1:  Baseline Characteristics of the Experienced and Less Experienced Meditators.  Values are Group Mean.
+Citation: Telles S, Singh N, Naveen KV, Deepeshwar S, Pailoor S, et al. (2015) A FMRI Study of Stages of Yoga Meditation Described in 
+Traditional Text. J Psychol Psychother 5: 185. doi: 10.4172/2161-0487.1000185
+Page 3 of 6
+Volume 5 • Issue 3 • 1000185
+J Psychol Psychother
+ISSN: 2161-0487 JPPT, an open access journal 
+Design
+A block design was used. The paradigm consisted of two repeat 
+sessions of 8 minutes duration. The session was repeated on another day 
+at the same time of the day. Each session had 4 blocks corresponding to 
+Random Thinking (RT), Focusing (FC), Meditative Focusing (MF) and 
+‘pure’ Meditation (ME) in a fixed sequence, for 120 seconds per block, 
+20 dynamic scans per block (20 × 4 = 80 dynamic scans in one session); 
+hence in total 160 dynamic scans from the 2 sessions were used for 
+analysis. Participants had been informed that a simple instruction to 
+change their mental state would be given using the intercom to avoid 
+their getting startled.
+The sequence (i.e., RT-FC-MF-ME) was fixed. The fact that it 
+was not randomized is a disadvantage of the study. However (i) this 
+sequence is pre-determined in the traditional descriptions [9], and 
+(ii) participants had been trained to follow a fixed sequence during 
+familiarization sessions in the scanner environment.
+For one month prior to the experiment the participants were trained 
+to meditate in a fabricated ‘simulated scanner’ which was a cylinder 
+of comparable dimensions. During this time the participants were 
+required to listen to pre-recorded ‘scanner noise’ which was recorded 
+during actual acquisition. These familiarization sessions were of the 
+same duration as the actual recording sessions. The practice session 
+included two trials : that is 2 minute sessions for each of the 4 states, 
+practiced in 16 minute sessions, 5 days a week during the month.
+Assessments
+Functional image data acquisition and reduction
+MRI scanning was conducted using a 3.0-Tesla Phillips-MRI head 
+scanner with an 8 channel head frequency coil. To minimize motion 
+artifact the participants’ head was padded with foam coil. Functional 
+images were acquired in 160 slices rotated about 30o above the anterior-
+posterior commissure (AC-PC) using a T2*-weighted EPI pulse 
+sequence (repetition time, TR=3000; echo time, TE=35;flip angle, 
+FA=90°;field of view, FOV=230×230×128 mm; slice thickness = 8mm, 
+with 0mm slice gap). The 30oline offset was intended to reduce signal 
+loss due to susceptibility artifact in the orbito-frontal cortex [15]. Scan 
+acquisition was time-locked to the onset of each trial. Before functional 
+scanning, a T1-weighted MP-RAGE high resolution 3D anatomical 
+image was acquired. There were 160 slices, 1 mm thick; TR=8.1 ms; 
+TE=3.7 ms; FA=90°; FOV=240×240×160 mm. The purpose was to 
+evaluate structural abnormalities (there were none) and to allow for 
+transformation of functional data into standard reporting space for 
+spatial normalization [16]. With the block design paradigm used, 
+which is detailed above and in Figure 1,160 dynamic scans from the 2 
+sessions were obtained.
+Imaging data were processed using Brain Voyager (BVQX 2.1; 
+Brain Innovation, Maastricht, The Netherlands). Preprocessing 
+included (i) 3-D motion correction using trilinear interpolation, (ii) 
+Figure 1: Experienced meditators (n = 10): Areas showing supra threshold activation in right middle temporal cortex, right inferior frontal cortex and left orbital gyrus in 
+meditation  (p < 0.05, t-tests for unpaired data Bonferroni adjusted following one-way ANOVA).
+Citation: Telles S, Singh N, Naveen KV, Deepeshwar S, Pailoor S, et al. (2015) A FMRI Study of Stages of Yoga Meditation Described in 
+Traditional Text. J Psychol Psychother 5: 185. doi: 10.4172/2161-0487.1000185
+Page 4 of 6
+Volume 5 • Issue 3 • 1000185
+J Psychol Psychother
+ISSN: 2161-0487 JPPT, an open access journal 
+slice-scan time correction to temporally realign the slices, (iii) spatial 
+smoothing using a 3D 6mm full width at half maximum (FWHM) 
+Gaussian filter, (iv) voxel-wise linear detrending, and (v) temporal 
+filtering of frequencies below 3 cycles per time course to remove low 
+frequency non-linear drifts. Registration of the functional images to 
+anatomical volumes was completed with standard BVQX methods. 
+For group-wise analysis, spatial normalization of functional images 
+was carried out by scaling the functional images into standard 
+Talairach space.
+Self–Report of Meditation on Visual Analog Scales (VAS)
+At the end of each session participants were asked to rate the extent 
+that they felt they were able to follow instructions on a liner continuous 
+scale from 0 to 10, where 0 meant ‘not being able to at all’ and 10 meant 
+‘being able to do so perfectly’
+.
+Data Analysis
+Imaging data were analyzed using whole brain voxel-wise statistical 
+tests (Brain Innovation Version 2.1, The Netherlands). The Talairach 
+Client (Version 2.4.3) was used to assign Talairach atlas 3D co-
+ordinates and overlay statistical maps onto the reference anatomical 
+image, transformed as standard reporting co-ordinates.
+A General Linear Model was applied for group whole-brain 
+analysis. Following separate one-factor ANOVAs for each of the two 
+groups, separate t-tests were carried out to compare overlay values 
+of (i) Focused attention (FA), (ii) Meditative Focusing (MF), and 
+(iii) Pure Meditation (ME), where each of them were compared with 
+Random Thinking (RT) for comparison, and for any change. The level 
+of significance was p < 0.01 with a cluster threshold of 10. Comparisons 
+were made with t-tests which were Bonferroni adjusted or FDR 
+corrected to reduce Type I errors
+Results
+(i)	 Self-rated ability to switch between states on the VAS: All 
+participants rated their ability to switch between states as 7 or 
+more on the 10 point scale, where 0 meant ‘not able to switch at 
+all’ and 10 meant ‘able to switch perfectly without any difficulty 
+at all’ [17]. There was no further analysis performed on the self-
+reports,
+(ii)	The imaging data of the two sets of participants, (a) experienced 
+meditators with 6048 hours of meditation practice, and (b) the 
+less experienced meditators with 288 hours of experience of 
+meditation practice:
+Experienced meditators
+	 The 10 experienced meditators showed a significant change in the 
+comparison between pure meditation (ME) and random thinking (RT) 
+(p = 0.049, one tailed); One Factor ANOVA followed by Bonferroni 
+adjusted t tests). Areas showing supra-threshold activation are 
+mentioned in Table 2 and shown in Figure 1. 
+Less experienced meditators
+There were no significant areas of activation for the three 
+comparisons, which is (i) RT with FA, and (ii) RT with MF and (iii) 
+RT with ME (p > 0.05); One Factor ANOVA after Bonferroni adjusted 
+t tests. 
+Discussion
+Meditators with a total of 6048 (7 years) of experience of meditation 
+on the Sanskrit syllable “Om’ showed significant activation in the right 
+medial temporal cortex (rMTG), right inferior frontal cortex (rIFG), 
+and left orbital gyrus (LOG) during the stage of effortless or “pure” 
+meditation. The comparison was with a period of random thinking. 
+There were no changes during meditation with focusing or during 
+focusing alone compared to random thinking.
+In the present study the activation was observed in the right middle 
+temporal cortex and right inferior frontal cortex which has been 
+observed in earlier studies on meditation [18]. The medial temporal 
+cortex is known to be involved in cognition and specifically in memory 
+processing [19,20]. Other aspects of cognition required for memory such 
+as attentional control are regulated by the inferior frontal gyrus [21,22]. 
+Multichannel EEG of an advanced meditator during four different 
+meditations using Low Resolution Electromagnetic Tomography 
+(LORETA) was carried out. Functional images showed activation 
+in the right fronto-temporal region along with other areas. The right 
+fronto-temporal areas are considered to be involved in self-induced 
+meditational dissolution and reconstitution of the experience of the self. 
+Hence the results of the present and the earlier study [18] suggest that 
+meditation activates brain areas concerned with self-representation. 
+While the LORETA study [18] demonstrated activity in the right 
+fronto-temporal region, the present study showed activity specifically 
+in the right inferior frontal cortex. These results are comparable with 
+an eLORETA study. Here eLORETA was used to compare differences in 
+cortical source activity in intermediate (average experience 4 years) and 
+advanced (average experience 30 years) Australian meditators of the 
+Satyananda Yoga tradition [23]. Assessments were made during a body 
+steadiness meditation, mantra meditation and non meditation mental 
+calculation. Across all conditions differences were greatest in the same 
+regions as the present study which included the right inferior frontal 
+gyrus, and right anterior temporal lobe.
+The above studies [18,23] demonstrated changes in the right inferior 
+frontal gyrus and temporal region. The activation of the rMTG reported 
+in the present study is in contrast to the findings of a report [24] which 
+measured the performance of participants during an fMRI adapted 
+Stroop word-color task. The comparison was between meditators and 
+non-meditators. The Stroop task performance was comparable for the 
+two groups. The MTG among other regions showed greater activity 
+in the non-meditators than meditators during the incongruent task 
+condition. The absence of activity during meditation in these areas 
+was considered to suggest that meditation improves efficiency possibly 
+through sustained attention and impulse control. The fact that the 
+Sl. No.
+Activation Area
+Brodmann Area
+L/Ra
+Talaraich Coordinatesb (mm)
+t-test
+X
+Y
+Z
+p - valueb (uncorrected)
+Bonferroni corrected
+Right middle temporal cortex (rMTC)
+37
+R
+66
+-54
+0
+p < 0.000002
+p < 0.049
+Right inferior frontal cortex (rIFC)
+44, 45 and 47
+R
+-48
+14
+18
+p < 0.000002
+p < 0.049
+Left lateral orbital gyrus (LOG)
+11
+L
+6
+42
+-21
+p < 0.000002
+p < 0.049
+aLeft or Right Hemisphere
+bFrom the atlas of Talairach and Tournoux (1988)
+Table 2: Areas of Activation and Talairach Coordinates in the Comparison Between Random Thinking and Pure Meditation
+Citation: Telles S, Singh N, Naveen KV, Deepeshwar S, Pailoor S, et al. (2015) A FMRI Study of Stages of Yoga Meditation Described in 
+Traditional Text. J Psychol Psychother 5: 185. doi: 10.4172/2161-0487.1000185
+Page 5 of 6
+Volume 5 • Issue 3 • 1000185
+J Psychol Psychother
+ISSN: 2161-0487 JPPT, an open access journal 
+middle temporal gyrus was activated during pure meditation (ME) in 
+the present study could be related to the fact that in this state attention 
+was maintained on the object of focus without effort. The findings of the 
+present fMRI study may be correlated with a morphometry assessment 
+of cortical thickness in Brain Wave Vibration (BWV) meditation [25], 
+a practice intended to increase awareness. Among other areas the 
+meditators showed greater cortical thickness in the temporal cortex 
+[25]. The regions with greater thickness were considered to be involved 
+in internal mentation or attention that is detached from the external 
+world [26]. While the present study demonstrated significantly greater 
+activation in the right middle temporal cortex based on functional 
+neuroimaging, structural cortical thickness mapping and diffusion 
+tensor imaging showed greater cortical thickness in 46 experienced 
+meditators compared with 46 matched meditation naïve volunteers in 
+several brain areas including the middle temporal cortex [25].
+The increased activation in the inferior frontal cortex in the present 
+study has been reported in another neuroimaging study on meditation 
+[27]. When two meditation techniques, a ‘focused based’ practice and 
+a ‘breath based’ practice were studied, a strong correlation was found 
+between the depth of meditation and activation in several areas of the 
+brain including the inferior frontal cortex and temporal pole [28]. 
+In the present study the increased activation of the lateral orbital 
+gyrus during meditation may be associated with certain changes in 
+mental attitude. The LOG is associated with specific personality traits 
+including Machiavellian scores [29,30]. The Machiavelli personality 
+is described as unemotional and detached from social morality for 
+personal benefits. During meditation there is a possibility of attaining 
+a mental state detached from all thoughts unrelated to meditation 
+[31]. The activation of the LOG during ME suggests detachment 
+which is ideal in meditation provided it co-exists with empathy, social 
+consciousness and compassion. Also the orbital gyrus is considered 
+to have a role in processing changes in reward related information 
+[32]. Meditation could possibly influence factors involved in reward 
+gratification with a detached attitude. 
+In meditation the ability to voluntarily shift from normal 
+consciousness to meditation is enhanced. Thirty one meditators with 
+meditation experience between 1.5 and 25 years were assessed using 
+a block on-off design with 45 seconds alternating epochs. During the 
+onset of meditation and normal relaxation SPM and ICA analysis 
+showed activation in multiple regions in the frontal, temporal, parietal 
+and limbic areas which was presumed to constitute a combination 
+of fronto-parietal and cingulo-oppicular activation [33]. The block 
+design in the present study which required practitioners to switch 
+between random thinking and the three stages of meditation within a 
+short period suggests that experienced meditators were able to change 
+from non-meditation to meditation even though this was assessed 
+subjectively without any biological marker.
+ It was also found by the study of Thomas et al. [23] that the networks 
+greatly expanded during meditation practice to include homologous 
+regions of the left hemisphere. It may be speculated that this may be 
+true for the present study as well. Hence the apparent restriction of 
+activation to the right hemisphere may be a partial result with the actual 
+activation involving an extended network within the brain. 
+The absence of changes in the less experienced meditators is 
+possibly related to their shorter duration of meditation experience, 
+rather than to other differences between the groups such as the age. 
+This is supported partly by a single study [34] which did not find any 
+difference in self-focused attention between two groups whose mean 
+age differed by 10 years. However the contribution of the difference in 
+ages cannot be entirely ruled out. 
+The present study has certain unique features, particularly the 
+attempt to study changes in the brain during meditation as described 
+in traditional texts. This description does not specify a particular 
+object or mantra, but describes a process to direct attention which 
+can be used across different meditation techniques. The findings are 
+limited by factors such as (i) the fixed sequence in the block design 
+even though the stages of meditation are sequential, (ii) the absence of 
+a group of non-meditators, (iii) the experienced meditators’ ages varied 
+considerably, though their experience and intensity of meditation 
+experience was comparable and (iv) the self-reports of efficacy to shift 
+from state to state could have been influenced by subjectivity and the 
+short time intervals of each block (2 minutes) made it all the more 
+necessary to check this.
+Conclusion
+In conclusion, the present results showed that there are differences 
+during effortless or ‘pure’ meditation as described by traditional yoga 
+texts compared to random thinking, involving activation of areas 
+involved in semantic cognition, memory, sustained attention, creativity 
+and the ability to detach mentally.
+Acknowledgement
+The authors gratefully acknowledge the funding from the Indian Council of 
+Medical Research (ICMR), Government of India, as part of a grant for a Center 
+for Advanced Research in Yoga and Neurophysiology (CAR-Y&N), (Project No. 
+2001-05010).
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+Page 6 of 6
+Volume 5 • Issue 3 • 1000185
+J Psychol Psychother
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+Choosing between small, likely rewards and large, unlikely rewards activates 
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+A FMRI Study of Stages of Yoga Meditation Described in Traditional Text. J 
+Psychol Psychother 5: 185. doi: 10.4172/2161-0487.1000185
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subfolder_0/A Psycho-Oncological Model of Cancer according to Ancient Texts of Yoga.txt

@@ -0,0 +1,663 @@
+Volume 3 • Issue 1 • 1000129
+J Yoga Phys Ther
+ISSN: 2157-7595 JYPT, an open access journal 
+Research Article
+Open Access
+Amritanshuram, J Yoga Phys Ther 2013, 3:1
+http://dx.doi.org/10.4172/2157-7595.1000129
+Research Article
+Open Access
+Yoga & Physical Therapy
+A Psycho-Oncological Model of Cancer according to Ancient Texts of 
+Yoga
+Amritanshuram R*, Nagendra HR, Shastry ASN, Raghuram NV and Nagarathna R 
+ S-VYASA University, Bengaluru, India 
+*Corresponding author: Amritanshuram, Division of Life Sciences, Swami 
+Vivekananda Yoga Anusandhana Samsthana, Bangalore, India, E-mail: 
+[email protected]
+Received December 17, 2012; Accepted January 28, 2013; Published January 
+31, 2013
+Citation: Amritanshuram R, Nagendra HR, Shastry ASN, Raghuram NV, Nagarathna R 
+(2013) A Psycho-Oncological Model of Cancer according to Ancient Texts of Yoga. J 
+Yoga Phys Ther 3:129. doi:10.4172/2157-7595.1000129
+Copyright: © 2013 Amritanshuram R. This is an open-access article distributed 
+under the terms of the Creative Commons Attribution License, which permits 
+unrestricted use, distribution, and reproduction in any medium, provided the 
+original author and source are credited.
+Keywords: Yoga; Psycho-neuro-immunological studies; Etiology of 
+cancer
+Introduction
+Cancer is a leading cause of death worldwide accounting for 7.4 
+million deaths (13% of all deaths worldwide) in 2008 [1]. Research 
+to understand the etiology and eradicate the tumor burden without 
+harming the host has progressed greatly and has resulted in successful 
+cure (in a few cancers), improved longevity and quality life. But the 
+world statistics indicates that the prevalence of the disease has not 
+reduced which is intriguing. 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 is one of the reasons that have 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]. In India, approximately 
+56% of the cancer patients took recourse to alternative therapies [3]. 
+Among these, yoga was the third most commonly accepted therapy 
+[3]. These surveys have also compiled the reasons for resorting to 
+CAM. They were: management of side effects, reduction of costs 
+involved, avoiding poor quality of life, minimizing psychological ill-
+health and reducing recurrences in spite of undergoing such traumatic 
+treatments [3]. The reason appears to stem from a more fundamental 
+cause than these. As treating professionals and researchers we seem to 
+have missed a major factor, namely the mind, in our entire search for 
+a solution. Conventional treatment has concentrated on dealing with 
+pathophysiology at physical, physiological and molecular levels, but in 
+reality the human system is governed by a more powerful subtle entity 
+called the mind [4].
+Life style and psychosocial stresses were recognized to be 
+contributory to sickness, by a few researchers, as early as nineteen 
+seventies [4,5], but it is only recently that enough data has been 
+accumulated to propose a psycho-neuro-immunological model for 
+Abstract
+Background: Several psycho-oncological models of cancer have been published. Integrated module of yoga 
+has been found to be effective as an add-on to conventional management of cancer through randomized control 
+studies.
+Objectives: To develop a model of the aetiopathogenesis of cancer according to ancient yoga texts. 
+Methods: This process had four phases: 1) Review of modern scientific and original texts dating back to 5000 
+years, 2) Focused Group Discussions (8 members) to develop the model, 3) preparation of the module based on the 
+proposed model and 4) field testing of yoga modules for patients with cancer.
+Results: Yoga texts propose that cancer is disturbed homeostasis (an imbalance) based in the mind. Persistent, 
+uncontrolled, fast recycling of thoughts in the mind due to wrong knowledge about the source of happiness is the 
+origin. This activates wasteful release of vital energy, (prana), which in due course, expresses onto the physical body 
+as habituated imbalance resulting in uncontrolled molecular (gene) level activity. This ‘local violence’, progresses 
+by activating the chemical reactions, resulting in inflammation or uncontrolled mitosis. The goal of yoga therapy 
+is ‘mastery over inner chemical processes through mindfulness and alertful rest to reduce the inner violence’. 
+Yoga modules were developed based on this understanding of the etiology of cancer. Review of literature and 
+group discussions which also contributed to these modules, aided to keep the focus on scriptural relevance and 
+clinical feasibility. These modules were used in patients with stage 2 and 3 breast cancer in randomized control 
+studies between 2003 till 2008. The results of these studies pointed to the beneficial effects of yoga as compared 
+to conventional management. During surgery, IAYT reduced hospital stay, faster wound healing and lower drain 
+retention; during chemotherapy, practice of yoga demonstrated lower nausea intensity and frequency, anxiety, 
+depression, better immunological status and quality of life; yoga practice during radiation therapy brought about 
+lesser side effects, less stress levels, better cortisol rhythm, sleep. During and after the treatment period patients 
+indicated better quality of life. Controlled studies on breast cancer patients provided the scientific evidence that these 
+modules are effective in clinical settings.
+Conclusion: This yoga based, workable model has incorporated the subtle aspects of mind (prana, mind and 
+the self) into the psycho-neuro-immunological model of cancer. Evidence suggests that yoga techniques that are 
+based on the models are effective in the management of breast cancer. Mechanism studies and intense dialogue are 
+necessary to consolidate these concepts.
+Citation: Amritanshuram R, Nagendra HR, Shastry ASN, Raghuram NV, Nagarathna R (2013) A Psycho-Oncological Model of Cancer according 
+to Ancient Texts of Yoga. J Yoga Phys Ther 3:130. doi:10.4172/2157-7595.1000129
+Page 2 of 6
+Volume 3 • Issue 1 • 1000129
+J Yoga Phys Ther
+ISSN: 2157-7595 JYPT, an open access journal 
+cancer [6]. This has helped to create an awareness of the role of mind 
+body relationship in the etiology and progression of cancer. Anderson 
+et al. [7] proposed a model in 1994 that pointed to a relationship 
+between mind and cancer. By 2006 they moved on to create a model 
+that portrayed a linear progressive casual relationship between 
+psychological stress, immune disturbance and cancer [8]. Further, in 
+2010 Ao P et al. [9] proposed a dynamic non linear mathematical model 
+of the etiology and progression of cancer based on the interaction of 
+the caspase-3 molecules to indicate the states of normalcy, disease and 
+stress. 
+Among the various CAM treatments available, yoga offers a holistic 
+model using an entirely different concept of understanding human 
+body in health and disease states; it also offers self corrective techniques 
+to restore normalcy. Ancient texts dating back to about 5000 years (Rig 
+Veda, Patanjali Yoga Sutra and ayurveda] provide a highly evolved 
+conceptual basis of aetiopathogenesis of disease and its management. 
+The ‘Integrated Approach of Yoga Therapy (IAYT) for Cancer’
+, used 
+as complimentary to conventional medicine in all studies conducted 
+by Swami Vivekananda Yoga Anusandana Samsthana (S-VYASA) 
+consisted of practices that were based on this model. The aim of the 
+present study is to present a holistic model of etiopathogenesis of 
+cancer using both the ancient and present knowledge.
+Methods
+This retrospective scientific narrative has been classified under four 
+phases (Table 1).
+Content generation
+Research scholars reviewed traditional yoga and ayurveda texts 
+for references to disease etiology and cancer specific pathology and 
+progression [10–13]. A comprehensive list of all the attributes and 
+treatment modalities were compiled for further discussion.
+Scientific literature including empirical evidence and review 
+articles were also scrutinized and hypothesized cancer etiology models 
+[9] were noted apart from accumulating information regarding latest 
+trials that had been done in the field of mind body medicine as a disease 
+management strategy [14–18].
+Model development
+Focused Group Discussions (FGD): The literature thus compiled 
+was presented to a group of experts for deliberations. The participants 
+of the focused group discussion (FGD) included eight members 
+consisting of 3 yoga experts with in-depth scriptural knowledge who 
+were practitioners of these techniques, one post graduate physician, two 
+oncologists who work with cancer patients and understand their major 
+concerns and needs at physical, mental and emotional levels during the 
+conventional therapies, and two research fellows.
+For each item on the list, the experts were asked to mark ‘useful’
+, 
+or ‘not relevant’ for understanding cancer etiology. The group was also 
+asked to suggest more references regarding cancer and its etiopathology. 
+In addition to this, in-depth discussions ensued which formed a major 
+method for data generation. These discussions and suggestions thereof 
+were noted and were added to the pre-existing list. Inputs by the experts 
+were used to finalize the model for cancer etiopathogenesis. 
+The flexibility of the FGD structure facilitated exploratory 
+discussions which made the outcome more humanized rather than 
+a score based questionnaire method. Despite its time consuming 
+characteristic, it helped the researchers to interact as contributors 
+to the model. The probing questions and discussions facilitated the 
+development of the model by sharing each others’ experiences also. The 
+entire process involved several small group meetings, correspondences, 
+sitting together for meditation and visiting the experts in the field apart 
+from the FGDs. 
+All the suggestions offered by the group of experts were deemed 
+equally important and taken into consideration for designing the 
+model. This was done by the research scholars under the guidance of 
+the yoga experts.
+Module preparation
+The FGD resulted in the formation of a etiopathological model of 
+cancer. A check list of yoga practices which was developed based on this 
+model were provided to the same team of experts for their opinion. This 
+process followed a semi-structured format, using open-ended questions 
+in a face-to-face conversational style and the focus was to document the 
+interviews and discussions that were based on the literature review and 
+experiential knowledge. Inputs regarding feasibility, need, relevance of 
+several yoga techniques were used to develop the modules of integrated 
+approach of yoga that formed the material for another publication [19].
+Field testing
+The modules that evolved were initially administered to patients 
+with different cancers as part of the pilot study. These subjects were 
+recruited from the residential health home of the institution, admitted 
+for two to three weeks to undergo integrated approach of yoga therapy. 
+These modules were administered to them for the period of their stay 
+by trained experts (two of the senior faculty who were involved in the 
+FGD). Feedback from these patients was recorded immediately after 
+each session. Based on this, further changes were made to the modules. 
+Further we conducted two randomized controlled studies that 
+used the modules of IAYT for cancer as an add-on to conventional 
+management of breast cancer (stages 2 and 3) results of which formed 
+the material for the eight publications on the complimentary role of 
+IAYT in breast cancer [20–27].
+Results
+Contents of the model: Panchakoshva viveka (the five components 
+of human being).
+According to yoga texts (Taittereya Upanishad), the human system 
+consists of five components [pancha kosha]: Physical body (Annamaya 
+Kosha), Subtle Energy or Prana (Pranamaya kosha), Instinctual mind 
+(Manomaya kosha), Intellectual or discriminative mind (Vignanamaya 
+kosha) and bliss-full silent state (Anandamaya kosha) (Figure 1). 
+Content Generation
+o	
+Review of traditional texts
+o	
+Review of scientific literature on cancer pathology
+o	
+Interactions and discussions with experienced yoga 
+gurus
+Model 
+Development
+o	
+Focused Group Discussions and semi structured 
+interviews
+o	
+8 experts from yoga or oncology field
+o	
+preparation of yogic model for cancer management
+Yoga Module 
+Preparation
+o	
+List of practices based on etiopathology and need
+o	
+Validation of yoga modules
+Field Testing
+o	
+Pilot studies on patients with cancer in stages 2-4 in 
+sites such as breast, cervix, stomach, colon cancers 
+included
+o	
+Randomized controlled studies on patients with 
+breast cancer( stage 2-3)
+Table 1:  Stages in the development of yogic model for the aetiopathogenesis of 
+cancer.
+Citation: Amritanshuram R, Nagendra HR, Shastry ASN, Raghuram NV, Nagarathna R (2013) A Psycho-Oncological Model of Cancer according 
+to Ancient Texts of Yoga. J Yoga Phys Ther 3:130. doi:10.4172/2157-7595.1000129
+Page 3 of 6
+Volume 3 • Issue 1 • 1000129
+J Yoga Phys Ther
+ISSN: 2157-7595 JYPT, an open access journal 
+Shvetashvatara Upanishad [10] describes that a human being is 
+in perfect harmony with nature and healthy when he is established in 
+Anandamaya kosha which is the unchanging state of being, the self 
+(called Brahman) and the causal state of beings from where all other 
+(ever changing) Koshas emerge [28]. Analogies to explain that Ananda/
+perfect health is the unchanging core of one’s personality include ‘this 
+kosha is like the string in a necklace of beads’ (Bhagavad Gita 7.7), like 
+the gold in all jewels (Chandogya Upanishad, 6.1.6) [12] or the clay in 
+different shaped pots (Chandogya Upanishad, 6.1.3) [12]. This state is 
+experienced as a state wherein one reaches a state of inner quietitude 
+with awareness and the knowledge that ‘I am made of the same 
+universal consciousness and bliss that forms the base material of the 
+entire creation’
+.
+ (Mandukya Upanishad 2) [29]; e.g. a salt doll dives into the ocean 
+to understand the depth of the ocean but gets the joy of becoming the 
+ocean itself by losing its individual entity [30]. 
+Waves begin in this ocean of blissful quietitude and become grosser 
+and grosser to form the other four components of the body (Ch3v3-6) 
+[28]. The first wave (spandana) that appears is the ‘I’ (self awareness) 
+followed by several varieties of waves that form a template of right 
+knowledge, the Vignanamaya kosha. In this state man is in perfect 
+health as he is in tune with nature [28] and leads a healthy life style with 
+complete mastery over his mind (Ch1v3) [31]. As these waves gather 
+momentum with higher amplitude and rewinding speed (ch5v26) 
+[11], (ch8v88) [13] it gathers energy to become the Manomaya kosha 
+in which likes and dislikes begin (Tattva Bodha v49) [32]. As the 
+process of grossification continues it goes on to become the vital energy 
+(pranamaya kosha) and the physical molecules (Annamaya kosha) 
+(Ch3 v5) [28]. Yoga techniques offer techniques of mastering the gross 
+[13] to reach the subtle layers of one’s existence by introspective slowing 
+down of thoughts. The subtle controls the gross e.g. if one masters prana 
+he can manipulate the functions of physical body; mind can manipulate 
+prana; vignana can master the mind and prana (Ch1v40) [31]. The goal 
+of life is to establish in a state of complete mastery by remaining in a 
+state of vignana , a state of complete freedom and contentment, freedom 
+from all distress and disease (shvetashvatara Upanishad ch2v12) [10]. 
+This is a state in which one develops the ability to manipulate the laws 
+of nature within the body and outside the body (ch1v4) [31]. 
+The model proposes the ability to master the law that governs 
+programmed cell cycle. Mind is the most highly evolved and the 
+most powerful entity in the manifest universe. A living human 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. 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 scriptures are 
+very emphatic when they say that this imbalance occurs due to lack 
+of mastery over mind which is the starting point of any mind body 
+disease. Sage Vasistha describes the progression of this imbalance that 
+results in cancer (and/or other lifestyle related disorder) in the text yoga 
+Vasistha (ch9 v82-117) [13]. The search for happiness in outside objects 
+continues with unresolved conflicts due to wrong notion about the 
+meaning of life and nature of happiness. The nature of this conflict or 
+distress is described as ‘uncontrolled recycling of sentences in the mind’ 
+(yogic definition of stress) (ch5v23) [11], the Manomaya kosha. This 
+imbalance due to uncontrolled speed (udvega) of suppressed emotions 
+when unchecked results in an imbalance and percolates into pranamaya 
+kosha. This is detectable as disturbed pattern of breathing (increased 
+rate and irregular rhythm) and poor digestion. As this imbalance and 
+loss of mastery goes on for some time it becomes an involuntary habit, 
+a reflex. Chronic constipation or irritable bowel (alternate constipation 
+and diarrhea), fatigue and generalized body aches are the other 
+general (non-specific) manifestations at this level. When unattended 
+by correcting the imbalance at the root cause (the Manomaya and 
+Vignanamaya koshas) the process continues and localizes to a specific 
+zone in the physical body (Annamaya kosha). Thus, the uncontrolled 
+rush of prana (vital energy) results in uncontrolled electro-chemical 
+processes in the physical body, the annamaya kosha. This appears to 
+mean that the physical fight (tissue inflammation) is a reflection of 
+the violence or fight in the mind. We know today that inflammation 
+is a feature of cancer. Thus, the uncontrolled excessive prana (subtle 
+energy) flow seems to cause the changes in the molecular level that 
+goes on to alter the apoptotic programming resulting in immortal 
+cells and perpetuation of cancer cells (Figure 2). Further, the texts go 
+on to describe that the localization of the disease (cancer) depends on 
+external (insult by carcinogenic agents, trauma, toxins, and infections) 
+or internal (genetic) factors.
+Thus, the yogic model proposes that the entire problem is due to 
+repetitive on slaught by uncontrolled thoughts (suppressed emotions) 
+at the mind level (Manomaya kosha) which causes excessive prana 
+activity and manifests as violence (inflammation) at annamaya kosha 
+to show up as cancer.
+Figure 1:  showing etiopathogenesis of cancer, combining knowledge from yoga 
+texts and modern literature.
+Figure 2: Five Layers of the Human system.
+Citation: Amritanshuram R, Nagendra HR, Shastry ASN, Raghuram NV, Nagarathna R (2013) A Psycho-Oncological Model of Cancer according 
+to Ancient Texts of Yoga. J Yoga Phys Ther 3:130. doi:10.4172/2157-7595.1000129
+Page 4 of 6
+Volume 3 • Issue 1 • 1000129
+J Yoga Phys Ther
+ISSN: 2157-7595 JYPT, an open access journal 
+Integrated approach of yoga therapy for cancer
+The integrated approach of yoga offers a comprehensive means 
+to overcome the damage by achieving mastery at all levels through 
+deep cellular rest (reducing the speed, violence and inflammation). At 
+the physical level (Annamaya kosha) there are practices that include: 
+cleansing the body (yogic kriyas) of the endotoxins (Aama as portrayed 
+in ayurveda) both at the gross (fecal matter) and subtle (molecular 
+toxins e.g. free radicals) levels [33]; correcting the life style through 
+yogic diet and injunctions for healthy behavior (sleep, activity, speech, 
+righteousness); and providing deep rest (reduce the speed) to the 
+damaged/sick tissues through physical postures (asanas). Pranayama 
+or breathing techniques corrects the imbalances in pranamaya kosha 
+through voluntary reduction in the rate of breathing (Ch2 v49) [34]. 
+Meditation (Dharana, Dhyana, Samadhi and Sanyama), the Manomaya 
+kosha practice is the most important as it aims at direct mastery over the 
+mind, the root cause of the problem by establishing in an introspective 
+state of blissful awareness (dhyana=effortless flow of a single thought) 
+(Ch2 v2) [31] (Ch3 v2) [34]. Devotion (bhakti yoga or emotional 
+culture) is another important component that helps in harnessing the 
+uncontrolled surge of violent suppressed emotions through using ‘pure 
+love’
+. At the vignanamaya kosha level (intellectual) correction of the 
+false notion is achieved through understanding that ‘I am made of the 
+universal consciousness and bliss (Ananda) which is independent of 
+the mind’
+. At anandamaya kosha level, karma yoga helps in achieving 
+blissful awareness free from all fears (including fear of death). Thus 
+the highlight of this model is the possibility of the practitioner to de-
+identify and dissolve oneself in the universal consciousness that is 
+described as existence (sat), consciousness (chit) and bliss (ananda), 
+through right knowledge and awareness. All practices including 
+yogic diet, kriyas (cleansing), asanas, pranayama, dharana, dhyana, 
+devotion and self analysis prepare the system to stop the turbulent 
+fluctuations (superficial and deep seated subconscious activities) and 
+allow the mind to rest in a state of inner quietitude(wakeful sleep) . 
+A single positive thought (a resolve) dropped in the ocean of blissful 
+quietitude (sanyamah) has the ability to reverse the imbalances at all 
+levels [31]. Thus the process of reversing the structural and functional 
+abnormalities at the tissue level is described through this model.
+Field testing
+The major changes suggested by the patients, after having 
+undergone sessions of the yoga module, as part of the pilot study, were: 
+(a) the duration of each module of the practice had to be reduced from 
+60 to 30 minutes, (b) there was a need for recorded audio CDs/cassettes 
+to help them continue the practice and (c) some of the imageries used 
+during the practice had to be replaced. E.g.: the ‘death experience’ had 
+to be replaced by ‘surrender to the divine lord’ which gave much more 
+confidence to face the disease.
+The results of randomized control trials on stage 2 and 3 breast 
+cancer patients have shown beneficial effects of IAYT, throughout the 
+entire treatment phase, as an add-on to conventional treatment. 
+Stage 2 and 3 breast cancer patients undergoing surgery showed 
+shorter hospital stay, suture removal and lower drain retention in 
+the group that were administered IAYT. Patients receiving IAYT 
+along with radiotherapy showed significantly lower levels of anxiety, 
+depression distress, fatigue, insomnia, and appetite loss, negative effect 
+and stress and improved activity levels, positive effect, emotional and 
+functional quality of life while the amount of change in DNA damage 
+was significantly lower as compared to controls. Cortisol rhythms 
+also showed restorative changes in yoga group. Breast cancer patients 
+receiving chemotherapy and IAYT reported lower nausea intensity 
+and frequency apart from lower state and trait anxiety, depression, 
+symptom severity, distress and better quality of life. Higher immune 
+parameters like NK cells, CD8+ and CD56+ counts were also observed 
+for this group. 
+Discussion
+This narrative summary of a pre-clinical process, presents a model 
+of the aetiopathogenesis of cancer that has evolved over 5000 years of 
+research in the east by yoga masters as an introspective science. This 
+model of origin and progression of cancer takes into account the 
+existence of subtle aspects of the personality such as prana, mind, and 
+the self (the soul). The holistic model proposes that the root cause of 
+the disease is the wrong mindset or incorrect notion viz. ‘the source of 
+happiness is the external agents of enjoyment’
+. The life’s ambitions and 
+plans are all based on this notion. Frustrations occur when these are 
+not fulfilled. Emotional suppressions become mandatory to carry on 
+with life. This results in chronic imbalance that disturbs homeostasis 
+and culminates to cancer. This analysis provides the logical basis for 
+using corrective techniques that are used in yoga practices. 
+Our studies that used intervention modules called IAYTC 
+(integrated approach of yoga therapy for cancer) based on this model 
+as an add-on during the entire course of conventional management of 
+breast cancer (stages 2 and 3) have shown the beneficial effects [20–27]. 
+The results of these studies indicate that the IAYT modules complement 
+conventional treatment and are clinically relevant to cancer patients. 
+However, they do not provide direct evidence for the etiopathological 
+model that is proposed in this article and is a working hypothesis that 
+has been suggested.
+Comparisons with other psyco-oncological models
+Anderson et al. [7] proposed a bio-behavioral model of the 
+relationship between stresses of cancer based on several publications 
+up until 1994. 
+Her study highlighted the mechanisms by which psychological and 
+behavioral responses may influence biological processes and the health 
+outcomes and gave insights into the role of mind in compliance to 
+standard therapies. Further, based on a decade long (between 1995 and 
+2005) explosive discoveries on the relationship between psyche and the 
+immune modulation the same researchers Thornton and Anderson [8] 
+presented a psycho-neuro-immunological model of cancer. This model, 
+for the first time, hypothesized a causal linear relationship between the 
+chain of events starting from stressors, psychological stress response 
+that may lead to physiological stress response going on to immune 
+changes and the disease processes. They could also incorporate many 
+molecular mediators and moderators in the model. There has been 
+continuing debate on this psycho-neuro-immunological model of the 
+genesis and progression of cancer. A robust study by Surtees et al. [35] 
+investigated the associations between lifetime social adversity measures 
+that included stressful life events in childhood and adult life, stress 
+adaptive capacity, and perceived stress over a 10-year period. Looking 
+at the Incidence through the cancer registry data showed no evidence 
+that social stress exposure or individual differences in its experience are 
+associated with the development of breast cancer [35].
+Research in the last decade identified several mediators involved in 
+the genetics of cancer that has led to successful drug discoveries. Based 
+on these, Ao et al. [9] proposed a non linear mathematical physical 
+(stochastic dynamic) model. According to this model, the oncogenes 
+and other molecular and cellular agents form pathways and modules 
+Citation: Amritanshuram R, Nagendra HR, Shastry ASN, Raghuram NV, Nagarathna R (2013) A Psycho-Oncological Model of Cancer according 
+to Ancient Texts of Yoga. J Yoga Phys Ther 3:130. doi:10.4172/2157-7595.1000129
+Page 5 of 6
+Volume 3 • Issue 1 • 1000129
+J Yoga Phys Ther
+ISSN: 2157-7595 JYPT, an open access journal 
+that cross talk to each other to form endogenous networks. The 
+nonlinear dynamical interactions among these generate many locally 
+stable states of which some states may be normal such as cell growth, 
+apoptosis, arresting, etc,; others may be abnormal, such as growth 
+with elevated immune response and high energy consumption, likely 
+the signature of cancer; some may be useful to deal with rare stressful 
+situations. 
+Similar to basic discoveries at molecular levels that led to safer 
+drugs to scavenge for cancer cells, the eastern yoga model offers a 
+sound conceptual basis for psycho-oncological processes that leads to 
+techniques of yoga with the potential of returning to normalcy.
+Since the first published research article evaluating the benefits of 
+a support group therapy [36] 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. 
+To date there are three metaanalyses [37–39] of all published papers on 
+yoga in cancer, that provide consistent evidence to the strong beneficial 
+effects on distress, anxiety and depression, moderate effects on fatigue, 
+general HRQoL, emotional function and social function, small effects 
+on functional well-being, and no significant effects on physical function 
+and sleep disturbances. Looking at the results of all these studies, it 
+raises a question as to how all these studies could show similar results 
+although they had used different practices ranging from only physical 
+practices to meditative practices. The answer lies in the understanding 
+that all these (asanas, pranayama, meditation etc) are only techniques to 
+help the patient arrive at an internal mastery over the mind and prana 
+that helps in correcting the imbalances. As the premise for calling any 
+practice ‘yoga’ is clarified in ancient Indian literature, researchers had 
+the freedom to modify the intervention to suit the desired objectives.
+Summary
+The scriptural basis of the IAYTC has been discussed. The model 
+incorporates all aspects of the personality with mind as the starting 
+point with cancer as the end point of the process. 
+Limitations of the study
+This work refers 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 model. Statistically acceptable check 
+lists and scoring were not used during all group discussions and the 
+format was semi structured. Not all members of the focused group met 
+during all discussions and there were several meetings that were not 
+documented. Statistical calculations of split half reliability were not 
+planned. 
+The clinical trials performed using yoga techniques developed 
+based on the proposed model cannot directly validate the model but 
+indicate that yoga is an effective tool for the management of cancer. 
+Although cancer patients and yoga teachers would greatly benefit from 
+the knowledge of this model, it is not a necessity that this model be the 
+only mechanisms of action.
+Strengths
+This is the first proposed model that explains the role of imbalances 
+at several levels of existence (physical body, prana and mind). It 
+forms the basis for self corrective techniques. RCTs that led to eight 
+publications [20–27] provide the evidence. This offers new direction to 
+research on cancer at subtler levels. 
+Conclusion
+This study offers a model for holistic approach to cancer research 
+as it incorporates the subtle components into the psycho-neuro-
+immunological model of cancer. More robust studies to understand the 
+mechanism are to be designed, in the future, in order to find evidence 
+for each process in the hypothesized model.
+Acknowledgements
+We acknowledge the support and the funding provided by the librarian and the 
+staff of S-VYASA University.
+References
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+to Ancient Texts of Yoga. J Yoga Phys Ther 3:130. doi:10.4172/2157-7595.1000129
+Page 6 of 6
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+J Yoga Phys Ther
+ISSN: 2157-7595 JYPT, an open access journal 
+al. (2007) Effects of an integrated yoga programme on chemotherapy- induced 
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+Influence of yoga on mood states, distress, quality of life and immune outcomes 
+in early stage breast cancer patients undergoing surgery. Int J Yoga 1: 11–20. 
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+Effects of yoga on symptom management in breast cancer patients: A 
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+induced genotoxic stress in breast cancer patients undergoing radiotherapy. 
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+Radical Mediated Disorders in Ayurveda with Special Referance to Bhutagni 
+Vyapara and Ama at molecular Level. Anc Sci Life. 19: 17–20. 
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+S 
+(1999) 
+Raja Yoga. 
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+Raja Yoga. 
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+psychological health, quality of life, and physical health of patients with cancer: 
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+Physical and psychosocial benefits of yoga in cancer patients and survivors, 
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+patients and survivors: a systematic review and meta-analysis. BMC cancer 
+12: 412. 
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+Yoga. J Yoga Phys Ther 3:130. doi:10.4172/2157-7595.1000129

subfolder_0/A Questionnaire designed to measure tridosha values in adolescents changes in score pre-post an IAYT yoga module.txt

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+Kaur et al.                                                                       European Journal of Biomedical and Pharmaceutical Sciences 
+ 
+ 
+www.ejbps.com 
+ 
+205 
+ 
+ 
+ 
+A QUESTIONNAIRE DESIGNED TO MEASURE TRIDOSHA VALUES IN 
+ADOLESCENTS: CHANGES IN SCORE PRE-POST AN IAYT YOGA MODULE 
+ 
+ 
+Devika Kaur1, Alex Hankey2* and HR Nagendra3 
+ 
+1S-VYASA, Prashanthi Kutiram Campus, Manchenahalli, Kalluballu Post, Jigani, Anekal Taluk, Bengaluru District, 
+Karnataka 560105. 
+2Distinguished Professor of Yoga and Physical Science S-VYASA, Prashanthi Kutiram Campus, Manchenahalli, 
+Kalluballu Post, Jigani, Anekal Taluk, Bengaluru District, Karnataka 560105. 
+3Chancellor, S-VYASA, Prashanthi Kutiram Campus, Manchenahalli, Kalluballu Post, Jigani, Anekal Taluk, 
+Bengaluru District, Karnataka 560105. 
+ 
+ 
+ 
+ 
+ 
+Article Received on 30/07/2019                               Article Revised on 19/08/2019                                    Article Accepted on 09/09/2019 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+INTRODUCTION 
+India‟s ancient science of life, Ayurveda[1,2] lays great 
+emphasis on the concept of Prakriti[3], because that 
+concept provides a preliminary assessment of patients‟ 
+physiological tendencies when faced by stressors[4], 
+continuing exposure to which will inevitably lead to 
+pathogenesis.[5] In the historical system, many Vaidyas 
+were trained to use Nadi Vigyan.[6,7] Ayurveda‟s system 
+of pulse diagnosis, in addition to Dashavidha Pariksha, 
+for the all-important evaluation of Prakriti and Vikriti in 
+those who came to consult them.[8] 
+ 
+The drift away from traditional systems of healthcare 
+under British influence[9,10], led to neglect of Ayurveda 
+and its systems of diagnosis and treatment. Medical 
+training colleges did not cover them, though Vaidyas 
+trained by traditional Guru-Shishya principles continued 
+to learn them. More recently, this been remedied with 
+present Ayurveda training institutions teaching them as 
+part of their curriculum.[1]* The present need is to 
+develop equivalent ways to obtain the same patient 
+information. 
+A 
+previous 
+paper[11] 
+described 
+the 
+development and testing of a questionnaire for children. 
+We ourselves have developed a separate questionnaire, 
+the Kashyapa Prakriti Inventory (KPI), aiming to 
+evaluate Prakriti in adolescents. This paper describes its 
+administration to adolescents before and after training in 
+a 90-minute Yoga module, designed in accordance with 
+the principles of the Integrated Approach to Yoga 
+Therapy[12] (IAYT).  
+ 
+Historically, Yoga originated in India as the ancient 
+Vedic civilization‟s system of personal development for 
+the children of Rishis, Kings and other leaders of 
+society.[13] The discipline is informally described in the 
+first Upanishads[14], and slowly acquired a formal status 
+as the path to union (Yuj) with the Divine[15], and 
+consequent release from the cycle of birth and death.[16] 
+ 
+Yoga focuses on gaining mastery over body and mind[17] 
+and consequent acceleration to gaining life‟s true goal of 
+self-realization and enlightenment.[18] It integrates body, 
+mind and spirit using a comprehensive, holistic approach 
+in practices emphasizing breathing and stretching, 
+postures and pranayama, chanting and meditation, as 
+detailed below. Yoga practices for the individual may 
+SJIF Impact Factor 6.044 
+ 
+Research Article 
+ejbps, 2019, Volume 6, Issue 11, 205-211. 
+European Journal of Biomedical 
+AND Pharmaceutical sciences 
+ 
+http://www.ejbps.com 
+ 
+ 
+ISSN 2349-8870 
+Volume: 6 
+Issue: 11 
+205-211 
+Year: 2019 
+*Corresponding Author: Alex Hankey 
+Distinguished Professor of Yoga and Physical Science S-VYASA, Prashanthi Kutiram Campus, Manchenahalli, Kalluballu Post, Jigani, Anekal 
+Taluk, Bengaluru District, Karnataka 560105.  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ABSTRACT  
+Background: Ayurveda emphases the prakriti concept as fundamental to assessing patients‟ physiologies. Recent 
+decades have proposed new ways to evaluate it. Previous papers describe formulation and testing of new 
+inventories to evaluate physiological and psychological aspects of prakriti in children and adolescents. Here, we 
+report changes in adolescents pre-post a Yoga intervention. Methodology: The study was conducted at a high 
+school and PU-college level on 82 adolescents, aged 15.29±1.65 years. The Yoga module was given thrice per 
+week for four weeks. It included Yoga breathing/stretching practices, postures, Mind Sound Resonance 
+Technique, mantra recitation and relaxation techniques. The Inventory was administered pre-and-post the 
+intervention. Statistical analysis used SPSS-21.0 Wilcoxon Signed-Ranks-Test. Results: Vata decreased, p<0.05; 
+Pitta and Kapha increased, p<0.05. Discussion: Participant‟s initial states were Vata dominant. Results indicate 
+that their tridosha became more balanced; psychologies calmer, personalities steadier, causing fewer problems. 
+Changes are attributable to alteration of underlying Tridoshas; epigenetics may provide an explanation.  
+ 
+KEYWORDS: Prakriti, Psychology, Vata, Pitta, Kapha, Yoga.  
+ 
+Kaur et al.                                                                       European Journal of Biomedical and Pharmaceutical Sciences 
+ 
+ 
+www.ejbps.com 
+ 
+206 
+also include consideration of bodily compositions. The 
+texts hold that nature and body are directly related to 
+each other as described in the phrase „Avinabhaava 
+Sambandha‟[19], inseparable connection.  
+ 
+Today, many top Yoga research institutions like 
+NIMHANS 
+and 
+Kaivalyadhama[20,21], 
+and 
+other 
+academic organizations like Harvard University[22] and 
+Patanjali Yoga Peeth[23], have worked with great 
+dedication to observe benefits of Yoga practices and 
+validate them. Studies have been done on all age groups: 
+children[24]; adolescents[25]; adults[26] and the elderly.[27] 
+In adolescents (the concern of this study), effects of yoga 
+have been seen in such fields as: increased academic 
+motivation and persistence[28]; social behavior[25]; coping 
+with stress[29], dealing with anxiety[30], and similarly yoga 
+as a complementary treatment for the quality of life of 
+adolescents suffering from IBS[31], etc. However, there 
+seems to be no study of possible effects of yoga on 
+Prakriti in adolescents; hence the present study.  
+ 
+Allied to yoga is the ancient Vedic system of medicine, 
+Ayurveda.[1-3] According to Ayurveda, the human body is 
+organized by three fundamental physiological principles 
+called Doshas that govern all bodily functions[32], Vata 
+dosha, Pitta dosha & Kapha dosha.[33] Strictly speaking, 
+the word „Dosha‟ means impurity, because Doshas may 
+express imbalances in the composition of important 
+aspects of the physiology.[34] However, the Ashtanga 
+Sangraha by Vaghbata, related to the third of Ayurveda’s 
+main three texts[1-3], states that when functioning in 
+balance, Doshas are „Dhatus‟, i.e. they nourish & 
+support the system.[35] A fundamental idea in Ayurveda 
+is that each well-functioning Dosha possesses an 
+intrinsic strength, Bala[36], that may vary from person to 
+person, e.g. the strength of a person‟s digestion is 
+proportional to the strength of their Jataragni, an aspect 
+of their Pitta Dosha. If Jataragni and hence Pitta Bala is 
+strong, then digestion is good[37], but if it is low, then 
+weak digestion may give rise to toxicity, known as 
+Ama[38], and so to disease.  
+ 
+The relative strengths of the three doshas are 
+summarized in Ayurveda‟s theory of Prakriti, or 
+„physiological types‟.[39] The dominant Dosha is used to 
+name the corresponding Prakriti: a Vata Prakriti type 
+has Vata Dosha dominant in their system; a Pitta 
+Prakriti type has Pitta Dosha dominant, while a Kapha 
+Prakriti type possesses dominant Kapha Dosha. If a 
+person has the strongest two Dosha Balas close to each 
+other, then they belong to a combination of types, Vata-
+Pitta, Pitta-Kapha or Kapha-Vata.[40] 
+ 
+When such matters are considered in further depth, 
+imbalances between a person‟s Doshas are recognized to 
+increase susceptibility to disease. Dosha imbalances are 
+thus seen as precursors to all diseases, both physical and 
+mental.[41] Disease in Ayurveda is seen as driven by both 
+general and specific considerations. Dosha imbalances 
+tell the general class of pathology, while more detailed 
+considerations 
+tell 
+the 
+specific 
+disease. 
+If 
+one 
+subcomponent of Vata is driven out of balance by 
+another subcomponent of Vata, the result is a Vata-vyadi, 
+a neurological disorder.[42] For example, Pranavruta-
+samana vatavyadhi[43], where the Vata subdosha, prana, 
+drives another Vata subdosha, samana, out of balance 
+corresponds to Alzheimers disease. Charaka Samhita[1] 
+also mentions several related Vata-vyadhis which 
+correspond to other neurological disorders, such as MS, 
+Parkinson‟s disease, Hemiplegia and Paraplegia.[42] 
+  
+Common understanding of Ayurveda propagates the 
+view that an individual‟s Prakriti is fixed from birth – or 
+rather from the time of conception and zygote formation. 
+In reality, the process of Prakriti selection is more 
+complex. Sushruta Samhita states[44]: the seven prakriti 
+types have contributions from conception & birth, 
+family, place, time, age, balas and factors acquired by 
+the individual. However, Gangadhar Tika‟s celebrated 
+commentary[45] on Charaka Samhita interprets the 
+concept of Prakriti as a state of „equilibrium of doshas‟, 
+so that other types with dominance of single, or pairs of, 
+Doshas, are states of Arogya, i.e. pathophysiology – 
+Vikriti.  
+ 
+In studies of human psychophysiology, it is natural to 
+connect strengths of various organ systems to properties 
+of the personality. A strong digestion, high Pitta Dosha, 
+may be connected to a „fiery personality‟, showing anger 
+more easily (Choleric)[46]; a person with dominant Vata 
+Dosha may be more subject to attacks of anxiety, and 
+neurotic disorders.[47] People with dominant Kapha 
+Dosha may be more relaxed, happier and easy-going 
+than their peers, but will be more susceptible to 
+overweight, and thus to the metabolic syndrome 
+spectrum of disorders.[48] 
+ 
+In this way, ancient Indian Psychology associates 
+Doshas with different facades of the human personality. 
+The Ayurveda classics propose seven types of Prakriti: 
+Vataja, Pittaja, Kaphaja, Vata-Pittaja, Vata-Kaphaja, 
+Pitta-Kaphaja and Sama, with each of which a different 
+style of personality may be associated.[49] 
+ 
+In addition to these seven physiological types, the 
+Ayurveda 
+texts 
+introduce 
+sixteen 
+mental 
+types, 
+categorized 
+according 
+to 
+three 
+different 
+basic 
+dimensions, known as Gunas or qualities. The first, 
+Sattvoguna, has seven types associated with it; the 
+second, Rajoguna, has six related types, and the third, 
+Tamoguna has three associated types.[50] Thus, besides 
+its personality types connected to the physiology, 
+Ayurveda texts also utilize these three, more spiritually-
+oriented, personality concepts. Sattva – luminous with 
+wisdom and self-knowledge; Rajas – more focused on 
+enjoyment and pleasures in the external world, and 
+driven by impulsiveness, aggression etc.; and Tamas – 
+dragged down with inertia from failure to adhere to high 
+moral precepts, past disasters in life etc.[51] 
+ 
+Kaur et al.                                                                       European Journal of Biomedical and Pharmaceutical Sciences 
+ 
+ 
+www.ejbps.com 
+ 
+207 
+These last three qualities (Gunas) of personality, 
+Triguna, are often associated with Yoga, due to their use 
+to assess an individual‟s personal capacity for spiritual 
+growth: a soul is thought to evolve from Tamas 
+dominance to Rajas dominance, and on to Sattva 
+dominance, which is transcended in the final stages of 
+spiritual liberation. Such a process may take many 
+lifetimes.[52] 
+ 
+Many studies of these concepts from Yoga and Ayurveda 
+have been carried out. Those on adolescents are clearly 
+more relevant to the study reported here. For example, in 
+a study in a public school, Yoga practice was seen to 
+improve 
+adolescent‟s 
+mood 
+and 
+affect.[53] 
+An 
+uncontrolled pilot study of a module based on Patanjali‟s 
+ashtanga Yoga for children and adolescents has observed 
+benefits for weight management and psychological well-
+being.[54] A paper offering guidance to clinicians on 
+prescription of Yoga as a complementary therapy for 
+children and adolescents has proved very beneficial.[55] 
+In these various fields, studies of adolescents have 
+broadened scientific understanding gained from studies 
+on adults.  
+ 
+Previous 
+papers 
+on 
+young 
+people 
+include 
+the 
+development and assessment of a self-rating scale to 
+measure Tridoṣhas in children aged 6 to 12 years.[56] One 
+study assessed changes in Triguna in children observed 
+in a 10-day Personality Development Camp.[57] Another 
+found that yoga / meditation training improved abilities 
+to learn self-control and self-care in adolescent sex 
+offenders.[58] A further study observed that exercise, 
+Yoga and meditation improved adolescents‟ depressive 
+and anxiety disorders.[59] Management through yoga of 
+academic anxiety was also considered, while effects of a 
+youth empowerment seminar on adolescents‟ impulsive 
+behavior has been reported.[25] A feasibility study has 
+validated a Yoga module for emotional and behavioral 
+disorders in adolescents and younger children.[60] 
+ 
+Medically, a study has measured effects of yoga practice 
+on stress, depression, and health-related quality of life in 
+a non-clinical sample of adolescents, finding it very 
+useful.[61] Similarly yoga as a complementary treatment 
+for the quality of life of adolescents suffering from IBS, 
+hemophilia, cancer, and emotional and behavioral 
+disorders was found highly beneficial, as was a study of 
+the subjective experience of yoga as a management 
+strategy for stress and depression in pregnant, urban, 
+African-American adolescents.[62] Finally, a literature 
+review has evaluated the effects of yoga practice on 
+pulmonary function in healthy adolescents, including 
+perspectives on barriers to, and facilitators of, physical 
+activity.[63] 
+ 
+AIMS AND OBJECTIVES 
+The aim of this study was to evaluate the use of the new 
+KPI for adolescents. The objective was to administer the 
+inventory pre and post a Yoga program and assess any 
+changes. To this end, the study assessed the effects on 
+adolescents of an IAYT Yoga module designed for that 
+purpose. The research hypotheses were that the module 
+would have significant observable changes on each 
+variable being assessed. The null hypotheses were either 
+that such changes would not occur, or that they would 
+not attain p < 0.05 significance.  
+ 
+MATERIALS AND METHODS 
+Study Protocol (see Figure 1): The study was conducted 
+in Vivekananda Education Centre, Jayanagar and MES 
+Pre-University college, Maleshwaram, Bengaluru. It was 
+a Pre-Post design on 82 randomly selected adolescents 
+aged 13-18 years. For the mean ages for each gender and 
+both together, see Table 1.  
+ 
+Table 1: Age Distribution by Gender. 
+AGE 
+13 YRS 
+14 YRS 
+15 YRS 
+16 YRS 
+17 YRS 
+18 YRS 
+TOTAL 
+Mean±SD 
+BOYS 
+8 
+9 
+8 
+9 
+7 
+6 
+47 
+15.34±1.66 
+GIRLS 
+7 
+6 
+7 
+6 
+5 
+4 
+35 
+15.23±1.66 
+TOTAL 
+15 
+15 
+15 
+15 
+12 
+10 
+82 
+15.29±1.65 
+Caption: Table 1 shows numbers of students in each year of age according to gender and in total. 
+ 
+Inclusion Criteria: Physically and Mentally Healthy, 
+Either Gender, Aged 13 to 18 years.  
+ 
+Exclusion Criteria: Attention Deficit Hyperactive 
+Disorder, Psychosis, Autism / Mentally Challenged.  
+ 
+Intervention: 90-minute Integrated Yoga Module (see 
+Table 2) with seven different sections- Breathing 
+Exercises, 
+Dynamic 
+Exercises 
+including 
+Suryanamaskara, Asanas, Pranayamas, Chanting, Yogic 
+Games, and Relaxation Techniques; given 3 times per 
+week for four weeks. Also, participants were instructed 
+to practice at home daily for the other days of each week, 
+and given a printed sheet of the module to use to direct 
+their practices.  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Kaur et al.                                                                       European Journal of Biomedical and Pharmaceutical Sciences 
+ 
+ 
+www.ejbps.com 
+ 
+208 
+Table 2: Integrated Yoga Module. 
+SECTION 
+PRACTICE 
+TIME (mins) 
+1. Breathing Exercises 
+Hands In & Out Breathing 
+2min 
+ 
+Vertical Hand Stretch 
+1min 
+ 
+Ankle Stretch 
+1min 
+ 
+Tiger Breathing 
+1min 
+ 
+Dog Breathing 
+1min 
+ 
+Rabbit Breathing 
+1min 
+ 
+Sectional Breathing 
+2min 
+2. Dynamic Exercise 
+Hand Swing 
+2min 
+ 
+Twisting 
+1min 
+ 
+Alternate Side Bending 
+1min 
+ 
+Forward & Backward Bending 
+1min 
+ 
+Jogging 
+3min 
+ 
+Pavanamuktasana Kriya 
+4min 
+Suryanamaskara 
+Suryanamaskara 
+5 min 
+3. Asana 
+Ardhakati chakrasana 
+1min 
+ 
+Padahastasana 
+2min 
+ 
+Ardhachakrasana 
+1min 
+ 
+Ushtrasana 
+2min 
+ 
+Paschimottanasana 
+2min 
+ 
+Suptavajrasana 
+1min 
+ 
+Makarasana 
+1min 
+4. Pranayama 
+Nadishuddhi 
+3min 
+ 
+Kapalabhati (a Yoga Kriya) 
+2min 
+ 
+Bhramari 
+1min 
+ 
+Sheetali 
+1min 
+5. Chanting 
+Vedic Chanting (Choice of 10 Sections) 
+6min 
+Different on Different Days 
+Bhagavad Gita 
+8min 
+ 
+Nadanusandhana / Omkara Meditation 
+4min/5min 
+6. Yogic Games: Choice of - 
+Find Ram-Shyam 
+5min 
+Different on Different Days 
+Accepting Criticism 
+2min 
+ 
+Find-a-Leader 
+1min 
+ 
+Search Engine 
+5min 
+7. Relaxation Technique 
+IRT, QRT & DRT (from SMET Program) 
+1min,3min,7min 
+ 
+Assessment: The KPI was administered before and after 
+the four-week intervention.  
+ 
+Statistical Analysis: Employed SPSS version 21.0. First, 
+the Kolmogorov-Smirnov test was used to check whether 
+the data were normally distributed; since it was not, the 
+Wilcoxon Signed Ranks Test was applied to assess the 
+significance of within-group changes in the data.  
+ 
+RESULTS  
+Results are displayed in Table 3 below, which shows that 
+Dosha Prakriti measured according to the KPI changed 
+highly significantly for each Dosha. Changes generally 
+indicate improved health, since, once imbalances have 
+set in, excess Vata Dosha tends to drive other doshas 
+further out of balance. The decreases in Vata Dosha seen 
+over the course of the four-week period indicate more 
+steadiness of mind suggesting reductions in a. Chitta-
+Vritti activity[64], and b. generally unnerving speed of 
+thought, which lead to speedier actions on a physical 
+level. This result also suggests slowing of the breath and 
+/ or breathing. In contrast, the other two Doshas, Pitta 
+Dosha and Kapha Dosha were both strikingly much 
+stronger than Vata Dosha at the end of the month.  
+ 
+Table 3a: Pre and Post Dosha Values of Present Study. 
+VATA 
+PITTA 
+KAPHA 
+Pre 
+Post 
+Pre 
+Post 
+Pre 
+Post 
+11.28±3.12 
+8.09±2.60 
+12.91±3.24 
+15.86±3.32 
+16.37±3.34 
+19.59±3.25 
+Table 3b: Pre and Post Dosha Values of Patil Study. 
+10.74±3.42 
+7.98±2.11† 
+12.80±3.57 
+13.96±1.85† 
+11.80±4.42 
+13.72±2.04 
+Caption: Tables 3as & 3b display Pre and Post Values of Dosha Prakritis for Adolescents (3a) & Children (3b) 
+ 
+ 
+ 
+Kaur et al.                                                                       European Journal of Biomedical and Pharmaceutical Sciences 
+ 
+ 
+www.ejbps.com 
+ 
+209 
+DISCUSSION 
+The last statement requires comment: high Kapha levels 
+can precipitate Kapha Rogas, of which obesity and 
+related disorders like metabolic syndrome are all too 
+common among today‟s population. However, the 
+participants‟ ages must be taken into consideration: ages 
+5 to 13 are dominated by anabolism related to physical 
+growth and thus naturally exhibit high levels of Kapha 
+Dosha; similarly, ages 13 to 18 are dominated by Pitta 
+Dosha, as the physicality of youth comes into play. 
+Observing higher levels of Pitta and Kapha Doshas, 
+when assessing youth in the age range addressed in this 
+study is quite acceptable. The final Dosha Prakriti scores 
+therefore reflect processes taking place all during the 4-
+week module practice. They can be interpreted as 
+indicating restoration of Dosha Prakriti values towards 
+their usual ranges for this age group.  
+ 
+Comparison with Patil‟s study[11] is instructive. Pre-post 
+percentage changes obtained in Patil‟s study and this 
+study are as follows: (Vata: -25.6, -28.2) (Pitta: +8.90, 
++22.8) and (Kapha: +16.2, +19.7). The two studies 
+therefore show similar changes in Dosha scores after a 
+one month Yoga module intervention; the only major 
+difference being in percent change in Pitta score, with 
+adolescents, in a naturally Pitta stage of life, showing 
+greater increase. This observed difference was almost to 
+be expected. 
+ 
+Generally, in recent times, because of modern Ahara-
+Vihara habits common in this stage of life, we see Dosha 
+Balas opposite to those said to characterize the age group 
+in question. The data therefore indicate that inculcating 
+the module‟s Yoga practices at an early age will help 
+restore desired Dosha balances, and, as Vata Dosha 
+reduces and Pitta Dosha increases, the memory, 
+intelligence and basic learning skills characteristic of 
+youth.  
+ 
+Practising dynamic exercises like those in the module 
+will tend to induce or increase sweating, sweda. 
+According to Ayurveda classics, swedana is a treatment 
+that reduces Vata Dosha, and that will benefit the three 
+gunas by reducing Rajas and Tamas.  
+ 
+Strengths: The strengths of the study are: a. it is the first 
+to assess the effect of Yoga on Tridosha in adolescents; 
+b. being a pre-post design, the first to observe significant 
+changes in state in all three Doshas, Vata, Pitta and 
+Kapha; c. the intervention can bring changes in Tridosha 
+large enough to significantly alter adolescents‟ physical 
+and psychophysiological states – and possibly reshape 
+their personalities. 
+ 
+Limitations: No control group was included in the 
+study.  
+ 
+Future Research: Any future study should include a 
+control group along with the Yoga group. A randomized 
+controlled trial would then be the best study design, but 
+with the following caveat: here, the same Yoga module 
+was used for all the participants, despite their having 
+different Dosha Prakritis; future studies should use 
+several Yoga modules, each adapted to a particular 
+Dosha Prakriti. Then we may anticipate improved 
+progress towards Sama Prakriti being achieved in all 
+cases.  
+ 
+CONCLUSIONS  
+The study suggests that the four-week IAYT Yoga 
+module employed in the intervention brings significant 
+balancing benefits for Tridoshas in adolescents. It may 
+also benefit levels of the three Gunas. Practiced regularly 
+over a sufficient period of time, breathing techniques like 
+sectional breathing, Nadi Shuddhi, and Sitali, named in 
+the yoga module help to reduce Vata at the physical 
+level, and simultaneously overcome Tamas. Adopting 
+dynamic practices like Suryanamaskara, Asanas & 
+Kapalabhati, Pitta increases so that the individual 
+him/herself transforms inertia (Tamas) into Rajas, thus 
+bringing lightness and flexibility to the body and 
+dynamism to brain activity (Rajas). In yogic lore, this is 
+considered an advance on the path to transcending the 
+influence of Gunas. Along with these practices, addition 
+of meditation, Japa, breath retention in Pranayama and 
+increasing time of maintaining each Asana helps to 
+increase stability of body and mind (Sattva).[57] 
+ 
+ACKNOWLEDGEMENT  
+We would like to thank all the students from the school 
+and college for their active participation, also the 
+management for their kind support. I would like to thank 
+Dr. Suchitra for the timely discussions regarding the 
+study. All the experts involved in the study.  
+ 
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+ 

subfolder_0/A composite of BMI and waist circumference may be a better obesity metric in Indians with high risk for type 2 diabetes An analysis of NMB-2017, a.txt

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+A composite of BMI and waist circumference may
+be a better obesity metric in Indians with high risk
+for type 2 diabetes: An analysis of NMB-2017, a
+nationwide cross-sectional study
+Murali Venkatrao, Raghuram Nagarathna, Suchitra S. Patil, Amit Singh, S.K. Rajesh,
+Hongasandra Nagendra *
+Division of Yoga and Life Sciences, SVYASA University, Prashanti Kutiram, Vivekananda Road, Kalluballu Post, Jigani, Bengaluru 560015,
+India
+A R T I C L E
+I N F O
+Article history:
+Received 13 October 2019
+Received in revised form
+26 December 2019
+Accepted 27 January 2020
+Available online 29 January 2020
+Keywords:
+Type 2 diabetes
+BMI
+Central fat
+Obesity
+Anthropometric
+A B S T R A C T
+Aims: Obesity measurement is a vital component of most type 2 diabetes screening tests;
+while studies had shown that waist circumference (WC) is a better predictor in South
+Asians, there is evidence that BMI is also effective. Our objective was to evaluate the effi-
+cacy of BMIWC, a composite measure, against BMI and WC.
+Methods: Using data from a nationwide randomized cluster sample survey (NMB-2017), we
+analyzed 7496 adults at high risk for type 2 diabetes. WC, BMI, and BMIWC were evaluated
+using Odds Ratio (OR), and Classification scores (Sensitivity, Specificity, and Accuracy).
+These were validated using Indian Diabetes Risk Score (IDRS) by replacing WC with BMI
+and BMIWC, and calculating Sensitivity, Specificity, and Accuracy.
+Results: BMIWC had higher OR (2
300) compared to WC (1
87) and BMI (2
26). WC, BMI, and
+BMIWC were all highly Sensitive (0
75, 0
81, 0
70 resp.). But BMIWC had significantly higher
+Specificity (0.36) when compared to WC and BMI (0.27 each). IDRSWC, IDRSBMI, and
+IDRSBMIWC were all highly Sensitive (0
87, 0
88, 0
82 resp.). But IDRSBMIWC had significantly
+higher Specificity (0
39) compared to IDRSWC and IDRSBMI (0
30, 0
31 resp.).
+Conclusions: Both WC and BMI are good predictors of risk for T2DM, but BMIWC is a better
+predictor, with higher Specificity; this may indicate that Indians with high values of both
+central (high WC) and general (BMI > 23) obesity carry higher risk for type 2 diabetes than
+either one in isolation. Using BMIWC in IDRS improves its performance on Accuracy and
+Specificity.
+
 2020 Elsevier B.V. All rights reserved.
+1.
+Introduction
+Diabetes is a serious and escalating health burden in India,
+with an age-adjusted comparative prevalence of 10.4%. Over
+77 million people have been diagnosed with the disease. Of
+equal concern is that an additional estimated 43 million peo-
+ple have type 2 diabetes but are undiagnosed [1]. Obesity is a
+well-known risk factor for Diabetes. In India, more than 135
+https://doi.org/10.1016/j.diabres.2020.108037
+0168-8227/
 2020 Elsevier B.V. All rights reserved.
+* Corresponding author.
+E-mail address: [email protected] (H. Nagendra).
+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 6 1 ( 2 0 2 0 ) 1 0 8 0 3 7
+Contents available at ScienceDirect
+Diabetes Research
+and Clinical Practice
+journal homepage: www.elsevier.com/locate/diabres
+million individuals were affected by obesity [2]. There is thus
+an urgent need to screen the general population for diabetes
+risk and implement preventive lifestyle change interventions.
+Many screening models have been developed to assess
+diabetes risk [3]. All of these models include an obesity com-
+ponent. The most commonly used model in India, the Indian
+Diabetes Risk Score (IDRS) [4], uses Waist Circumference (WC)
+for obesity; so does the German Diabetes Risk Score [5]. Other
+models (Cambridge Risk Score [6] and Framingham Offspring
+Diabetes Risk Score [7],) use Body Mass Index (BMI), while Fin-
+nish Diabetes Risk Score [8] uses both WC and BMI.
+However, it is not clear whether WC or BMI is better for
+determining type 2 diabetes risk. Various studies [14–23] have
+been done in this area and have drawn conflicting conclu-
+sions. Some studies have found that WC is a better measure
+of risk [17,18,21,22]. Other studies have drawn the opposite
+conclusion [15,19]. At least one study has found both mea-
+sures to be equally good [23]. Given the great breadth and
+depth of these studies, these conflicting conclusions probably
+point to the fact that each metric only partially captures the
+etiological association between obesity and type 2 diabetes.
+We postulated that a composite metric which combines
+central and general obesity would be a better indicator than
+either one in isolation. We defined a composite metric called
+BMIWC and analyzed its performance as a risk factor.
+2.
+Subjects, materials and methods
+2.1.
+Study design
+Niyantrita Madhumeha Bharata (‘‘Control of Diabetes in India”)
+2017, or NMB 2017, was a two-phased study undertaken
+across 29 most populous states/union territories in India.
+The twin objectives of the study were:
+- (Phase 1) To estimate the prevalence of diabetes and predi-
+abetes in 2017 simultaneously in all zones of India
+- (Phase 2) To conduct an RCT using a validated yoga life-
+style protocol
+Phase 1 [9] was a nationwide cross-sectional survey using
+a multi-level stratified cluster sampling technique with ran-
+dom selection among urban and rural populations covering
+29 states and union territories of the country. In a door to door
+survey, researchers used a questionnaire to collect data on
+diabetes status and diabetes risk.
+Phase 2 [9] involved a sub-sample of the phase-I partici-
+pants, from which were selected high-risk individuals (those
+with self-reported diabetes or for whom IDRS was 60) for
+further assessment through blood tests and a more detailed
+questionnaire; and to determine the efficacy of intervention.
+The intervention was a 3-month practice of a standard Yoga
+protocol [10].
+2.2.
+Phase 1 sampling strategy
+Sampling was done at 4 levels: Zones, States, Districts, and
+Villages (rural) or Towns (urban). We chose 24 (of 29) states
+and 4 (of 7) Union Territories. These states were grouped into
+seven zones based on cultural homogeneity [9]. To ensure dis-
+tricts samples within a state were not clustered, we grouped
+the state into geographical regions and chose a district from
+each region (e.g., if a state needed 3 districts, it was grouped
+into north, south, and central).
+Each district was also grouped into geographical regions,
+and we chose:
+1. (Rural) up to four villages with population between 500 and
+1000.
+2. (Urban) up to four Census Enumeration Blocks (CEBs), such
+that total population was around 2000.
+All households within the selected village or CEB were
+surveyed.
+2.3.
+Phase 2 sampling strategy
+From the Phase 1 sample, we selected adults of both genders
+who had the ability to do yoga (and consented to doing it), and
+satisfied one of the following criteria:
+1. Self-reported and newly diagnosed diabetes with or with-
+out glycemic control, using/not using oral hypoglycemic
+agents or insulin
+2. IDRS score was 60
+2.4.
+Procedure for biochemical measures
+All biochemical assays were carried out by the same method
+by the same nationally accredited laboratory. HbA1c, the pri-
+mary glycemic measure, was estimated by high-pressure liq-
+uid
+chromatography
+using
+VariantTM
+II
+Turbo
+(Bio
+Rad,
+Hercules, CA) method [9].
+2.5.
+Participants and outcomes
+We included all individuals in Phase 2 for whom all the fol-
+lowing data were available: WC, Weight, Height, Family his-
+tory of diabetes, Age, Physical Activity, HbA1c, and Diabetes
+Self Declaration (Yes or No). The sole outcome was whether
+the individual had diabetes or not, as determined by the value
+of HbA1c or self-declaration.
+2.6.
+Definitions of obesity metrics
+Values of WC and BMI were bucketed into five risk categories
+(Table 1). The 5 categories for BMI were picked from the stan-
+dardized ranges established for Asian populations [11]. For
+WC, we added two more categories at the bottom and top of
+the three categories established for the Asian Indian popula-
+tion [4].
+We created a composite obesity metric, BMIWC, which
+combines BMI and WC according to the following algorithm:
+If WC was <3, then BMI was scored as BMI – 1; if WC was
+3, the value of BMI remained unchanged. Thus, BMIWC rec-
+ognizes that individuals with both low WC and high BMI are
+at lower risk while individuals with high WC or high BMI
+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 6 1 ( 2 0 2 0 ) 1 0 8 0 3 7
+are at higher risk. This adds an additional risk category at the
+lower end, with a score of zero, designated ‘‘Ultra Low”
+(Table 1).
+Below are some examples of obesity risk scores, calculated
+using data from NMB 2017:
+
+Male with WC 85 cm, BMI 27
6 kg/m2 has: WC = 2, BMI = 4,
+and BMIWC = 3
+
+Male with WC 108 cm, BMI 26.3 kg/m2 has: WC = 4, BMI = 3,
+and BMIWC = 3
+2.7.
+Definitions of IDRS and its variants
+The second part of the study sought to validate the efficacy of
+BMIWC by replacing the obesity component of IDRS (WC) with
+BMIWC. We also studied the efficacy of IDRS when the obesity
+component is replaced by BMI. The modified risk scores were
+called IDRSBMIWC and IDRSBMI resp. The definitions of IDRS [3],
+IDRSBMI and IDRSBMIWC are shown in Table 2.
+2.8.
+Analysis
+Contingency table methods (for risk assessment) and confu-
+sion matrix methods (for assessing classification efficacy)
+were used to evaluate each obesity metric. Validation was
+done by replacing WC with BMIWC as the obesity component
+of IDRS and determining classification efficiency of the mod-
+ified IDRS.
+WC, BMI, and BMIWC were compared for their association
+to type 2 diabetes risk. A contingency table of risk categories
+and outcome was created for each metric, and v2 statistic was
+calculated to measure risk association. Using the lowest risk
+category as a reference, Odd Ratio (OR) calculated for each
+risk category. They were also compared for their ability to
+classify the population into two groups: people with type 2
+diabetes and people without. An ROC curve was drawn for
+each measure to determine the threshold score for classifica-
+tion. Based on this threshold, a confusion matrix was created
+for each measure. Efficacy of classification was determined by
+calculating Sensitivity, Specificity, and Accuracy [12]. McNe-
+mar’s statistic was calculated to determine the statistical sig-
+nificance of the difference in Specificities, as discussed by
+Hawass [13].
+IDRS, IDRSBMI and IDRSBMIWC were compared for efficacy of
+classification. An ROC curve was drawn for IDRSBMI and
+IDRSBMIWC to determine classification thresholds. The thresh-
+old for IDRS has already been determined to be 60 [4]. Using
+these threshold values, Sensitivity, Specificity and Accuracy
+were calculated. McNemar’s statistic was calculated to as
+before to determine statistical significance. All analyses were
+done using Python v.3
7. Pandas v.0
23 was used to import
+data, calculate obesity metrics and risk levels. Contingency
+table creation and calculation of risk measures were done
+using Statsmodels v.0
10
1. Confusion matrix creation and
+calculation
+of
+classification
+measures
+were
+done
+using
+Scikit-learn v.0
21
3. v2 and McNemar’s statistics were calcu-
+lated using Scipy v.1
3
0.
+Ethical clearance was obtained by the EC of Indian yoga
+association.
+The
+study
+was
+registered
+in
+CTRI
+CTRI/2018/03/012804.
+3.
+Results
+3.1.
+Description of data
+A total of 7496 individuals at high risk (60 on IDRS) for type 2
+diabetes (3935 females, 3561 males) were analyzed. They var-
+ied in age from 20 to 85 years (m = 48
39, r = 11
86). Waist cir-
+Table 1 – Definitions of Obesity Metrics.
+Metric
+Risk Score
+WC Value (in cm)
+69
99* (female), 79
99* (male)
+1 = Very Low (VL)
+70–79
99 (female), 80–89
99 (male)
+2 = Low (L)
+80–89
99 (female), 90–99
99 (male)
+3 = Moderate (M)
+90–99
99 (female), 100–109
99 (male)
+4 = High (H)
+ 100 * (female), 110* (male)
+5 = Very High (VH)
+BMI Value (in kg/m2)
+ 18
49
+1 = Very Low (VL)
+18
5–22
99
+2 = Low (L)
+23–27
49
+3 = Moderate (M)
+27
5–32
49
+4 = High (H)
+32
5
+5 = Very High (VH)
+BMIWC (dimensionless), values of BMI and WC below refer to risk scores
+BMI = 1 & WC < 3
+0 = Ultra Low (UL)
+BMI = 2 & WC < 3 OR BMI = 1 & WC  3
+1 = Very Low (VL)
+BMI = 3 & WC < 3 OR BMI = 2 & WC  3
+2 = Low (L)
+BMI = 4 & WC < 3 OR BMI = 3 & WC  3
+3 = Moderate (M)
+BMI = 5 & WC < 3 OR BMI = 4 & WC  3
+4 = High (H)
+BMI = 5 & WC  3
+5 = Very High (VH)
+* Two additional categories added at the top and bottom of the three categories established for Asian Indian
+populations.
+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 6 1 ( 2 0 2 0 ) 1 0 8 0 3 7
+3
+cumference varied from 60 to 150 cm (m = 91.21, r = 10.91) and
+BMI varied from 12.2 to 66.2 kg/m2 (m = 28.13, r = 4.60). Fig. 1
+shows the distribution of each of these characteristics across
+relevant categories.
+Total number with type 2 diabetes was 3079, of which 1093
+individuals were
+newly
+diagnosed
+and
+1986
+were
+self-
+reported.
+3.2.
+Risk analysis of obesity metrics
+The v2 test of association showed statistically significant
+association between obesity metrics and type 2 diabetes risk:
+WC: v2(4, N = 7496) = 29
10, p < 0
001; BMI: v2(4, N = 7496)
+= 66.58, p < 0
001; BMIWC: v2(5, N = 7496) = 59.06, p < 0
001.
+Odds that a person in the lowest obesity category (VL for
+WC and BMI, UL for BMIWC) had diabetes was calculated for
+each obesity metric, which was used as the reference odds.
+Odds were also calculated at each of the higher obesity
+categories, and the odds ratio was determined by taking the
+ratio of this with the reference odds.
+The following OR values were seen at the highest risk cat-
+egory (VH) for each obesity metric:
+
+For WC: 1
87 (95% CI 1.47–2.37)
+
+For BMI: 2
26 (95% CI 1.58–3.24)
+
+For BMIWC: 2
30 (95% CI 1.51–3.51)
+We can see that WC, BMI and BMIWC each higher odds in
+the VH category compared to the reference (lowest) category.
+But BMIWC outperformed WC and BMI by having a higher OR.
+We also observed that the OR for BMIWC was higher at
+every risk category than the corresponding scores for WC
+and BMI, as seen in Fig. 2.
+WC showed an actual decrease in OR between Moderate
+(M) and High (H) risk levels but showed a dramatically
+increased odds between High (H) and Very High (VH). This
+non-monotonic behavior is an indication that the risk cate-
+gories of WC don’t adequately capture increasing diabetes
+risk. BMI encapsulates diabetes risk better by showing a
+monotonically increasing OR. But BMIWC clearly outperforms
+the WC and BMI: OR is monotonically increasing, and the
+value of OR is higher at every risk category – as can be seen
+by the blue line (representing BMIWC) lying above the orange
+(WC) and green (BMI) lines.
+3.3.
+Classification analysis of obesity metrics
+We plotted ROC curves for WC, BMI, and BMIWC to determine
+the classification thresholds for each measure. These curves
+are shown in Fig. 3. We can see that a risk level of three
+(Moderate) is the optimum threshold. Using this value, we
+calculated Sensitivity, Specificity, and Accuracy. Table 3 shows
+the results.
+BMI had better Sensitivity (6
89%) when compared to WC
+but showed the same Specificity. BMIWC showed slightly
+decreased Sensitivity (7
00%) but vastly improved Specificity
+(34
01%) when compared to WC. In terms of Accuracy, BMI
+was slightly better than WC (4
41%), and BMIWC was better
+still (6
69%).
+Matched sample tables for Specificity were created using
+True Negative (TN) and False Positive (FP) counts, one for
+BMIWC and WC, and another for BMIWC and BMI. Table 4
+shows the counts of tied (FP-FP, TN-TN) and untied (TN-
+FP, FP-TN) pairs. McNemar’s statistic calculated on the val-
+ues untied pairs in these tables as described by Hawass
+[12]. The results were: BMIWC and WC: v2 (1, N = 695)
+= 234
84, p < 0
001; BMIWC and BMI: v2 (1, N = 410) = 408
00,
+p < 0
001. This shows that the increase the Specificity of
+BMIWC
+as
+compared
+to
+WC
+and
+BMI
+is
+statistically
+significant.
+3.4.
+Classification analysis of IDRS variants
+We plotted ROC curves for IDRSBMI, and IDRSBMIWC to deter-
+mine the classification thresholds for each score. These
+curves are shown in Fig. 4. We can see that 60 is the optimum
+threshold for IDRSBMI, and 70 is the threshold for IDRSBMIWC.
+The threshold for IDRS has already determined to be 60 [3].
+Table 2 – Definitions IDRS, IDRSBMI, and IDRSBMIWC.
+Metric
+Score
+IDRS
+Age
+<35 years
+0
+35–49 years
+20
+50
+30
+Physical Activity
+Exercise [regular] + strenuous work
+0
+Exercise [regular] or strenuous work
+20
+No exercise and sedentary work
+30
+Family History
+No family history
+0
+Either parent
+10
+Both parents
+20
+Obesity (WC)
+WC Risk Score  2
+0
+WC Risk Score = 3
+10
+WC Risk Score  4
+20
+Range of the Score
+0–100
+IDRSBMI
+Age, Physical Activity, Family History
+are same as IDRS
+0–80
+Obesity (BMI)
+BMI Risk Score  2
+0
+BMI Risk Score = 3
+10
+BMI Risk Score  4
+20
+Range of the score
+0–100
+IDRSBMIWC
+Age, Physical Activity, Family History are
+same as IDRS
+0–80
+Obesity (Composite)
+If WC Risk Score  2
+0
+BMI Risk Score  2
+0
+BMI Risk Score = 3
+10
+BMI Risk Score  4
+20
+If Waist Risk Score > 2
+BMI Risk Score  2
+10
+BMI Risk Score = 3
+20
+BMI Risk Score  4
+30
+Range of the score
+0–110
+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 6 1 ( 2 0 2 0 ) 1 0 8 0 3 7
+These values were used to calculate Sensitivity, Specificity,
+and Accuracy. Table 3 shows the results.
+IDRSBMI showed marginally better Sensitivity (1
27%) and
+Specificity
+(1
85%)
+when
+compared
+to
+IDRS.
+IDRSBMIWC
+showed slightly decreased Sensitivity (6
14%) but vastly
+improved Specificity (26
61%) when compared to IDRS. In
+terms of Accuracy, IDRSBMI was slightly better than IDRS
+(1
46%), and IDRSBMIWC was better still (4
79%).
+Matched
+sample
+tables
+for
+Specificity
+were
+created
+using True Negative (TN) and False Positive (FP) counts,
+Fig. 1 – Respondent Characteristics, n = 7496.
+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 6 1 ( 2 0 2 0 ) 1 0 8 0 3 7
+5
+one for IDRSBMIWC and IDRS, and another for IDRSBMIWC
+and IDRSBMI. Table 4 shows the counts of tied (FP-FP,
+TN-TN)
+and
+untied
+(TN-FP,
+FP-TN)
+pairs.
+McNemar’s
+statistic calculated on the values untied pairs in these
+tables
+as
+described
+by
+Hawass
+[12].
+The
+results were:
+IDRSBMIWC
+and
+IDRS:
+v2
+(1,
+N = 567) = 226
04,
+p < 0
001;
+IDRSBMIWC and IDRSBMI: v2 (1, N = 334) = 332
00, p < 0
001.
+This shows that the increase the Specificity of IDRSBMIWC
+as
+compared
+to
+IDRS
+and
+IDRSBMI
+is
+statistically
+significant.
+1
+1.2
+1.4
+1.6
+1.8
+2
+2.2
+2.4
+UL
+VL
+L
+M
+H
+VH
+Odds Rao
+Risk Categories
+WC
+BMI
+BMIWC
+Fig. 2 – Odds Ratio for WC, BMI, and BMIWC.
+Fig. 3 – ROC Curves for WC, BMI, and BMIWC.
+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 6 1 ( 2 0 2 0 ) 1 0 8 0 3 7
+4.
+Discussion and conclusions
+Although obesity is an established risk factor for type 2 dia-
+betes, it is unclear what the best anthropometric measure
+for this is. Current studies in this area have focused on two
+metrics – WC (for central fat), and BMI (for general adiposity).
+While there are many studies that have investigated the link
+between WC, BMI, and Diabetes, the result of these studies
+paints a confusing picture.
+Some studies have found that WC is a better predictor of
+Diabetes than BMI. A 2016 [17] study of Chinese, Malays, Asian
+Indians found that ‘‘Abdominal adiposity measures generally
+performed better than BMI in identifying undiagnosed dia-
+betes.”.
+A
+2016
+[18]
+pooled
+analysis
+of
+four
+German
+population-based cohort studies found that ‘‘there were
+stronger associations between anthropometric markers that
+reflect abdominal obesity (WC and WHR) and incident type-
+2 diabetes than for BMI and weight.” A 1991 [21] study of
+South Asians settled in London found that ‘‘Insulin resistance
+syndrome, prevalent in South Asian populations is associated
+with a pronounced tendency to central obesity.” A 2008 [22]
+collaborative analysis of cross-sectional data from 16 cohorts
+from the DECODA study, which involved multiple Asian eth-
+nicities, found that ‘‘WSR (Waist to Stature Ratio, a measure
+of central fat) was stronger than BMI in association with
+diabetes.”
+Other studies have found BMI to be a better predictor of
+Diabetes than WC. A 2018 [23] five-year prospective study of
+elderly Chinese found that ‘‘BMI was the strongest predictor
+of diabetes among both men and women.” A 2015 [16] study
+of Asian Indian, Chinese, and Japanese found that ‘‘Popula-
+tion Attributable Risk (PAR) for BMI was high among Indians.”
+Still other studies have concluded that neither WC nor BMI
+are reliable predictors of Diabetes. A 2000 [15] study of White,
+Black, Hispanic Americans found that ‘‘the positive predictive
+value (PPV) of WC for diabetes was low.” A 2018 [14] study of
+Asian Americans found that ‘‘one in seventeen Asian Ameri-
+Table 3 – Classification analysis.
+Metric
+Sensitivity
+Specificity
+Accuracy
+WC
+0
75
+0
27
+0
47
+BMI
+0
81
+0
27
+0
49
+BMIWC
+0
70
+0
36
+0
50
+IDRS
+0
87
+0
30
+0
53
+IDRSBMI
+0
88
+0
31
+0
54
+IDRSBMIWC
+0
82
+0
39
+0
56
+Table 4 – Matched Samples tables for Specificity.
+WC
+BMIWC
+IDRS
+IDRSBMIWC
+FP
+TN
+FP
+TN
+FP
+2676
+145
+FP
+2605
+104
+TN
+550
+1046
+TN
+463
+1245
+BMI
+BMIWC
+IDRSBMI
+IDRSBMIWC
+FP
+TN
+FP
+TN
+FP
+2821
+0
+FP
+2709
+0
+TN
+410
+1186
+TN
+334
+1374
+Fig. 4 – ROC Curves for IDRS, IDRSBMI, and IDRSBMIWC.
+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 6 1 ( 2 0 2 0 ) 1 0 8 0 3 7
+7
+cans with BMI less than 17 has diabetes.” The authors con-
+cluded that regular screening for diabetes was required
+within this group.
+It is clear that neither metric adequately measures obesity
+as it is related to diabetes risk. One reason could be confound-
+ing factors that are inherent to each metric: a tall individual is
+likely to have a higher WC and a muscular individual will
+have a higher BMI, without being more obese. There could
+be deeper, yet to be understood reasons as well.
+Our approach was to study if a composite metric, which
+combines both WC and BMI, would perform better as a risk
+factor for type 2 diabetes. Following the suggestion of the
+WHO expert consultation [11], our metric uses BMI as the
+base metric and gives ‘‘credit” to individuals who had low
+WC – i.e. reduce their risk level.
+We have shown, through v2 analysis, that there is a statis-
+tically significant association BMIWC and the outcome (type 2
+diabetes). We have also shown that BMIWC is superior to WC
+or BMI in predicting type 2 diabetes risk, as demonstrated
+by higher values of OR at every risk category. We can thus
+conclude that BMIWC is a better risk factor for type 2 diabetes
+either central or general fat.
+We also found WC, BMI, and BMIWC are similar in their
+ability to pick individuals with type 2 diabetes from a popula-
+tion (this is measured by Sensitivity): 81% of people with mod-
+erate or higher BMI, 75% of people with moderate or higher
+WC, and 70% of the people with moderate or higher BMIWC
+had type 2 diabetes. Thus, individuals with type 2 diabetes
+are likely to be higher on the obesity scale, regardless of
+which metric is used.
+But, to be useful as a risk factor, WC, BMI, and BMIWC
+should be lower in individuals without type 2 diabetes (this
+is measured by Specificity). We found that WC and BMI have
+low Specificity: among people who did not have type 2 dia-
+betes, only 27% had lower than moderate WC or BMI. How-
+ever, BMIWC was significantly more specific, as 36% of
+people without type 2 diabetes had lower than moderate
+BMIWC. Thus, individuals who have either high central fat or
+general adiposity are at higher risk of diabetes, while individ-
+uals with both low central fat and low general adiposity are at
+lower risk of diabetes. It follows that BMIWC is a better risk
+factor for type 2 diabetes than just WC or BMI.
+It is to be noted a viable screening score considers not just
+obesity, but also other risk factors such as age, family history,
+and physical activity. As mentioned in Section 1, IDRS is an
+effective screening technique used in India which considers
+all of these risk factors. We validated our conclusion that
+BMIWC is a better measure of obesity by modifying IDRS to
+replace
+WC
+with
+BMI
+(IDRSBMI)
+and
+then
+with
+BMIWC
+(IDRSBMIWC). All three variants were highly sensitive: among
+people with type 2 diabetes, 88% had IDRSBMI of 60 or more;
+87% had IDRS of 60 or more, while 82% had IDRSBMIWC of 70
+or more. However, when selecting ONLY people with type 2
+diabetes from within a high-risk population (Specificity),
+IDRSBMIWC significantly outperformed IDRS by 26
61% and
+IDRSBMI by 24
31%.
+This is an important result from both public health and clin-
+ical perspectives. Height, weight, and WC are typically avail-
+able for a patient (or are easily measured). Thus, there is no
+added cost to calculating BMIWC, and IDRSBMIWC. Given the
+significantly better Specificity of IDRSBMIWC, it should be used
+as a screening test in both public health and clinical situations.
+4.1.
+Limitations of this study
+We studied high-risk individuals (41
08% of the study popula-
+tion had type 2 diabetes). We would expect the risk measures
+and Specificity to be different in a sample reflective of the
+general population.
+Our study of IDRSBMIWC has established a classification
+threshold of 70. This threshold may change when future anal-
+ysis will be done using data on individuals in all risk
+categories.
+4.2.
+Suggestions for future work
+We postulated that a proper anthropometric measure of obe-
+sity should take into account both central fat and general adi-
+posity and have established that this is true among high-risk
+Indians. Future work should expand this work by: (a) verifying
+our conclusion within a population sample which includes
+both high- and low-risk individuals, and (b) study BMIWC
+among other ethnic groups.
+Funding
+Ministry of AYUSH, Govt. of India, routed through Central
+Council for Research in Yoga and Naturopathy.
+Role of the funding source
+The study funder had no role in study design, collection, anal-
+ysis, and interpretation of data. The authors had full access to
+the data and the final responsibility to submit their results for
+publication.
+Declaration of Competing Interest
+None.
+Acknowledgements
+We are thankful to (a) funding by the Ministry of AYUSH, Govt.
+of India, routed through Central Council for Research in Yoga
+and Naturopathy (b) the executive committee of Indian yoga
+Association for conducting NMB (c) Art of Living Institute,
+Vethathiri Maharishi College of Yoga, Patanjali Yogpeeth, PGI
+Chandigarh, and SVYASA for providing more than 1200 vol-
+unteers and (d) the members of the research advisory board
+of NMB for their inputs at all stages of the study.
+R E F E R E N C E S
+[1] https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-
+figures.html. Date accessed: Dec 19, 2019.
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+systematic review. Diabetes Matab Syndr 2019;13(1):318–21.
+Available from: https://doi.org/10.1016/j.dsx.2018.08.032.
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+IJOY_40_18.
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+Optimal anthropometric measures and thresholds to identify
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+org/10.1007/s00125-010-1670-7.
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+obesity and insulin resistance with high diabetes and
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+compared with central obesity indicators in relation to
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+9

subfolder_0/A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain.txt

@@ -0,0 +1,6318 @@
+Complementary
+ Therapies
+ in
+ Medicine
+ (2012)
+ 20,  107—118
+Available
+ online
+ at
+ www.sciencedirect.com
+jou
+ rnal
+ h
+ om
+ epa
+ ge:
+ www.elsevierhealth.com/journals/ctim
+A
+ comprehensive
+ yoga
+ programs
+ improves
+ pain,
+anxiety
+ and
+ depression
+ in
+ chronic
+ low
+ back
+ pain
+patients
+ more
+ than
+ exercise:
+ An
+ RCT
+P.
+ Tekur a,∗,  R.
+ Nagarathna a,  S.
+ Chametcha a,  Alex
+ Hankey a,
+ H.R.
+ Nagendra b
+a Division
+ of
+ Yoga
+ &
+ Life
+ Sciences,
+ Swami
+ Vivekananda
+ Yoga
+ Research
+ Foundation
+ (SVYASA),
+ Bengaluru,
+ India
+b SVYASA,
+ Bengaluru,
+ India
+Available
+ online
+ 28
+ January
+ 2012
+KEYWORDS
+Yoga;
+Chronic
+ low
+ back
+pain;
+Anxiety;
+Depression;
+Mobility
+Summary
+Introduction:
+ Previously,
+ outpatient
+ Yoga
+ programs
+ for
+ patients
+ with
+ chronic
+ low
+ back
+ pain
+(CLBP)
+ lasting
+ several
+ months
+ have
+ been
+ found
+ to
+ reduce
+ pain,
+ analgesic
+ requirement
+ and
+disability,
+ and
+ improve
+ spinal
+ mobility.
+ This
+ study
+ evaluated
+ changes
+ in
+ pain,
+ anxiety,
+ depression
+and
+ spinal
+ mobility
+ for
+ CLBP
+ patients
+ on
+ short-term,
+ residential
+ Yoga
+ and
+ physical
+ exercise
+programs,
+ including
+ comprehensive
+ yoga
+ lifestyle
+ modifications.
+Methods:
+ A
+ seven
+ day
+ randomized
+ control
+ single
+ blind
+ active
+ study
+ in
+ an
+ residential
+ Holistic
+Health
+ Centre
+ in
+ Bangalore,
+ India,
+ assigned
+ 80
+ patients
+ (37
+ female,
+ 43
+ male)
+ with
+ CLBP
+ to
+ yoga
+and
+ physical
+ exercise
+ groups.
+ The
+ Yoga
+ program
+ consisted
+ of
+ specific
+ asanas
+ and
+ pranayamas
+for
+ back
+ pain,
+ meditation,
+ yogic
+ counselling,
+ and
+ lectures
+ on
+ yoga
+ philosophy.
+ The
+ control
+group
+ program
+ included
+ physical
+ therapy
+ exercises
+ for
+ back
+ pain,
+ and
+ matching
+ counselling
+ and
+education
+ sessions.
+Results:
+ Group
+ ×
+ time
+ interactions
+ (p
+ <
+ 0.05)
+ and
+ between
+ group
+ differences
+ (p
+ <
+ 0.05)
+ were
+significant
+ in
+ all
+ variables.
+ Both
+ groups’
+ scores
+ on
+ the
+ numerical
+ rating
+ scale
+ for
+ pain
+ reduced
+significantly,
+ 49%
+ in
+ Yoga
+ (p
+ <
+ 0.001,
+ ES
+ =  1.62),
+ 17.5%
+ in
+ controls
+ (p
+ =
+ 0.005,
+ ES
+ =  0.67).
+ State
+anxiety
+ (STAI)
+ reduced
+ 20.4%
+ (p
+ <  0.001,
+ ES
+ =
+ 0.72)
+ and
+ trait
+ anxiety
+ 16%
+ (p
+ <  0.001,
+ ES
+ =
+ 1.09)
+ in
+the
+ yoga
+ group.
+ Depression
+ (BDI)
+ decreased
+ in
+ both
+ groups,
+ 47%
+ in
+ yoga
+ (p
+ <
+ 0.001,
+ ES
+ =  0.96,)
+ and
+19.9%
+ in
+ controls
+ (p
+ <
+ 0.001,
+ ES
+ =  0.59).
+ Spinal
+ mobility
+ (‘Sit
+ and
+ Reach’
+ instrument)
+ improved
+in
+ both
+ groups,
+ 50%,
+ in
+ yoga
+ (p
+ <  0.001,
+ ES
+ =
+ 2.99)
+ and
+ 34.6%
+ in
+ controls
+ (p
+ <
+ 0.001,
+ ES
+ =  0.81).
+Conclusion:
+ Seven
+ days
+ intensive
+ residential
+ Yoga
+ program
+ reduces
+ pain,
+ anxiety,
+ and
+ depres-
+sion,
+ and
+ improves
+ spinal
+ mobility
+ in
+ patients
+ with
+ CLBP
+ more
+ effectively
+ than
+ physiotherapy
+exercises.
+©
+ 2012
+ Elsevier
+ Ltd.
+ All
+ rights
+ reserved.
+∗Corresponding
+ author
+ at:
+ Division
+ of
+ Yoga
+ and
+ Life
+ Sciences,
+ Swami
+ Vivekananda
+ Yoga
+ Research
+ Foundation
+ (a
+ Yoga
+ University),
+#
+ 19,
+ Eknath
+ Bhavan,
+ Gavipuram
+ Circle,
+ K.G.
+ Nagar,
+ Bengaluru.
+ 560019.
+ Tel.:
+ +91
+ 80
+ 22639963.
+E-mail
+ addresses:
+ [email protected],  p
+ [email protected]
+ (P
+.
+ Tekur),
+ [email protected]
+ (R.
+ Nagarathna).
+0965-2299/$
+ —
+ see
+ front
+ matter
+ ©
+ 2012
+ Elsevier
+ Ltd.
+ All
+ rights
+ reserved.
+doi:10.1016/j.ctim.2011.12.009
+108
+ 
+P
+.
+ Tekur
+ et
+ al.
+Introduction
+Back
+ pain
+ is
+ a  common
+ problem
+ affecting
+ around
+ 1  in
+ 5  adults
+during
+ their
+ lifetime
+ with
+ it’s
+ prevalence
+ rising
+ to
+ 40%
+ when
+asked
+ if  they
+ have
+ experienced
+ symptoms
+ during
+ the
+ previ-
+ous
+ month.1 Its
+ prevalence
+ is
+ well
+ studied:
+ worldwide,
+ 37%
+of
+ CLBP
+ is
+ attributable
+ to
+ occupational
+ ergonomic
+ stressors,
+both
+ physical
+ and
+ psychosocial.
+ In
+ South
+ East
+ Asia,
+ including
+India
+ and
+ China,
+ the
+ figure
+ is
+ 39%.2
+A
+ comparative
+ study3 surveyed
+ back
+ pain
+ in
+ 3  groups
+ of
+manual
+ workers
+ (MW)
+ and
+ 3  groups
+ of
+ office
+ workers
+ (OW)
+in
+ India
+ and
+ the
+ UK
+ totalling
+ 814
+ subjects.
+ They
+ found
+ MWs
+in
+ India
+ to
+ have
+ least
+ prevalence
+ at
+ 15%.
+ In
+ the
+ UK,
+ they
+found
+ 33%
+ for
+ MWs
+ of
+ Indian
+ origin,
+ and
+ 37%
+ for
+ white
+ MWs.
+Similarly,
+ in
+ three
+ groups
+ of
+ OWs,
+ the
+ figures
+ were
+ 25%
+ in
+India,
+ and
+ in
+ the
+ UK,
+ 24%
+ for
+ NRI’s,
+ and
+ 28%
+ for
+ whites.
+ In
+India
+ itself,
+ Sharma
+ et
+ al.4 reported
+ a  23%
+ prevalence
+ of
+CLBP
+ in
+ a  north
+ India
+ outpatient
+ orthopaedic
+ unit.
+Psychological
+ disturbances
+ may
+ cause
+ CLBP
+,
+ or
+ result
+from
+ it:
+ they
+ have
+ predictive
+ value5—7 and
+ greater
+ impact
+than
+ biomechanical
+ factors
+ 8.
+ Most
+ frequently
+ reported
+disturbances
+ are
+ depression,9 anxiety,8 fear10 and
+ anger.11
+Functional
+ disability
+ of
+ any
+ kind
+ has
+ a  high
+ psychological
+impact.
+ CLBP
+ is
+ strongly
+ correlated
+ with
+ state
+ anxiety.12
+In
+ patients
+ with
+ lumbar
+ disc
+ herniation,
+ pain
+ and
+ func-
+tional
+ disability
+ correlate
+ with
+ scores
+ on
+ both
+ anxiety
+ and
+depression.13
+Non
+ pharmacological
+ CAM
+ studies
+ are
+ being
+ tried
+ of
+which
+ yoga
+ with
+ its
+ holistic
+ approach
+ has
+ emerged
+ as
+ an
+important
+ modality
+ in
+ the
+ management
+ of
+ chronic
+ medi-
+cal
+ conditions
+ recently.
+ Many
+ studies
+ of  various
+ kinds
+ of
+Yoga
+ therapy
+ have
+ shown
+ significant
+ benefits
+ to
+ CLBP
+ and
+related
+ chronic
+ conditions
+ like
+ osteoarthritis,14 rheumatoid
+arthritis,15 hypertension16 and
+ asthma.17 Also,
+ mindfulness
+based
+ stress
+ reduction
+ (MBSR)
+ has
+ produced
+ increased
+ well-
+being,
+ and
+ decreased
+ stress
+ and
+ pain-related
+ symptoms
+ in
+patients
+ with
+ both
+ anxiety
+ and
+ chronic
+ pain.18
+There
+ are
+ several
+ schools
+ of
+ yoga
+ that
+ use
+ different
+ com-
+ponents
+ of
+ the
+ 8  limbs
+ of
+ yoga
+ as  propounded
+ by
+ Sage
+Patanjali.19 Amongst
+ different
+ studies
+ conducted
+ on
+ yoga
+therapy
+ specifically
+ designed
+ for
+ CLBP
+,
+ two
+ RCTs
+ on
+ out-
+patients
+ have
+ demonstrated
+ its
+ efficacy
+ in
+ reducing
+ pain,
+analgesic
+ usage,
+ and
+ functional
+ disability:
+ Sherman
+ et
+ al.20
+applied
+ 3  months
+ Vini
+ yoga,
+ and
+ Williams
+ et
+ al.21 4  months
+Iyengar
+ Yoga.
+ Vini
+ yoga
+ has
+ used
+ asanas,
+ pranayama,
+ med-
+itation,
+ and
+ lectures
+ on
+ yoga
+ philosophy.
+ Iyengar
+ yoga
+ has
+used
+ all
+ the
+ above
+ components
+ with
+ greater
+ emphasis
+ on
+the
+ physical
+ postures.
+ Short
+ term,
+ 9—10
+ day,
+ outpatient
+programs
+ have
+ also
+ been
+ studied:
+ Bijlani
+ et
+ al.22 found
+improvement
+ in
+ health
+ status,
+ while
+ Gupta
+ et
+ al.23 addi-
+tionally
+ found
+ benefits
+ to
+ state/trait
+ anxiety.
+ The
+ fast
+ pace
+of
+ contemporary
+ life
+ means
+ that
+ such
+ intensive,
+ short-term
+programs
+ are
+ preferred:
+ patients
+ need
+ to
+ return
+ to
+ normalcy
+quickly.
+In
+ response,
+ SVYASA
+ used
+ its
+ 25
+ years
+ experience
+ of
+ ‘Inte-
+grated
+ Approach
+ of
+ Yoga
+ Therapy’
+ (IAYT)
+ treating
+ similar
+chronic
+ conditions
+ to
+ design
+ a  special
+ back
+ pain
+ mod-
+ule
+ for
+ CLBP
+,
+ including:
+ asanas
+ for
+ back
+ pain;
+ pranayama;
+relaxation
+ techniques;
+ meditation;
+ Yogic
+ counselling
+ for
+stress
+ management;
+ chanting;
+ and
+ lectures
+ on
+ yogic
+ lifestyle
+and
+ philosophy,
+ for
+ application
+ in
+ week-long,
+ intensive
+treatments
+ (Table
+ 1).
+ It  was
+ developed
+ from
+ traditional
+Table
+ 1a
+ 
+Back
+ pain
+ special
+ techniques
+ for
+ yoga
+ group.
+I.
+ Supine
+ postures
+1.
+ Pavanamuktasana
+ (Wind
+ releasing
+ pose)
+ series
+•
+ Supta
+ Pawanamuktasana
+ (leg
+ lock
+ pose)
+•
+ Jhulana
+ Lurkhanasana
+ (rocking
+ and
+ rolling)
+2.
+ Ardha
+ Navasana
+ (half
+ boat
+ pose)
+3.
+ Uttanapadasana
+ (straight
+ leg
+ raise
+ pose)
+4.
+ Sethubandhasana
+ breathing
+ (bridge
+ pose
+ lumbar
+stretch)
+5.
+ Supta
+ Udarakarshanasana
+ (folded
+ leg
+ lumbar
+ stretch)
+6.
+ Shavaudarakarshanasana
+ (crossed
+ leg
+ lumbar
+ stretch)
+II.
+ Prone
+ postures
+1.
+ Bhujangasana
+ (serpent
+ pose)
+2.
+ Shalabhasana
+ breathing
+ (locust
+ pose)
+III.
+ Quick
+ relaxation
+ technique
+ in
+ Shavasana
+ (corpse
+ pose)
+IV.
+ Sitting
+ postures
+1.
+ Vyaghra
+ Svasa
+ (tiger
+ breathing)
+2.
+ Shashankasana
+ breathing
+ (moon
+ pose)
+V.
+ Standing
+ postures
+1.
+ Ardha
+ Chakrasana
+ (half
+ wheel
+ pose)
+2.
+ Prasarita
+ Pada
+ Hastasana
+ (forward
+ bend
+ with
+legs
+ apart)
+3.
+ Ardha
+ kati
+ Chakrasana
+ (lateral
+ arc
+ pose)
+VI.
+ Deep
+ relaxation
+ technique,
+ in
+ Shavasana
+ with
+ folded
+legs.
+Table
+ 1b
+ 
+Control
+ group
+ practices.
+(1)
+ Standing
+ hamstring
+ stretch
+(2)
+ Cat
+ and
+ camel
+(3)
+ Pelvic
+ tilt
+(4)
+ Partial
+ curl
+(5)
+ Piriformis
+ stretch
+(6)
+ Extension
+ exercise
+(7)
+ Quadriceps
+ leg
+ raising
+(8)
+ Trunk
+ rotation
+(9)
+ Double
+ knee
+ to
+ chest
+(10)
+ Bridging
+(11)
+ Hook
+ lying
+ march
+(12)
+ Single
+ knee
+ to
+ chest
+ stretch
+(13)
+ Lumbar
+ rotation
+(14)
+ Press
+ up
+(15)
+ Curl
+ ups
+yoga
+ literature
+ (Patanjali
+ Yogasutras,
+ Upanishads,
+ and
+ Yoga
+Vasishtha).
+ The
+ module
+ was
+ evaluated
+ in
+ unpublished
+ pilot
+studies,
+ for
+ severity
+ of
+ pain,
+ functional
+ disability,
+ and
+ spinal
+flexibility.
+ The
+ first
+ full
+ study
+ demonstrated
+ improvements
+on
+ all
+ 3  variables.24 This
+ led
+ to
+ the
+ present
+ study,
+ which
+includes
+ associated
+ changes
+ in
+ anxiety
+ and
+ depression,
+ as
+the
+ most
+ important
+ causative
+ factors.
+ We
+ hypothesized
+ that
+the
+ yoga
+ group
+ would
+ show
+ greater
+ reductions
+ on
+ all
+ mea-
+sures
+ than
+ controls.
+Methods
+Sample
+ size:
+ a  required
+ n  =  35
+ was
+ obtained
+ by
+ applying
+Cohen’s
+ formula
+ for
+ an
+ expected
+ Effect
+ Size
+ (ES)
+ of
+ 0.89
+and
+ an
+ alpha
+ of
+ 0.05,
+ powered
+ at
+ 0.95,
+ using
+ the
+ G*Power
+A  comprehensive
+ yoga
+ programs
+ 
+109
+program.25 The
+ ES
+ was
+ calculated
+ from
+ the
+ mean
+ and
+ SD
+ of
+the
+ pilot
+ study
+ on
+ 120
+ subjects.26 A  study
+ size
+ of
+ 80
+ subjects
+was
+ decided
+ on,
+ considerably
+ more
+ than
+ the
+ 35
+ required.
+Subjects:
+ comprised
+ the
+ first
+ 80
+ of
+ 160
+ CLBP
+ patients
+admitted
+ between
+ April
+ 2005
+ and
+ June
+ 2006,
+ who
+ satisfied
+the
+ selection
+ criteria.
+Inclusion
+ criteria:  History
+ of
+ CLBP
+ of
+ more
+ than
+ 3  months;
+pain
+ in
+ lumbar
+ spine
+ with
+ or
+ without
+ radiation
+ to
+ legs27;  age,
+18—60
+ years.
+Exclusion
+ criteria:  Confirmed
+ organic
+ spinal
+ pathology
+such
+ as
+ malignancy
+ (primary
+ or
+ secondary),
+ or
+ chronic
+ infec-
+tion
+ such
+ as
+ Tuberculosis;
+ severe
+ obesity
+ (BMI
+ >  39.9)
+ and
+critically
+ ill.
+Medical
+ assessment:
+ was
+ conducted
+ by
+ a  rheumatol-
+ogist.
+ Two
+ experts
+ (radiologist
+ and
+ orthopaedic
+ surgeon)
+gave
+ opinions
+ on
+ whether
+ anteroposterior
+ and
+ lateral
+lumbar
+ spine
+ X-rays
+ satisfied
+ the
+ selection
+ criteria.
+ A  semi-
+structured
+ interview
+ was
+ used
+ to
+ obtain
+ demographic
+ and
+vital
+ clinical
+ data,
+ including
+ personal,
+ family
+ and
+ stress
+ his-
+tory.
+Study
+ approval:
+ was
+ obtained
+ from
+ SVYASA’s
+ review
+ board
+and
+ ethical
+ committee.
+Signed
+ informed
+ consent:
+ It  was
+ obtained
+ from
+ all
+ sub-
+jects.
+ The
+ consent
+ form
+ clearly
+ stated
+ that
+ subjects
+ would
+be
+ randomly
+ allocated
+ to
+ one
+ of
+ two
+ active
+ intervention
+groups.
+Study
+ design: was
+ a  seven
+ day
+ randomized
+ single
+ blind
+active
+ control
+ trial
+ comparing
+ two
+ interventions,
+ yoga
+ ther-
+apy
+ and
+ physical
+ therapy,
+ both
+ designed
+ for
+ lower
+ back
+ pain.
+Randomization:
+ used
+ two
+ sets
+ of
+ 40
+ numbers
+ spanning
+integers
+ 1—80
+ created
+ by
+ a  random
+ number
+ table
+ from
+www.randomizer.org.  CLBP
+ patients
+ admitted
+ week
+ by
+ week
+were
+ sequentially
+ assigned
+ to
+ each
+ group.
+ Numbered
+ con-
+tainers
+ were
+ used
+ to
+ conceal
+ the
+ random
+ allocation
+ before
+implementation.
+Blinding
+ and
+ masking:  the
+ statistician
+ who
+ generated
+the
+ randomization
+ sequence,
+ and
+ subsequently
+ analysed
+ the
+data,
+ the
+ clinical
+ psychologist
+ who
+ administered
+ and
+ scored
+psychological
+ questionnaires,
+ and
+ the
+ researcher
+ who
+ car-
+ried
+ out
+ allocation
+ and
+ assessments,
+ were
+ blind
+ to
+ subjects’
+intervention
+ groups.
+ Coded
+ answer
+ sheets
+ were
+ analysed
+only
+ after
+ the
+ study’s
+ completion.
+ In
+ intervention
+ studies
+of
+ this
+ kind,
+ subjects
+ clearly
+ identify
+ their
+ own
+ treatment:
+double
+ blinding
+ is
+ not
+ possible.
+Setting:
+ SVYASA’s
+ Holistic
+ Health
+ Centre
+ (Arogyadhama)
+is
+ situated
+ at
+ Prashanti
+ Kutiram
+ in
+ quiet
+ countryside,
+ 35
+ km
+south
+ of
+ Bangalore,
+ India.
+Yoga
+ intervention
+ (Table
+ 1a)
+The
+ IAYT
+ back
+ pain
+ module
+ described
+ above
+ is
+ holistic
+ at
+physical,
+ mental,
+ emotional
+ and
+ intellectual
+ levels.28 Spe-
+cial
+ asana
+ techniques
+ for
+ back
+ pain
+ progress
+ slowly
+ over
+ the
+intervention’s
+ first
+ three
+ days
+ from
+ initial
+ safe
+ movements
+to
+ full
+ asanas
+ aiming
+ to:
+(a)
+ relax
+ 
+the
+ 
+spinal
+ 
+muscles,
+ 
+achieved
+ 
+through
+ 
+safe
+stretches
+ of
+ para
+ spinal
+ muscles
+ during
+ folded
+ leg
+ and
+crossed
+ leg
+ lumbar
+ stretch
+ practices,
+ followed
+ by
+ guided
+deep
+ relaxation
+ in
+ supine
+ position29;
+(b)
+ provide
+ a  traction
+ effect
+ (pavanamuktasana);
+ and
+(c)
+ strengthen
+ lumbar
+ (sethubandhasana)
+ and
+ abdominal
+(ekapadasana)
+ muscles.
+Subjects
+ avoid
+ acute
+ forward
+ or
+ backward
+ bends
+ and
+jerky
+ spinal
+ movements.30
+IAYT’s
+ CLBP
+ Pranayama
+ practices
+ reduce
+ breath
+ fre-
+quency
+ to
+ master
+ emotional
+ surges,31 and
+ increase
+ deep
+internal
+ awareness
+ in
+ preparation
+ for
+ meditation,
+ antaranga
+yoga,  its
+ method
+ of
+ stress
+ management.
+ Lectures
+ help
+ sub-
+jects
+ understand
+ corrective
+ yoga
+ healing
+ techniques.
+Physical
+ exercise
+ therapy
+ intervention
+ (Table
+ 1b)
+An
+ independent
+ consultant
+ physiatrist
+ specializing
+ in
+back
+ 
+pain
+ 
+developed
+ 
+the
+ 
+module’s
+ 
+physical
+ 
+therapy
+movements,
+ non-yogic
+ breathing
+ exercises,
+ and
+ scientific
+lectures.
+ The
+ latter
+ included:
+ (a)
+ causes
+ of
+ back
+ pain,
+ (b)
+stress
+ and
+ CLBP
+ and
+ (c)
+ the
+ benefits
+ of
+ physical
+ exercises.
+Nature
+ video
+ programs
+ to
+ relax
+ and
+ engage
+ subjects
+ corre-
+sponded
+ to
+ yoga
+ group
+ chanting.
+Daily
+ routines:
+ were
+ matched
+ hour
+ by
+ hour
+ (Table
+ 2).
+ The
+two
+ groups
+ received
+ identical
+ diets.
+Final
+ interview:
+ included
+ qualitative
+ impressions
+ on
+global
+ improvement,
+ treatment
+ satisfaction,
+ and
+ adverse
+events.
+Outcome
+ variables:
+ were
+ recorded
+ for
+ each
+ subject
+ on
+the
+ first
+ and
+ final
+ days,
+ at
+ the
+ same
+ times.
+State
+ — trait
+ anxiety
+ inventory
+ (STAI) 32:  has
+ 2  forms,
+Y1/Y2,
+ evaluating
+ state
+ anxiety,
+ how
+ subjects
+ feel
+ ‘at
+ this
+moment’;
+ and
+ trait
+ anxiety,
+ how
+ they
+ feel
+ ‘most
+ of
+ the
+ time’
+respective.
+ It
+ has
+ been
+ extensively
+ used
+ in
+ India.
+Beck’s
+ depression
+ inventory
+ (BDI) 33:  measures
+ cognitive,
+affective
+ and
+ vegetative
+ depression
+ symptoms.
+ Scores
+ for
+each
+ items
+ are
+ 0—3,
+ total
+ 0—63.
+ Total
+ scores
+ signify:
+ 0—9,
+ no
+depression;
+ 10—19,
+ mild
+ depression
+ (21
+ in
+ CLBP
+ patients33;
+20—25,
+ moderate
+ depression;
+ 26+,
+ severe
+ depression.
+Numerical
+ rating
+ scale
+ (NRS)
+ for
+ pain:
+ a  horizontal
+ 10
+ cm
+straight
+ line
+ on
+ a
+ white
+ sheet
+ from
+ ‘0’
+ (No
+ pain)
+ by
+ cm
+ up
+to
+ ‘10’
+ (Worst
+ possible
+ pain).
+ Subjects
+ indicate
+ day’s
+ pain
+intensity
+ by
+ a  dot
+ on
+ the
+ line.
+Sit
+ and
+ reach
+ (SAR)34:  measures
+ hamstring
+ and
+ lower
+ back
+flexibility.
+ Subjects
+ sit
+ on
+ floor
+ with
+ legs
+ extended,
+ feet
+resting
+ against
+ apparatus,
+ bend
+ maximum
+ forward,
+ fingers
+pushing
+ the
+ indicator
+ without
+ bending
+ their
+ elbows;
+ distance
+measured
+ in
+ centimetres;
+ correlation
+ with
+ hamstring
+ flexi-
+bility
+ r  =  0.64.
+Statistical
+ analysis:
+ used
+ SPSS
+ 10.0:
+ normal
+ distribution
+of
+ pre
+ values
+ checked
+ using
+ Shapiro—Wilk
+ test.
+ All
+ between
+groups
+ comparisons
+ used
+ post
+ hoc
+ analysis
+ with
+ Bon
+ Ferroni
+correction.
+Results
+Fig.
+ 1  shows
+ the
+ study
+ profile.
+ There
+ were
+ no
+ drop
+ outs.
+ The
+two
+ groups
+ were
+ similar
+ with
+ respect
+ to
+ socio-demographic
+and
+ medical
+ characteristics
+ (Table
+ 3).
+ Baseline
+ data
+ for
+ all
+variables
+ matched
+ between
+ groups
+ (p
+ >
+ 0.05).
+ Baseline
+ val-
+ues
+ of
+ SAR,
+ BDI
+ and
+ NRS
+ only
+ had
+ minor
+ deviations
+ from
+normality.
+ Because
+ the
+ two
+ groups
+ had
+ equal
+ sample
+ sizes35
+and
+ the
+ repeated
+ measures
+ ANOVA
+ test
+ is
+ robust
+ for
+ small
+deviations
+ from
+ normality,
+ it
+ was
+ used
+ to
+ analyse
+ results
+on
+ all
+ variables:
+ group
+ ×  time
+ interaction,
+ within
+ group
+ pre-
+post
+ comparisons,
+ and
+ between
+ groups
+ comparisons.
+ Table
+ 4
+shows
+ results
+ after
+ the
+ intervention.
+ All
+ patients
+ reported
+improvements
+ in
+ sleep,
+ sense
+ of
+ well
+ being,
+ and
+ confidence
+110
+ 
+P
+.
+ Tekur
+ et
+ al.
+Table
+ 2
+ 
+Time
+ table
+ for
+ the
+ two
+ groups
+ for
+ the
+ week
+ long
+ residential
+ program.
+ Daily
+ schedule
+ of
+ practices
+ for
+ yoga
+ and
+ control
+group.
+S.
+ no.
+ 
+Time
+ 
+Yoga
+ group
+ 
+Control
+ Group
+1
+ 
+05.00—05.30
+ am
+ 
+OM
+ meditation
+ —
+ 30
+ min
+ 
+Walking
+ —
+ 30
+ min
+2
+ 
+05.30—06.30
+ am
+ 
+Yoga
+ based
+ special
+ technique
+ —
+ 60
+ min
+ 
+Exercise
+ based
+ special
+ technique
+ —
+ 60
+ min
+3
+ 
+06.30—07.30
+ am
+ 
+Bath
+ &
+ wash
+ 
+Bath
+ &
+ wash
+4
+ 
+07.30—08.15
+ am
+ 
+Chanting
+ of
+ yogic
+ hymns
+ —
+ 45
+ min
+ 
+Video
+ show
+ (on
+ nature)
+ —
+ 45
+ min
+5
+08.15—08.45
+ am
+ 
+Breakfast
+ 
+Breakfast
+6
+08.45—10.00
+ am
+ 
+Rest
+ 
+Rest
+7
+10.00—11.00
+ am
+Lecture
+ (on
+ yogic
+ lifestyle)
+ — 60
+ min
+ 
+Lecture
+ (on
+ healthy
+ lifestyle)
+ —
+ 60
+ min
+8
+11.00—12.00
+ noon
+Pranayama
+ (yogic
+ breathing)
+ — 60
+ min
+ 
+Non
+ yogic
+ breathing
+ practice
+ — 60
+ min
+9
+12.00—01.00
+ pm
+Yoga
+ based
+ special
+ technique
+ — 60
+ min
+ 
+Exercise
+ based
+ special
+ technique
+ — 60
+ min
+10
+ 
+01.00—02.00
+ pm
+ 
+Lunch(vegetarian
+ diet)
+ 
+Lunch
+ (vegetarian
+ diet)
+11
+ 
+02.00—02.30
+ pm
+ 
+Deep
+ relaxation
+ technique
+ —
+ 30
+ min
+ 
+Rest
+ at
+ room
+ —
+ 30
+ min
+12
+ 
+02.30—04.00
+ pm
+ 
+Assessments
+ and
+ counselling
+ 
+Assessments
+ and
+ counselling
+13
+ 
+04.00—05.00
+ pm
+ 
+Cyclic
+ meditation
+ —
+ 60
+ min
+ 
+Listening
+ to
+ music
+14
+ 
+06.15—06.45
+ pm
+ 
+Divine
+ hymns
+ session
+ (Bhajan)
+ —
+ 30
+ min
+ 
+Video
+ show
+ (on
+ nature)
+ —
+ 30
+ min
+15
+ 
+06.45—07.45
+ pm
+ 
+Meditation
+ with
+ yogic
+ chants
+ (mind
+sound
+ resonance
+ technique)
+ —
+ 45
+ min
+Walking
+ —
+ 45
+ min
+16
+ 
+07.45—08.30
+ pm
+ 
+Dinner
+ (vegetarian
+ diet)
+ 
+Dinner
+ (vegetarian
+ diet)
+17
+ 
+08.30—10.00
+ pm
+ 
+Self
+ study
+ 
+Self
+ study
+Hour
+ to
+ hour
+ matching
+ for
+ the
+ type
+ of
+ practices
+ for
+ the
+ two
+ groups
+ was
+ ensured.
+Figure
+ 1
+ 
+Trial
+ Profile.
+A  comprehensive
+ yoga
+ programs
+ 
+111
+Table
+ 3
+ 
+Demographic
+ data.
+Variables
+ 
+YOGA
+ 
+CONTROL
+Number
+ of
+ participants
+ 
+40
+ 
+40
+Males
+ (M)
+ 
+19
+ 
+25
+Females
+ (F)
+ 
+21
+ 
+15
+Age
+ (mean
+ ±
+ SD)
+ 
+49
+ ±
+ 3.6
+ 
+48
+ ±
+ 4
+Education:
+ 
+(a)
+ High
+ school
+ 
+M-3,
+ F-11
+ 
+M-5,
+ F-3.
+(b)
+ College
+M-10,
+ F-8
+ 
+M-13,
+ F-10
+(c)
+ Post
+ graduate
+M-6,
+ F-2
+M-7,
+ F-2
+Males
+Working-sedentary
+14
+16
+Working-non
+ sedentary
+5
+8
+Females
+Working
+6
+7
+Housewives
+ 
+15
+ 
+8
+CLBP
+ 
+<1
+ year
+ 
+10
+ 
+11
+1—5
+ years
+ 
+9
+ 
+11
+5—10
+ years
+ 
+11
+ 
+10
+>10
+ years
+ 
+10
+ 
+8
+Cause
+ 
+Lumbar
+ spondylosis(LS)
+ 
+6
+ 
+5
+Prolapsed
+ intervertebral
+ Disc(PID)
+ 
+6
+ 
+7
+LS
+ with
+ PID
+ 
+19
+ 
+15
+Muscle
+ spasm
+ 
+9
+ 
+13
+after
+ the
+ program.
+ Neither
+ group
+ reported
+ adverse
+ side
+effects.
+STAI:
+ State
+ anxiety
+ scores:
+ Group
+ ×
+ time
+ interactions
+were
+ significant
+ (Table
+ 4)
+ [F(1,78)
+ =  12.96,
+ p  <
+ 0.001],
+ as
+ was
+difference
+ between
+ groups
+ (p
+ <  0.001).
+ Yoga
+ group
+ scores
+decreased
+ 20.4%
+ (p
+ <  0.001,
+ ES
+ =  0.72).
+ The
+ control
+ group
+showed
+ no
+ significant
+ change.
+Trait
+ anxiety
+ scores:
+ Again,
+ group
+ ×  time
+ interactions
+were
+ significant
+ [F(1,78)
+ =  14.90,
+ p  <  0.001]
+ with
+ significant
+difference
+ between
+ groups
+ (p
+ <  0.001).
+ Yoga
+ group
+ scores
+reduced
+ 16%
+ (p
+ =
+ 0.001,
+ ES
+ =
+ 1.09).
+BDI:
+ In
+ both
+ groups,
+ BDI
+ baseline
+ scores
+ were
+ less
+ than
+21
+ (the
+ cut
+ off
+ for
+ moderate
+ depression
+ in
+ CLBP
+ patients.33
+Group
+ × time
+ interaction
+ was
+ significant
+ [F(1,78)
+ =
+ 5.85,
+p
+ =  0.018],
+ 
+with
+ 
+significant
+ 
+difference
+ 
+between
+ 
+groups
+(p
+ <
+ 0.001).
+ Yoga
+ group
+ scores
+ reduced
+ 47%
+ (p
+ =  0.001,
+ES
+ =  0.96).
+ Controls
+ reduced
+ 19.9%
+ (p
+ <  0.001,
+ ES
+ =  0.59).
+NRS:
+ 
+Group
+ × time
+ 
+interaction
+ 
+was
+ 
+significant
+[F(1,78)
+ =
+ 20.52,
+ 
+p  =  0.001].
+ 
+Between
+ 
+groups
+ 
+difference
+was
+ significant
+ (p
+ <  0.001).
+ Yoga
+ group
+ NRS
+ score
+ decreased
+49%
+ 
+(p
+ <  0.001,
+ 
+ES
+ =
+ 1.62).
+ 
+Controls
+ 
+decreased
+ 
+17.5%
+(p
+ =
+ 0.005,
+ ES
+ =
+ 0.67).
+SAR:
+ 
+Group
+ ×
+ time
+ 
+interaction
+ 
+was
+ 
+significant
+[F(1,78)
+ =
+ 4.16,
+ p  =
+ 0.045].
+ Yoga
+ group
+ SAR
+ scores
+ increased
+49.5%
+ (p
+ <
+ 0.001,
+ ES
+ 2.99),
+ controls
+ 34.6%
+ (p
+ <  0.001,
+ ES
+0.81),
+ difference
+ between
+ groups
+ not
+ significant.
+Discussion
+This
+ study
+ has
+ shown
+ better
+ improvement
+ in  STAI,
+ BDI,
+ NRS
+and
+ SAR
+ with
+ significant
+ group
+ ×  time
+ interactions
+ in
+ the
+Yoga
+ group
+ than
+ the
+ control
+ group.
+ Within
+ groups
+ improve-
+ments
+ were
+ significant
+ on
+ all
+ variables
+ in
+ both
+ groups,
+ except
+STAI
+ in
+ controls.
+Strengths
+ of  the
+ study
+(i)
+ Its
+ crossover
+ RCT
+ design
+ in
+ an
+ residential
+ setting
+with
+ active
+ control
+ intervention,
+ consisting
+ of
+ standard
+physical
+ therapy
+ and
+ other
+ practices
+ matched
+ hour
+ by
+hour
+ with
+ the
+ yoga
+ intervention,
+(ii)
+ Acceptability
+ of
+ short-term,
+ intensive
+ residential
+ pro-
+grams
+ in
+ today’s
+ fast
+ pace
+ of
+ life.
+(iii)
+ The
+ number
+ of
+ subjects
+ (80)
+ yielded
+ good
+ p  values
+ and
+statistical
+ power.
+Its
+ weakness
+ is
+ that,
+ despite
+ special
+ care
+ being
+ taken
+ to
+keep
+ the
+ two
+ groups
+ engaged
+ independently,
+ the
+ possibility
+of
+ interactions
+ between
+ them
+ cannot
+ be
+ discounted.
+Strength
+ and
+ weaknesses
+ in
+ relation
+ to
+ other
+ studies
+Two
+ earlier
+ RCTs
+ of
+ yoga
+ for
+ back
+ pain,20,21 also
+ found
+both
+ pain
+ reduction
+ and
+ increased
+ spinal
+ mobility.
+ No
+ pre-
+vious
+ yoga
+ study
+ has
+ observed
+ significant
+ improvements
+ on
+CLBP’s
+ psychological
+ components,36 A
+ review
+ by
+ Chou37 of
+17
+ nonpharmacologic
+ therapies
+ for
+ low
+ back
+ pain
+ found
+that
+ psychological
+ interventions
+ (cognitive-behavioral
+ ther-
+apy
+ and
+ progressive
+ relax
+ ation),
+ exercise,
+ interdisciplinary
+rehabilitation,
+ functional
+ restoration,
+ and
+ spinal
+ manip-
+ulation
+ were
+ effective
+ for
+ CLBP
+.
+ The
+ exercise
+ therapy,
+was
+ associated
+ with
+ small
+ to
+ moderate
+ effects
+ on
+ pain;
+acupuncture
+ was
+ more
+ effective
+ than
+ sham
+ acupuncture;
+massage
+ was
+ similar
+ to
+ other
+ noninvasive
+ interventions
+ and
+Viniyoga
+ was
+ slightly
+ superior
+ to
+ traditional
+ exercises.
+ Seri-
+ous
+ adverse
+ events
+ for
+ all
+ of
+ the
+ noninvasive
+ therapies
+ were
+rare.
+ Some
+ studies
+ of
+ non-yoga
+ interventions
+ (CBT
+,
+ phar-
+macotherapy,
+ aerobics,
+ physical
+ therapies)
+ have
+ observed
+improvements
+ in
+ CLBP
+ pain
+ and
+ disability
+ accompanied
+ by
+reduction
+ in
+ anxiety
+ and
+ depression.38 Reductions
+ in
+ both
+STAI
+ and
+ depression
+ scores
+ after
+ short
+ intensive
+ residential
+112
+ 
+P
+.
+ Tekur
+ et
+ al.
+Table
+ 4
+ 
+Results
+ of
+ all
+ variables
+ post
+ intervention
+ (RMANOVA)
+ 1st
+ day
+ to
+ 7th
+ day.
+Within
+ groups
+ 
+Between
+ groups
+Variable
+ 
+Yoga
+ 
+Control
+ 
+ES
+ 
+p
+ Value
+Mean
+ ±
+ SD
+ 
+95%
+ CI
+ LB
+ UB
+ 
+ES
+ 
+%
+ 
+p
+ Values
+ 
+Mean
+ ±
+ SD
+ 
+95%
+ CI
+ LB
+ UB
+ 
+ES
+ 
+%
+ 
+p
+ Values
+State
+anxiety
+Pre
+42.02
+ ±
+ 9.80
+ 
+38.89
+0.72
+ 
+20.44
+ 
+<0.001
+44.20
+ ±
+ 8.83
+ 
+41.38
+0.07
+1.17
+NS
+1.14
+<0.001
+45.16
+ 
+47.02
+Post 33.43
+ ±
+ 8.08
+ 
+30.84
+ 
+43.68
+ ±
+ 9.89
+ 
+40.51
+36.01
+ 
+46.84
+Trait
+anxiety
+Pre
+43.18
+ ±
+ 8.48
+ 
+40.46
+1.09
+15.88
+ 
+<0.001
+44.25
+ ±
+ 8.25
+ 
+41.61
+0.15
+ 
+2.25
+NS
+ 
+0.94
+<0.001
+45.89
+ 
+46.89
+Post 36.32
+ ±
+ 7.15
+ 
+34.05
+ 
+43.25
+ ±
+ 7.57
+ 
+40.83
+38.60
+ 
+45.67
+BDI
+ 
+Pre
+12.13
+ ±
+ 8.82
+ 
+9.30
+0.96
+ 
+46.99
+<0.001
+13.05
+ ±
+ 6.53
+ 
+10.96
+0.48
+19.92 <0.001
+0.59
+0.001
+14.95
+ 
+15.14
+Post
+6.43
+ ±
+ 7.73
+ 
+3.95
+ 
+10.45
+ ±
+ 5.55
+ 
+8.68
+8.90
+ 
+12.22
+VAS
+ 
+Pre
+6.68
+ ±
+ 1.82
+ 
+6.09
+1.62
+ 
+49.10
+<0.001
+5.88
+ ±
+ 2.15
+ 
+5.19
+0.67
+17.51 0.005
+0.76
+<0.001
+7.26
+ 
+6.56
+Post
+3.40
+ ±
+ 1.88
+ 
+2.79
+ 
+4.85
+ ±
+ 1.96
+ 
+4.22
+4.01
+ 
+5.48
+SAR
+ 
+Pre
+11.62
+ ±
+ 10.11
+ 
+8.39
+1.189
+ 
+49.48
+<0.001
+10.45
+ ±
+ 8.03
+ 
+7.88
+13.02
+11.25
+16.9
+0.81
+34.69 <0.001
+ 
+0.34
+NS
+14.86
+Post 17.37
+ ±
+ 10.77
+ 
+13.93
+ 
+10.07
+ ±
+ 8.84
+20.82
+BDI
+ —
+ beck
+ depression
+ inventory,
+ VAS
+ —
+ visual
+ analogue
+ scale
+ for
+ pain,
+ SAR
+ —
+ sit
+ and
+ reach,
+ CI
+ —
+ confidence
+ interval,
+ LB
+ —
+ lower
+ bound,
+ UB
+ —
+ upper
+ bound,
+ ES
+ —
+ effect
+ size,
+ %
+ —
+ percentage.
+Change,
+ NS
+ —
+ non
+ significant.
+A  comprehensive
+ yoga
+ programs
+ 
+113
+yoga
+ programs
+ are
+ unique
+ to
+ this
+ study,
+ probably
+ a  result
+of
+ the
+ IAYT
+ module’s
+ stress-management
+ components.
+ In
+ 2
+of
+ our
+ earlier
+ publications
+ we
+ have
+ shown
+ significantly
+ bet-
+ter
+ improvement
+ in
+ spinal
+ flexibility
+ — functional
+ disability
+(Oswestry
+ disability
+ index)
+ scores
+ and
+ quality
+ of
+ life
+ (WHO
+QOL)
+ in
+ the
+ yoga
+ group
+ compared
+ to
+ exercise
+ group.39,40 A
+study
+ compared
+ graded
+ exercise
+ therapy
+ with
+ graded
+ behav-
+ioral
+ exposure
+ program
+ for
+ CLBP
+ (a
+ 7
+ h  day
+ rehabilitation-9
+am—4
+ pm,
+ 5
+ days
+ a  week
+ for
+ 3—5
+ weeks)
+ comparable
+ to
+ our
+study
+ (8
+ h  per
+ day
+ for
+ 1  week).
+ They
+ observed
+ 33.3%
+ and
+43.5%
+ reduction
+ in
+ pain
+ intensity
+ in
+ exercise
+ and
+ behavioral
+therapy
+ groups
+ where
+ as
+ the
+ changes
+ were
+ 17.5%
+ and
+ 49%
+in
+ the
+ exercise
+ and
+ IAYT
+ intervention
+ groups
+ respectively
+ in
+our
+ study.
+ Similarly
+ the
+ depression
+ scores
+ reduced
+ by
+ 72%
+(exercise)
+ and
+ 57.6%
+ (behavioral
+ therapy)41 as
+ compared
+ to
+20%
+ (exercise)
+ and
+ 47%
+ (IAYT).
+A study
+ of
+ BDI42 observed
+ correlations
+ between
+ somatic
+and
+ physical
+ function
+ subscales
+ with
+ dysfunctional
+ cogni-
+tions
+ related
+ to  their
+ CLBP
+,
+ reflecting
+ how
+ it
+ was
+ interfering
+with
+ their
+ daily
+ life.
+Meaning
+ of
+ the
+ study
+The
+ detailed
+ design
+ of
+ the
+ Yoga
+ module
+ and
+ its
+ specific
+ new
+features
+ therefore
+ merit
+ consideration.
+ There
+ are
+ different
+yoga
+ therapy
+ schools
+ which
+ incorporate
+ various
+ limbs
+ of
+ yoga
+like
+ asanas,
+ pranayama,
+ meditation,
+ lectures
+ on
+ yoga
+ philos-
+ophy
+ including
+ codes
+ of
+ conduct.
+ For
+ eg,
+ Iyengar
+ yoga
+ uses
+more
+ of
+ the
+ physical
+ practices
+ combined
+ with
+ breathing.
+Vini
+ yoga
+ uses
+ a  smooth
+ flow
+ of
+ postures
+ followed
+ by
+ relax-
+ation
+ and
+ meditation.
+ IAYT
+ incorporates
+ all
+ the
+ components
+to
+ offer
+ a  holistic
+ therapeutic
+ module.
+A
+ first
+ observation
+ is  that
+ simultaneous
+ muscle
+ strength-
+ening
+ and
+ relaxation
+ may
+ be
+ involved.
+ Careful
+ body
+movement
+ together
+ with
+ active
+ mindfulness
+ both
+ strength-
+ens
+ spinal
+ and
+ abdominal
+ muscles,
+ and
+ promotes
+ deeper
+relaxation.
+ This
+ may
+ explain
+ observed
+ improvements
+ in
+ both
+spinal
+ mobility
+ and
+ pain
+ levels,
+ agreeing
+ with
+ findings
+ in
+previous
+ studies
+ of
+ IAYT
+ in
+ healthy
+ volunteers:
+ improved
+stamina
+ and
+ strength,43 and
+ decreased
+ metabolism.44
+Observed
+ stress
+ reduction
+ is
+ consistent
+ with
+ previous
+studies,
+ in
+ which
+ yoga
+ was
+ observed
+ to
+ correct
+ disturbed
+moods
+ in
+ psychiatric
+ patients
+ with
+ anxiety
+ disorders45,46
+and
+ major
+ depressive
+ illness,47 showing
+ that
+ it
+ can
+ bene-
+fit
+ even
+ pathological
+ levels
+ of
+ stress.
+ It
+ suggests
+ that
+ yoga
+has
+ the
+ ability
+ to
+ reverse
+ the
+ interlinked
+ downward
+ spiral,
+whereby
+ CLBP
+ causes
+ depression,
+ which
+ gives
+ rise
+ to
+ fur-
+ther
+ back
+ pain,
+ resulting
+ in  increased
+ depression,
+ and
+ so
+ on.
+This
+ conclusion
+ is
+ corroborated
+ by
+ several
+ studies,
+ in
+ which
+physical
+ well-being,
+ fatigue,
+ stress
+ (PSS)
+ and
+ anxiety
+ (on
+STAI)
+ after
+ yoga
+ practice29,48—50 have
+ been
+ observed.
+ Telles
+et
+ al.51 found
+ reduced
+ physiological
+ arousal
+ and
+ improved
+autonomic
+ stability.
+ Together,
+ these
+ studies
+ provide
+ strong
+evidence
+ for
+ yoga’s
+ stress
+ reducing
+ effects,
+ indicating
+ that
+it
+ can
+ neutralize
+ CLBP’s
+ psychological
+ impact
+ as
+ well
+ as
+ its
+physical
+ symptoms.
+Participants
+ often
+ report
+ that
+ Yoga
+ courses
+ give
+ them
+‘space’
+ to  recognize
+ causes
+ of
+ suppressed
+ negative
+ emo-
+tions.
+ Although,
+ as
+ yet,
+ we
+ have
+ no
+ hard
+ data
+ supporting
+this,
+ medical
+ records
+ indicate
+ that
+ counselling
+ helps
+ IAYT
+residential
+ learn
+ to
+ be
+ more
+ objective
+ about
+ previously
+ dis-
+tressing
+ situations.
+ This
+ seems
+ closely
+ allied
+ to
+ the
+ CBT
+perspective,
+ which
+ sees
+ chronic
+ pain
+ not
+ simply
+ as
+ a
+ neu-
+rophysiologic
+ state,
+ but
+ one
+ including
+ sensory,
+ affective,
+behavioral,
+ and
+ cognitive
+ factors
+ influencing
+ the
+ way
+ the
+patient
+ cognizes
+ the
+ world
+ and
+ assigns
+ meaning
+ to
+ events.52
+Indeed,
+ yoga
+ texts
+ highlight
+ a  major
+ change
+ in  per-
+spective:
+ ‘happiness
+ is
+ an
+ inner
+ state,
+ not
+ depending
+ on
+external
+ situations’.53 Since
+ anxiety
+ and
+ depression
+ are
+significant
+ causes
+ of
+ CLBP
+,
+ The
+ three
+ meditations
+ OM
+meditation,51 cyclic
+ meditation,54,55 mind
+ sound
+ resonance
+technique56 and
+ yogic
+ counselling
+ helped
+ in
+ stress
+ manage-
+ment.
+ Yogic
+ counselling,
+ and
+ lectures
+ similar
+ to
+ modern
+ CBT
+.
+The
+ ‘happiness
+ analysis’
+ derived
+ from
+ Upanishadic
+ texts53
+to
+ encourage
+ participants
+ to
+ recognize
+ sources
+ of
+ their
+emotional
+ surges,
+ restore
+ freedom
+ to
+ remain
+ unaffected,
+and
+ change
+ habituated
+ patterns
+ of
+ response
+ to
+ chronic
+pain.
+This
+ new
+ perspective
+ makes
+ previously
+ difficult
+ situa-
+tions
+ easier
+ to
+ handle.
+ Its
+ occurrence,
+ in
+ an
+ Indian
+ context,
+may
+ explain
+ some
+ of
+ the
+ anxiety
+ reduction.
+ More
+ generally,
+reduction
+ in
+ scores
+ on
+ anxiety
+ and
+ depression
+ indicate
+ that
+subjects
+ were
+ given
+ a
+ margin
+ of
+ safety
+ from
+ subsequently
+redeveloping
+ pathological
+ levels
+ of
+ these
+ conditions,
+ a  point
+of
+ significance,
+ since
+ Yoga
+ medicine
+ is
+ as
+ much
+ preventive
+as
+ curative.
+Next
+ let
+ us
+ consider
+ possible
+ mechanisms
+ for
+ the
+observed
+ degrees
+ of
+ pain
+ reduction.
+ Part
+ may
+ have
+ been
+produced
+ by
+ neural
+ impulses
+ from
+ stretch
+ proprioceptors
+interfering
+ with,
+ and
+ blocking,
+ impulses
+ on
+ the
+ ascend-
+ing
+ pain
+ pathway,
+ as
+ hypothesized
+ in
+ gate
+ control
+ theory.57
+A
+ second
+ level
+ of
+ explanation
+ for
+ Yoga’s
+ efficacy
+ in
+ pain
+reduction
+ may
+ lie
+ in
+ endorphin
+ production
+ at
+ a  cortical
+level,
+ which
+ is
+ known
+ to
+ result
+ from
+ alternate
+ stretch-and-
+relax
+ procedures
+ of
+ Yoga
+ asana
+ practice.58 Anxiety
+ reduction
+requires
+ special
+ consideration.
+ Consistency
+ of
+ observed
+reduction
+ in
+ state
+ anxiety
+ during
+ yoga
+ interventions45,46,48
+with
+ non-significant
+ changes
+ during
+ the
+ physical
+ exercise
+intervention,
+ corroborates
+ earlier
+ studies
+ on
+ yoga
+ in
+ other
+chronic
+ stress-related
+ conditions.59 A
+ previous
+ short
+ term
+out-patient
+ yoga
+ study
+ (3—4
+ h/day
+ for
+ 9
+ days)
+ observed23
+reductions
+ in
+ trait
+ anxiety
+ in
+ patients
+ with
+ chronic
+ disease.
+Thus,
+ the
+ present
+ study’s
+ improvement
+ in
+ trait
+ anxiety
+ (16%)
+by
+ the
+ Yoga
+ group
+ with
+ significant
+ group
+ ×
+ time
+ interac-
+tion,
+ and
+ between
+ groups
+ differences,
+ may
+ be
+ considered
+evidence
+ for
+ the
+ power
+ of
+ yoga
+ interventions
+ to
+ reduce
+deep-rooted
+ stress.
+The
+ transformation
+ may
+ be
+ compared
+ to
+ well
+ sub-
+stantiated
+ changes
+ in
+ emotionality
+ as
+ a  result
+ of
+ regular
+Trancendental
+ Meditation
+ practice,
+ something
+ in
+ which
+ EPI
+author
+ HA
+ Eysenck,
+ himself
+ took
+ great
+ interest
+ when
+ it
+ was
+discovered.60 Both
+ emotionality
+ and
+ trait
+ anxiety
+ are
+ con-
+sidered
+ long
+ term,
+ stable
+ properties
+ of
+ the
+ personality.
+ In
+both
+ the
+ cases,
+ deep,
+ Yoga-oriented
+ programs
+ indicate
+ that
+they
+ may
+ not
+ be
+ as
+ permanent
+ as
+ originally
+ supposed.
+The
+ observed
+ improvements
+ apparently
+ continued
+ after
+the
+ completion
+ of
+ the
+ program:
+ subjects
+ were
+ routinely
+asked
+ to
+ continue
+ one
+ hour
+ daily
+ yoga
+ practice
+ at
+ home
+aided
+ by
+ a  video.
+ At
+ the
+ present
+ time,
+ over
+ 3
+ years
+ after
+the
+ study
+ terminated,
+ many
+ of
+ the
+ previously
+ most
+ incapac-
+itated
+ subjects
+ i.e.
+ those
+ who
+ had
+ made
+ the
+ most
+ progress,
+are
+ still
+ doing
+ their
+ home
+ program,
+ in
+ contact
+ with
+ SVYASA,
+and
+ expressing
+ appreciation
+ for
+ having
+ participated
+ in
+ the
+study.
+114
+ 
+P
+.
+ Tekur
+ et
+ al.
+Possible
+ mechanisms
+ and
+ implications
+ for
+ clinicians
+ or
+policy
+ makers.
+ We
+ recommend
+ that
+ this
+ safe
+ yoga
+ therapy
+for
+ backpain
+ program
+ may
+ be
+ included
+ in  conventional
+ Low
+backpain
+ management
+ protocols
+1.
+ As
+ it
+ has
+ been
+ shown
+ that
+ it
+ is
+ better
+ than
+ physical
+ ther-
+apy
+ in
+ alleviating
+ pain,
+ anxiety
+ and
+ depression
+2.
+ It  is
+ applicable
+ in
+ all
+ age
+ groups
+ since
+ our
+ study
+ included
+adolescents
+ to
+ the
+ elderly
+ (18—65
+ years)
+ and
+ both
+ gen-
+ders.
+3. Cost
+ effectiveness
+ of
+ this
+ self
+ corrective
+ techniques
+which
+ can
+ be
+ practiced
+ at
+ home
+ once
+ learnt
+ is
+ notewor-
+thy.
+Unanswered
+ question
+With
+ increasing
+ popularity
+ of
+ yoga
+ round
+ the
+ globe,
+ gener-
+alisability
+ of
+ this
+ module
+ to
+ different
+ ethnic
+ groups
+ should
+be
+ studied.
+Suggestions
+ for
+ future
+ research
+(i)
+ Long-term
+ follow-up
+ including
+ measures
+ of
+ cognitive
+changes
+ should
+ be
+ studied.
+(ii)
+ EMG
+ studies
+ should
+ be
+ included.
+Short
+ term,
+ intensive
+ residential
+ Yoga
+ programs
+ for
+ back
+pain,
+ designed
+ according
+ to
+ the
+ Integrated
+ Approach
+ of
+Yoga
+ Therapy
+ (IAYT),
+ significantly
+ reduce
+ scores
+ on
+ state
+and
+ trait
+ anxiety,
+ and
+ depression
+ scales
+ as
+ well
+ as
+ reducing
+pain,
+ and
+ improving
+ lower
+ back
+ and
+ hamstring
+ flexibility
+and
+ QoL
+ scores
+ in
+ CLBP
+ patients.
+ The
+ Yoga
+ intervention
+significantly
+ outperformed
+ the
+ control
+ intervention
+ on
+ all
+measures
+ except
+ SAR
+ which
+ did
+ well
+ in
+ both
+ groups.
+Conflict
+ of
+ interest
+ statement
+None
+ declared.
+Source
+ of funding
+SVYASA
+ (Institutional).
+Acknowledgements
+We
+ acknowledge
+ assistance
+ from
+ Ravi
+ Kulkarni
+ PhD
+ —
+ Bio
+Statistician
+ and
+ Balram
+ Pradhan
+ PhD
+ in
+ statistical
+ analysis.
+We
+ thank:
+ Mrs.
+ Ritu
+ Mishra
+ (clinical
+ psychologist)
+ and
+ Dr
+ Usha
+Rani
+ for
+ administering
+ and
+ scoring
+ psychological
+ question-
+naires;
+ SVYASA
+ for
+ co-operation
+ in
+ conducting
+ the
+ program;
+and
+ consultant
+ orthopaedic
+ surgeon
+ Dr
+ John
+ Ebnezer,
+ for
+opinions
+ on
+ X-ray
+ images.
+ We
+ acknowledge
+ the
+ director
+ of
+Jubilee
+ Camdarc
+ radiological
+ institute
+ for
+ assistance
+ with
+x-rays.
+Appendix
+ A.
+ Line
+ diagrams
+ of
+ back
+ pain
+special
+ techniques
+ for  yoga
+ group
+I.
+ Supine
+ postures
+1.Pavanamuktasana
+ (Wind
+ releasing
+ pose)
+•
+ Supta
+ Pawanamuktasana
+ (leg
+ lock
+ pose)
+•
+ Jhulana
+ Lurkhanasana
+ (rocking
+ and
+rolling)
+2.
+ Ardha
+ Navasana
+ (half
+ boat
+ pose)
+3.
+ Uttanapadasana
+ (straight
+ leg
+ raise
+ pose)
+A  comprehensive
+ yoga
+ programs
+ 
+115
+Appendix
+ A  (Continued
+ )
+4.
+ Sethubandhasana
+ breathing
+ (bridge
+ pose
+lumbar
+ stretch)
+5.
+ Supta
+ Udarakarshanasana
+ (folded
+ leg
+lumbar
+ stretch)
+6.
+ Shavaudarakarshanasana
+ (Crossed
+ leg
+lumbar
+ stretch)
+[10pt]
+ II.
+ Prone
+ postures
+1.
+ Bhujangasana
+ (serpent
+ pose)
+2.
+ Shalabhasana
+ breathing
+ (locust
+ pose)
+3.
+ Quick
+ relaxation
+ Technique
+ in
+ Shavasana
+(corpse
+ pose)
+III.
+ Sitting
+ postures
+116
+ 
+P
+.
+ Tekur
+ et
+ al.
+Appendix
+ A  (Continued
+ )
+1.
+ Vyaghra
+ Svasa
+ (Tiger
+ breathing)
+2.
+ Shashankasana
+ breathing
+ (moon
+ pose)
+IV.
+ Standing
+ postures
+1.
+ Ardha
+ Chakrasana
+ (half
+ wheel
+ pose)
+2.
+ Prasarita
+ Pada
+ Hastasana
+ (forward
+ bend
+with
+ legs
+ apart)
+A  comprehensive
+ yoga
+ programs
+ 
+117
+Appendix
+ A  (Continued
+ )
+3.
+ Ardha
+ kati
+ Chakrasana
+ (lateral
+ arc
+ pose)
+V.
+ Deep
+ relaxation
+ technique,
+ in
+ Shavasana
+with
+ folded
+ legs
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+ Tomlinson
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+ Systematic
+ review:
+strategies
+ for
+ using
+ exercise
+ therapy
+ to
+ improve
+ outcomes
+ in
+chronic
+ low
+ back
+ pain.
+ Ann
+ Intern
+ Med
+ 2005;142(9):776—85.
+60.
+ Abrams
+ AI.
+ A
+ follow-up
+ study
+ on
+ the
+ effects
+ of
+ the
+ transcenden-
+tal
+ meditation
+ program
+ on
+ inmates
+ at
+ Folsom
+ State
+ Prison.
+ Paper
+280.
+ In:
+ Chalmers
+ R,
+ Clements
+ G.,
+ Schenkluhn
+ H.,
+ Weinless
+M.,
+ editors.
+ Scientific
+ research
+ on
+ Maharishi’s
+ transcendental
+meditation
+ and
+ TM-Sidhi
+ programme
+ collected
+ papers,
+ Vol.
+ 3.
+Vlodrop:
+ MERU
+ Press;
+ 1990.
+ p.
+ 2108—12.

subfolder_0/A randomised control trail of the effect of yoga on gunas.txt

@@ -0,0 +1,1324 @@
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+2
+A randomized control trial of the effect of yoga on Gunas 
+(personality) and Health in normal healthy volunteers
+Sudheer Deshpande, Nagendra H R, Raghuram Nagarathna
+Department of Yoga Research, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, India.
+Objective: To study the effi
+ cacy of yoga on Guna (yogic personality measure) and general health in normal adults.
+Methods: Of the 1228 persons who attended introductory lectures, 226 subjects aged 18–71 years, of both sexes, who satisfi
+ ed 
+the inclusion and exclusion criteria and who consented to participate in the study were randomly allocated into two groups. 
+The Yoga(Y) group practised an integrated yoga module that included asanas, pranayama, meditation, notional correction 
+and devotional sessions. The control group practised mild to moderate physical exercises (PE). Both groups had supervised 
+practice sessions (by trained experts) for one hour daily, six days a week for eight weeks. Guna (yogic personality) was 
+assessed before and after eight weeks using the self-administered Vedic Personality Inventory (VPI) which assesses Sattva 
+(gentle and controlled), Rajas (violent and uncontrolled) and Tamas (dull and uncontrolled).
+The general health status (total health), which includes four domains namely somatic symptoms (SS), anxiety and insomnia 
+(AI), social dysfunction (SF) and severe depression (SP), was assessed using a General Health Questionnaire (GHQ). 
+Results: Baseline scores for all the domains for both the groups did not differ signifi
+ cantly (P > 0.05, independent samples 
+t test). Sattva showed a signifi
+ cant difference within the groups and the effect size was more in the Y than in the PE group. 
+Rajas showed a signifi
+ cant decrease within and between the groups with a higher effect size in the PE group. Tamas showed 
+signifi
+ cant reduction within the PE group only. The GHQ revealed that there was signifi
+ cant decrease in SS, AI, SF and SP in 
+both Y and PE groups (Wilcoxcon Singed Rank t test). SS showed a signifi
+ cant difference between the groups (Mann Whitney 
+U Test). 
+Conclusions: There was an improvement in Sattva in both the Yoga and control groups with a trend of higher effect size in 
+Yoga; Rajas reduced in both but signifi
+ cantly better in PE than in Yoga and Tamas reduced in PE. The general health status 
+improved in both the Yoga and control groups. 
+Keywords: General health; guna; Yoga.
+The present age of speed and competition has increased 
+the stresses and strains resulting in an increasing 
+prevalence of life style-related health problems.[1] One 
+of the increasingly popular tools to overcome this new 
+challenge is physical activity. There is growing evidence 
+that has established the benefits of physical exercises in 
+preventing life style-related diseases[2] such as primary 
+prevention of diabetes,[3] prevention of cardiac diseases 
+through control over major risk factors such as smoking, 
+lipids, obesity and stress,[4] better quality of life of cancer 
+patients,[5] positive health in normal persons through 
+better physical fitness[6] and stress reduction.[7] Yoga 
+which is considered to be a tool for both physical and 
+mental development of an individual is being recognized 
+Original Article
+around the globe only in the last century although it has 
+been practised in India over several centuries to promote 
+positive health and well being. It gives solace for the 
+restless mind and can give great relief to the sick.[8,9] It has 
+become quite fashionable even for the common man to keep 
+fit.[10] Some use yoga for developing memory, intelligence 
+and creativity.[11] With its multifold advantages, yoga is 
+becoming a part of school education.[12] Specialists use 
+it to unfold deeper layers of consciousness in their move 
+towards spiritual perfection.[13] With growing scientific 
+evidence, yoga is emerging as an important health 
+behavior-modifying practice to achieve states of health, 
+both at physical and mental levels. Several studies have 
+demonstrated the beneficial effects of yoga on health 
+Correspondence to: Dr. Nagarathna Raghuram
+No19, Eknath Bhavan,  Gavipuram Circle, 
+K. G. Nagar,  Bangalore – 560 019. India.
+E-mail: [email protected]
+ABSTRACT
+[Downloaded free from http://www.ijoy.org.in on Tuesday, August 18, 2009]
+3
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+behavior in many life style-related somatic problems 
+such as hypertension,[14] bronchial asthma,[15] diabetes[16] 
+including some psychiatric conditions such as anxiety 
+neurosis[17] and depressive illness[18] etc. 
+The philosophy of yoga believes that somatic problems are 
+nothing but a manifestation of an imbalance between three 
+Gunas (Sattva, Rajas and Tamas) that go to constitute the 
+body-mind complex of the individual.[19] Further, in the 
+famous scriptural text, the Gita; a guna indicates a specific 
+behavior style. Sattva is symbolized by purity, wisdom, 
+bliss, serenity, love of knowledge, spiritual excellence and 
+other noble and sublime qualities. Rajas is symbolized 
+by egoism, activity, restlessness and hankering after 
+mundane things like wealth, power, valor and comforts. 
+Tamas is related to qualities such as bias, heedlessness 
+and inertia, perversion in taste, thought and action.[20] Ill 
+health occurs if Rajas or Tamas become dominant and 
+the individual gets habituated to either of these response 
+patterns. Furthermore, the Gita goes on to analyze the 
+state of mind and says that when one is dominated by 
+these two gunas, the individual loses mastery over the 
+uncontrolled, speeded-up loop of sentences of the internal 
+dialogue, which shows up as upsurges of emotions and 
+impulsive behavior. In an ideal state of perfect health, 
+man has the complete freedom to use any of these three 
+patterns (Satva, Rajas or Tamas) of responses. Hence, 
+the degree of positive health can be measured by a tool 
+that can grade these three patterns of behavior.[19] The 
+tool can be used for assessment of interventions used for 
+treatment or prevention of diseases as well as for promotion 
+of positive health. The Vedic Personality Inventory 
+(VPI)[21] is a valid and reliable inventory that can measure 
+the three patterns of behavior.
+While Yoga is getting popular, the relative roles of yoga 
+and physical exercises have not been studied on gunas 
+and health. Hence, the present study was designed to 
+assess the changes in the personality and overall health 
+status after yoga as compared to physical exercise 
+in a randomized controlled study in normal healthy 
+volunteers.
+METHOD
+Subjects
+Of the 1228 adults who attended motivational lectures, 
+226 subjects consented to participate in the study and 
+were randomly allocated to two groups of equal size. After 
+attrition, the final sample sizes were 87 in both the yoga 
+and control groups. 
+Inclusion criteria were: (a) normal healthy volunteers, (b) 
+age 18–71 years, (c) literacy and (d) scores less than 4/5 
+in the General Health Questionnaire.[22]
+Exclusion criteria were: (a) subjects with any ailment, (b) 
+smoking and (c) substance abuse.
+Source of subjects: Normal adults were recruited from 
+five different locations in Bangalore after public talks at 
+different institutions such as colleges, health clubs, Rotary 
+Clubs, Lion’s clubs and big apartment complexes.
+Informed consent was obtained from all the subjects 
+who participated in the project and also from the 
+institutional heads where the classes were conducted. 
+The institutional ethical committee of SVYASA cleared 
+the project proposal. 
+Design
+This is a prospective, randomized, single-blind, controlled 
+study aiming to compare the efficacy of yoga (Y) and 
+physical exercise (PE) in normal healthy volunteers in 
+a South Indian population. Introductory lectures were 
+arranged in public centers such as colleges, health clubs, 
+Rotary clubs, Lion’s clubs and apartment complexes. The 
+classes were planned in five different centers in the city 
+of Bangalore. Two hundred and twenty-six persons who 
+consented to participate in the study and satisfied the 
+inclusion and exclusion criteria were randomly allotted 
+to two groups by using five random number tables 
+(different table for each center) generated from the random 
+number generator program.[23] The experimental group 
+was given Y practices and the control group was given 
+PE for one hour daily on empty stomach (6 to 7 a.m.). 
+The classes were conducted six days a week for eight 
+weeks and attendance was maintained by the teachers. 
+Trained experts (in yoga for the Y group and PT for the 
+PE group) conducted parallel sessions for the two groups 
+in different rooms in the same venue. It was ensured that 
+there was no interaction between the subjects. The tests 
+were self-administered before and eight weeks after the 
+intervention. Arrangements were made for the subjects to 
+sit in a quiet place free from distractions and influence 
+from other people. 
+Masking: The answered questionnaires were coded and 
+kept away for future scoring. A psychologist who was not 
+involved in the subject allocation or supervision of the 
+classes scored the questionnaires which were decoded 
+only after the scoring of both the before and after data 
+was completed. 
+Assessments
+Assessments were done using the following 
+questionnaires:
+1. The Vedic Personality Inventory (VPI): In 1998, Wolf 
+developed an inventory to assess three personality 
+Effect of Yoga on Gunas and Health
+[Downloaded free from http://www.ijoy.org.in on Tuesday, August 18, 2009]
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+4
+constructs (gunas) based on their description in the 
+most ancient Indian scriptures called Vedas. Hence, 
+this inventory was named the VPI and it measures 
+the three gunas—Sattva, Rajas and Tamas. It has 30 
+items for the Sattva guna, 28 for rajoguna and 32 for 
+tamo guna. VPI has good internal consistency and 
+reliability with Cronbach’s alpha ranging from 0.850 
+for Sattva, 0.915 for Rajas and 0.699 for Tamas. In 
+terms of discriminant validity, all but one facet had 
+significant differences.[21] 
+2. General Health Questionnaire (GHQ): The GHQ 
+designed by Goldberg in order to identify psychiatric 
+morbidity in general practice, is a self-administered 
+questionnaire (English version). It has 28 items with 
+four subscales to measure somatic symptoms (SS), 
+anxiety and insomnia (AI), social dysfunction (SF) and 
+severe depression (SP). It provides information about 
+the recent mental status, thus identifying the presence 
+of possible psychiatric disturbance. This questionnaire 
+has acceptable psychometric properties and has good 
+internal consistency and reliability with Cronbach’s 
+alpha of 0.85 and validity of 0.76.[24]
+INTERVENTION
+Yoga group 
+The Integrated yoga module was selected from the 
+integrated set of yoga practices used in earlier studies on 
+the effects of yoga for positive health.[25] This integrated 
+approach is developed based on ancient Yoga texts[26] 
+to bring about a total development at physical, mental, 
+emotional, social and spiritual levels.[27] The techniques 
+include physical practices (kriyas, asanas, a healthy 
+yoga diet), breathing practices with body movements and 
+Pranayama, meditation, devotional sessions, lectures on 
+yoga, stress management and lifestyle change through 
+notional corrections for blissful awareness under all 
+circumstances (action in relaxation). Yoga was taught by 
+qualified yoga teachers.
+Physical exercise group 
+The set of physical exercises were standard execises[28] 
+meant to provide mild to moderate activity designed by 
+experts in physical education.
+Data extraction
+The scoring of the questionnaires was carried out as per 
+the instructions in the manuals. The structure of these 
+questionnaires is described below:
+1. VPI evaluates the Sattva, Rajas and Tamas gunas by 
+using a 7-point Likert-type scale. Scores for the gunas 
+are obtained by adding the responses for the items for a 
+guna and then dividing by the number of items for that 
+mode. For each subscale, a higher score indicates a greater 
+predominance of that mode. The minimum and maximum 
+possible scores for the three domains range from 1–7. 
+2. GHQ: This 28 item test using a binary method of scoring 
+(0, 0, 1, 1) yields an assessment on four robust subscales: 
+somatic symptoms (SS), anxiety and insomnia (AI), social 
+dysfunction (SF) and severe depression (SP). A sum of the 
+scores for these four subscales gives the score for total 
+health. The lower the scores in the GHQ, the better the 
+state of health. The cut-off scores for the GHQ used for 
+this study were 4 or 5 (4/5).[22]
+Statistical analysis
+Data was analyzed using the SPSS package version 10.0.
+Based on a previous study,[29] the effect size was calculated 
+to be 0.8. With a power of 0.8 and alpha set to 0.05, 
+the minimum sample size was found to be 164. This 
+calculation was done using G power.[30] The size of the 
+sample actually used was 174.
+Data at baseline was assessed for normal distribution 
+using Shapiro-Wilk’s test for both the groups. Independent 
+samples t-test was done for checking homogeneity of 
+baseline scores of the two groups. Paired samples t test 
+and independent samples t test were used for VPI which 
+had normally distributed data and Wilcoxon’s signed ranks 
+and Mann Whitney U tests were used for GHQ data which 
+were not normally distributed. An independent samples 
+t test was done to analyze between the groups and paired 
+samples test within groups. The effect size of the study 
+(mean A – mean B)/ standard deviation (SD) of difference 
+scores) is an absolute measure of the difference that exists 
+between the populations for a parameter, a concept first 
+introduced by the sociologist, J. Cohen.[31]
+As the study population had a wide age range, statistical 
+analysis was also carried out by grouping them as juniors 
+(age ≤ 24 years) and seniors (age > 24 years) based on the 
+median age. The independent samples t-test for between 
+groups and paired samples t test for within groups were 
+conducted for the two age groups. The data was also 
+analyzed using gender as a factor.
+RESULTS
+Figure 1 shows the study profile wherein of 1228 subjects 
+who attended the motivational lectures, only 226 who 
+satisfied the inclusion and exclusion criteria were selected 
+and randomly allotted to the Y and PE groups. The reasons 
+Deshpande S, et al.
+[Downloaded free from http://www.ijoy.org.in on Tuesday, August 18, 2009]
+5
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+for dropout of 52 subjects are shown in Figure 1. 
+Table 1 shows the demographic data. There were 87 
+subjects (40 females) in each group aged 18–71 years, the 
+mean age being 29.44 ± 11.94 years. They belonged to 
+different callings such as college students, professionals, 
+housewives and retired persons. 
+The baseline values were normally distributed for Tamas 
+(P = 0.209) and Sattva (P = 0.717) and were well-matched 
+for all three domains (Independent samples t-test). 
+Table 2 shows the comparison of the baseline scores for 
+the three gunas of the VPI with the norms provided in the 
+manual. It showed that the scores are within the predicted 
+normal range. The mean value is marginally higher for 
+Sattva and lower for Rajas and Tamas in the South Indian 
+population selected in the present study as compared to 
+the norms from studies in the USA. 
+Tamas: The PE group showed a significant decrease in 
+the Tamas score from 3.24 to 2.99 (P = 0.001) (paired 
+samples t test). The senior subjects (age > 24 years) in both 
+the Y (3.09 to 2.67) and PE (3.21 to 2.83) groups showed 
+a significant decrease (P = 0.001). In gender analysis, 
+females showed a decrease with Y (P = 0.040) and males 
+showed a decrease with PE (P = 0.032). 
+Rajas: The PE group showed a significant decrease in 
+scores from 3.67 to 3.43 (P = 0.002). Seniors in both the 
+Y (3.81 to 3.51) (P = 0.002) and PE (3.62 to 3.31) groups 
+(P = 0.015) have shown significant decreases. In gender 
+analysis, males showed a decrease with PE (3.73 to 3.37) 
+(P = 0.014). Significantly greater reduction was observed 
+in the PE than in the Y group (P = 0.005) and in juniors 
+(P = 0.012).
+Sattva: Sattva scores have increased significantly in 
+both Y (4.88 to 5.26) (P = 0.001) and PE (4.91 to 5.21) 
+(P < 0.001) groups with a greater effect size in the Y 
+Table 1: Demographic data for VPI
+Age                                          Sex 
+ 
+Y 
+PE
+ 
+ 
+(n = 87) 
+(n = 87)
+ 
+ 
+31.33±11.9 5 
+32.35±11.32
+≤ 24 years (Juniors) 
+Male (m±SD) 
+26.79±12.20 
+28.00±11.76
+ 
+Female (m±SD) 
+20.00±1.75 
+20.29±1.44
+> 24 years (Seniors) 
+Male (m±SD) 
+20.61±1.82 
+20.73±1.89
+ 
+Female (m±SD) 
+38.88±9.55 
+30.85±8.56
+Gender 
+Male (m±SD) 
+41.36±13.89 
+40.82±10.85
+ 
+Range 
+18–71 
+18–58
+ 
+Female 
+40 
+40
+Categories 
+Male 
+47 
+47
+ 
+Students 
+49 
+44
+ 
+Employees 
+18 
+30
+ 
+Housewives 
+10 
+7
+ 
+Business 
+10 
+6
+Table 2: VPI scores for yoga and control groups—comparison of means (paired samples test)
+ 
+Before 
+After 
+P value 
+Effect Size 
+Before 
+After 
+P value 
+Effect Size
+ 
+Means±SD 
+Means±SD 
+ 
+ 
+Means±SD 
+Means±SD 
+ 
+ 
+Y 
+Y 
+ 
+ 
+PE 
+PE 
+ 
+Tamas 
+3.12 ± 0.51 
+2.97 ± 0.91 
+0.095 
+0.18 
+3.24 ± 0.67 
+2.99 ± 0.69 
+0.001 
+0.36
+Rajas 
+3.83 ± 0.62 
+3.72 ± 0.51 
+0.12 
+0.17 
+3.67 ± 0.62 
+3.43 ± 0.79 
+0.002* 
+0.33
+Sattva 
+4.88 ± 0.52 
+5.26 ± 0.51 
+<0.001 
+0.61 
+4.91 ± 0.53 
+5.21 ± 0.65 
+<0.001 
+0.45
+* Rajas showed a significant difference between the groups (P = 0.005) (Independent Samples Test); (Effect size = difference in means (after–before)/SD of the 
+difference scores)
+Table 3: VPI scores in age groups - Age ≤ 24 years and > 24 years (paired-samples t test)
+ 
+ 
+Before 
+After 
+P value 
+Before 
+After 
+P value
+ 
+ 
+Means±SD 
+Means±SD 
+ 
+Means±SD 
+Means±SD 
+ 
+ 
+Y  
+Y 
+ 
+PE 
+PE 
+Age ≤ 24 years 
+Tamas 
+3.16 ± 0.49 
+3.20 ± 1.63 
+0.774 
+3.28 ± 0.67 
+3.16 ± 2.13 
+0.4
+ 
+Rajas 
+3.84 ± 0.66 
+3.99 ± 0.74 
+0.286 
+3.75 ± 0.63 
+3.56 ± 0.75 
+0.152
+ 
+Sattva 
+4.67 ± 0.47 
+5.26 ± 0.55 
+<0.001 
+4.79 ± 0.44 
+5.14 ± 0.65 
+0.002
+Age > 24 years 
+Tamas 
+3.09 ± 0.53 
+2.67 ± 0.69 
+0.001 
+3.21 ± 0.68 
+2.83 ± 0.77 
+0.001
+ 
+Rajas 
+3.81 ± 0.61 
+3.51 ± 0.57 
+0.002 
+3.62 ± 0.62 
+3.31 ± 0.83 
+0.015
+ 
+Sattva 
+4.91 ± 0.59 
+5.12 ± 0.45 
+0.001 
+5.00 ± 0.59 
+5.09 ± 0.62 
+0.014
+Effect of Yoga on Gunas and Health
+[Downloaded free from http://www.ijoy.org.in on Tuesday, August 18, 2009]
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+6
+(0.61) than in the PE (0.45) group. Juniors, seniors, males 
+and females in both the Y and PE groups have all shown 
+significant increase in Sattva scores.
+Table 5 shows the results for all variables of the GHQ.
+Somatic symptoms (SS): SS symptoms have reduced 
+significantly in both Y (0.57 to 0.29) (P = 0.011) and PE 
+(0.41 to 0.11) (P = 0.001) groups. Juniors, seniors, males 
+and females of the PE group have shown significant 
+decrease in SS. Seniors and males in the Y group have 
+shown significant decrease in SS. There was a significant 
+difference between the groups.
+Anxiety and insomnia (AI): AI symptoms have decreased 
+significantly in both the Y (0.61 to 0.08) (P < 0.01) and PE 
+(0.49 to 0.18) (P = 0.011) groups. Juniors, seniors, females 
+and males in the in Y group have shown significant 
+decrease in AI whereas only seniors and males have shown 
+significant decrease in AI in the PE group.
+Social dysfunction (SF): A significant decrease was 
+observed in both the Y (0.60 to 0.15) (P ≤ 0.001) and PE 
+(0.60 to 0.23) (P = 0.001) groups. Juniors, females and 
+males have shown significant decrease in SD with Yoga 
+whereas juniors, seniors, males and females have shown 
+significant decrease in SD due to PE. 
+Severe depression (SP): Both Y (0.44 to 0.22) (P = 0.017) 
+and PE (0.52 to 0.15) (P < 0.01) groups have shown 
+significant reduction in SP
+. Juniors, seniors, females and 
+males have shown a significant decrease in SP due to PE. 
+Only seniors and males have shown a significant decrease 
+in SP due to yoga.
+DISCUSSION
+This is a randomized, controlled, prospective study in 
+normal adults comparing the efficacy of yoga with a 
+control intervention of PE of eight weeks in 174 normal 
+adults on changes in their personality (guna) and General 
+health as assessed by VPI and GHQ. The results showed 
+that there was an increase in Sattva scores (P < 0.001) in 
+both Y and PE groups and a decrease in Rajas (P = 0.002) 
+and tamas (P = 0.01) scores in the PE group. The scores for 
+Tamas decreased significantly in seniors of both the groups 
+(females in Y and males in PE) (paired samples t test). 
+The increase in Sattva scores was higher in the Y group 
+Orientation Seminar Conducted at different parts of Bangalore 
+1228 
+Consented to participate in the project 
+226 
+Centre I 
+66 
+Centre II 
+30  
+Centre V 
+32  
+Centre III 
+50 
+Centre IV 
+48 
+Randomized 
+226 
+Yoga 
+33 
+PE 
+33 
+Yoga 
+15 
+PE  
+15 
+Yoga 
+25 
+PE 
+25 
+Yoga 
+24 
+Yoga 
+22 
+PE 
+30 
+No. of People dropped 
+52 
+No, of subjects in the project 
+174 
+Yoga 
+24 
+PE 
+16 
+Yoga 
+16 
+Reasons for dropping 
+                                                   
+Yoga       PE
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+        
+ 
+ 
+                                                      
+        
+  
+              
+ 
+                                                      
+        
+ 
+ 
+Yoga 
+87 
+PE 
+87 
+1. Change of address 
+4 
+10
+2. Unexpected duty shifts 
+5 
+7
+3. Weather conditions 
+3 
+ 2
+4. Out of station 
+7 
+3
+5. Ill health 
+3 
+–
+6. Wanted to shift to yoga 
+ 
+8
+              Total 
+       22 
+30
+Comparison between our data and Vpi data
+Deshpande S, et al.
+[Downloaded free from http://www.ijoy.org.in on Tuesday, August 18, 2009]
+7
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+(effect size 0.61) than in the PE group (effect size 0.45) 
+(paired samples t test). The decrease in the Rajas scores 
+was significantly higher in the PE than in the Y (P=0.005) 
+(independent samples t-test) groups and this was seen 
+in juniors and males. The GHQ revealed a significant 
+improvement on all four domains and the overall health in 
+both groups after the intervention (P ≤ 0.001) (Wilcoxon’s 
+signed rank test). It can be seen from the GHQ scores that 
+PE was more effective in reducing somatic symptoms 
+(P = 0.018) (Mann Whitney test), severe depression (effect 
+size for Y = 1.46, PE = 1.60) and anxiety and insomnia 
+(effect size for Y = 0.98, PE = 1.93). 
+A similar study by Dasa[32] conducted by the use of 
+mahamantra in a three-armed, randomized prospective, 
+controlled study on 62 volunteers showed that the 
+mahamantra group had increased Sattva and decreased 
+Tamas with no significant change in Rajas scores on the VPI 
+questionnaire after a month of chanting of mahamantra, 
+20 minutes daily for four weeks. In the present study, 
+apart from an increase in Sattva and decrease in Tamas, 
+there is a significant decrease in Rajas which was not 
+observed after Mahamantra. This difference could be 
+because of the inclusion of Asanas and Pranayama to 
+the Meditation technique in the integrated yoga program 
+used in the present study as compared to the mahamantra 
+which is mainly a form of meditation. In their study, Dasa 
+et al. also showed a significant reduction in stress, anxiety 
+and depression after mahamantra as measured by State 
+Trait Anxiety Inventory (STAI) comparable to the results 
+of GHQ in this study.
+The behavior of a human being is an expression of 
+a combination of different gunas. Tamas (meaning 
+darkness) is the grossest aspect of our personality 
+characterized by excessive sleep, innocence, laziness, 
+depression, procrastination, a feeling of helplessness, 
+impulsivity, anger and arrogance (packed up with vital 
+energy). When we reduce Tamas through mastery over 
+the mind, we become dynamic, sensitive and sharp to 
+move towards Rajas (the shining one) characterized by 
+intense activity, ambitiousness, competitiveness, high 
+Table 6: GHQ scores: Age ≤ 24 years and > 24 years (Wilcoxon signed ranks test)
+ 
+ 
+Before 
+After 
+P value 
+Before 
+After 
+P value
+ 
+ 
+Means±SD 
+Means±SD 
+ 
+Means±SD 
+Means±SD 
+ 
+ 
+Y 
+Y 
+ 
+PE 
+PE 
+Age ≤ 24 years 
+SS 
+0.65 ± 0.93 
+0.43 ± 0.76 
+0.161 
+0.43 ± 0.76 
+0.14 ± 0.35 
+0.01
+ 
+AI 
+0.71 ± 0.96 
+0.10 ± 0.47 
+<0.001 
+0.66 ± 0.99 
+0.30 ± 1.00 
+0.057
+ 
+SF 
+0.80 ± 0.98 
+0.18 ± 0.44 
+<0.001 
+0.75 ± 1012 
+0.34 ± 0.64 
+0.019
+ 
+SP 
+0.45 ± 0.71 
+0.29 ± 0.68 
+0.185 
+0.64 ± 0.89 
+0.16 ± 0.43 
+<0.001
+ 
+TH 
+2.61 ± 2.54 
+1.00 ± 1.44 
+<0.001 
+2.48 ± 3.11 
+0.93 ± 1.53 
+0.001
+Age > 24 years 
+SS 
+0.47 ± 0.89 
+0.11 ± 0.39 
+0.004 
+0.40 ± 0.85 
+0.09 ± 0.29 
+0.044
+ 
+AI 
+0.47 ± 0.86 
+0.05 ± 0.23 
+0.002 
+0.33 ± 0.78 
+0.06 ± 0.26 
+0.047
+ 
+SF 
+0.34 ± 0.75 
+0.11 ± 0.31 
+0.071 
+0.44 ± 0.83 
+0.12 ± 0.32 
+0.017
+ 
+SP 
+0.42 ± 0.76 
+0.13 ± 0.41 
+0.047 
+0.40 ± 0.79 
+0.14 ± 0.41 
+0.013
+ 
+TH 
+1.71 ± 2.25 
+0.39 ± 1.00 
+0.001 
+1.56 ± 2.00 
+0.42 ± 0.00 
+0.003
+Table 4: Gender-based VPI scores (paired samples t test)
+ 
+ 
+Before 
+After 
+P value 
+Before 
+After 
+P value
+ 
+ 
+Means±SD 
+Means±SD 
+ 
+Means±SD 
+Means±SD 
+ 
+ 
+Y 
+Y 
+ 
+PE 
+PE 
+Females 
+Tamas 
+3.15 ± 0.52 
+2.80 ± 1.04 
+0.04 
+3.20 ± 0.71 
+2.97 ± 0.71 
+0.053
+ 
+Rajas 
+3.66 ± 0.62 
+3.43 ± 0.48 
+0.502 
+3.64 ± 0.63 
+3.50 ± 0.80 
+0.196
+ 
+Sattva 
+4.91 ± 0.42 
+5.20 ± 0.50 
+0.004 
+4.98 ± 0.58 
+5.23 ± 0.62 
+0.034
+Males 
+Tamas 
+3.11 ± 0.50 
+3.10 ± 0.58 
+0.924 
+3.28 ± 0.65 
+3.01 ± 0.46 
+0.032
+ 
+Rajas 
+3.96 ± 0.63 
+3.96 ± 0.41 
+0.898 
+3.73 ± 0.63 
+3.50 ± 0.79 
+0.014
+ 
+Sattva 
+4.86 ± 0.60 
+5.33 ± 0.52 
+<0.001 
+4.80 ± 0.49 
+5.19 ± 0.68 
+0.001
+Table 5: GHQ scores (Wilcoxon signed ranks test) 
+ 
+Before 
+After 
+P value 
+Before 
+After 
+P value
+ 
+Means±SD 
+Means±SD 
+ 
+Means±SD 
+Means±SD 
+ 
+Y 
+Y 
+ 
+PE 
+PE 
+SS 
+0.57 ± 0.91 
+0.29 ± 0.65 
+<0.001 
+0.41 ± 0.80 
+0.11 ± 0.32 
+0.001
+AI 
+0.61 ± 0.92 
+0.08 ± 0.38 
+<0.001 
+0.49 ± 0.90 
+0.18 ± 0.74 
+0.011
+SF 
+0.60 ± 0.91 
+0.15 ± 0.39 
+<0.001 
+0.60 ± 0.99 
+0.23 ± 0.52 
+0.001
+SP 
+0.44 ± 0.73 
+0.22 ± 0.58 
+0.017 
+0.52 ± 0.65 
+0.15 ± 0.42 
+<0.001
+TH 
+2.22 ± 2.48 
+0.74 ± 1.21 
+<0.001 
+2.02 ± 2.78 
+0.68 ± 1.28 
+<0.001
+SS: Somatic symptoms; AI: Anxiety and insomnia; SF: Social dysfunction; SP: Severe depression; TH: Total health
+SS: Somatic symptoms; AI: Anxiety and insomnia; SF: Social dysfunction; SP: Severe depression; TH: Total health
+Effect of Yoga on Gunas and Health
+[Downloaded free from http://www.ijoy.org.in on Tuesday, August 18, 2009]
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+8
+Deshpande S, et al.
+sense of self importance, desire for sense gratification, 
+little interest in spiritual elevation, dissatisfaction 
+with one’s position, envy of others and a materialistic 
+cleverness.[33] With further growth and mastery, one moves 
+into Sattva–a dominance which includes the qualities of 
+truthfulness, stability, discipline, sense of control, sharp 
+intelligence, preference for vegetarianism, truthfulness, 
+gravity, dutifulness, detachment, respect for superiors 
+and staunch determination[21] and stability in the face of 
+adversity and also conscious action. Thus, we can see 
+that although both Rajas and Tamas have both positive 
+and negative qualities, they are the manifestation of a 
+violent state of mind in which a person lacks mastery 
+over upsurges of emotions and impulsive behaviour.[33] 
+Most of the qualities of Sattva which are manifestation 
+of a calm state of mind are achievable by different 
+yoga techniques (physical postures, pranayama and/
+or meditation) meant for mastery over the mind-body 
+complex.[34] Several earlier studies have independently 
+corroborated these notions. It has been shown that self 
+esteem as well as the sense of control and determination 
+improved after meditation.[35] Reduction in crime rate 
+after transcendental meditation (TM) supported the 
+effect of a calm state of mind on social health.[36] These 
+positive effects also show up as better perception and 
+memory as well as better motor performance (dexterity 
+and coordination tests).[37] Better academic performance 
+has also been documented.[38]
+Although in this study, Yoga has shown a better effect 
+on the Sattva guna than PE with a better effect size, the 
+main difference between Y and PE practices seems to 
+be the effect on rajas guna. The reduction in this guna 
+was significantly higher after PE than after Y (this group 
+difference was in males and juniors). The scores for Tamas 
+Table 7: Gender-based GHQ scores (Wilcoxon signed ranks test)
+ 
+ 
+Before 
+After 
+ 
+Before 
+After
+ 
+ 
+Means±SD 
+Means±SD 
+ 
+Means±SD 
+Means±SD
+ 
+ 
+Y 
+Y 
+P value 
+PE 
+PE 
+P value
+Females 
+SS 
+0.50 ± 0.99 
+0.25 ± 0.58 
+0.115 
+0.40 ± 0.74 
+0.07± 0.27 
+0.018
+ 
+AI 
+0.50 ± 0.85 
+0.02± 0.16 
+0.001 
+0.57 ± 0.98 
+0.30 ± 1.04 
+0.208
+ 
+SF 
+0.40 ± 0.81 
+0.10 ± 0.30 
+0.038 
+0.45 ± 0.81 
+0.15 ± 0.36 
+0.038
+ 
+SP 
+0.35 ± 0.62 
+0.28 ± 0.72 
+0.584 
+0.50 ± 0.85 
+0.10 ± 0.45 
+0.005
+ 
+TH 
+1.71 ± 2.35 
+0.65 ± 1.03 
+0.01 
+1.93 ± 2.80 
+0.70 ± 1.44 
+0.018
+Males 
+SS 
+0.64 ± 0.85 
+0.32 ± 0.69 
+0.027 
+0.43 ± 0.85 
+0.15± 0.36 
+0.022
+ 
+AI 
+0.70 ± 0.98 
+0.13± 0.49 
+<0.001 
+0.43 ± 0.83 
+0.08± 0.28 
+0.007
+ 
+SF 
+0.77 ± 0.96 
+0.19 ± 0.45 
+<0.001 
+0.72 ± 1.12 
+0.30 ± 0.62 
+0.009
+ 
+SP 
+0.51 ± 0.80 
+0.17 ± 0.43 
+0.008 
+0.53 ± 0.86 
+0.13 ± 0.40 
+<0.001
+ 
+TH 
+2.62 ± 2.53 
+0.81 ± 1.36 
+<0.001 
+2.11 ± 2.78 
+0.66 ± 1.15 
+<0.001
+also decreased significantly in seniors of both groups 
+(females in Y and males in PE groups) with the effect 
+size being higher in the PE than in the Y groups. Thus, 
+significantly greater reductions in Rajas and Tamas were 
+worthy of note with PE than with Y. This positive effect 
+of PE in reducing Rajas and Tamas adds to the fund of 
+knowledge about several psycho-physiological benefits 
+of PE. Hence, it appears that physical practices are more 
+effective in reducing the limitations of Rajas and Tamas 
+such as lack of mastery over upsurges of emotions and 
+impulsive behavior, while yoga improves the softer 
+qualities of Sattva. The mechanism of how physical 
+exercises may reduce Rajas and tamas and how yoga may 
+increase Sattva needs to be investigated by further studies. 
+Thus, we may conclude that both physical activity (to 
+reduce Rajas and Tamas) and Yoga (to improve Sattva) 
+may be recommended for the harmonious promotion of 
+personality. 
+The GHQ showed significant differences within groups 
+in all domains in both groups. There was a significant 
+difference in SS between the Y and PE groups (Mann 
+Whitney Test). 
+Observations by Atlantis et al. on the efficacy of physical 
+exercise practised for eight weeks in a population of 
+Australian employees showed that the intervention 
+significantly improved the Quality of Life as compared to a 
+waiting list control group (measured by SF-36). They have 
+shown an improvement of 12.8% in physical functioning, 
+9.90% in general health, 44.50% in vitality and 15.90% in 
+mental health scores.[29] The significantly better reduction 
+in SS in the Yoga group in our study may be due to deeper 
+rest and relaxation obtained in Yoga.
+TABLE 8: Comparison between our data (before and after) and standard VPI data
+ 
+n 
+Observed range 
+Observed mean±SD 
+n 
+Predicted range 
+Predicted mean±SD
+Sattva 
+ 
+3.04 - 6.17 
+4.90±0.53 
+ 
+3.00 - 6.39 
+4.67±0.75
+Rajas 
+174 
+2.11 - 5.25 
+3.76±0.63 
+247 
+2.46 - 5.96 
+4.07±1.08
+Tamas 
+ 
+1.47 - 5.38 
+3.19±0.60 
+ 
+1.43 - 6.00 
+3.49±0.90
+SS: Somatic symptoms; AI: Anxiety and insomnia; SF: Social dysfunction; SP: Severe depression; TH: Total health
+[Downloaded free from http://www.ijoy.org.in on Tuesday, August 18, 2009]
+9
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+Effect of Yoga on Gunas and Health
+The results of the study seem to point out clear differences 
+between Y and PE on VPI whereas differences between Y 
+and PE are not found in most domains of GHQ (except SS). 
+Hence, although GHQ is a good measure of the various 
+aspects of health and disease, VPI seems to be a better 
+measure to differentiate the effects of Y and PE.
+In summary, this randomized, prospective, single-blind, 
+comparative study has shown the efficacy of both Y and 
+PE in improving all components of general health. While 
+physical exercise has reduced Rajas and Tamas, the yogic 
+practice has increased Sattva. Hence, yoga which is more 
+traditionally practised in India and cost-effective, can be 
+recommended with additional benefits of promotion of 
+the Sattva guna.
+The strength of our design is a PE intervention matched 
+with the integrated Y module. The study population was 
+taken from different parts of Bangalore from different 
+socioeconomic classes of the city. The improvement 
+observed in both groups after eight weeks of intervention 
+in all variables in both groups not only provides hitherto 
+undemonstrated evidence of the efficacy of physical 
+activity in a normal South Indian adult population but 
+also shows that yoga could be an equally effective tool. 
+This study also brings out the subtle differences in 
+the efficacy of the two interventions (Y or PE). It also 
+points out the utility of the VPI as a tool for measuring 
+the subtle dimensions of guna described in traditional 
+texts of yoga that can measure the steps of growth of 
+an individual.
+ACKNOWLEDGMENTS
+Our grateful acknowledgements for all who helped in this project. 
+We are grateful to SVYASA for supporting this study. We thank 
+the volunteers, teachers and supporters who participated in 
+this study.
+REFERENCES
+1. 
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+Margareta Eriksson K, Westborg CJ, Eliasson MC. A randomized trial 
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+Brukner PD, Brown WJ. Is exercise good for you? Med J Aust 2005;
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+Brena SH. Yoga and Medicine. The Julian Press Inc: New York; 1975.
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+yoga on hypertensive persons in Thailand. Holist Nurs Pract 2005;19:173-
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+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:1 
+ 
+! 
+ 
+Jan-Jun-2008
+10
+36. Abrams AI. Transcendental meditation and rehabilitation at Folsom prison: 
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+Effect of Yoga on Gunas and Health
+[Downloaded free from http://www.ijoy.org.in on Tuesday, August 18, 2009]

subfolder_0/A randomized trial comparing effect of yoga and exercises on quality of life in among nursing population with chronic low back pain.txt

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+© 2018 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+208
+Introduction
+Nursing profession is the largest chunk 
+of health‑care professionals.[1] Physical, 
+psychological, 
+and 
+psychosocial 
+challenges contribute to musculoskeletal 
+disorders among nurses. Chronic low 
+back pain (CLBP) is the most common 
+musculoskeletal disorder among the nurses. 
+It is reported that 63%–86% of nursing 
+professionals suffer from LBP in their 
+lifetime.[1,2] CLBP in nurses is multifactorial, 
+and the risk factors pertain to lifestyle, 
+physical, 
+psychological, 
+psychosocial, 
+and occupational domains, namely, age, 
+gender, physical status, smoking, workplace 
+stress, awkward postures, poor ergonomics, 
+carrying and repositioning of patients, 
+prolonged standing, night shifts, working 
+without sufficient breaks, and psychological 
+stress are important causative/risk factors 
+for CLBP in nurses. Nurses are required 
+to lift and transport patients or equipment, 
+often in difficult environment particularly 
+Address for correspondence: 
+Assoc. Prof and Head.  
+Nitin J Patil, 
+Department of Integrative 
+Medicine, Sri Devaraj Urs 
+Academy of Higher Education 
+and Research, Kolar - 563 103, 
+Karnataka, India.  
+E-mail: [email protected]
+Abstract
+Background: Chronic low back pain  (CLBP) adversely affects quality of life  (QOL) in nursing 
+professionals. Integrated yoga has a positive impact on CLBP. Studies assessing the effects of 
+yoga on CLBP in nursing population are lacking. Aim: This study was conducted to evaluate the 
+effects of integrated yoga and physical exercises on QOL in nurses with CLBP. Methods: A  total 
+of 88 women nurses from a tertiary care hospital of South India were randomized into yoga group 
+(n = 44; age – 31.45 ± 3.47 years) and physical exercise group (n = 44; age – 32.75 ± 3.71 years). 
+Yoga group was intervened with integrated yoga therapy module practices, 1 h/day and 5 days a week 
+for 6 weeks. Physical exercise group practiced a set of physical exercises for the same duration. All 
+participants were assessed at baseline and after 6 weeks with the World Health Organization Quality 
+of Life‑brief  (WHOQOL‑BREF) questionnaire. Results: Data were analyzed by Paired‑samples 
+t‑test and Independent‑samples t‑test for within‑ and between‑group comparisons, respectively, using 
+the Statistical Package for the Social Sciences  (SPSS). Within‑group analysis for QOL revealed a 
+significant improvement in physical, psychological, and social domains  (except environmental 
+domain) in both groups. Between‑group analysis showed a higher percentage of improvement in 
+yoga as compared to exercise group except environmental domain. Conclusions: Integrated yoga 
+was showed improvements in physical, psychological, and social health domains of QOL better than 
+physical exercises among nursing professionals with CLBP. There is a need to incorporate yoga as 
+lifestyle intervention for nursing professionals.
+Keywords: Exercises, low back pain, nurses, quality of life, yoga
+A Randomized Trial Comparing Effect of Yoga and Exercises on Quality of 
+Life in among nursing population with Chronic Low Back Pain
+Original Article
+Nitin J Patil, 
+Nagaratna R1, 
+Padmini Tekur2, 
+Manohar PV3, 
+Hemant Bhargav4, 
+Dhanashri Patil
+Department of Integrative 
+Medicine, Sri Devaraj Urs 
+Academy of Higher Education 
+and Research, 3Department 
+of Orthopedics, Sri Devaraj 
+Urs Medical College, 
+Kolar, 1Medical Director, 
+Arogyadhama, S-VYASA 
+Yoga University, 2Division 
+of Yoga and Life Sciences, 
+S-VYASA Yoga University,
+4Integrated Centre for Yoga
+(NICY), NIMHANS, Bengaluru,
+Karnataka, India
+in developing nations where lifting aids are 
+not always available or practicable. These 
+multiple factors contribute toward higher 
+prevalence of CLBP in this population.[3] 
+CLBP is one of the main concerns, which 
+negatively impacts the quality of life (QOL) 
+leading to reduced work productivity, 
+absenteeism, 
+and 
+disabilities 
+among 
+nurses.[4] Harrington and Gill stated that 
+LBP is the most common cause of early 
+retirement on grounds of ill health, sickness 
+absenteeism, job changes, and a fall in the 
+work speed among the working population. 
+Especially for young nurses, the mental 
+demands of work have a critical influence 
+on their QOL and workability.[5]
+QOL 
+measurements 
+are 
+being 
+used 
+increasingly relevant in the evaluation of 
+disease progression, treatment, and the 
+management of musculoskeletal disorders. 
+QOL is recognized as a concept representing 
+individual 
+responses 
+to 
+the 
+physical, 
+mental, and social effects of illness on daily 
+Access this article online
+Website: www.ijoy.org.in
+DOI: 10.4103/ijoy.IJOY_2_18
+Quick Response Code:
+How to cite this article: Patil NJ, Nagaratna R, Tekur P, 
+Manohar PV, Bhargav H, Patil D. A randomized trial 
+comparing effect of yoga and exercises on quality of 
+life in among nursing population with chronic low back 
+pain. Int J Yoga 2018;11:208-14.
+Received: January, 2018. Accepted: April, 2018.
+This is an open access journal, and articles are distributed under 
+the terms of the Creative Commons Attribution-NonCommercial-
+ShareAlike 4.0 License, which allows others to remix, tweak, and 
+build upon the work non-commercially, as long as appropriate 
+credit is given and the new creations are licensed under the 
+identical terms.
+For reprints contact: [email protected]
+Patil, et al.: Yoga for nurses with low back pain
+International Journal of Yoga | Volume 11 | Issue 3 | September-December 2018
+209
+living, which influences the extent of personal satisfaction 
+with life circumstances that can be achieved. Measuring 
+QOL is recognized as an important add‑on to objectify 
+clinical effectiveness in recent clinical trials.[6,7] CLBP is 
+a major deterrent for QOL, and the QOL scores correlate 
+with pain and disability of CLBP. Furthermore, QOL 
+correlated inversely with poor quality of sleep in nursing 
+population. Such multifactorial problems of CLBP demand 
+a multifaceted approach for management.[8‑10]
+Yoga has emerged as a popular mind‑body therapy for 
+CLBP as suggested by emerging scientific literature across 
+the globe.[11] Yoga adopts a multifaceted approach utilizing 
+practices at body (postures), breath (breathing techniques), 
+and mind levels  (meditation and relaxation techniques), 
+respectively. According to national surveys, yoga practice 
+and research have increased exponentially and in the last 
+decade with over 10 million Americans practicing yoga for 
+health reasons in 2002 and over  13 million in 2007.[11‑13] 
+Literature review reveals that viniyoga, hatha yoga, Iyengar 
+yoga, and integrated yoga are the most commonly used 
+forms to treat LBP.[14‑16]
+In a systematic review, Chou and Huffman concluded 
+that there was a fair evidence reflecting efficacy of 
+yoga therapy in subacute or CLBP.[17] In another similar 
+review 
+which 
+included 
+four 
+randomized 
+controlled 
+trials  (RCTs), it was observed that the intervention by 
+Iyengar yoga and viniyoga for a period of 12–24  weeks 
+was beneficial in CLBP.[15] Yet, another meta‑analysis 
+consisting of eight RCTs by Cramer et  al. found strong 
+evidence for short‑term effectiveness  (pain, back‑specific 
+disability, and global improvement parameters) and 
+moderate evidences (back‑specific disability) for long‑term 
+effectiveness of yoga on CLBP. Yoga was not found to be 
+associated with serious adverse events.[18]
+A study by Tekur et  al. had observed usefulness of yoga 
+intervention in improving QOL in patients with CLBP. 
+However, this study was used in general population with 
+intense residential yoga intervention. We did not come 
+across any study that has assessed the same in nursing 
+population with an OPD or outdoor setup intervention 
+(1 h/day). As discussed earlier, nursing population is more 
+prone for CLBP due to specific demands of the occupation.
+Thus, the present randomized controlled study was planned 
+to compare the effect of integrated yoga and physical 
+exercise of similar intensity on QOL of nurses suffering 
+from LBP.
+Methods
+Subjects
+This study was conducted among nursing population, 
+who were diagnosed by an orthopedician to be suffering 
+from CLBP. Participants were working in the tertiary 
+care teaching hospital in Kolar district of Karnataka state 
+in India. They were randomly divided into two groups: 
+yoga (n  =  44; age  –  31.45  ±  3.47  years) and physical 
+exercise (n = 44; age – 32.75 ± 3.71 years) using random 
+number generator  (www.randomizer.org). Participants in 
+the two groups did not differ much in relation to their age, 
+education, or duration of illness between the groups as 
+shown in Table 1.
+Two groups’ randomized controlled single‑blind design was 
+followed with participants from both the groups (yoga and 
+exercise) receiving intervention for 6  weeks. Assessments 
+for QOL were performed at two points of time at baseline 
+and after 6 weeks of interventions. The statistician and the 
+interviewer were unaware of the allocation status of the 
+participants.
+The inclusion requirements were as follows:  (a) female 
+nurses with diagnosis of either nonspecific LBP, lumbar 
+spondylosis, or intervertebral disc prolapse, suffering 
+from LBP for 3  months or more as diagnosed by an 
+orthopedician and  (b) knowledge of English, Hindi, 
+and Kannada language. The exclusion criteria were as 
+follows:  (a) pain due to organic causes such as infective 
+and inflammatory conditions, metabolic disorders, and 
+posttraumatic condition,  (b) patients with degenerative 
+disorders of muscles,  (c) patients with comorbid cardiac 
+or neuropsychiatric illness,  (d) history of major surgery 
+or injury in the past, (e) pregnant women, and (f) patients 
+with neurological complications of CLBP.
+Written informed consent was taken from all the 
+participants before the study and Institutional Ethical 
+Clearance was obtained.
+Study profile
+From January 2015 to December 2016, nurses were 
+screened and referred by the orthopedician. Out of 176 
+nurses referred for the study, 88 satisfied the study criteria. 
+Table 1: Sociodemographic and clinical variables 
+comparison between yoga and exercises
+Variables
+Yoga
+Exercises
+Number of participants (only female)
+44
+44
+Age (mean±SD)
+31.45±3.47
+32.75±3.71
+Education
+ANM
+8
+3
+GNM
+28
+32
+Bachelor of nursing
+8
+9
+CLBP
+3 months‑1 year
+34
+37
+>1 year
+10
+07
+Causes
+Nonspecific/muscle spasm
+37
+35
+Lumbar spondylosis
+6
+3
+Intervertebral disc prolapse
+4
+3
+SD=Standard deviation, ANM=Auxiliary nursing midwifery, 
+GNM=General nursing midwifery, CLBP=Chronic low back pain
+Patil, et al.: Yoga for nurses with low back pain
+International Journal of Yoga | Volume 11 | Issue 3 | September-December 2018
+210
+Informed consent was obtained. Baseline assessments 
+were done, and they were randomly allocated to yoga 
+(n  =  44) and control  (n  =  44) groups. They underwent 
+intervention  (either integrated yoga or physical exercise) 
+for 6  weeks; repeat assessments were performed on both 
+groups. There were no dropouts in the study. Figure  1 
+provides a flow diagram of the study profile.
+Materials
+Assessment
+The World Health Organization Quality of Life‑brief 
+(WHOQOL‑BREF) questionnaire English and Kannada 
+version was used to assess the QOL of the participants.
+WHOQOL‑BREF developed by the WHO is a standardized 
+comprehensive 
+instrument 
+for 
+assessment 
+of 
+QOL 
+comprising 26 items. The scale provides a measure of 
+an individual’s perception of QOL on four domains: 
+(1) physical health  (seven items),  (2) psychological 
+health  (six items),  (3) social relationships  (three items), 
+and  (4) environmental health  (eight items). In addition, it 
+also includes two questions for “overall QOL” and “general 
+health” facets. The domain scores are scaled in a positive 
+direction (i.e., higher scores denote higher QOL). The range 
+of scores is 4–20 for each domain. The internal consistency 
+of WHOQOL‑BREF ranged from 0.66 to 0.87 (Cronbach’s 
+alpha coefficient). The scale has been found to have good 
+discriminant validity. It has good test–retest reliability and 
+is recommended for use in health surveys and to assess the 
+efficacy of any intervention at suitable intervals according 
+to the need of the study.[19,20]
+Intervention
+Integrated approach of yoga therapy  (IAYT) is based on 
+the basic principle that there are five layers of the existence 
+to human beings, namely, Annamaya Kosa  (physical 
+level), Pranamaya Kosa  (subtle energy level), Manomaya 
+Kosa (emotional level), Vijnanamaya Kosa  (level of 
+intellect), and Anandamaya Kosa  (level of bliss). Yogic 
+pathophysiology propounds that the disturbances at the 
+emotional level  (adhi) percolate to the physical level 
+(vyadhi) through the layer of prana. Furthermore, all layers 
+are interrelated and they affect each other indirectly. The 
+IAYT is an approach which consists in not only dealing 
+with physical layer but also includes using techniques to 
+operate on different layers of our existence. The practices 
+at body level  (Annamaya Kosa) include yogasanas, 
+loosening practices, at subtle energy level  (Pranamaya 
+Kosa) include breathing practices and pranayama, and 
+at the mind level  (Manomaya Kosa) are meditations and 
+relaxation techniques.
+A 1‑h integrated yoga therapy module  (IYTM) was 
+designed after reviewing the literature in the field of yoga 
+and LBP by utilizing the components of yoga at the body, 
+subtle energy, and mind level, respectively. The designed 
+IYTM was validated by subject experts.[21] Tekur et  al. 
+used as a similar intervention in an earlier study.[22] This 
+yoga module was practiced 5 days a week for 6 weeks. The 
+details of yoga practice are provided in Table 2.
+Self and physician refered nursing professionals with CLBP 
+(Recruitment Period :  January 2015  to December 2016)
+Assessed for  Inclusion and Exclusion criteria, 
+Obtained informed consent form
+Randomly allocatted to Yoga and Exercise group
+Outcome measures were assessed at baseline for All 88 subjects
+Group 1 - Yoga; n = 44
+Group 2 Exercise; n = 44
+Intervention: 1 Month (1 Hour per Day / 5 Days a week)
+Group1 - IYTM  for CLBP
+Group 2 - Physical Exercise
+Assessement of outcome measures were repeated
+Statistical Analysis
+Report writting
+Figure 1: Trail profile
+Table 2: Intervention: Integrated yoga therapy module 
+versus physical exercises
+List of practices in IYTM for CLBP List of physical exercises
+Supta udarakarshanasana (folded leg 
+lumbar stretch)
+Standing hamstring stretch
+Shava udarakarshanasana (crossed leg 
+lumbar stretch)
+Cat and camel
+Pavanamuktasana 
+(wind‑releasing pose)
+Pelvic tilt
+Setu bandhasana breathing (bridge 
+pose lumbar stretch)
+Partial curl
+Vyaghrasana (tiger breathing)
+Piriformis stretch
+Bhujangasana (serpent pose)
+Extension exercise
+Shalabhasana breathing (locust pose)
+Quadriceps leg raising
+Uttanapadasana (straight leg raise pose) Trunk rotation
+Ardha kati chakrasana (lateral arc pose) Double knee to chest
+Ardha chakrasana (half wheel pose)
+Bridging
+Quick relaxation techniques
+Hook lying march
+Nadi shuddhi (alternate nostril 
+breathing)
+Single knee to chest stretch
+Bhramari (humming bee breath)
+Lumbar rotation
+Nadanusandhana (A, U, M, AUM 
+chanting)
+Press up
+Deep relaxation technique
+Curl ups
+Laghoo shankhaprakshalana (yogic 
+colon cleansing) (weekly once)
+IYTM=Integrated yoga therapy module, CLBP=Chronic low 
+back pain
+Patil, et al.: Yoga for nurses with low back pain
+International Journal of Yoga | Volume 11 | Issue 3 | September-December 2018
+211
+Control group intervention
+Control group practiced physical exercise of similar 
+intensity as IYTM for the same duration and frequency 
+as shown in Table  2 provides the details of control 
+intervention.
+Data collection
+Data were taken at the same time of the day on 
+the 1st and 43rd day. Orientation to yoga program was given 
+to the participants for 3  days, and then on the next day, 
+predata collection was done after satisfactory performance. 
+WHOQOL‑BREF assessments were done on day 1 and 
+day 43 (after 6  weeks). A  trained psychologist assisted in 
+data collection.
+Data analysis
+Statistical Package for the Social Sciences (SPSS) - (Version 
+21.0., Armonk, NY: IBM Corp.) was used for all analyses. 
+Data of all four domains were normally distributed on 
+Shapiro–Wilk test. Hence, the parametric tests were used. 
+“Paired‑samples t‑test” and “Independent‑samples t‑test” 
+were used to analyze within‑  and between‑group data, 
+respectively.
+Results
+Within‑group comparisons in yoga group
+Within‑group pre‑  and postcomparison showed that, 
+after the yoga intervention, there was a significant 
+improvement in three domains of WHOQOL‑BREF, 
+namely, physical (P  <  0.01), psychological  (P  <  0.01), 
+and social  (P  <  0.01) with a trend of insignificant 
+positive impact in environmental domain  (P  =  0.07) 
+[Table 3].
+Within‑group comparisons in exercise group
+Similar to yoga group, exercise group also showed a 
+significant improvement in three domains, namely, physical 
+(P < 0.01), psychological (P < 0.01), and social (P < 0.01) 
+with no significant difference in the environmental domain 
+(P = 0.95) [Table 4].
+Between‑group comparisons in yoga versus control 
+group
+Preintervention data
+There was a no significant difference between the 
+yoga and control groups at the baseline for all the four 
+domains of WHOQOL‑BREF:  (a) physical  (P  =  0.296), 
+(b) psychological  (P  =  0.987),  (c) social  (P  =  0.661), and 
+(d) environmental (P = 0.904) as shown in Table 5.
+Postintervention data
+There was a significant difference between the yoga and 
+control groups after the intervention in the following 
+domains of WHOQOL‑BREF:  (a) physical  (P  <  0.01), 
+(b) psychological  (P  <  0.01), and  (c) social  (P  <  0.01) 
+with the scores of yoga group being higher than 
+those of the control group for all the three domains, 
+respectively. 
+There 
+was 
+no 
+significant 
+difference 
+between 
+the 
+groups 
+for 
+environmental 
+domains 
+(P = 0.249).
+Table 3: Within yoga group (pre and post) comparison of 
+World Health Organization Quality of Life‑BREF scores
+Variables
+Pre/
+post
+Yoga group
+Mean±SD
+Percentage change
+P
+Physical 
+domain QOL
+Pre
+41.27±6.603
+44.12
+<0.001
+Post
+59.48±9.041
+Psychological 
+domain QOL
+Pre
+34.91±5.356
+97.07
+<0.001
+Post
+68.80±13.428
+Social domain 
+QOL
+Pre
+43.07±12.705
+55.02
+<0.001
+Post
+66.77±12.004
+Environmental 
+domain QOL
+Pre
+55.70±5.325
+2.81
+0.078
+Post
+57.27±6.028
+QOL=Quality of life, SD=Standard deviation
+Table 4: Within exercise group (pre and post) 
+comparison of World Health Organization Quality of 
+Life‑BREF scores
+Variables
+Pre/
+post
+Exercise group
+Mean±SD
+Percentage change
+P
+Physical 
+domain QOL
+Pre
+39.82±6.377
+25.33
+<0.005
+Post
+49.91±8.575
+Psychological 
+domain QOL
+Pre
+34.93±7.315
+20.89
+<0.001
+Post
+42.23±7.358
+Social domain 
+QOL
+Pre
+44.09±8.757
+14.49
+<0.001
+Post
+50.48±8.609
+Environmental 
+domain QOL
+Pre
+55.84±5.278
+0.089
+0.957
+Post
+55.89±5.136
+QOL=Quality of life, SD=Standard deviation
+Table 5: Between group (yoga vs. exercise) comparison 
+of World Health Organization Quality of Life‑BREF 
+scores
+Variables
+Pre/post
+Group
+Mean±SD
+P
+Physical 
+domain QOL
+Pre
+Yoga
+41.27±6.60
+0.296
+Pre
+Exercise
+39.82±6.34
+Post
+Yoga
+59.48±9.04
+<0.005
+Post
+Exercise
+49.91±8.57
+Psychological 
+domain QOL
+Pre
+Yoga
+34.91±5.36
+0.987
+Pre
+Exercise
+34.93±7.31
+Post
+Yoga
+68.80±13.43
+<0.001
+Post
+Exercise
+42.23±7.36
+Social domain 
+QOL
+Pre
+Yoga
+43.07±12.70
+0.661
+Pre
+Exercise
+44.09±8.76
+Post
+Yoga
+66.77±12.00
+<0.001
+Post
+Exercise
+50.48±8.61
+Environmental 
+domain QOL
+Pre
+Yoga
+55.70±5.33
+0.904
+Pre
+Exercise
+55.84±5.28
+Post
+Yoga
+57.27±6.03
+0.249
+Post
+Exercise
+55.89±5.14
+Patil, et al.: Yoga for nurses with low back pain
+International Journal of Yoga | Volume 11 | Issue 3 | September-December 2018
+212
+Discussion
+At the end of 6 weeks of intervention as mentioned before, 
+we observed that both the groups showed significant 
+improvements in physical, psychological, and social 
+domains of WHOQOL‑BREF, whereas the environmental 
+domain did not show significant improvements in either 
+of the groups. As compared to the control group, patients 
+who 
+performed 
+yoga 
+reported 
+significantly 
+higher 
+scores on the psychological domain  (yoga  –  97.7% and 
+control – 20.89%). It was further observed that percentage 
+improvement in physical and social domains was higher 
+in the yoga group as compared to the exercise group 
+(physical domain: yoga  –  44.12% vs. control  –  25.33%; 
+and social domain: yoga – 55.02% vs. control – 14.49%).
+Previously, Tekur et  al.[22] demonstrated the usefulness 
+of a 7  day intensive residential integrated yoga in 
+improving QOL in 80  patients with CLBP in a highly 
+controlled setting where patients were away from their 
+occupational and other duties. They observed a significant 
+improvement in all the four domains of WHOQOL‑BREF 
+in the yoga‑based lifestyle module as compared to physical 
+exercise‑based lifestyle change module. One of the 
+limitations with such trials is that they are not practical for 
+working young nursing population and difficult to replicate 
+such studies. In our study, we used 1‑h yoga program 
+which included all major components of yoga therapy, 
+namely, asanas, pranayama, and relaxation. The exercise 
+group also followed similar duration and frequency of 
+intervention. We also observed improvement in physical, 
+psychological, and social domains in both the groups 
+but not in the environmental domain. The percentage 
+improvements were higher in yoga group than the exercise 
+group for physical, psychological, and social domains, 
+respectively. This may be because the intervention offered 
+by Tekur et al. was much more intensive than ours and the 
+residential setup involved exposure to such an environment 
+which was significantly different from the workplace. We 
+performed this research in much more pragmatic setup and 
+observed similar outcomes.
+Underplaying mechanism of integrated yoga therapy 
+module
+The probable mechanism of action of yoga may be 
+through improvement of autonomic functions through 
+triggering 
+neurohormonal 
+mechanisms 
+that 
+suppress 
+sympathetic activity through downregulation of the 
+hypothalamic–pituitary–adrenal axis.[23] Mindfulness‑based 
+practices may also enhance cognitive flexibility, which may 
+further reduce stress, anxiety, and pain, thereby improving 
+QOL.[24] Furthermore, the cellular effects of mechanical 
+and fluid pressure on structures such as cartilage suggest 
+that yoga postures might alter joint function. Low levels of 
+intermittent fluid pressure, as occur during joint distraction, 
+have been shown in  vitro to decrease production of 
+catabolic cytokines, such as interleukin‑1 and tumor 
+necrosis factor.[25] Yoga may be one way to provide the 
+motion and forces on joints needed to preserve integrity. In 
+addition, pranayama, meditations, and relaxation techniques 
+following yogasanas help to relax joints and muscles, 
+reduce oxidative stress, and calm the mind.[26] This study 
+implicates a probable role of integrated yoga therapy in the 
+management of patients suffering from CLBP.
+In a cross‑sectional study on 501 nurses from different 
+hospitals of Turkey, it was observed that there was a positive 
+correlation between QOL as assessed by WHOQOL‑BREF 
+and job satisfaction  (assessed using Short‑Form Minnesota 
+Questionnaire).[27] Similarly, another cross‑sectional study 
+on 435 female nurses from five regional centers in Taiwan 
+revealed that associations between scores on the sleep‑quality 
+and QOL scales were statistically significantly inversely 
+correlated.[28] Another survey on 1534 nursing professionals 
+from eight different hospitals in Taiwan found that improved 
+QOL of nurses translated into better workability (which may 
+indirectly contribute to better health‑care service delivery to 
+the patients).[29] In the above study, it was also observed that 
+mental demands of work were a critical influence on QOL 
+and workability, especially in young nursing professionals. 
+The authors further recommended countermeasures such as 
+enhancing the ability to cope with the job’s mental demands 
+for improving and maintaining the workability of nurses.
+Yoga may be considered one such intervention which 
+has been found useful in enhancing the ability to cope 
+with mental demands and thereby improve QOL and 
+workability of nurses. An anonymous E‑mail survey 
+was conducted between April and June 2010 of North 
+American nurses interested in mind‑body training to 
+reduce stress.[30] Of the 342 respondents, 96% were women 
+and 92% were Caucasian. Most  (73%) reported one or 
+more health conditions, notably anxiety  (49%), back 
+pain  (41%), gastrointestinal problems such as irritable 
+bowel syndrome (34%), or depression (33%). Their median 
+occupational stress level was 4 (0 = none and 5 = extreme 
+stress). Nearly all  (99%) reported already using one or 
+more mind‑body practices to reduce stress. The most 
+common mind‑body practices used by the nurses were 
+as follows: intercessory prayer  (86%), breath‑focused 
+meditation  (49%), healing or therapeutic touch  (39%), 
+yoga/tai 
+chi/qi 
+gong 
+(34%), 
+or 
+mindfulness‑based 
+meditation  (18%). The greatest expected benefits were for 
+greater spiritual well‑being (56%); serenity, calm, or inner 
+peace (54%); better mood (51%); more compassion (50%); 
+or better sleep (42%).[30]
+Physical domain of WHOQOL‑BREF features such as 
+mobility, fatigue, pain, sleep, and work capacity. The higher 
+percentage of improvement in the yoga group compared to 
+exercises therapy group can be credited to better reduction in 
+pain and disability with improvement in spinal flexibility.[31]
+Psychological domain features such as feelings, self‑esteem, 
+spirituality, thinking, learning, and memory. The higher 
+Patil, et al.: Yoga for nurses with low back pain
+International Journal of Yoga | Volume 11 | Issue 3 | September-December 2018
+213
+percentage of improvement in the yoga group compared to 
+exercises therapy group may be credited to better reduction 
+in stress, anxiety, and depression.[31,32]
+Social domain of WHOQOL‑BREF features questions 
+relating to problems in interpersonal relationships and 
+social support. Yoga also acts like cognitive behavioral 
+therapy; this may be the reason for the superior impact of 
+yoga intervention compared to physical exercises in nurses 
+with CLBP.
+Environmental domain deals with problems relating 
+to financial resources, physical safety, and physical 
+environment such as pollution, noise, and climate. As 
+working environment remained same throughout, this 
+might have been the reason, we did not able to notice any 
+significant changes in the environmental domain in both 
+the groups.
+Thus, yoga appears to be an integrated therapeutic tool 
+and feasible intervention for improving QOL in nursing 
+professionals compared to physical exercise as it offers 
+holistic approach.
+The strengths of the study are as follows:  (a) this 
+multidisciplinary study encompasses the fields of yogic 
+science, orthopedics, and psychology;  (b) a large sample 
+of 88 CLBP patients were enrolled for the study with 
+no dropouts,  (c) no earlier study has reported effect 
+of integrated yoga intervention on QOL of nurses 
+suffering from CLBP;  (d) because the study involved 
+a pragmatic approach, the acceptability and adherence 
+to therapy were good; and  (e) as yoga and control 
+program was delivered through a standard protocol, 
+it could be reproduced in the exact way for future 
+interventions.
+This study has a few limitations, namely: this study was 
+a preliminary attempt to assess the response of nursing 
+population suffering from CLBP, and future studies 
+should incorporate more objective variables such as 
+electromyography, radio‑imaging, biochemical measures, 
+and other advanced objective variables of autonomic 
+functions.
+Conclusions
+IYTM improves physical, psychological, and social 
+health domains of QOL among nursing professionals with 
+CLBP more than the physical exercises. There is a need 
+to incorporate yoga as lifestyle intervention for nursing 
+professionals with CLBP.
+Acknowledgments
+We are thankful for the management of Sri Devaraj Urs 
+Academy of Higher Education and Research, Tamaka, 
+Kolar, India, for their support throughout. We acknowledge 
+the participants who gave their consent and participated 
+in this study. We acknowledge Dr. Ananta Bhattacharyya, 
+Dr.  Balaram Pradhan, and Mr. Ravishankar S. for their 
+support.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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+Notwithstanding the ProQuest Terms and Conditions, you may use this content
+in accordance with the terms of the License.

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subfolder_0/Acute effects of 3G mobile phone radiations on frontal haemodynamics during a cognitive task in teenagers.txt

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+Full Terms & Conditions of access and use can be found at
+http://www.tandfonline.com/action/journalInformation?journalCode=iirp20
+Download by: [14.139.155.82]
+Date: 27 July 2016, At: 04:08
+International Review of Psychiatry
+ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: http://www.tandfonline.com/loi/iirp20
+Acute effects of 3G mobile phone radiations on
+frontal haemodynamics during a cognitive task
+in teenagers and possible protective value of Om
+chanting
+Hemant Bhargav, Manjunath N. K., Shivarama Varambally, A.
+Mooventhan, Suman Bista, Deepeshwar Singh, Harleen Chhabra, Ganesan
+Venkatasubramanian, Srinivasan T. M. & Nagendra H. R.
+To cite this article: Hemant Bhargav, Manjunath N. K., Shivarama Varambally, A. Mooventhan,
+Suman Bista, Deepeshwar Singh, Harleen Chhabra, Ganesan Venkatasubramanian,
+Srinivasan T. M. & Nagendra H. R. (2016) Acute effects of 3G mobile phone radiations
+on frontal haemodynamics during a cognitive task in teenagers and possible
+protective value of Om chanting, International Review of Psychiatry, 28:3, 288-298, DOI:
+10.1080/09540261.2016.1188784
+To link to this article:  http://dx.doi.org/10.1080/09540261.2016.1188784
+Published online: 07 Jun 2016.
+Submit your article to this journal 
+Article views: 135
+View related articles 
+View Crossmark data
+Citing articles: 1 View citing articles 
+ORIGINAL ARTICLE
+Acute effects of 3G mobile phone radiations on frontal haemodynamics
+during a cognitive task in teenagers and possible protective value of
+Om chanting
+Hemant Bhargava, Manjunath N. K.a, Shivarama Varamballyb, A. Mooventhana, Suman Bistaa,
+Deepeshwar Singha, Harleen Chhabrab, Ganesan Venkatasubramanianb, Srinivasan T. M.a and
+Nagendra H. R.c
+aAnvesana Research Laboratories, Division of Yoga and Life Sciences, S-VYASA Yoga University, Bangalore, India; bDepartment of
+Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India; cS-VYASA Yoga University,
+Bangalore, India
+ABSTRACT
+Mobile phone induced electromagnetic field (MPEMF) as well as chanting of Vedic mantra ‘OM’
+has been shown to affect cognition and brain haemodynamics, but findings are still inconclusive.
+Twenty right-handed healthy teenagers (eight males and 12 females) in the age range
+of 18.25 ± 0.44 years were randomly divided into four groups: (1) MPONOM (mobile phone ‘ON’
+followed by ‘OM’ chanting); (2) MPOFOM (mobile phone ‘OFF’ followed by ‘OM’ chanting); (3)
+MPONSS (mobile phone ‘ON’ followed by ‘SS’ chanting); and (4) MPOFSS (mobile phone ‘OFF’
+followed by ‘SS’ chanting). Brain haemodynamics during Stroop task were recorded using a
+64-channel fNIRS device at three points of time: (1) baseline, (2) after 30 min of MPON/OF expos-
+ure, and (3) after 5 min of OM/SS chanting. RM-ANOVA was applied to perform within- and
+between-group comparisons, respectively. Between-group analysis revealed that total scores on
+incongruent Stroop task were significantly better after OM as compared to SS chanting
+(MPOFOM vs MPOFSS), pre-frontal activation was significantly lesser after OM as compared to SS
+chanting in channel 13. There was no significant difference between MPON and MPOF conditions
+for Stroop performance, as well as brain haemodynamics. These findings need confirmation
+through a larger trial in future.
+ARTICLE HISTORY
+Received 8 January 2016
+Revised 10 April 2016
+Accepted 7 May 2016
+Published online 2 June 2016
+KEYWORDS
+Electro-magnetic field;
+mobile phone; om chanting;
+pre-frontal activation; Stroop
+Introduction
+With over 5.9 billion reported mobile phone users,
+mobile phone constitutes to a new rapidly growing
+exposure network in the world, putting almost all the
+humans into a wide spectra of electromagnetic radi-
+ation. Mobile phones emit a radiofrequency electro-
+magnetic field (MPEMF), a large part of energy of
+which is absorbed into the user’s head (Schonborn,
+Burkhardt, & Kuster, 1998). Accumulating evidence
+suggests that MPEMF may alter brain physiology.
+Modulating effects of MPEMF on the human electro-
+encephalogram in waking and sleep have repeatedly
+been demonstrated in recent years, while results on
+cognitive
+performance
+are
+inconsistent
+(Regel
+&
+Achermann, 2011). The lack of a validated tool, which
+reliably assesses changes in cognitive performance
+caused by MPEMF exposure, may contribute to the
+current
+inconsistency
+in
+outcomes
+(Regel
+&
+Achermann, 2011). Some behavioural studies have sug-
+gested that EMF might have a facilitative effect on
+cognitive performance (Preece et al., 2005; Smythe &
+Costall, 2003), although more recent studies primarily
+revealed an impairment of mental abilities or no effect
+at all (Haarala, Aalto et al., 2003; Haarala, Bj€
+ornberg
+et al., 2003; Regel & Achermann, 2011). Results of a
+meta-analysis suggested that MPEMF might have a
+small impact on human attention and working mem-
+ory
+(Barth,
+Ponocny,
+Ponocny-Seliger,
+Vana,
+&
+Winker, 2010). All these studies have chiefly been per-
+formed on adults and children. Studies on teenage
+group are lacking. This age-group is among the most
+prolific users of mobile phones, which puts them at
+higher risk for MPEMF exposure-related effects (Aydin
+et al., 2011).
+Functional near-infrared spectroscopy (fNIRS) is a
+new non-invasive optical method that can measure the
+real
+time
+change
+in
+oxygenated
+haemoglobin
+(oxyHb) and deoxygenated haemoglobin (deoxyHb)
+concentrations and their sum, i.e. total haemoglobin
+(totalHb) or blood volume in the brain areas, suggesting
+CONTACT Hemant Bhargav
+[email protected]
+Anvesana Research Laboratories, Division of Yoga and Life Sciences, S-VYASA Yoga
+University, Bangalore, India
+ 2016 Institute of Psychiatry
+INTERNATIONAL REVIEW OF PSYCHIATRY, 2016
+VOL. 28, NO. 3, 288–298
+http://dx.doi.org/10.1080/09540261.2016.1188784
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+activation (increase in oxygenation) or deactivation
+(reduction in oxygenation) of a particular brain area
+(Ferrari & Quaresima, 2012). An fNIRS device has
+excellent temporal resolution, and fNIRS results are
+physiologically comparable to fMRI and PET results
+(Obrig & Villringer, 2003). In a study using fNIRS, local
+cerebral blood flow (CBF) on short-term exposure to
+MPEMF was measured in 26 boys, aged 14–15 years.
+Temperatures were also measured from both ear canals,
+and skin temperatures at several sites of the head,
+trunk, and extremities. It was found that local CBF and
+ear canal temperature did not change and the auto-
+nomic nervous system was not interfered with by
+MPEMF (Lindholm et al., 2011). The study showed the
+utility of fNIRS for EMF-related research. Compared to
+previous studies using PET, fNIRS provides a much
+higher time resolution, which allows investigation of
+the short-term effects of EMF non-invasively, without
+the use of radioactive tracers and with high sensitivity.
+The Stroop task is a useful test of selective attention
+and
+inhibition
+and
+involves
+frontally
+mediated
+cognitive processes such as response inhibition and
+interference
+resolution
+(Stroop,
+1935).
+Functional
+neuro-imaging studies have found several areas of the
+prefrontal cortex that appear to be specifically acti-
+vated during the performance Stroop task. The Stroop
+task has been used in several PET, fMRI, and fNIRS
+studies (Taylor, Kornblum, Lauber, Minoshima, &
+Koeppe, 1997).
+OM is a cosmic sound that has a harmonizing effect
+on the system (Kumar, Nagendra, Manjunath, Naveen,
+& Telles, 2010). An fMRI study assessed neuro-haemo-
+dynamic correlates of ‘OM’ chanting and found signifi-
+cant deactivation in bilateral orbito-frontal, anterior
+cingulate, para-hippocampal gyri, thalami, and hippo-
+campi, and right amygdala as compared to chanting of
+the sound Ssss or ‘SS’. Since similar observations have
+been recorded with vagus nerve stimulation treatment
+which
+is
+used
+in
+depression
+and
+epilepsy
+management, the study findings argued for a potential
+role of OM chanting in clinical practice (Kalyani,
+Venkatasubramanian, Arasappa, Rao, Kalmady, Behere,
+et al., 2011). Another recent study used fNIRS to assess
+the immediate effect of 20 min of OM meditation (men-
+tal chanting with effortless defocusing on syllable ‘OM’)
+on Stroop task and found better performance and effi-
+ciency (deactivation of pre-frontalcortices) after OM
+meditation (Deepeshwar, Vinchurkar, Visweswaraiah,
+& Nagendra, 2014).
+Very few studies have assessed the effect of MPEMF
+exposure on cognitive functions and brain haemo-
+dynamics in adolescent population using fNIRS (Kwon
+& H€
+am€
+al€
+ainen,
+2011). Similarly, the effect of OM
+chanting on the above variables after mobile phone
+exposure has not been assessed before. We hypothe-
+sized that MPEMF exposure of 30 min would affect
+Stroop
+task
+performance
+and
+pre-frontal
+haemo-
+dynamics during the task in teenagers, and OM chant-
+ing of 5 min following MPEMF exposure will have a
+balancing effect on changes induced by MPEMF. The
+present pilot study was planned to assess feasibility of
+the protocol for future larger trails.
+Materials and methods
+Participants
+We enrolled 20 right-handed teenagers (eight males
+and 12 females) in the age range of 18.25 ± 0.44 years
+from educational institutes in Bangalore city of India.
+All subjects were healthy, as assessed by general health
+questionnaire (GHQ-12), their mean GHQ score was
+0.8 ± 0.69,
+and
+average
+body
+mass
+index
+was
+21.7 ± 3.7 kg/m2. Subjects were fresh admissions in an
+undergraduate degree course after recently clearing
+their higher secondary school examinations and their
+last academic performance was with an aggregate of
+72.48 ± 11.3%, suggesting absence of mental retardation
+or other significant psychological morbidity. Subjects
+who were able to read and write in English language
+were selected. Subjects who had visual disturbances or
+colour blindness (screened using Ishihara Charts) or
+those with a peak flow rate below 150 L/min were
+excluded; those who were regular meditators or who
+were regularly chanting OM (or other similar mantras)
+for the last 1 month or more were also excluded.
+Similarly, female subjects were excluded during men-
+struation. Subjects were given a week long orientation
+in performing OM chanting or producing the sound
+‘sssss
+. . .’
+(SS)
+for
+same
+duration
+before
+the
+assessments.
+Study design
+A four groups randomized controlled design was fol-
+lowed. Each subject was exposed to mobile phone on/
+off for 30 min and then was asked to chant OM or SS
+for 5 min. Depending on the status of phone (on or off)
+and whether it is followed by chanting OM or SS, sub-
+jects
+were
+randomly
+divided
+into
+four
+groups.
+Randomization was performed using an online ran-
+domization program (www.randomizer.org). It was gen-
+der-stratified randomization to include equal number of
+males and females (two males and three females) in
+each
+group.
+Four
+groups
+were
+as
+follows:
+(1)
+INTERNATIONAL REVIEW OF PSYCHIATRY
+289
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+MPONOM group: In this group, subjects were exposed
+to MPEMF through a mobile phone in ‘ON’ mode for
+30 min and after this subjects chanted OM for 5 min;
+similarly,
+in
+(2)
+MPOFOM
+group:
+Subjects
+were
+exposed to mobile phone in ‘OFF’ mode and chanted
+OM; in (3) MPONSS group: Subjects were exposed to
+mobile phone in ‘ON’ mode followed by ‘SS’ chanting;
+and, lastly in (4) MPOFSS group: subjects were exposed
+to mobile phone in ‘OFF’ mode and chanted ‘SS’ after-
+wards. Assessments were done at three points of time
+in each group: (1) Baseline; (2) After mobile phone on/
+off exposure; and (3) after OM/SS chanting. Table 1
+provides demographic details of the subjects in each
+group. Demographic details did not differ significantly
+between the groups. A schematic representation of the
+study design is provided in Figure 1. Signed informed
+consent was taken from the subjects who were above
+18 years of age and from the guardian/parents of those
+below 18 years of age. Research was approved by insti-
+tutional ethical committee.
+EMF exposure settings
+The source of EMF was a 2100 MHz 3G mobile phone
+with a Universal Mobile Telecommunications System’s
+(UMTS) network. It was an FCC approved device and
+had a head specific absorption ratio (SAR) of 0.4 W/
+Kg and body SAR of 0.54 W/Kg. Subjects sat on a
+comfortable chair with head resting on the chair and
+two identical mobile phones were kept at 0.5 cm dis-
+tance from the tragus, one on each side, using an
+adjustable wooden stand. On calling mode, the device
+emitted average EMF energy of 1.305 ± 0.94 mW/m2
+(with peak value of 2.34 mW/m2) at 5 mm. Left side
+mobile was kept in off mode permanently with battery
+removed. Right side mobile status only was changed
+depending on the group to which the subject belongs.
+Identical phones were kept on both sides at the same
+distance from the ear to rule out lateralization effects
+on brain haemodynamics. When subjects were exposed
+to MPEMF, i.e. in MPON groups, fully charged mobile
+was placed on the right side and a call was made for
+30 min from another phone. Both the phones (caller
+and receiver) were kept mute throughout. During
+sham exposure, the right side mobile was kept off with
+battery removed. Subjects were unaware of the group
+status
+they
+were
+allocated
+to.
+A
+counterbalanced
+experiment with eight independent subjects, each with
+four trials, indicated that the subjects could not detect
+the EMF exposure condition any better than by guess-
+ing (response accuracy 50%). FNIRS cap was fixed on
+the head of the subject and recording was taken in a
+dark room with a computer screen displaying Stroop
+task. Figure 2 shows the settings of the study. During
+the 30- min period of mobile phone on/off exposure,
+subjects
+heard
+an
+audio
+describing
+geography
+of
+Karanataka state. To ensure that subjects remained
+awake during this period, subjects were asked to
+Table 1. Demographic details of the subjects.
+Variables/Group
+MPONOM (mean ± SD)
+MPOFOM (mean ± SD)
+MPONSS (mean ± SD)
+MPOFSS (mean ± SD)
+n
+5
+5
+5
+5
+Age (years)
+18.40 ± 0.548
+18.40 ± 0.548
+18.20 ± 0.447
+18.20 ± 0.447
+Gender (numbers)
+Male (n ¼ 2)
+Female (n ¼ 3)
+Male (n ¼ 2)
+Female (n ¼ 3)
+Male (n ¼ 2)
+Female (n ¼ 3)
+Male (n ¼ 2)
+Female (n ¼ 3)
+Height (m)
+1.64 ± 0.06
+1.63 ± 0.08
+1.61 ± 0.12
+1.63 ± 0.05
+Weight (kg)
+53.60 ± 4.10
+52.98 ± 6.61
+56.80 ± 8.32
+61.40 ± 20.71
+BMI (kg/m2)
+20.41 ± 1.83
+20.10 ± 1.94
+21.69 ± 3.71
+22.40 ± 7.01
+Head circumference (cm)
+53.80 ± 1.10
+54.40 ± 1.82
+55.00 ± 1.41
+55.20 ± 0.84
+Last academic performance (%)
+74.20 ± 8.56
+77.60 ± 7.96
+71.36 ± 12.13
+72.76 ± 12.01
+GHQ-12 scores
+0.9 ± 0.44
+0.8 ± 0.50
+0.8 ± 0.31
+0.7 ± 0.66
+MPONOM: mobile phone ‘ON’ followed by ‘OM’ chanting; MPOFOM: mobile phone ‘OFF’ followed by ‘OM’ chanting; MPONSS: mobile
+phone ‘ON’ followed by ‘SS’ chanting; MPOFSS: mobile phone ‘OFF’ followed by ‘SS’ chanting.
+Figure 1. Schematic representation of the study design. R: Rest; C: Congruent task; I: Incongruent task.
+290
+H. BHARGAV ET AL.
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+answer 10 simple multiple choice questions at the end,
+based on the audio. Those scoring more than 50%
+were only included in the study further.
+fNIRS device
+We used a 64 channel continuous wave fNIRS device
+(NIRx Medical Technologies, LLC, NY, USA) with a
+sampling rate of 15.6 Hz. With eight light emitting
+sources and eight detector probes, 18 channels were
+measured quasi-simultaneously over both the pre-
+frontal cortices using two wavelengths of near-infrared
+light (760 nm and 850 nm). Probes were fixed on the
+head based on 10–20 system using whole head stand-
+ard sized caps (NIRScaps) for the age group assessed.
+Figure 3 provides the montage and Table 2 provides
+the channel distribution of fNIRS device followed in
+the study.
+Stroop task and procedure
+Subjects were seated comfortably on a reclining chair
+in a Faraday cage, facing a 21-inch LCD monitor
+placed at a distance of 70 cm from their eyes. The cog-
+nitive paradigm used in the present study was Stroop
+task. The traditional 100 item paper and pencil version
+of Stroop was projected on a computer screen and ver-
+bal responses were recorded. The Stroop task was
+designed based on the paradigm followed in previous
+research (Taniguchi, Sumitani, Watanabe, Akiyama, &
+Ohmori, 2012). During the Stroop task subjects were
+asked to read as many words as possible on a com-
+puter screen displaying 100 words. Subjects were ran-
+domly presented with words ‘red’, ‘blue’, ‘yellow’, and
+‘green’ which were written in red, blue, yellow, and
+green ink. The task was presented in block design that
+consisted of rest periods and two test conditions: con-
+gruent and incongruent. In the congruent condition
+the name of the word was congruent with the colour
+of the ink and subjects were asked to read them out.
+In incongruent conditions, the four words were written
+in incongruent colours. The time for Stroop task was
+fixed and it was given using an automated software for
+a total duration of 2 min and 30 s in the following
+blocks: 30 s rest - 30 s task (congruent) - 30 s rest -
+30 s task (incongruent) - 30 s rest. In the rest periods,
+clear instructions were shown to the subject for the
+next task condition, for e.g. before congruent condition
+the instruction was: ‘Please read the words on the
+screen loudly and as quickly as possible’ and before
+Figure 3. Montage of the study.
+Figure 2. Settings of the study.
+INTERNATIONAL REVIEW OF PSYCHIATRY
+291
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+the incongruent condition the instruction was: ‘Please
+read the colour of the words on the screen loudly and
+as quickly as possible’. Each subject was given orienta-
+tion to the task 1 day prior to data collection. The
+responses (number of total, correct, and incorrect
+responses in 30 s of each condition) were recorded
+manually by two trained psychologists using an answer
+key for each condition. Both psychologists were blind
+to the group allocations of the subject. Data was con-
+sidered valid only when the scores from both the psy-
+chologists were matching. The fNIRS measurement
+was performed during the whole task. Markers were
+applied for each task condition (congruent and incon-
+gruent)
+during
+recording
+to
+segregate
+respective
+haemodynamic responses.
+OM/SS chanting procedure
+All the subjects were trained in ‘OM’ chanting by an
+experienced yoga teacher and an orientation training
+of 1 week was given to all the subjects before data col-
+lection. The subjects were trained to chant ‘OM’ loudly
+without distress and interruption—the vowel (O) part
+of the ‘OM’ for 5 s continuing into the consonant
+(M) part of the ‘OM’ for the next 10 s, maintaining a
+ratio of 1:2. The control condition was continuous
+production of ‘sssss . . .’ or ‘SS’ syllable for the same
+duration. This was chosen to control for the expiratory
+act of chanting ‘OM’, but without the vibratory sensa-
+tion around the ears (Kalyani et al., 2011).
+Data extraction and analysis
+NIRS optical intensity data was processed by NIRstar
+acquisition software and extracted using accompanying
+topography
+software
+(nirsLAB;
+NIRx
+Medical
+Technologies, LLC). Data were corrected for the effects
+of vascular pulsation (Gratton & Fabiani, 2010). Pulse
+corrected data were filtered using a low-pass (zero
+phase
+shift)
+filter
+with
+a
+cut-off
+frequency
+at
+0.01–0.2 Hz. For every subject, the channel measure-
+ments showing low signal-to-noise ratio were dis-
+carded. Linear trends of continuous oxyHb changes
+and fluctuations were also eliminated. For oxyhaemo-
+globin (oxyHb) concentration changes a 30 s baseline
+was taken for analysis. To obtain haemodynamic data,
+the
+modified
+Beer–Lambert
+Law
+was
+applied
+to
+artifact-free segments (Hoshi, Kobayashi, & Tamura,
+1985). We focused on oxyHb concentration changes
+for further analysis because they provide the most
+robust signal-to-noise ratio and are the most sensitive
+parameter of cerebral blood flow (Hoshi et al., 1985;
+Sato et al., 2012). Values for changes in oxyHb were
+obtained during the contrast of interest (Incongruent
+minus Congruent Stroop), i.e. Stroop interference, for
+all 18 channels at three points of time: (1) Baseline,
+(2) Post mobile on/off, and (3) Post OM/SS for all the
+four
+groups
+(MPONOM,
+MPOFOM,
+MPONSS,
+MPOFSS). Similarly, Stroop task performance was
+assessed at these three points of time for the four
+groups.
+Analysis
+of
+variance-repeated
+measures
+(RM-
+ANOVA) was used for data analysis using SPSS ver-
+sion 10. For analysis of Stroop performance, Stroop
+task condition (correct, incorrect, and total scores for
+each condition: congruent and incongruent) was the
+dependent variable with ‘group’ as between-subjects
+and ‘time point’ as within-subject factor. For haemo-
+dynamics data, one multivariate RM-ANOVA analysis
+was performed for all the 18 fNIRS channels. Channels
+1–18 were the dependent variable (level), with ‘group’
+as between-subjects and ‘time point’ as within-subject
+factor.
+Post-hoc
+comparisons
+between
+individual
+groups/time points were made through Bonferroni’s
+correction after checking for significance of main
+effects or interactions.
+Results
+Forty-six subjects were screened, out of which 30 gave
+consent to participate in the study. Out of 30, 24 satis-
+fied the selection criteria and orientation training was
+started.
+Finally,
+four
+subjects
+left
+the
+project
+in
+between and final data collection was successfully per-
+formed on 20 subjects.
+Stroop performance
+As depicted in Figure 4, for Stroop incongruent total
+scores (task condition), RM-ANOVA revealed signifi-
+cant main effects for the time points, F(2, 15) ¼ 28.57,
+p < 0.001, and a significant interaction between group
+and time point, F(6, 32) ¼ 4.64, p < 0.05. Follow-up
+Bonferroni’s adjustment showed that total scores in
+Table 2. Channel distributions followed in the study while using fNIRS device.
+Left side
+S1-D1
+S2-D1
+S2-D2
+S3-D1
+S3-D3
+S4-D1
+S4-D2
+S4-D3
+S4-D4
+Ch-1
+2
+3
+4
+5
+6
+7
+8
+9
+Right side
+S5-D5
+S5-D6
+S5-D7
+S5-D8
+S6-D6
+S6-D8
+S7-D7
+S7-D8
+S8-D8
+10
+11
+12
+13
+14
+15
+16
+17
+18
+S1–S8: Sources; D1–D8: Detectors; Ch1–18: Channels.
+292
+H. BHARGAV ET AL.
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+incongruent Stroop task were significantly better in
+MPOFOM group after OM chanting as compared to
+those in MPOFSS group after SS chanting (Table 3;
+Figure 4). Within-group analysis showed that there
+was a significant improvement in total scores of incon-
+gruent Stroop task after OM chanting in MPONOM
+(p < 0.01) and MPOFOM (p < 0.001) groups as com-
+pared to the baseline and in MPOFOM group as com-
+pared to the post-mobile values (p < 0.05), respectively
+(Table 4). Also, in MPONSS group, there was a signifi-
+cant improvement in scores of same task condition
+after
+SS
+chanting
+as
+compared
+to
+the
+baseline
+(p < 0.01; Table 4). For other task conditions no sig-
+nificant main effects or interactions were observed.
+fNIRS results
+Multivariate RM-ANOVA for all the 18 channels
+revealed
+significant
+main
+effects
+for
+levels
+[F(2,
+5) ¼ 6.18; p < 0.05; Effect Size ¼0.62] and significant
+interaction between level and group [F(6, 12) ¼ 5.82,
+p < 0.05; Effect Size ¼0.60]. Subsequent RM-ANOVA
+tests for each channel showed significant main effects
+for the time points in fNIRS channels 2, 6, 7, 8, 10,
+13, and 18 [Channel 2: F(2, 26) ¼ 3.51, p < 0.05;
+Channel 6: F(2, 26) ¼ 3.27, p < 0.05; Channel 7: F(2,
+26) ¼ 6.11,
+p < 0.01;
+Channel
+8:
+F(2,
+26) ¼ 6.05,
+p < 0.01;
+Channel
+10:
+F(2,
+26) ¼ 3.11,
+p < 0.05;
+Channel 13: F(2, 26) ¼ 3.41, p < 0.05; Channel 18: F(2,
+26) ¼ 3.46,
+p < 0.05]
+and
+a
+significant
+interaction
+between group and time point for channels 13 and 18
+[Channel 13: F(6, 26) ¼ 2.50, p < 0.05; Channel 18:
+Figure 4. Graph showing changes in total scores of incongru-
+ent Stroop task in all the four groups at three points of time:
+Group: 1: MPONOM; 2: MPONSS; 3: MPOFOM; 4: MPOFSS; Level:
+1: Baseline; 2: After 30 min of MPON/OF exposure; 3: After OM/
+SS chanting. Y-axis: Total scores during Stroop Incongruent
+Task.
+Table 3. Comparison within groups for Stroop performance at the baseline, after mobile phone on/off exposure and after OM/SS
+chanting.
+Group
+Task
+condition
+Scores
+Baseline
+(mean ± SD) (1)
+After mobile
+(mean ± SD) (2)
+After OM/SS
+(mean ± SD) (3)
+F values
+(df hypothesis,
+error)
+Effect
+size
+pa value
+(1 vs 2)
+pa value
+(2 vs 3)
+pa value
+(1 vs 3)
+MPONOM
+CT
+C
+47.00 ± 12.79
+51.40 ± 14.69
+53.00 ± 6.86
+(2,15) 1.71
+2.53
+1
+1
+1
+IC
+1.00 ± 1.00
+1.00 ± 0.71
+1.00 ± 1.22
+(2,15) 0.91
+0.01
+1
+1
+1
+T
+50.40 ± 6.11
+51.60 ± 5.77
+53.20 ± 5.97
+(2,15) 0.81
+1.14
+1
+1
+1
+ICT
+C
+25.60 ± 3.97
+27.40 ± 7.37
+30.60 ± 4.22
+(2,15) 2.48
+2.06
+1
+0.934
+0.072
+IC
+1.80 ± 2.17
+1.20 ± 1.30
+1.60 ± 1.14
+(2,15) 0.51
+0.24
+0.624
+0.533
+1
+T
+27.40 ± 3.97
+28.60 ± 7.47
+32.20 ± 4.66
+(2,15) 6.03
+2.03
+1
+0.821
+0.033*
+MPONSS
+CT
+C
+45.80 ± 3.19
+43.20 ± 6.30
+46.40 ± 7.50
+(2,15) 3.76
+1.38
+1
+0.342
+1
+IC
+1.20 ± 1.30
+2.20 ± 1.48
+1.60 ± 1.14
+(2,15) 0.34
+0.41
+0.267
+0.914
+1
+T
+48.40 ± 4.62
+46.20 ± 4.92
+49.80 ± 4.92
+(2,15) 0.84
+1.48
+1
+0.276
+1
+ICT
+C
+25.20 ± 3.56
+29.20 ± 3.96
+30.00 ± 5.39
+(2,15) 2.1
+2.09
+0.057
+1
+0.072
+IC
+2.00 ± 1.58
+1.80 ± 1.92
+2.00 ± 1.58
+(2,15) 0.24
+0.09
+1
+1
+1
+T
+27.20 ± 3.42
+31.00 ± 2.83
+32.00 ± 4.95
+(2,15) 6.79
+2.06
+0.215
+1
+0.028*
+MPOFOM
+CT
+C
+46.40 ± 6.02
+48.80 ± 3.63
+50.00 ± 3.67
+1.93 (2,15)
+1.49
+0.466
+1
+1
+IC
+0.40 ± 0.89
+0.20 ± 0.45
+0.40 ± 0.55
+(2,15) 0.21
+0.24
+1
+1
+1
+T
+49.80 ± 13.41
+56.00 ± 12.19
+54.80 ± 5.81
+(2,15) 21.5
+2.60
+0.662
+1
+1
+ICT
+C
+26.00 ± 5.10
+30.60 ± 3.91
+35.40 ± 2.07
+(2,15) 2.87
+3.83
+0.141
+0.084
+0.065
+IC
+1.80 ± 1.48
+1.60 ± 0.89
+1.40 ± 1.14
+(2,15) 0.10
+0.16
+1
+1
+1
+T
+27.80 ± 4.60
+32.20 ± 4.02
+36.80 ± 2.77
+(2,15) 21.5
+3.67
+0.234
+0.034*
+0.052
+MPOFSS
+CT
+C
+51.40 ± 3.78
+49.40 ± 9.15
+52.60 ± 6.39
+(2,15) 1.17
+1.31
+1
+0.226
+1
+IC
+1.20 ± 1.30
+1.40 ± 1.67
+1.40 ± 1.14
+(2,15) 0.21
+0.94
+1
+1
+1
+T
+45.80 ± 2.39
+43.80 ± 6.02
+48.60 ± 7.02
+(2,15) 1.1
+1.96
+1
+0.19
+1
+ICT
+C
+21.40 ± 8.88
+24.20 ± 5.97
+24.80 ± 4.32
+(2,15) 1.2
+1.48
+0.985
+1
+0.616
+IC
+3.40 ± 3.97
+2.60 ± 2.19
+2.00 ± 2.35
+(2,15) 2.7
+0.57
+1
+0.211
+0.404
+T
+24.80 ± 5.02
+26.80 ± 4.44
+26.80 ± 2.39
+(2,15) 1.32
+0.94
+0.958
+1
+0.871
+CT: Congruent task; ICT: Incongruent task; C: Correct score; IC: Incorrect score; T: Total score.
+aRepeated measures ANOVA after Bonferroni’s adjustment.
+*p < 0.05.
+INTERNATIONAL REVIEW OF PSYCHIATRY
+293
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+F(2, 26) ¼ 2.53, p < 0.05]. Post-hoc analysis through
+Bonferroni’s
+correction
+further
+revealed
+that
+pre-
+frontal oxygenation was significantly lesser in the
+MPOFOM group after OM chanting as compared to
+the MPONSS group after SS chanting in channel 13
+(p < 0.05) and channel 18 (p < 0.05; Table 5; Fig. 5
+and 6). Within-group analysis showed that there was a
+significant reduction in oxygenation after OM chanting
+in the MPOFOM group as compared to post-MPOF
+values in channels 2, 6, 7, 8, 13, and 18 (Table 5).
+Also, in the MPONSS group, there was a significant
+increase in pre-frontal oxygenation in channel 10 after
+SS chanting as compared to the baseline (p < 0.05;
+Table 5). For other fNIRS channels no significant
+main effects or interactions were observed.
+Discussion
+The present pilot work was planned to assess feasibility
+of the protocol for future larger trails. We found the
+protocol to be feasible and none of the subjects
+reported any side-effects. We did not observe any sig-
+nificant difference between MPON or MPOF condi-
+tions
+for
+Stroop
+Task
+performance
+or
+brain
+haemodynamics, but there was a tendency for better
+Stroop incongruent performance and reduced oxygen-
+ation in some channels after OM chanting as com-
+pared
+to
+SS
+chanting.
+Previously,
+Regel
+and
+Achermann (2011) reviewed 41 studies, where distinct
+cognitive tasks were employed at various levels of diffi-
+culty
+to
+evaluate
+effects
+of
+MPEMF.
+Six
+studies
+revealed an increase in performance speed, and seven
+studies reported a decrease. Similarly, accuracy of per-
+formance was reduced and elevated in several experi-
+ments. Most of the previous studies have not found
+any effect of MPEMF exposure for less than 20 min on
+brain haemodynmaics (Regel & Achermann, 2011);
+therefore, in the present trial we chose a duration of
+30 min for exposure. In the present study, even after
+30 min of MPEMF exposure, we did not observe any
+significant improvement or decline in cognitive per-
+formance or changes in brain haemodynamics. The
+present study used a task (Stroop task) which requires
+less duration and yet is complex enough to elicit a
+cognitive response (Stroop, 1935). Previously, a cross-
+sectional study used the Stroop task to find out associ-
+ations between cognitive performance and mobile
+phone use and found that mobile phone use was asso-
+ciated with faster and less accurate responding to
+higher level cognitive tasks (Abramson et al., 2009).
+In
+another
+study,
+the acute
+effect
+of
+45 min
+of
+MPEMF exposure was tested on 168 subjects using
+the Stroop paradigm. Subjects were in the age range
+Table 4. Comparison between MPOFOM and MPOFSS groups for Stroop Performance (Incongruent Task) at the baseline, after mobile phone on/off exposure and after OM/SS
+chanting.
+Correct score
+Incorrect score
+Total score
+MPOFOM
+MPOFSS
+F value
+(df contrast,
+error)
+pa value
+MPOFOM
+MPOFSS
+F value
+(df contrast,
+error)
+pa value
+MPOFOM
+MPOFSS
+F value
+(df contrast,
+error)
+pa value
+Baseline
+26.00 ± 5.10
+21.40 ± 8.88
+(3,16) 0.67
+1
+1.80 ± 1.48
+3.40 ± 3.97
+(3,16) 0.91
+1
+27.80 ± 4.60
+24.80 ± 5.02
+(3,16) 0.63
+1
+After mobile on/off
+30.60 ± 3.91
+24.20 ± 5.97
+(3, 16) 0.32
+0.5
+1.60 ± 0.89
+2.60 ± 2.19
+(3,16) 0.63
+1
+32.20 ± 4.02
+26.80 ± 4.44
+(3,16) 0.33
+0.63
+After OM/SS
+35.40 ± 2.07
+24.80 ± 4.32
+(3,16) 5.38
+0.005**
+1.40 ± 1.14
+2.00 ± 2.35
+(3,16) 0.17
+1
+36.80 ± 2.77
+26.80 ± 2.39
+(3,16) 5.6
+0.006**
+MPOFOM: mobile phone off followed by Om chanting; MPOFSS: Mobile phone off followed by ‘SS’ chanting.
+aRM-ANOVA after Bonferroni’s adjustment.
+**p < 0.01.
+294
+H. BHARGAV ET AL.
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+of 18–42 years. It was observed that, with neutral
+Stroop condition, the mean reaction time of subjects
+was significantly lesser when exposed to MPEMF
+signals than in the sham condition, whereas with
+incongruent Stroop condition, there was no signifi-
+cant difference between the groups (Cinel, Boldini,
+Fox, & Russo, 2008). In the present study, we did
+not
+find
+any
+difference
+in
+performance
+between
+MPEMF and sham exposure for either congruent or
+incongruent Stroop task after 30 min of exposure.
+This may be due to a very small sample size in the
+present study as compared to the study by Cinel
+et al. (2008). Probably, 45 min of MPEMF exposure
+would have produced some changes in cognitive per-
+formance, as observed by Cinel et al. (2008), but,
+since the institutional ethical committee did not per-
+mit exposure of mobile phone radiation for more
+than 30 min to teenagers, the duration of 30 min
+was chosen for our study.
+A previous positron emission tomography (PET)
+study found increased cerebral blood flow (CBF) in
+the prefrontal cortex after 30 min exposure to a 900-
+Table 5. Significant changes in oxyHb levels (lmol/l) in different groups across fNIRS channels.
+Group
+Channel
+Side
+Baseline
+(mean ± SD)
+(1)
+After mobile
+(mean ± SD)
+(2)
+After OM/SS
+(mean ± SD)
+(3)
+F values
+(df hypoth-
+esis, error)
+Effect size
+pa value
+(1 vs 2)
+pa value
+(2 vs 3)
+pa value
+(1 vs 3)
+MPOFOM
+2
+Left
+1.41 ± 6.43
+4.50 ± 2.77
+4.95 ± 5.94
+(2, 26) 3.51
+0.46
+1
+0.03*
+0.18
+6
+Left
+2.12 ± 4.91
+3.67 ± 3.43
+7.58 ± 3.60
+(2, 26) 3.27
+0.46
+0.28
+0.03*
+0.51
+7
+Left
+3.76 ± 9.24
+9.21 ± 3.37
+2.27 ± 8.42
+(2, 26) 6.11
+0.52
+0.55
+0.04*
+0.11
+8
+left
+0.33 ± 5.22
+6.40 ± 2.27
+5.17 ± 2.88
+(2, 26) 6.05
+0.64
+0.40
+0.002**
+0.26
+13
+Right
+2.27 ± 5.87
+2.36 ± 2.00
+6.74 ± 5.72#
+(2, 26) 3.41
+0.42
+0.86
+0.04*
+0.32
+18
+Right
+1.34 ± 10.46
+4.11 ± 1.50
+8.16 ± 8.39$
+(2, 26) 3.46
+0.57
+0.55
+0.03*
+0.016*
+MPONSS
+10
+Right
+1.94 ± 7.19
+0.70 ± 8.10
+3.77 ± 4.78
+(2, 26) 3.11
+0.49
+1
+1
+0.011*
+13
+Right
+0.81 ± 6.55
+0.40 ± 5.56
+1.68 ± 2.40#
+(2, 26) 0.74
+0.04
+1
+0.71
+1
+18
+Right
+0.54 ± 4.66
+2.16 ± 6.82
+1.11 ± 3.40$
+(2, 26) 0.72
+0.04
+1
+0.75
+1
+oxyHb: oxygenated haemoglobin; fNIRS: functional near infrared spectroscopy; MPOFOM: mobile phone ‘OFF’ followed by ‘OM’ chanting; MPONSS: mobile
+phone ‘ON’ followed by ‘SS’ chanting.
+aRepeated measures ANOVA after Bonferroni’s adjustment
+*p < 0.05;
+**p < 0.01.
+#Significant between-group differences; F(6, 26) ¼ 2.50, p < 0.05.
+$Significant between-group differences; F(2, 26) ¼ 2.53, p < 0.05.
+Figure 5. Graph showing changes in oxyHb levels in channel
+13 during Stroop task in all the four groups at three points of
+time: Group: 1: MPONOM; 2: MPONSS; 3: MPOFOM; 4: MPOFSS;
+Level: 1: Baseline; 2: After 30 min of MPON/OF exposure; 3:
+After OM/SS chanting. Y-axis: Concentration of oxygenated
+haemoglobin (oxyHb) expressed in lmol/l.
+Figure 6. Graph showing changes in oxyHb levels in channel
+18 during Stroop task in all the four groups at three points of
+time: Group: 1: MPONOM; 2: MPONSS; 3: MPOFOM; 4: MPOFSS;
+Level: 1: Baseline; 2: After 30 min of MPON/OF exposure; 3:
+After OM/SS chanting. Y-axis: Concentration of oxygenated
+haemoglobin (oxyHb) expressed in lmol/l.
+INTERNATIONAL REVIEW OF PSYCHIATRY
+295
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+MHz GSM signal (Huber et al., 2005). Another
+similar PET study showed decreased cerebral blood
+flow
+in
+the
+temporal
+cortex
+after
+a
+continuous
+51 min exposure to a 902-MHz GSM signal (Aalto
+et al., 2006). A brain energy metabolism study done
+using PET on 13 young male subjects exposed to a
+pulse modulated 902.4 MHz GSM for 33 min while
+performing
+a
+simple
+visual
+vigilance
+task
+also
+showed that relative cerebral metabolic rate of glu-
+cose was significantly reduced in the temporo-par-
+ietal junction and anterior temporal lobe of the right
+hemisphere ipsilateral to the exposure (Kwon et al.,
+2011). Another study investigated the effects induced
+by an exposure to a GSM signal on brain BOLD
+(blood-oxygen-level dependent) response, as well as
+its time course while performing a Go–No-Go task.
+BOLD response of active brain areas and reaction
+times (RTs) while performing the task were meas-
+ured both before and after the exposure. It was
+observed that reaction times to the somato-sensory
+task did not change as a function of exposure (real
+vs sham) to GSM signal. BOLD results revealed sig-
+nificant activations in inferior parietal lobule, insula,
+precentral, and postcentral gyri associated with Go
+responses
+after
+both
+‘real’
+and
+‘sham’
+exposure,
+whereas no significant effects were observed in the
+between-group analysis. The authors concluded that
+there were no changes in BOLD response as a con-
+sequence of EMFs exposure (Curcio et al., 2012).
+Most of these researches used a 900 MHz GSM sig-
+nal which corresponds to the 2G spectrum and the
+results were mixed. In the present study, depending
+on
+the
+increasing
+use,
+we
+exposed
+subjects
+to
+2170 MHz UMTS (which corresponds to 3G spec-
+trum MPEMFs) to find that results may not differ
+much with the band width of EMFs. Very few stud-
+ies have used a fNIRS device to assess effects of
+MPEMF
+before.
+In
+one
+study
+(Wolf,
+Haensse,
+Morren,
+&
+Froehlich,
+2006),
+effects
+of
+GSM
+900 MHz signals (EMF) were assessed on the cere-
+bral blood circulation using near-infrared spectropho-
+tometry in a three armed (12 W/kg, 1.2 W/kg,
+sham), double blind, randomized crossover trial in
+16 healthy volunteers. During exposure there was a
+borderline significant short -term responses of oxy-
+haemoglobin
+(oxyHb)
+and
+deoxyhaemoglobin
+(deoxyHb)
+concentration,
+which
+correspond
+to
+a
+decrease of cerebral blood flow and volume. The
+authors found that there was no detectable dose–res-
+ponse relation or long-term response within 20 min
+of exposure and the detection limit was a fraction of
+the
+regular
+physiological
+changes
+elicited
+by
+functional activation. The above study did not use a
+cognitive task along with the fNIRS device. In the pre-
+sent study, we did not assess the effect of MPEMF dur-
+ing the exposure on brain haemodynamics, but only
+after the exposure, on the haemodynamic responses
+during a cognitive challenge to understand the mechan-
+ism through which MPEMF exposure may affect cogni-
+tive
+functions.
+Our
+results
+also
+demonstrated
+no
+significant change. The only effect we observed was a
+slight tendency towards higher activation during Stroop
+interference after MPEMF exposure in channel 10
+(right side) in the MPONSS group after SS chanting as
+compared to the baseline. Since the sample size in the
+present work is very small as compared to previous
+researches; it is difficult to draw definitive conclusions
+at present. Cognition enhancing effects of OM chanting
+have been reported in a few studies before. In a com-
+parative study, middle latency auditory evoked poten-
+tials were recorded in 18 male volunteers with ages
+between 25–45 years before, during, and after 20 min of
+OM chanting as compared to chanting of syllable ‘one’.
+There was a significant difference between senior and
+naive subjects’ response in terms of increase and reduc-
+tion in peak amplitude of Na waves, suggesting experi-
+ence dependent neural changes due to OM chanting
+(Telles, Nagarathna, & Nagendra, 1994). Previously,
+Deepeshwar et al. (2014) assessed the immediate effect
+of 20 min of OM meditation (mental chanting with
+effortless defocusing on syllable ‘OM’) on Stroop task
+using fNIRS technology. They found that the mean
+reaction time was shorter during Stroop colour word
+task with concomitant reduction in total haemoglobin
+after OM meditation as compared to random thinking
+for same duration, suggestive of improved performance
+and efficiency after OM meditation in task-related to
+attention. Our findings with OM chanting of 5 min are
+similar to this study (Deepeshwar et al., 2014), i.e. there
+may be lesser pre-frontal activation with better per-
+formance on cognitive tasks after OM chanting. This
+may suggest improved efficiency, i.e. better cognitive
+output with lesser utilization of resources after OM
+chanting. Previous researches also report that medita-
+tion may induce a state of reduced psycho-physiological
+arousal
+with
+enhanced
+awareness
+and
+attention
+(Subramanya & Telles, 2009). Thus, chanting OM ver-
+bally may have similar effects, as produced by mental
+chanting with effortless defocusing on syllable OM,
+even when it is chanted for as low a duration as 5 min.
+Although
+there
+were
+between-group
+differences
+(MPOFOM vs MPOFSS) where incongruent Stroop
+task performance after OM chanting was significantly
+better as compared to SS chanting, this result was
+296
+H. BHARGAV ET AL.
+Downloaded by [14.139.155.82] at 04:08 27 July 2016 
+found within the MPOFOM group only and not in the
+MPONOM group. In our study, each subject per-
+formed the Stroop task three times and the last per-
+formance was after OM/SS chanting. As Stroop tasks
+are
+known
+to
+produce
+a
+practice
+effect
+(Lemay,
+B
+edard, Rouleau, & Tremblay, 2004), the possibility of
+the results being obtained simply due to practice effect
+cannot be denied. Also, the sample size in our study is
+very small to draw any conclusion. Deactivation of
+pre-frontal cortices following OM chanting may be
+due to the vibrations produced by the sound ‘OM’,
+which may have a stimulating effect on branch of
+vagus nerve in the ear canal (Kalyani et al., 2011).
+Although the present study followed a randomized
+controlled design and used an objective functional
+neuro-imaging device, along with a standard validated
+cognitive task to assess effect of MPEMF exposure and
+OM chanting on teenagers, small sample size is a major
+limitation which restricts generalization of the results.
+As a traditional version of Stroop was used, it was not
+possible to record the reaction time along with Stroop
+performance scores. In future, we plan to overcome
+these shortcomings and repeat the same protocol with
+larger sample size to confirm the findings.
+Conclusion
+Although it was observed that MPEMF exposure of
+30 min did not produce any significant impact on cog-
+nition or brain haemodynamics of teenagers, and OM
+chanting had some cognition enhancing effect which
+was associated with lesser oxygenation of pre-frontal
+cortices during the task in some channels, no definite
+conclusion can be drawn from this preliminary study.
+The study protocol followed in the present study was
+found feasible and a future trial with larger sample
+size is implicated.
+Acknowledgements
+The authors are thankful to the Science and Engineering
+Research
+Board
+(SERB),
+Department
+of
+Science
+and
+Technology (DST), Ministry of Science and Technology,
+Government of India for funding this research work.
+Disclosure statement
+The authors report no conflicts of interest. The authors alone
+are responsible for the content and writing of the paper.
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subfolder_0/Autonomic changes in Brahmakumaris Raja yoga meditation.txt

@@ -0,0 +1,1710 @@
+International Journal of 
+Psychophysiology, 15 (1993) 147-152 
+0 1993 Elsevier 
+Science 
+Publishers 
+B.V. All rights reserved 
+0167-8760/93/$06.00 
+147 
+INTPSY 
+00471 
+Autonomic changes in Brahmakumaris 
+Raja yoga meditation 
+Shirley Telles and T. Desiraju 
+Department of Neurophysiology, National Institute of Mental Health and Neuroscience& Bangalore (India) 
+(Accepted 
+4 May 1993) 
+Key words: Autonomic 
+change; 
+Meditation; 
+Heart 
+rate; Skin resistance; 
+Finger plethysmogram; 
+Respiratory 
+rate 
+This report 
+presents 
+the changes 
+in various 
+autonomic 
+and respiratory 
+variables 
+during 
+the practice 
+of Brahmakumaris 
+Raja 
+yoga meditation. 
+This practice 
+requires 
+considerable 
+commitment 
+and involves concentrated 
+thinking. 
+18 males in the age range of 
+20 to 52 years (mean 34.1 5 8.1), with 5-25 years experience 
+in mediation 
+(mean 
+10.1 f 6.2). participated 
+in the study. Each subject 
+was assessed 
+in three test sessions which included 
+a period of meditation, 
+and also in three control 
+(non-meditation) 
+sessions, which 
+included 
+a period 
+of random 
+thinking. 
+Group 
+analysis 
+showed 
+that the heart 
+rate during 
+the meditation 
+period 
+was increased 
+compared 
+to the preceding 
+baseline 
+period, 
+as well as compared 
+to the value during 
+the non-meditation 
+period of control 
+sessions. 
+In contrast 
+to the change 
+in the heart rate, there was no significant 
+change 
+during 
+meditation, 
+for the group 
+as a whole, in palmar 
+GSR, finger plethysmogram 
+amplitude, 
+and respiratory 
+rate. On an individual 
+basis, changes 
+which met the following 
+criteria 
+were 
+noted: (11, changes 
+which were greater 
+during 
+meditation 
+(compared 
+to its preceding 
+baseline) 
+than changes 
+during post meditation 
+or non-meditation 
+periods 
+(also compared 
+to their preceding 
+baseline); 
+(2), Changes 
+which occurred 
+consistently 
+during 
+the three 
+repeat 
+sessions 
+of a subject 
+and (3), changes 
+which 
+exceeded 
+arbitrarily-chosen 
+cut-off 
+points 
+(described 
+at length 
+below). 
+This 
+individual 
+level analysis 
+revealed 
+that 
+changes 
+in autonomic 
+variables 
+suggestive 
+of both 
+activation 
+and 
+relaxation 
+occurred 
+simultaneously 
+in different 
+subdivisions 
+of the autonomic 
+nervous 
+system in a subject. 
+Apart 
+from this, there were differences 
+in 
+patterns 
+of change 
+among 
+the subjects 
+who practised 
+the same meditation. 
+Hence, 
+a single model 
+of sympathetic 
+activation 
+or 
+overall 
+relaxation 
+may be inadequate 
+to describe 
+the physiological 
+effects of a meditation 
+technique. 
+INTRODUCTION 
+Most of the reports 
+on physiological 
+effects of 
+meditation 
+have dealt with Transcendental 
+Medi- 
+tation 
+(TM), 
+Zen 
+and 
+Tantric 
+Yoga. 
+TM 
+was 
+adapted 
+from the Indian 
+Yogic tradition 
+by Ma- 
+harishi 
+Mahesh 
+Yogi. Practising 
+TM, subjects 
+sit 
+in a comfortable 
+posture 
+and 
+silently 
+repeat 
+a 
+given 
+mantram, 
+returning 
+their 
+attention 
+to it 
+whenever 
+attention 
+wanders. 
+Zen 
+meditation 
+forms an integral 
+part of Zen Buddhism. 
+Subjects 
+sit in the lotus position, 
+keep their eyes open and 
+their attention 
+focussed 
+(initially 
+on their breath- 
+Correspondence 
+to: S. Telles, 
+Vivekananda 
+Kendra 
+Yoga 
+Research 
+Foundation, 
+No. 9, Appajappa 
+Agrahara, 
+Cham- 
+arajpet, 
+Bangalore-560018. 
+India. 
+ing, and later on, on a ‘Koan’ or riddle). 
+Tantric 
+Yoga involves 
+intense 
+concentration 
+of attention, 
+with the ultimate 
+aim of channelling 
+all of ones 
+energies 
+into the spiritual 
+energy 
+of union 
+with 
+the object of devotion. 
+The 
+practice 
+of TM was reported 
+to cause 
+reductions 
+in heart 
+rate, 
+respiratory 
+rate, 
+and 
+oxygen consumption, 
+and to increase 
+the level or 
+stability 
+of the electrodermal 
+response 
+(Wallace, 
+1970; Wallace 
+et al., 1971). A later report 
+(Heide, 
+1986), noted 
+a difference 
+in the heart-rate 
+re- 
+sponse 
+but 
+not 
+in the 
+electrodermal 
+response 
+evoked 
+by 80 dB tones, 
+when 
+TM practitioners 
+and non-meditators 
+were compared. 
+Contradictory 
+results 
+were 
+observed 
+in Zen 
+and Tantric 
+meditations. 
+One 
+set of studies 
+re- 
+ported 
+changes 
+suggestive 
+of autonomic 
+activa- 
+tion 
+(Hirai, 
+1974; Corby 
+et al., 19781, whereas 
+148 
+another 
+set of studies 
+reported 
+changes 
+sugges- 
+tive of autonomic 
+relaxation 
+(Kasamatsu 
+and Hi- 
+rai, 1966; Sugi and Akutsu, 
+1968; Elson 
+et al., 
+1977) 
+With 
+the background 
+of contradictory 
+reports 
+on the effects of meditation 
+techniques, 
+the pre- 
+sent study was carried 
+out to determine 
+whether 
+a given meditation 
+technique 
+would 
+bring 
+about 
+the same effects 
+in all the subjects 
+practising 
+it. 
+Practitioners 
+with 5 or more years of experience 
+in Brahmakumaris 
+Raja 
+yoga 
+meditation 
+were 
+chosen. 
+This 
+technique 
+requires 
+considerable 
+commitment 
+and involves 
+concentrated 
+thinking. 
+METHODS 
+Subjects 
+18 healthy 
+male volunteers 
+participated 
+in this 
+study They were between 
+20 and 52 years (mean 
+& S.D. was 34.1 t- 8.1 years), 
+and they had 5-25 
+years 
+experience 
+of the 
+meditation 
+procedure 
+(mean + S.D. 
+was 
+10.1 f 6.2 years). 
+The 
+study 
+was explained 
+to the subjects 
+and 
+their 
+signed 
+informed 
+consent 
+was taken, 
+according 
+to the 
+ethics laid down by the Indian 
+Council 
+of Medical 
+Research; 
+New Delhi. 
+Meditation 
+The Brahmakumaris 
+Raja (= Raj) yoga medi- 
+tation 
+(BK) has spread 
+from 
+the organisation’s 
+headquarters 
+at Mount 
+Abu 
+(Rajasthan, 
+India) 
+throughout 
+India, 
+and to other 
+countries 
+as well. 
+During 
+meditation, 
+subjects 
+sit in a comfortable 
+posture 
+with their eyes open, and with gaze fixed 
+on a meaningful 
+symbol 
+(a light). 
+At the same 
+time they actively think positive 
+thoughts 
+about 
+a 
+Universal 
+force 
+pervading 
+all over, 
+as light 
+and 
+peace (Easy Raj Yoga, 1981). 
+Test sessions 
+Each 
+subject 
+was 
+assessed 
+in two types 
+of 
+session 
+involving 
+either 
+a meditation 
+period 
+(with 
+targetted 
+thinking) 
+or a non-meditation 
+period 
+(with random 
+thinking). 
+Each type of session 
+was 
+repeated 
+thrice on different 
+days, but at the same 
+time of day. 
+During 
+the recording 
+session 
+the subject 
+sat in 
+a comfortable 
+chair in a dimly-lit, 
+air-conditioned 
+and 
+sound-attenuated 
+cabin. 
+Subjects 
+were 
+ob- 
+served 
+throughout 
+on a closed-circuit 
+television. 
+Each session was of 36 min duration, 
+of which 24 
+min 
+was spent 
+in meditation 
+(with 
+eyes open) 
+preceded 
+and followed 
+by 6-min periods 
+of relax- 
+ation, 
+also with eyes open. These 
+meditation 
+ses- 
+sions 
+were 
+repeated 
+thrice 
+by each 
+subject 
+on 
+different 
+days. In addition, 
+there were also three 
+non-meditation 
+(‘control’) 
+sessions, 
+which 
+were 
+similar 
+in design, 
+except 
+that 
+the period 
+corre- 
+sponding 
+to the 24 min of meditation 
+was spent 
+sitting 
+relaxed, 
+without 
+targetted 
+thinking. 
+Data acquisition 
+and analysis 
+Recordings 
+were 
+made 
+on Grass 
+model 
+78D 
+polygraph. 
+EKG 
+was recorded 
+using 
+a standard 
+limb lead 
+II configuration. 
+Skin resistance 
+(SR) 
+was recorded 
+with AgCl 
+disc electrodes 
+placed 
+approx. 
+4 cm apart 
+on the palmar 
+surface 
+of the 
+right hand. 
+Electrode 
+gel CSR (Technocarta, 
+Hy- 
+derabad, 
+India) 
+was used, and a constant 
+current 
+of 10 PA was passed. 
+Finger 
+plethysmogram 
+am- 
+plitude 
+was recorded 
+with a photo-cell 
+transducer 
+kept at the base of the right thumb 
+nail. Respira- 
+tion was recorded 
+via a rubber 
+stethograph 
+con- 
+nected 
+through 
+a pressure 
+transducer. 
+In addition, 
+the EEG was recorded 
+from elec- 
+trodes 
+placed 
+at F3, F4, 01 and 02, referenced 
+to the contralateral 
+earlobe. 
+Also, EOG 
+and chin 
+EMG 
+were recorded 
+as is usual 
+for sleep-stage 
+scoring 
+(Rechtschaffen 
+and 
+Kales, 
+1968). 
+This 
+allowed 
+any sleep 
+episodes 
+to be detected 
+and 
+excluded 
+from the analysed 
+data. 
+The SR values 
+were sampled 
+at 20-s intervals 
+from the continuously 
+acquired 
+record. 
+The heart 
+rate 
+was obtained 
+by counting 
+the 
+number 
+of 
+QRS complexes 
+occurring 
+in successive 
+epochs of 
+40-s periods 
+analysed 
+throughout. 
+The respiratory 
+rate was calculated 
+from the record 
+by counting 
+the breath 
+cycles in successive 
+40-s epochs contin- 
+uously. 
+20 s or its multiple 
+(i.e., 40 s) time epochs 
+were 
+used while 
+calculating 
+SR, heart 
+rate 
+and 
+respiratory 
+rate to make 
+it feasible 
+to correlate 
+these data with that of EEG 
+acquired 
+simultane- 
+ously and subjected 
+to computerized 
+power spec- 
+tral analysis 
+in 20-s epochs. 
+For the present 
+group 
+of meditators 
+the EEG data have been presented 
+elsewhere 
+(Kulkarni 
+et al., 1988), and have not 
+been 
+reiterated 
+here 
+as no interesting 
+correla- 
+tions 
+emerged 
+between 
+autonomic 
+and 
+EEG 
+changes. 
+The 
+finger 
+plethysmogram 
+amplitude 
+was calculated 
+from measurements 
+made 
+on 20 
+plethysmogram 
+waves picked up randomly 
+in each 
+6-min period. 
+Data 
+analysis 
+was done 
+in two ways, viz., (I), 
+For the group as a whole two statistical 
+tests were 
+used. (a), A two-factor 
+(Factor 
+A, meditation 
+vs. 
+non-meditation 
+and 
+Factor 
+B, pre 
+vs. during) 
+ANOVA 
+was carried 
+out to assess the effects of 
+both factors, 
+as well as the interaction 
+of all four 
+variables 
+listed 
+above 
+(Snedecor 
+and 
+Cochran, 
+1967; Zar, 1984). (b), A paired 
+t-test (two-tailed) 
+149 
+was performed 
+on the averaged 
+data. The values 
+of each variable 
+obtained 
+in the three meditation 
+sessions of a subject were averaged 
+for: (a>, the-24 
+min period 
+of meditation; 
+(b), the corresponding 
+24 min period 
+of a non-meditation 
+session; 
+(cl, 
+the baseline 
+state of the 6-min period 
+in the eyes 
+open state preceding 
+the meditation, 
+or the non- 
+meditation 
+period 
+in the corresponding 
+type of 
+sessions 
+and 
+(d), the post-meditation 
+(or post- 
+non-meditation 
+period). 
+The 
+averaged 
+data 
+of 
+each of the 18 meditators 
+were subjected 
+to the 
+paired 
+t-test 
+(two-tailed) 
+to assess 
+at the group 
+level whether 
+the following 
+comparisons 
+were sig- 
+nificantly 
+different: 
+(a>, meditation 
+period 
+and its 
+preceding 
+(eyes open) 
+baseline 
+period; 
+(b), non- 
+meditation 
+period 
+and its preceding 
+(eyes open) 
+TABLE 
+I 
+Heart rate in different conditions of the meditation and non-meditation sessions of the 18 subjects 
+M, meditation 
+period; 
+pre-M, 
+period 
+preceding 
+Meditation; 
+NM, non-mediation 
+period; 
+n, number 
+of values averaged 
+per subject; 
+pre-NM, 
+period 
+preceding 
+Non-meditation; 
+n.s., not significant. 
+Subject 
+&e 
+Meditation 
+Heart rate per 40 s (mean i S. D.) 
+(years) 
+experience 
+, 
+f 
+years) 
+Pre-M 
+M 
+Pre-NM 
+NM 
+(n = 20) 
+(n = 80) 
+(n = 20) 
+(n = 80) 
+DRN 
+38 
+8 
+RR 
+48 
+18 
+NAR 
+28 
+8 
+MNH 
+28 
+5 
+NLN 
+40 
+16 
+AM 
+30 
+9 
+MN 
+52 
+15 
+MG 
+29 
+5 
+JGN 
+34 
+10 
+SM 
+41 
+5 
+DP 
+20 
+8 
+su 
+38 
+6 
+SVP 
+30 
+5 
+AC 
+31 
+18 
+AG 
+36 
+15 
+FE 
+22 
+5 
+MR 
+33 
+15 
+GA 
+35 
+25 
+Mean k S.D. 
+Paird 
+t-test 
+(two-tailed) 
+on data of 
+whole group 
+51.4 + 2.8 
+42.1 * 0.8 
+50.4 * 3.9 
+51.5 f 1.6 
+44.6 f 2.6 
+54.4 f 0.6 
+56.4 * 0.9 
+50.5 f 3.5 
+40.9 f 3.1 
+42.8 k 3.9 
+61.0 + 2.5 
+63.0 + 6.1 
+53.3 f 1.6 
+53.4 * 0.3 
+62.2 k 1.6 
+39.0 * 1.4 
+48.5 + 0.7 
+49.2 k 4.7 
+50.81 f 7.1 
+51.5 k 2.7 
+43.3 k 1.8 
+52.6 f 4.0 
+57.5 f 2.3 
+45.1 f 1.8 
+60.0 k 2.7 
+55.6 * 0.8 
+54.9 * 2.9 
+48.3 f 3.0 
+43.5 f 3.5 
+60.3 + 3.5 
+62.5 f 5.1 
+51.7 k 2.1 
+54.1 f 1.3 
+65.2 + 2.0 
+41.5 * 0.9 
+48.6 f 1.1 
+51.8 f 3.6 
+52.7 + 6.8 
+t (17) 2.66 
+P < 0.02 
+(M vs. pre-M) 
+49.6 + 1.9 
+42.9 f 5.0 
+53.6 i 3.9 
+47.6 k 2.9 
+45.8 k 3.6 
+54.9 + 5.5 
+55.9 f 0.8 
+51.6 f 2.9 
+47.4 f 0.6 
+41.6 + 1.9 
+54.1 f 1.6 
+58.3 + 5.0 
+51.2 k 1.5 
+51.2 f 0.7 
+59.8 + 0.7 
+42.1 f 2.7 
+47.8 f 3.4 
+47.7 + 5.5 
+50.2 * 5.3 
+49.9 * 3.3 
+43.2 f 4.5 
+55.5 + 5.9 
+47.7 k 2.4 
+45.3 + 3.2 
+53.9 f 5.1 
+55.2 k 0.9 
+51.9 * 1.9 
+45.8 + 1.8 
+42.0 k 2.5 
+53.5 * 1.4 
+58.5 k 5.1 
+50.1 * 2.0 
+50.2 k 1.8 
+58.9 f 1.4 
+42.5 + 1.6 
+48.5 f 3.0 
+45.7 f 4.7 
+49.9 * 5.3 
+t (17) 1.19 
+n.s. 
+(NM vs. pre-NM) 
+Note: paired 
+t-test (two-tailed) 
+M vs. NM, t (17) 3.84 P < 0.01. 
+150 
+baseline 
+period; 
+(cl, meditation 
+period 
+and non- 
+meditation 
+period 
+and 
+Cd), post-meditation 
+pe- 
+riod and pre-meditation 
+period. 
+(II), 
+On 
+an 
+individual 
+basis 
+data 
+were 
+also 
+examined 
+and changes 
+which 
+met the following 
+criteria 
+were 
+noted: 
+(a), changes 
+during 
+medita- 
+tion (compared 
+to the preceding 
+period) 
+should 
+exceed 
+those 
+during 
+post-meditation 
+or 
+non- 
+meditation 
+periods 
+(also compared 
+to the initial 
+baseline 
+period); 
+(b), changes 
+should 
+occur in one 
+direction, 
+consistently 
+during 
+the 
+three 
+repeat 
+sessions 
+of a subject 
+and Cc), in order 
+to quantify 
+the change, 
+arbitrary 
+cut-off 
+points 
+were selected 
+for each variable 
+as follows: changes 
+in heart rate 
+should 
+be equal 
+to/more 
+than 
+2 beats 
+per 40 s, 
+similarly 
+for respiration, 
+a change 
+equal to/more 
+than one breath 
+per 40 s, for SR a change 
+equal 
+to/more 
+than 
+10 k0; 
+and for finger 
+plethysmo- 
+gram amplitude 
+a change 
+equal 
+to or more than 
+0.40 cm. 
+RESULTS 
+Heart rate 
+Group analysis. The 
+two-factor 
+ANOVA 
+did 
+not reveal significance 
+of (a), meditation 
+vs. non- 
+meditation 
+(F = 1.35); (b), states (pre vs. during) 
+(F = 0.31) 
+or (c), interaction 
+between 
+the 
+two 
+factors 
+(F = 0.50). 
+In contrast, 
+with 
+the paired 
+t-test, 
+comparison 
+of the data of meditation 
+(Ml 
+against 
+pre-meditation 
+(pre-M) 
+for the 
+18 sub- 
+jects as a group 
+showed 
+that the heart 
+rate was 
+increased 
+by 2.1 beats per 40 s during 
+M, and the 
+difference 
+was significant 
+(P < 0.02) (see the last 
+row of the column 
+M of Table 
+I). There 
+was no 
+significant 
+change during 
+the non-mediation 
+(NM) 
+period compared 
+to its preceding 
+baseline 
+(paired 
+t-test, 
+two-tailed, 
+see the last row of the column 
+NM of Table 
+I). A third comparison 
+(M vs. NM) 
+revealed 
+that 
+the heart 
+rate during 
+M was also 
+significantly 
+higher 
+than 
+during 
+NM (P < 0.01, 
+paired 
+t-test, two-tailed, 
+last row of the column 
+of 
+the extreme 
+right of Table 
+I). Also, since one way 
+of removing 
+the regression 
+of each treatment 
+on 
+its baseline 
+is to analyse 
+the change 
+score of heart 
+rate of the 18 subjects 
+CM-pre-M 
+vs. NM-pre- 
+NM). These data were subjected 
+to analysis 
+using 
+the paired 
+t-test, which revealed 
+that the change 
+scores 
+of 
+M 
+(mean 
+= + 1.4 change 
+of 
+heart 
+rate/40 
+s) were 
+significantly 
+different 
+from 
+the 
+change 
+scores of the NM condition 
+(mean = 0.3 
+change 
+of heart rate/40 
+s (t (17) 2.97, P < 0.01). 
+Also, the heart-rate 
+values of the meditation 
+con- 
+dition have a significant 
+correlation 
+with the base- 
+line value 
+of the subjects 
+obtained 
+in the pre- 
+meditation 
+period 
+(r = 0.94, P < 0.001 (2)), or in 
+the pre non-meditation 
+sitting 
+period 
+(r = 0.93, 
+P < 0.001 (2)). 
+Individual analysis. The heart-rate 
+data of each 
+subject 
+were also examined 
+separately. 
+Based on 
+the three criteria 
+mentioned 
+above (Methods 
+sec- 
+tion, 
+under 
+data 
+analysis), 
+it was noted 
+that 
+in 
+eight 
+subjects 
+there 
+was a definite 
+trend 
+of in- 
+crease 
+in heart 
+rate during 
+M, whereas 
+one sub- 
+ject showed 
+a decrease 
+in heart 
+rate during 
+NM. 
+Other parameters 
+(SR, finger plethysmogram am- 
+plitude, respiratory rate) 
+Group 
+analysis (using both two factor ANOVA, 
+as well 
+as the 
+paired 
+t-test> 
+did 
+not 
+reveal 
+a 
+significant 
+effect 
+of meditation 
+compared 
+to its 
+preceding 
+baseline, 
+or to the non-meditation 
+pe- 
+riod (P > 0.10 for both tests and in all the com- 
+parisons 
+described 
+in detail 
+for heart rate). 
+The group mean 
+&S.D. values for these three 
+variables 
+were as follows (11, SR; pre-M = 256.5 
++ 62.1 kR, 
+M = 246.3 + 55.8 K, pre-NM 
+= 264.3 
+f 47.6 K, and NM = 271.3 + 41.3 K. (2), Respira- 
+tory rate; pre-M = 12.1 + 2.4 breaths/40 
+s, M = 
+13.4 t- 3.5 
+breaths/40 
+s, 
+pre-NM 
+= 11.9 + 1.8 
+breaths/40 
+s, and NM = 12.2 k 2.3 breaths/40 
+s. 
+(31, Finger 
+plethysmogram 
+amplitude; 
+pre-M = 
+1.68 k 0.74 cm, M = 1.24 f 0.64 cm, pre-NM 
+= 
+1.72 + 0.71 cm, and NM = 1.66 + 0.56 cm.. 
+Individual 
+level 
+analysis 
+(based 
+on the three 
+criteria 
+cited 
+in the Methods 
+section) 
+has been 
+summarized 
+in Table 
+II. 
+It is given 
+below 
+in 
+detail. 
+Cl), SR; During 
+M, 5 subjects 
+showed 
+a 
+decrease 
+and 3 showed 
+an increase. 
+In contrast, 
+during 
+NM 7 subjects 
+showed an increase 
+and 3 a 
+decrease. 
+(2), Respiratory-rate 
+changes 
+occurred 
+during 
+M (but 
+not during 
+NM), 
+i.e., 4 subjects 
+showed 
+a decrease, 
+one showed 
+a increase. 
+(3), 
+Finger 
+plethysmogram 
+amplitude; 
+during 
+M, 4 
+151 
+TABLE 
+II 
+Changes in heart rate, palmar GSR, finger plethysmogram am- 
+plitude and respiratory rate based on individual leuel analysis 
+I, increase; 
+D, decrease; 
+M, Meditation 
+period; 
+Pre-M, period 
+preceding 
+meditation; 
+NM, nonmeditation 
+period; 
+pre-NM, 
+period 
+preceding 
+non-mediation 
+period. 
+Parameter 
+Number of subjects showing change 
+M against 
+NM against 
+pre-M 
+pre-NM 
+I 
+D 
+I 
+D 
+Heart 
+rate 
+8 
+0 
+0 
+1 
+Palmar 
+SR 
+3 
+5 
+7 
+3 
+Finger 
+plethysmogram 
+amplitude 
+0 
+4 
+2 
+0 
+Respiratory 
+rate 
+1 
+4 
+0 
+0 
+subjects 
+showed 
+a decrease, 
+whereas 
+2 subjects 
+showed an increase 
+during 
+NM. 
+DISCUSSION 
+The most 
+important 
+finding 
+of this study 
+on 
+the effects of Brahmakumaris 
+Raja yoga medita- 
+tion was a small (but consistent) 
+increase 
+in the 
+heart 
+rate 
+during 
+meditation, 
+compared 
+to the 
+preceding 
+period, 
+as well 
+as compared 
+to the 
+non-meditation 
+period. 
+In contrast, 
+changes 
+in 
+respiratory 
+rate, finger plethysmogram 
+amplitude 
+and SR were fewer and often 
+in opposite 
+direc- 
+tions for the subjects 
+practising 
+the same medita- 
+tion. However, 
+they were consistent 
+during 
+repeat 
+sessions 
+of a subject. 
+These individual 
+differences 
+did not seem to be correlated 
+with differences 
+in 
+age, duration 
+of meditation 
+experience, 
+or com- 
+mitment 
+to meditation. 
+Individual 
+differences 
+in 
+autonomic 
+response 
+specificity 
+have been 
+known 
+for a long time. Detailed 
+descriptions 
+have shown 
+that autonomic 
+responses 
+are a function 
+of both 
+the 
+evoking 
+stimulus 
+(stimulus-response 
+speci- 
+ficity) and of the responding 
+individual 
+(individ- 
+ual response 
+specifity 
+(Engel, 
+1960). It is interest- 
+ing to speculate 
+that the contradictory 
+reports 
+on 
+Transcendental 
+Meditation 
+(TM), 
+Zen, 
+and 
+Tantric 
+yoga, 
+described 
+in the 
+Introduction 
+as 
+either ‘activating’ 
+or ‘relaxing’, 
+may in fact be due 
+to differences 
+in the individual 
+response 
+patterns. 
+Holmes 
+(1984) 
+commented 
+that 
+no 
+studies 
+showed 
+consistent 
+differences 
+between 
+resting 
+and meditating 
+subjects 
+in heart rate, electroder- 
+ma1 activity, 
+respiratory 
+rate 
+and 
+other 
+similar 
+variables. 
+However, 
+he stated 
+that in 4 out of 16 
+experiments, 
+meditating 
+subjects 
+showed 
+greater 
+increases 
+in heart 
+rate than 
+did resting 
+subjects, 
+and none 
+showed 
+decreases. 
+In this study 
+also, 
+the most 
+consistent 
+change 
+was an increase 
+in 
+heart 
+rate during 
+the practice 
+of Brahmakumaris 
+Raja 
+yoga 
+meditation 
+which 
+was suggestive 
+of 
+cardiosympathetic 
+activation, 
+and a possible 
+sign 
+of psychophysiological 
+arousal. 
+This finding 
+can 
+be correlated 
+with the fact that 
+BK meditation 
+requires 
+intense 
+involvement 
+and concentration. 
+The changes 
+in the other variables 
+(though 
+often 
+consistent 
+for an individual) 
+did not reveal 
+any 
+group pattern. 
+These 
+results 
+suggest 
+that use of some auto- 
+nomic 
+and respiratory 
+variables 
+(e.g., heart 
+rate) 
+may reveal 
+group 
+effects 
+of meditation, 
+whereas 
+other variables 
+can alter in an individualistic 
+way. 
+Hence, 
+a single 
+model 
+of meditation 
+producing 
+either 
+overall 
+relaxation 
+or overall 
+activation 
+is 
+probably 
+inadequate. 
+REFERENCES 
+Corby, 
+J.C., 
+Roth, 
+W.T., 
+Zarcone, 
+V.P. 
+and 
+Kopell, 
+B.S. 
+(1978) 
+Psychophysiological 
+correlates 
+of the practice 
+of 
+Tantric 
+yoga meditation. 
+Arch. Gen. Psychiatr., 35: 571- 
+577. 
+Easy 
+Raj 
+yoga 
+(1981) 
+Prajapita Byahmakumaris 
+Ishwariya 
+Vishwa, Vidyalaya, 
+Bombay, 
+pp. 82 + 5. 
+Elson, 
+B.D., 
+Hauri, 
+P., and 
+Cunis, 
+D. (1977) 
+Physiological 
+changes 
+in Yoga meditation. 
+Psychophysiology, 14: 52-57. 
+Engel, B.T. (1960) Stimulus-response 
+and individual-response 
+specificity. 
+Arch. Gen. Psychiatr 2: 305-313. 
+Heide, 
+F. (1986) Psychophysiological 
+responsiveness 
+to audi- 
+tory stimulation 
+during 
+Transcendental 
+Meditation. 
+Pry- 
+chophysiology, 23: 71-75. 
+Hirai, 
+T. (1974) 
+The PsychophysioLogy of Zen, Igako 
+Shoin, 
+Tokyo. 
+Holmes, 
+D.S. (1984) Meditation 
+and somatic 
+arousal: 
+A re- 
+view of the experimental 
+evidence. 
+Am. Psychol. 39: l-10. 
+Kasamatsu, 
+A. and 
+Hirai, 
+T. (1966) 
+An electroencephalo- 
+graphic 
+study on the Zen meditation 
+(Zazen). 
+Folio Psy- 
+chiatr. Neural. Japonica, 20: 315-336. 
+Kulkarni, 
+D.D., 
+Ramachandra, 
+M., Hanumanthaiah. 
+B.H., 
+Narasimhalu, 
+G.. Joseph, 
+C. and Desiraju, 
+T. (1988) EEG 
+power 
+changes 
+in senior 
+practitioners 
+of Transcendental 
+Meditation, 
+Brahmakumaris 
+Raja 
+yoga 
+and 
+Pranayama. 
+Ind. J. Physiol. Pharmacol., 32: 419-420. 
+Rechtschaffen, 
+A. and Kales, 
+A. (1968). 
+A Manual of stan- 
+dard&d 
+terminology, techniques, and scoring system of hu- 
+man subjects, Public 
+Health 
+Service 
+Government 
+Printing 
+Office, 
+Washington, 
+pp. 8-15. 
+Snedecor, 
+G.W. 
+and Cochran, 
+W.G. 
+(1967) Statistical Meth- 
+ods, Oxford 
+& IBH, New Delhi, 593 pp. 
+Sugi, Y. and Akutsu, 
+K. (1968) Studies 
+on respiration 
+and 
+energy 
+metabolism 
+during 
+sitting 
+in Zazen. 
+Res. J. Phys. 
+Edu., 12: 190-206. 
+Wallace, 
+R.K. (1970) Physiological 
+effects 
+of Transcendental 
+Meditation. 
+Science, 167: 1751-1754. 
+Wallace, 
+R.K., 
+Benson, 
+H., and Wilson, 
+A.F. (1971) A wake- 
+ful hypometabollic 
+physiologic 
+state. 
+Am. J. Physiol., 221: 
+795-799. 
+Zar, J.H. (1984) Biostatistical analysis Prentice-Hall 
+Interna- 
+tional, 
+Englewood 
+Cliffs, pp. xiv + 718. 

subfolder_0/CHANGES IN P300 FOLLOWING TWO YOGA BASED RELAXATION TECHNIQUES.txt

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+This article was downloaded by:[Telles, shirley]
+On: 10 April 2008
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+Publisher: Informa Healthcare
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+Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
+International Journal of Neuroscience
+Publication details, including instructions for authors and subscription information:
+http://www.informaworld.com/smpp/title~content=t713644851
+CHANGES IN P300 FOLLOWING TWO YOGA-BASED
+RELAXATION TECHNIQUES
+S. P. Sarang a; Shirley Telles a
+a Swami Vivekananda Yoga Research Foundation, Bangalore, India
+Online Publication Date: 01 December 2006
+To cite this Article: Sarang, S. P. and Telles, Shirley (2006) 'CHANGES IN P300
+FOLLOWING TWO YOGA-BASED RELAXATION TECHNIQUES', International
+Journal of Neuroscience, 116:12, 1419 - 1430
+To link to this article: DOI: 10.1080/00207450500514193
+URL: http://dx.doi.org/10.1080/00207450500514193
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+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+Intern. J. Neuroscience, 116:1419–1430, 2006
+Copyright C
+⃝2006 Informa Healthcare
+ISSN: 0020-7454 / 1543-5245 online
+DOI: 10.1080/00207450500514193
+CHANGES IN P300 FOLLOWING TWO
+YOGA-BASED RELAXATION TECHNIQUES
+S. P. SARANG
+SHIRLEY TELLES
+Swami Vivekananda Yoga Research Foundation
+Bangalore, India
+Cyclic meditation (CM) is a technique that combines “stimulating” and “calming”
+practices, based on a statement in ancient yoga texts suggesting that such a
+combination may be especially helpful to reach a state of mental equilibrium.
+The changes in the peak latency and peak amplitude of P300 auditory event–related
+potentials were studied before and after the practice of cyclic meditation compared
+to an equal duration of supine rest in 42 volunteers (group mean age ± SD, 27 ±
+6.3 years), from Fz, Cz, and Pz electrode sites referenced to linked earlobes. The
+sessions were one day apart and the order was alternated. There was reduction in
+the peak latencies of P300 after cyclic meditation at Fz, Cz, and Pz compared to
+the “pre” values. A similar trend of reduction in P300 peak latencies at Fz, Cz,
+and Pz was also observed after supine rest, compared to the respective “pre” values,
+although the magnitude of change in each case was less after supine rest compared to
+after cyclic meditation. The P300 peak amplitudes after CM were higher at Fz, Cz,
+and Pz sites compared to the “pre” values. In contrast, no significant changes were
+observed in the P300 peak amplitudes at Fz, Cz, and Pz after supine rest compared
+to the respective “pre” state. The present results support the idea that “cyclic”
+meditation enhances cognitive processes underlying the generation of the P300.
+Keywords cognitive processes, cyclic meditation, P300, supine rest
+Received 14 October 2005.
+Address correspondence to Shirley Telles, Ph.D., Swami Vivekananda Yoga Research
+Foundation, #19, Eknath Bhavan, Gavipuram Circle, K. G. Nagar, Bangalore 560 019, India.
+E-mail: [email protected]
+1419
+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+1420
+S.P
+. SARANG AND S. TELLES
+INTRODUCTION
+Meditation has been described as a training in awareness that, over long periods,
+produces definite changes in perception, attention, and cognition (Brown,
+1977). Most of the early reports on the effects of meditation have dealt with
+Transcendental Meditation (TM). TM was adapted from ancient Indian texts
+by Maharishi Mahesh Yogi. While practicing TM, subjects sit in a comfortable
+posture and mentally repeat a given mantra, returning their attention to it
+whenever attention wanders (Woolfolk, 1975).
+The practice of TM was reported to cause reductions in heart rate,
+respiratory rate, and oxygen consumption, and to increase the level or stability
+of the electrodermal response as well as the alpha in the EEG (Wallace,
+1970; Wallace et al., 1971). These changes were the basis for describing the
+physiological state induced by TM as “wakeful and hypometabolic.” It was also
+considered interesting to investigate whether TM would improve meditators’
+overall performance while producing a state of reduced physiological arousal
+(Bloomfield et al., 1975).
+A study was conducted to compare three different measures of attention
+in 20 people who had been practicing TM for 3 months and a matched control
+group who were not practicing TM. The rationale for the study was that all types
+of meditations are supposed to increase the ability to concentrate on external
+tasks and objects (Pelletier, 1972). Meditators performed better on a test for:
+(i) auto-kinetic effect suggesting a better ability to concentrate, (ii) in a rod and
+frame test that suggested that they were more in tune with internal cues, and
+(iii) in an embedded figure test that suggested a better ability to concentrate
+without being distracted by surrounding factors.
+More recently the effects of transcendent experiences, described to
+occur during the practice of TM, were studied on the contingent negative
+variation (CNV) amplitude, rebound, and distraction effects in 41 healthy
+volunteers (Travis et al., 2002). CNV is an event-related potential occurring
+between a warning stimulus and an imperative stimulus requiring a response
+(Walter et al., 1964). Late CNV amplitudes were largest in meditators who
+had transcendent experiences daily. Because late CNV reflects proactive
+preparatory processes including mobilization of motor, perceptual, cognitive,
+and attentional resources, the data were taken to suggest that transcendent
+experiences enhance cortical responses and executive functioning.
+Another meditation technique, called “cyclic meditation” (CM) that also
+has its origin in ancient Yoga texts was shown to reduce oxygen consumption,
+breath rate, and increase breath volume more than a comparable period of
+supine rest (SR) in 40 male volunteers aged between 20 and 47 years. The
+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+P300 AND YOGA TECHNIQUES
+1421
+magnitude of change in these three measures was greater after CM: (i) oxygen
+consumption decreased by 32.1 % after CM compared with 10.1% after SR;
+(ii) breath rate decreased by 18.0% after CM and 15.2 % after SR; and (iii)
+breath volume increased by 28.8% after CM and 15.9% after SR (Telles et al.,
+2000).
+The present study was planned to determine whether cyclic meditation (like
+TM) would increase the ability to pay attention to a given stimulus in addition
+to the already described effect of reducing metabolic and respiratory rates
+(Telles et al., 2000). The P300 component of the event-related brain potentials
+(ERPs) is considered as a “cognitive” neuro-electric phenomenon because it
+is generated in psychological tasks when subjects attend to and discriminate
+stimuli that differ from one another on some dimension. Such discrimination
+produces a relatively large, positive waveform with a modal latency of about 300
+ms when elicited with auditory stimuli (Polish & Kok, 1995). The P300 event-
+related brain potentials (ERP) reflect fundamental cognitive events requiring
+attentional and immediate memory–processes (Polich, 1999).
+Hence, in the present study the P300 was recorded before and after (i)
+cyclic meditation and (ii) a comparable period of supine rest.
+METHODS
+Subjects
+Forty-two male volunteers with ages ranging from 18 to 48 years (group mean
+± S.D., 27.1 ± 6.3 years) participated in the study. They were residing at a
+yoga center. Male subjects alone were studied as auditory evoked responses
+have been shown to vary with the phases of the menstrual cycle (Yadav et
+al., 2002) and the P300 evoked by stimuli of the visual modality also varied
+with sex (Polich & Conroy, 2003). All of them were in normal health based
+on a routine clinical examination and none of the volunteers were taking any
+medication. The subjects had experience of the practice of cyclic meditation
+for more than 3 months (mean experience ± SD, 15.3 ± 13.3 months). The
+aims and methods of the study were explained to them and all the subjects gave
+their informed consent.
+Design of the Study
+Subjects were assessed in two separate sessions, namely, cyclic meditation
+(CM) and supine rest (SR). For half the subjects the CM session took place
+on the one day, with SR the next day. The remaining subjects had the order of
+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+1422
+S.P
+. SARANG AND S. TELLES
+the sessions reversed. Subjects were alternately allocated to either schedule to
+prevent the order of the sessions influencing the outcome. The subjects were
+unaware about the hypothesis of the study. The assessments were done before
+and after each session, which lasted for 22 min 30 s.
+Recording Conditions
+The peak latencies and peak amplitudes of P300 were recorded using Nicolet
+Bravo System (USA). The P300 component was elicited with a simple
+discrimination task known as the “oddball” paradigm because two stimuli
+are presented in a random series so that one of them occurred infrequently
+that is, the oddball (Polich, 1999). For assessments subjects were seated in a
+sound attenuated and dimly lit cabin and were monitored on a closed circuit
+television with instructions being given through an intercom, so that subjects
+could remain undisturbed during a session.
+Electrode Positions
+Ag/AgCl disk electrodes were affixed with electrode gel (Ten 20 conductive
+EEG paste, D.O. Weaver, USA) at the Fz, Cz, and Pz scalp sites, referred
+to linked earlobes (A1–A2) with the ground electrode on the forehead (FPz);
+according to the International 10–20 system (Jasper, 1958). The electro-ocular
+activity (EOG) was recorded with a bipolar derivation from electrodes placed
+1 cm above and 1 cm below the outer canthus of the right eye. The electrode
+impendence was kept below 5 k
 at all scalp sites.
+Amplifier Settings
+The electroencephalographic (EEG) activity was amplified with a sensitivity
+of 100 µV. The low pass filter was kept at 0.01 Hz and the high pass filter was
+kept at 30 Hz. The P300 ERPs were computer averaged in 300 trial sweeps, in
+the 75–750 ms range. The pre-stimulus delay was kept at 75 ms and the level
+of artifact rejection was set at 90%.
+Stimulus Characteristics
+Binaural tone stimuli of alternating polarity delivered at 0.9 ms with a frequency
+of 1 KHz (50 cycles for the plateau, 10 cycles for the ramp) for the standard
+stimuli and 2 KHz (10 cycles for the plateau, 20 cycles for the ramp) for the
+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+P300 AND YOGA TECHNIQUES
+1423
+target stimuli were used to trigger online averaging of the EEG. The percentage
+of standard stimuli was set at 80 and for the target stimuli at 20. The stimulus
+intensity was kept at 70 dB SPL.
+Recording Procedure
+Subjects were asked to avoid substances that influence cognitive performance
+(e.g., coffee for the caffeine content) for the day preceding and the day of the
+recording. Where this was unavoidable the session was taken on another day.
+The P300 evoked potentials were recorded in the eyes-closed supine position.
+The “standard” and “target” auditory stimuli were delivered through close-
+fitting earphones (TDH-39, Amplivox, UK). Subjects were asked to distinguish
+between the two tones by mentally counting the “target” stimuli. The P300
+responses were recorded before and immediately after the intervention.
+Interventions
+Cyclic Meditation. Throughout the practice subjects 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 (40 s) from the yoga text, the Mandukya Upanisad
+(Chinmayananda, 1984); followed by isometric contraction of the muscles
+of the body ending with supine rest (1 min); slowly coming up from the left
+side and standing at ease (called tadasana) and ‘balancing’ the weight on
+both feet (called centering) (2 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); a gap as before (1 min 10 s); forward
+bending (padahastasana, 1 min 20 s); another gap (1 min 10s); backward
+bending (ardhacakrasana, 1 min 20 s); and slowly coming down in the supine
+posture with instructions to relax different parts of the body in sequence (10
+min). The postures were practiced slowly, with awareness of all the sensations
+that are felt. The total duration of the practice was 22 min 30 s (Telles et al.,
+2000).
+Supine rest. During the supine rest session, the subjects lay supine with
+their legs apart and arms away from the sides of the body in corpse posture
+(shavasana), with their eyes closed. This practice lasted 22 min 30 s, so that
+the duration was the same as for CM.
+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+1424
+S.P
+. SARANG AND S. TELLES
+Data Extraction
+The peak amplitude and peak latency of the P300 was measured at the three
+electrode sites; that is, Fz, Cz and Pz. The peak amplitude (in µV) was defined as
+the voltage difference between a pre-stimulus baseline and the largest positive-
+going peak of the ERP waveform within 250–500 ms latency (Polich, 1999).
+The peak latency (ms) was defined as the time from stimulus onset to the point
+of maximum positive amplitude within the latency window. The peak latency
+and the peak amplitude were selected using the cursors.
+Data Analysis
+Statistical analysis was done using SPSS (Version 10.0). Data were analyzed
+using the repeated measures analysis of variance (ANOVA). There were two
+“Within subjects” factors, that is, Factor 1: Sessions, that is, CM and SR and
+Factor 2: States, that is, Pre and Post. Paired t-test analyses were performed
+to compare the data of the “post” periods with those of the respective “pre”
+periods.
+RESULTS
+Repeated Measures Analysis of Variance
+For the peak latency at Fz the repeated measures ANOVA showed a significant
+difference between the two Sessions (F = 9.526, df = 1,41, p < .01,
+Greenhouse-Geisser epsilon = 1.000), between the six States (F = 82.990,
+df = 1,41, p < .001, Greenhouse-Geisser epsilon = 1.000), and the interaction
+between Sessions and States (F = 20.532, df = 1,41, p < .001, Greenhouse-
+Geisser epsilon = 1.000).
+Also, for the peak amplitude at Fz there was a significant difference
+between the six States (F = 9.723, df = 1,41, p < .001, Greenhouse-Geisser
+epsilon = 1.000), and the interaction between Sessions and States (F = 4.944,
+df = 1,41, p < .001, Greenhouse-Geisser epsilon = 1.000); however, there was
+no significant difference between the two Sessions (F = 0.426, df = 1,41, p >
+.05, Greenhouse-Geisser epsilon = 1.000).
+For the peak latency at Cz the repeated measures ANOVA showed a
+significant difference between the two Sessions (F = 22.167, df = 1,41, p
+< .001, Greenhouse-Geisser epsilon = 1.000), between the six States (F =
+92.290, df = 1,41, p < .001, Greenhouse-Geisser epsilon = 1.000), and the
+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+P300 AND YOGA TECHNIQUES
+1425
+interaction between Sessions and States (F = 16.451, df = 1,41, p < .001,
+Greenhouse-Geisser epsilon = 1.000).
+Also, for the peak amplitude at Cz there was a significant difference
+between the six States (F = 8.932, df = 1,41, p < .01, Greenhouse-Geisser
+epsilon = 1.000), and the interaction between Sessions and States (F = 6.793,
+df = 1,41, p < .01, Greenhouse-Geisser epsilon = 1.000) however, there was
+no significant difference between the two Sessions (F = 1.178, df = 1,41, p >
+.05, Greenhouse-Geisser epsilon = 1.000).
+For the peak latency at Pz the repeated measures ANOVA showed a
+significant difference between the two Sessions (F = 16.622, df = 1,41, p
+< .001, Greenhouse-Geisser epsilon = 1.000), between the six States (F =
+130.831, df = 1,41, p < .001, Greenhouse-Geisser epsilon = 1.000), and the
+interaction between Sessions and States (F = 18.163, df = 1,41, p < .001,
+Greenhouse-Geisser epsilon = 1.000).
+Also, the for peak amplitude at Pz there was a significant difference in
+the interaction between Sessions and States (F = 4.577, df = 1,41, p <
+.05, Greenhouse-Geisser epsilon = 1.000); however, there was no significant
+difference between the two Sessions (F = 1.789, df = 1,41, p > .05,
+Greenhouse-Geisser epsilon = 1.000) and between the six States (F = 3.310,
+df = 1,41, p > .05, Greenhouse-Geisser epsilon = 1.000).
+Paired t-test
+There was a significant decrease in the P300 peak latencies at Fz, Cz, and Pz
+sites after the practice of cyclic meditation compared to the “pre” state (p <
+.001). There was a significant increase in the peak amplitude at Fz, Cz, and Pz
+sites after the practice of cyclic meditation compared to the “pre” state (p <
+.001).
+There was a significant decrease in the P300 peak latencies at Fz, Cz, and
+Pz sites after the practice of supine rest compared to the “pre” state (p < .001).
+However, there was no significant change in the peak amplitude at Fz, Cz, and
+Pz sites after the practice of supine rest compared to the “pre” state.
+The peak latencies at Fz, Cz, and Pz sites before cyclic meditation and
+before supine rest were not significantly different [p > .05, paired t-test (2)].
+However, the peak latencies at Fz, Cz, and Pz sites after cyclic meditation and
+after supine rest were significantly different [p < .001, paired t-test (2)].
+The group mean ± S.D., of the peak latencies and the peak amplitudes at
+Fz, Cz, and Pz sites are given in Table 1.
+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+Table 1. Peak latency (ms) and peak amplitude (µV) of the P300 component in “pre” and “post” cyclic meditation and supine rest sessions.
+Cyclic meditation (CM)
+Supine rest (SR)
+Electrode Site†
+Variables
+Pre
+Post
+Pre
+Post
+Fz
+Latency (ms)
+363.92 ± 23.63
+328.07∗∗∗± 19.95
+359.85 ± 25.52
+347.28∗∗∗± 19.41
+Amplitude (µV)
+5.92 ± 3.60
+7.96∗∗∗± 3.51
+7.06 ± 4.01
+7.36 ± 3.97
+Cz
+Latency (ms)
+362.92 ± 24.46
+326.21∗∗∗± 21.79
+364.64 ± 27.44
+346.85∗∗∗± 19.59
+Amplitude (µV)
+7.24 ± 3.62
+9.14∗∗∗± 3.43
+8.65 ± 3.72
+8.64 ± 3.66
+Pz
+Latency (ms)
+368.42 ± 27.34
+328.28∗∗∗± 22.06
+369.57 ± 29.81
+352.54∗∗∗± 23.32
+Amplitude (µV)
+8.71 ± 3.62
+9.88∗∗± 3.84
+9.79 ± 3.67
+9.90 ± 3.86
+Values are group mean ± S.D. ∗∗∗p < .001, ∗∗p < .01, ∗p < .05. Paired t-test (2-tailed), “Post” compared with respective “Pre” values.
+†Reference: linked earlobes.
+1426
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+P300 AND YOGA TECHNIQUES
+1427
+DISCUSSION
+The changes in the peak latency and peak amplitude of P300 auditory event-
+related potentials were studied before and after the practice of cyclic meditation
+compared to a comparable period of supine rest in 42 volunteers, from Fz, Cz
+and Pz electrode sites referenced to linked earlobes.
+Cyclic meditation consists of alternating cycles of practicing yoga postures
+interspersed with periods of supine rest (Nagendra & Nagarathna, 1997). The
+basis for this practice is an idea drawn from the ancient texts (Chinmayananda,
+1984). The underlying idea is that for most persons the mental state is routinely
+somewhere between the extremes of being “inactive” or of being “agitated” and
+hence to reach a balanced, relaxed state the most suitable technique would be
+one that combines “awakening” and “calming” practices. In cyclic meditation,
+the period of practicing yoga postures constitutes the “awakening” practices,
+whereas periods of supine rest comprise the “calming practices.” An essential
+part of the practice of cyclic meditation is being aware of sensations arising in
+the body (Nagendra & Nagarathna, 1997).
+In the present study, there was reduction in the peak latencies of P300 after
+cyclic meditation at Fz, Cz and Pz compared to the “pre” values. A similar trend
+of reduction in P300 peak latencies at Fz, Cz and Pz was also observed after
+supine rest, compared to the respective “pre” values, although the magnitude
+of change in each case was less after supine rest compared to after cyclic
+meditation.
+The P300 peak amplitudes after CM were higher at Fz, Cz and Pz sites
+compared to the “pre” values. In contrast, no significant changes were observed
+in the P300 peak amplitudes at Fz, Cz, and Pz after supine rest compared to the
+respective “pre” state.
+Previous studies have shown definite changes in the P300 evoked responses
+following Transcendental meditation (TM). The effect of TM practice on
+the P300 was studied using a passive auditory listening trial paradigm with
+variable interstimulus intervals (1–4 s) between identical tone stimuli (Cranson
+et al., 1990). The subjects were experienced TM meditators, novices, and
+nonmeditator controls with mean ages of 41, 28 and 20 years, respectively. The
+P300 latency was shorter for the two meditation groups, with the long-term
+meditators showing the shortest P300 latency regardless of their age. In another
+study an auditory oddball task was used with eyes-closed to assess experienced
+TM meditators at pretest baseline, after 10 min of rest, or after 10 min of TM
+practice with conditions counterbalanced across subjects (Travis & Miskov,
+1994). The P300 latency decreased at Pz after TM practice relative to no
+change after the rest condition.
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+1428
+S.P
+. SARANG AND S. TELLES
+Sudarshan Kriya Yoga (SKY) is a meditation system that emphasizes
+breathing techniques. This technique was used as an intervention for persons
+with dysthymia compared with an unaffected control group. At three months,
+the P300 amplitude increased to the levels of the control group in the patient
+group (Naga Venkatesh Murthy et al., 1998).
+The P300 amplitude is thought to indicate the amount of brain activity
+related to incoming information processing and it is more sensitive to the
+amount of attentive resources engaged during the task (Polich, 2004). The
+P300 latency reflects the stimulus classification (cognitive) speed, is generally
+unrelated to the overt response, and is independent of behavioral reaction
+time. Because P300 latency is an index of stimulus processing rather than
+response generation, it is used as a motor-free measure of cognitive function.
+The P300 peak latency has been found to be negatively correlated with mental
+function in normal subjects: shorter latencies are associated with superior
+cognitive performance from neuropsychologic tests of attention and immediate
+memory.
+In the present study, both the peak amplitude and the peak latency of the
+P300 potentials were changed following cyclic meditation. The reduction in
+latency was also seen following supine rest, however the magnitude of change
+was smaller than that after cyclic meditation. These results suggest increased
+attentional resources, stimulus processing speed and efficiency after cyclic
+meditation compared to an equal duration of supine rest.
+Yoga practice has been understood to help in reducing anxiety based
+on a reduction in levels of psychophysiological arousal (Telles & Srinivas,
+1998). In a previous study both cyclic meditation (CM) and supine rest (SR)
+practiced for the same duration as in the present study, resulted in decreased
+oxygen consumption, breath rate, and increased breath volume immediately
+after the practice (Telles et al., 2000). These changes suggested that both
+practices reduce physiological arousal. However, for all three variables the
+magnitude of change was greater following CM compared with following SR.
+This supported the idea that a combination of “stimulating” and “calming”
+techniques practiced with a background of relaxation and awareness (during
+CM) may reduce psychophysiological arousal more than SR. Hence, CM may
+be supposed to be able to reduce anxiety more than SR, which may explain the
+greater magnitude of change in the performance observed in the present study
+following CM.
+The neuroelectric events that underlie the P300 generation stem from
+the interaction between the frontal lobe and hippocampal and temporoparietal
+function (Halgren et al., 1998). The primary neural generators for the P300
+Downloaded By: [Telles, shirley] At: 07:09 10 April 2008 
+P300 AND YOGA TECHNIQUES
+1429
+components are in the anterior cingulate when new stimuli are processed into
+working memory with subsequent activation of the hippocampal formation
+when frontal lobe mechanisms communicate with the temporal or parietal lobe
+connections (Polich, 1999).
+In the present study the P300 peak amplitude increased at Fz, Cz and Pz
+but the increase was maximum at Fz, which indicates greater involvement of
+frontal areas, which are required for sustained attention. Various neuroimaging
+studies on meditators have shown increased regional cerebral blood flow in the
+frontal and prefrontal areas during meditation (Herzog et al., 1990). Hence, the
+present findings may also support the idea of activation of frontal cortical areas
+during meditation.
+Insummary, thepresent studysupports theideathat meditation(inthis case,
+“cyclic” meditation) enhances cognitive processes underlying the generation
+of the P300, though further research is required to understand mechanisms
+underlying the change.
+REFERENCES
+Bloomfield, H. H., Cain, M. P., Jaffe, D. T., & Kory, R. B. (1975). TM: Discovering
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+Brown, D. P. (1977). A model for the levels of concentrative meditation. The
+International Journal of Clinical and Experimental Hypnosis, 25(4), 236–
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+Chinmayananda, S. (1984). Mandukya Upanishad. Bombay, India: Sachin Publishers.
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+Polich, J., & Kok, K. (1995). Cognitive and biological determinants of P300: An
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subfolder_0/Cerebrovascular Hemodynamics during the Practice of Bhramari Pranayama, Kapalbhati and Bahir-Kumbhaka An Exploratory Study.txt

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+Vol.:(0123456789)
+1 3
+Applied Psychophysiology and Biofeedback 
+https://doi.org/10.1007/s10484-017-9387-8
+Cerebrovascular Hemodynamics During the Practice of Bhramari 
+Pranayama, Kapalbhati and Bahir-Kumbhaka: An Exploratory Study
+L. Nivethitha1 · A. Mooventhan1 · N. K. Manjunath1 · Lokesh Bathala2 · Vijay K. Sharma3
+ 
+© Springer Science+Business Media, LLC, part of Springer Nature 2017
+Abstract
+Various pranayama techniques are known to produce different physiological effects. We evaluated the effect of three-different 
+pranayama techniques on cerebrovascular hemodynamics. Eighteen healthy volunteers with the mean ± standard deviation 
+age of 23.78 ± 2.96 years were performed three-different pranayama techniques: (1) Bhramari, (2) Kapalbhati and (3) Bahir-
+Kumbhaka in three-different orders. Continuous transcranial Doppler (TCD) monitoring was performed before, during and 
+after the pranayama techniques. TCD parameters such as peak systolic velocity, end diastolic velocity (EDV), mean flow 
+velocity (MFV) and pulsatility index (PI) of right middle cerebral artery were recorded. Practice of Kapalbhati showed 
+significant reductions in EDV and MFV with significant increase in PI while, Bahir-Kumbhaka showed significant increase 
+in EDV and MFV with significant reduction in PI. However, no such significant changes were observed in Bhramari pranay-
+ama. Various types of pranayama techniques produce different cerebrovascular hemodynamic changes in healthy volunteers.
+Keywords  Brain blood flow · Breath control · Fast breathing · Pranayama · Slow breathing · Yoga
+Background
+Cerebral hemodynamic parameters change rapidly in 
+response to various physiological challenges. These 
+responses are responsible for cerebral auto-regulation i.e. 
+maintaining a constant cerebral blood flow (CBF) over a 
+wide range of blood pressure fluctuations. Blood flow in the 
+large intracranial arteries can be monitored using transcra-
+nial Doppler ultrasound (TCD) (Yang et al. 2015). Thus, 
+TCD is aptly called as a stethoscope of the brain. It is the 
+only diagnostic tool that can provide relatively inexpensive, 
+non-invasive, real-time measurement of blood flow charac-
+teristics and cerebrovascular hemodynamics (Bathala et al. 
+2013). Since the middle cerebral artery (MCA) supplies the 
+largest area of the cerebral hemisphere, the flow velocity 
+is higher than any other intracranial arteries (Aaslid et al. 
+1982).
+Yoga is an ancient Indian science and the way of life, 
+which includes practice of specific posture (asana) and 
+regulated breathing (pranayama). Pranayama is an art of 
+prolongation and control of breath (Mooventhan and Khode 
+2014). It consists of four important aspects: (1) Pooraka 
+(inhalation), (2) Rechaka (exhalation), (3) Antar-Kumbhaka 
+[internal breath retention (holding the breath after deep inha-
+lation)], and (4) Bahir-Kumbhaka [external breath retention 
+(holding the breath after full exhalation)] (Saraswati 2008). 
+Different types of pranayamas were shown to produce dif-
+ferent physiological responses. For example, practice of the 
+slow type of pranayama (3–6 breaths/min) (Madanmohan 
+et al. 2005) and Bhramari pranayama (Kuppusamy et al. 
+2016) were reported to produce a reduction in heart rate 
+(HR), rate pressure product (RPP) [a product of HR and 
+systolic blood pressure (i.e. HR × SP/100), used to deter-
+mine the myocardial workload] and double product (Do P) 
+[a product of HR and mean arterial pressure (MAP) (i.e. 
+HR × MAP/100) an index of cardiac oxygen consumption] 
+(Kuppusamy et al. 2016; Madanmohan et al. 2005), while a 
+fast type of pranayama (≥ 60 breaths/min) was reported to 
+increase it (Madanmohan et al. 2005).
+ 
+*	 L. Nivethitha 
+	
+[email protected]
+1	
+Division of Yoga and Life Sciences, Department of Research 
+and Development, S-VYASA University, Bengaluru, 
+Karnataka, India
+2	
+Department of Neurology, Aster CMI Hospital, Cauvery 
+Medical Centre, Bengaluru, Karnataka, India
+3	
+Division of Neurology, National University Hospital, 
+Singapore, Singapore
+	
+Applied Psychophysiology and Biofeedback
+1 3
+Many studies have reported the effect of various pra-
+nayama practices on cardiovascular functions (Madanmo-
+han et al. 2005; Sharma et al. 2013), pulmonary functions 
+(Dinesh et al. 2015), autonomic functions including HR 
+variability (Raghuraj et al. 1998; Raghuraj and Telles 2008), 
+cognitive functions (Sharma et al. 2014), fine motor skills 
+(finger dexterity) (Telles et al. 2012), handgrip strength, 
+endurance (Thangavel et al. 2014), visual discrimination 
+(Telles et al. 2012), reaction time (Madanmohan et al. 2005) 
+and perceived stress (Sharma et al. 2013). Though a study 
+reported the effect of Bhastrika pranayama [bellows breath-
+ing (forceful inhalation followed by forceful exhalation)] and 
+Antar-Kumbhaka (Nivethitha et al. 2017) on cerebrovascular 
+hemodynamics, there is no known study reporting the effect 
+of various other commonly practicing pranayama techniques 
+including Bhramari pranayama [humming bee breath (a 
+slow and vibrating type of pranayama)], Kapalbhati [frontal 
+brain cleansing breath (a fast type of yoga breathing tech-
+nique)] and Bahir-Kumbhaka (no breathing after exhalation) 
+on cerebrovascular hemodynamics. Hence, the present study 
+was conducted to evaluate the effect of Bhramari pranayama, 
+Kapalbhati, and Bahir-Kumbhaka on cerebrovascular hemo-
+dynamics in healthy volunteers.
+Materials and Methods
+Participants
+Eighteen healthy volunteers were recruited from a residen-
+tial yoga university in South India, based on the following 
+inclusion and exclusion criteria. Inclusion criteria Healthy 
+male and female volunteers with the age of 18-years and 
+above, willing to participate in the study and who have had 
+experience in practicing yoga including pranayama for mini-
+mum of 1 year. Exclusion criteria Participants with a history 
+of any systemic and mental illness, regular medication for 
+any diseases, chronic substance abuse, and the participant 
+who is unable to perform pranayama. The study protocol was 
+approved by the institutional ethics committee, S-VYASA 
+University, Bengaluru, India. A signed written informed 
+consent was obtained from each participant.
+Study Design
+A single group repeated measures design was used in this 
+study. Each participant was advised to perform three dif-
+ferent pranayama techniques: (1) Bhramari pranayama, 
+(2) Kapalbhati, and (3) Bahir-Kumbhaka in three dif-
+ferent orders. The order was randomly selected using 
+lottery method as follows: 18 papers [6 containing the 
+word ‘Bhramari’ (i.e. 1st order), 6 containing the word 
+‘Kapalbhati’ (i.e. 2nd order); and 6 containing the word 
+‘Bahir-Kumbhaka’ (i.e. 3rd 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 pranayama tasks were done 
+(Mooventhan and Khode 2014). In the first order (n = 6), 
+participants performed normal breathing followed by Bhra-
+mari, Kapalbhati and Bahir-Kumbhaka; in second the order 
+(n = 6), participants performed normal breathing followed 
+by Kapalbhati, Bahir-Kumbhaka and Bhramari; and in the 
+third order (n = 6), participants performed normal breathing 
+followed by Bahir-Kumbhaka, Bhramari and Kapalbhati. 
+Assessments were taken before (normal breath), during and 
+after each pranayama technique.
+Assessment
+Cerebrovascular Hemodynamic Changes
+Cerebrovascular hemodynamic changes of the right MCA 
+were assessed with TCD (Multi Dop X, DWL, Germany). 
+A 2-MHz TCD ultrasound transducer probe (DWL Systems) 
+was placed in the right temporal area just above the zygo-
+matic arch and in front of the tragus of the ear with the use 
+of a head frame (a supporting material that was placed in 
+the head to hold and fix the TCD transducer probe firmly in 
+a desired place where we get the maximum ultrasound sig-
+nals). The transducer was adjusted manually to get red color 
+signal between 40 and 65-mm (indicator of maximum ultra-
+sound signal reflected from the ipsilateral MCA) in order to 
+obtain the flow dynamics of the right MCA. Assessments 
+such as peak systolic velocity (PSV) (the first peak on a TCD 
+waveform from each cardiac cycle that indicates CBF veloc-
+ity at systolic phase) in cm/s, end diastolic velocity (EDV) 
+(the second peak on a TCD waveform from each cardiac 
+cycle that indicates CBF velocity at diastolic phase) in cm/s, 
+mean flow velocities (MFV) (EDV plus one-third of the dif-
+ference between PSV and EDV) in cm/s and pulsatility index 
+(PI) (an indicator of flow resistance) (Bathala et al. 2013) 
+were taken just before (baseline), during and immediately 
+after (post) each pranayama. Baseline assessment was taken 
+at 0 s i.e. just before starting of each pranayama. During 
+assessment was taken at 1st, 2nd, 3rd, 4th and 5th min of 
+Bhramari pranayama; 15, 30, 45, and 60 s of Kapalbhati 
+and normal breathing (as a control); and 10, 20 and 30 s of 
+Bahir-Kumbhaka. Post assessment was taken at 15, 30, 45, 
+and 60 s immediately after the practice of each pranayama 
+technique.
+Intervention
+Each participant was advised to perform three differ-
+ent pranayama techniques: (1) Bhramari pranayama, (2) 
+Kapalbhati, and (3) Bahir-Kumbhaka for the duration of 
+Applied Psychophysiology and Biofeedback	
+1 3
+5 min, 1 min and 30 s respectively in any one of the three 
+different orders as mentioned in the study design. Since 
+the nature of each type of pranayama technique is different 
+from one another, the time taken to complete one round of a 
+particular type of pranayama is also different from another 
+type. Thus, the duration of each pranayama technique was 
+kept differently based on its nature and participants’ ability 
+to complete one round of each pranayama comfortably. A 
+rest period of 5 min was given between each intervention to 
+allow the cerebral hemodynamic patterns to settle at their 
+baseline values (Müller et al. 1995; Nivethitha et al. 2017).
+Bhramari (Humming Bee Breath)
+Participants were asked to perform inhalation through both 
+nostrils and while exhaling (through both nostrils) produces 
+the sound of a humming bee (with closed mouth) (Mooven-
+than and Khode 2014) for the duration of 5 min.
+Kapalbhati (Frontal Brain Cleansing Breath)
+Participants were asked to perform forceful exhalation fol-
+lowed by passive inhalation through both nostrils (Saraswati 
+2008) for the duration of 1 min.
+Bahir‑Kumbhaka (External Breath Retention)
+Participants were asked to exhale completely through both 
+nostrils followed by hold/retain the breath (Saraswati 2008) 
+for the duration of 30 s (excluding exhalation).
+Normal Breathing
+Participants were asked to perform normal breathing before 
+all the pranayama techniques and immediately after each 
+pranayama technique.
+Data Analysis
+Statistical analysis was performed using a repeated measures 
+of analysis of variance with post-hoc analysis and Bonfer-
+roni adjustment using the Statistical Package for the Social 
+Sciences (SPSS) for Windows, Version 16.0. Chicago, SPSS 
+Inc.
+Results
+A total of 18 healthy volunteers were recruited in the study. 
+Demographic details of all the study participants have been 
+given in Table 1. All study participants’ demonstrated stable 
+cerebrovascular hemodynamic parameters and no significant 
+changes were observed in PSV, EDV, MFV and PI during 
+their normal breathing (Table 2) and Bhramari pranayama 
+(Table 3) tasks.
+During the practice of Kapalbhati, there was a significant 
+reduction in EDV and MFV with significant increase in PI 
+from 15 to 60 s (Table 1) and those values were reverted 
+back to normal within 30 s (EDV and PI) and 45 s (MFV) 
+after cessation of the practice (Table 4).
+During the practice of Bahir-Kumbhaka, there was a sig-
+nificant increase in EDV and MFV with significant reduction 
+in PI at 30 s and those values were reverted back to normal 
+within 15 s after cessation of the practice (Table 5).
+Discussion
+CBF is regulated by the autonomic nervous system (ANS) by 
+altering the tone of arteriolar sphincters. Some of the impor-
+tant determinants of CBF include partial pressure of arterial 
+­
+CO2 ­
+(PaCO2), mean arterial pressure (MAP), and cerebral 
+metabolism. ­
+PaCO2 is the strongest regulator of arteriolar 
+Table 1   Demographic variables of the study subjects (n = 18)
+Variables
+Study group (n = 18)
+Age (years)
+23.78 ± 2.96
+Gender
+Males (n = 17) and 
+female (n = 1)
+Height (m)
+1.71 ± 0.08
+Weight (kg)
+60.28 ± 8.82
+Body mass index (kg/m2)
+20.65 ± 2.10
+Table 2   Cerebrovascular 
+hemodynamics during normal 
+breathing (n = 18) (RMANOVA 
+with post-hoc analysis and 
+Bonferroni adjustment)
+All values are in mean ± Standard deviation
+RMANOVA repeated measures of analysis of variance, PSV peak systolic velocity, EDV end diastolic veloc-
+ity, MFV mean flow velocity, PI pulsatility index
+Parameter
+Baseline
+15 s
+30 s
+45 s
+60 s
+PSV (cm/s)
+58.56 ± 18.64
+59.06 ± 18.99
+59.67 ± 18.31
+58.11 ± 17.65
+59.28 ± 18.15
+EDV (cm/s)
+22.94 ± 8.95
+21.56 ± 5.16
+22.33 ± 7.53
+22.28 ± 7.92
+21.78 ± 6.25
+MFV (cm/s)
+34.94 ± 12.24
+34.22 ± 11.02
+34.72 ± 10.90
+34.39 ± 10.37
+34.78 ± 9.92
+PI
+1.04 ± 0.22
+1.08 ± 0.19
+1.08 ± 0.20
+1.05 ± 0.23
+1.07 ± 0.21
+	
+Applied Psychophysiology and Biofeedback
+1 3
+tone and an increase of 1 mm of Mercury (Hg) increases 
+CBF by 3–6% while a 1 mmHg reduction decreases CBF by 
+1–3% (Willie et al. 2014).
+In this study, no significant changes in the cerebral hemo-
+dynamic parameters were observed during normal breath-
+ing and even during Bhramari pranayama. This effect is 
+probably related to the maintenance of ­
+PaCO2 and the bal-
+anced state of autonomic nervous system within a very nar-
+row and stable range (Battisti-Charbonney et al. 2011). In 
+contrast, practice of both Kapalbhati and Bahir-Kumbhaka 
+showed significant changes in cerebrovascular hemodynamic 
+parameters such as EDV, MFV and PI but no such significant 
+change was observed in PSV.
+Interestingly, though both Kapalbhati and Bahir-Kumb-
+haka produced significant changes in cerebral hemodynam-
+ics, the direction of the changes was opposite to one another 
+(i.e. Kapalbhati produced a significant reduction in EDV and 
+MFV with a significant increase in PI, while Bahir-Kumb-
+haka produced a significant increase in EDV and MFV with 
+a significant reduction in PI).
+In previous studies, practice of Kapalbhati was shown 
+to modify the autonomic status either by increasing sym-
+pathetic activity (Raghuraj et al. 1998) or by reducing par-
+asympathetic modulation (Telles et al. 2011). Kapalbhati is 
+also known as high frequency yoga breathing (> 60 breath/
+min) which might lead to the development of hypocapnia 
+i.e. reduced level of the ­
+PaCO2 due to increased rate of the 
+respiration with forceful exhalation. Hence, the reduction 
+in EDV and MFV associated with the increase in PI during 
+Kapalbhati is probably mediated via an increased sympa-
+thetic activity (Raghuraj et al. 1998) while reducing the 
+parasympathetic modulation (Telles et al. 2011). The cer-
+ebral hemodynamic parameters gradually returned to their 
+baseline values within 45 s of cessation of Kapalbhati, 
+most probably related to the normalization of ANS and/
+or ­
+PaCO2 during the normal breathing after the practice 
+(Nivethitha et al. 2017).
+Breath retention/holding increases the ­
+PaCO2 and 
+reduces the partial pressure of oxygen (Parkes 2006). 
+These changes resulted in an increased CBF (Willie et al. 
+2014). Hence, we believed in that the practice of Bahir-
+Kumbhaka (breath holding after exhalation) also produces 
+the same phenomenon and increases CBF with a reduced 
+cerebrovascular resistance.
+Some other limitations of the study need to be acknowl-
+edged. We did not monitor the partial pressures of oxy-
+gen and ­
+CO2 and autonomic variables specifically blood 
+pressure and HR variability during the practice of various 
+types of pranayama techniques to delineate the underly-
+ing physiological mechanisms for the observed changes 
+in cerebrovascular hemodynamic parameters; study might 
+appear to have a small number of participants. Hence, 
+Table 3   Cerebrovascular hemodynamics during Bhramari pranayama (n = 18) (RMANOVA with post-hoc analysis and Bonferroni adjustment)
+All values are in mean ± standard deviation
+RMANOVA repeated measures of analysis of variance, PSV peak systolic velocity, EDV end diastolic velocity, MFV mean flow velocity, PI pulsatility index
+Parameter
+Baseline
+During Bhramari
+Post-test assessments
+1 min
+2 min
+3 min
+4 min
+5 min
+15 s
+30 s
+45 s
+60 s
+PSV (cm/s)
+55.89 ± 19.98
+53.89 ± 19.39
+52.28 ± 16.24
+51.72 ± 17.87
+51.72 ± 19.03
+52.50 ± 18.63
+52.61 ± 18.72
+53.06 ± 19.68
+56.00 ± 22.38
+57.44 ± 21.70
+EDV(cm/s)
+20.61 ± 6.90
+19.28 ± 6.28
+20.67 ± 6.24
+19.94 ± 5.74
+20.56 ± 7.01
+21.33 ± 7.19
+19.06 ± 8.86
+20.39 ± 8.45
+21.00 ± 10.44
+22.61 ± 8.52
+MFV(cm/s)
+33.83 ± 10.59
+30.61 ± 10.29
+31.94 ± 9.36
+30.28 ± 9.46
+30.39 ± 11.25
+32.89 ± 10.06
+31.06 ± 11.50
+31.67 ± 10.86
+34.22 ± 14.36
+35.78 ± 14.12
+PI
+1.03 ± 0.28
+1.11 ± 0.26
+1.00 ± 0.27
+1.03 ± 0.24
+1.02 ± 0.26
+0.93 ± 0.19
+1.10 ± 0.22
+1.02 ± 0.20
+0.97 ± 0.30
+0.98 ± 0.16
+Applied Psychophysiology and Biofeedback	
+1 3
+further study is required with the large sample size and 
+more objective measurements for the better understanding.
+Conclusion
+Our study shows that the practice of Kapalbhati and Bahir-
+Kumbhaka produced different cerebrovascular hemody-
+namic changes which are almost opposite to each other 
+while Bhramari pranayama produces no effect.
+Compliance with Ethical Standards 
+Conflict of interest  All authors declare that they have no conflict of 
+interest.
+Ethical Approval  Study protocol was approved by the institutional eth-
+ics committee, S-VYASA University, Bengaluru, India.
+Informed Consent  A written informed consent was obtained from each 
+participant.
+References
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+Table 4   Cerebrovascular hemodynamics during Kapalbhati (n = 18) [RMANOVA with post-hoc analysis and Bonferroni adjustment]
+All values are in mean ± standard deviation
+RMANOVA repeated measures of analysis of variance, PSV peak systolic velocity, EDV end diastolic velocity, MFV mean flow velocity, PI pul-
+satility index
+*p value < 0.05
+Parameter
+Baseline
+During Kapalbhati
+Post-test assessments
+15 s
+30 s
+45 s
+60 s
+15 s
+30 s
+45 s
+60 s
+PSV (cm/s)
+58.56 ± 19.18
+54.28 ± 15.60
+57.11 ± 18.13
+54.72 ± 17.88
+54.33 ± 17.62
+53.89 ± 18.33
+53.72 ± 19.08
+54.89 ± 21.28
+55.67 ± 20.42
+EDV (cm/s)
+22.56 ± 8.00
+8.72 ± 9.30*
+6.39 ± 8.10*
+6.61 ± 8.47*
+9.78 ± 7.48*
+14.00 ± 9.73*
+18.11 ± 10.06
+18.28 ± 9.81
+20.22 ± 9.47
+MFV (cm/s)
+36.89 ± 11.67
+26.72 ± 8.58*
+24.78 ± 8.22*
+24.33 ± 8.29*
+24.39 ± 8.60*
+27.56 ± 9.92*
+30.83 ± 12.01*
+33.06 ± 15.28
+34.17 ± 12.89
+PI
+0.97 ± 0.20
+1.82 ± 0.64*
+2.19 ± 0.74*
+2.14 ± 0.81*
+1.98 ± 0.81*
+1.55 ± 0.61*
+1.28 ± 0.61
+1.27 ± 0.74
+1.07 ± 0.37
+Table 5   Cerebrovascular hemodynamics during Bahir-Kumbhaka (n = 18) (RMANOVA with post-hoc analysis and Bonferroni adjustment)
+All values are in mean ± standard deviation
+RMANOVA repeated measures of analysis of variance, PSV peak systolic velocity, EDV end diastolic velocity, MFV mean flow velocity, PI pul-
+satility index
+*p value < 0.05
+Parameter
+Baseline
+During Bahir-Kumbhaka
+Post-test assessments
+10 s
+20 s
+30 s
+15 s
+30 s
+45 s
+60 s
+PSV (cm/s)
+55.83 ± 19.81
+55.33 ± 17.35
+59.61 ± 19.74
+63.50 ± 20.95
+58.33 ± 19.98
+54.50 ± 20.39
+56.28 ± 20.34
+55.67 ± 19.42
+EDV (cm/s)
+20.50 ± 7.82
+20.33 ± 5.96
+25.22 ± 9.43
+31.44 ± 13.34* 19.78 ± 5.73
+19.78 ± 5.85
+20.28 ± 9.40
+20.33 ± 9.20
+MFV (cm/s)
+33.56 ± 12.08
+32.44 ± 9.15
+37.89 ± 13.83
+44.78 ± 17.61* 33.17 ± 10.13
+32.06 ± 10.04
+32.89 ± 12.87
+33.56 ± 12.01
+PI
+1.06 ± 0.22
+1.07 ± 0.25
+0.93 ± 0.20
+0.74 ± 0.14*
+1.16 ± 0.28
+1.05 ± 0.19
+1.12 ± 0.24
+1.12 ± 0.25
+	
+Applied Psychophysiology and Biofeedback
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+© 2023 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow	
+1
+Comparative impact of yoga and 
+ayurveda practice in insomnia: 
+A randomized controlled trial
+Kanika Verma, Deepeshwar Singh, Alok Srivastava1
+Abstract:
+BACKGROUND: Insomnia is connected with a lifted hazard for neurocognitive dysfunction and 
+psychiatric disarranges. Clinical observations of psychosomatic patients indicate that their distorted 
+somatopsychic functioning necessitates their practice of yoga‑like therapy. Sleep and its modifications 
+and management have also been explained well in ayurveda. This study aimed to compare the 
+effectiveness of Yoga and Nasya Karma on the sleep quality, stress, cognitive function, and quality 
+of life of people suffering from acute insomnia.
+MATERIAL AND METHODS: It was an open‑label, randomized controlled trial. A  total of 
+120 participants were randomly (computer‑generated randomization) equally allocated to three groups, 
+yoga group (G‑1), ayurveda group (G‑2), and control group (G‑3). All the groups were assessed 
+on the first day before the start of the yoga regime and the 48th day. Participants in the study were 
+included in the age group of 18 to 45 years, fulfilling DSM‑V criteria for insomnia, physically fit for 
+the yoga module, and Nasya procedure. Outcomes were measured by the Pittsburgh Sleep Quality 
+Index (PSQI) questionnaire, Perceived Stress Scale (PSS), cognitive failure questionnaire, and 
+WHO Quality of Life Scale‑Brief (WHOQOL‑Brief). Proportions and frequencies were described 
+for categorical variables and compared using the Chi‑square test. ANOVA (one‑way) and post hoc 
+analysis, Bonferroni test, were performed for multiple comparisons in groups at a significance level 
+of P < 0.05 using SPSS (23 version).
+RESULTS: A total of 112 participants were analyzed as per protocol analysis. All groups have 
+observed significant mean differences for stress (<0.05) and sleep quality (<0.05). All five aspects 
+of quality of life – general health (<0.05), physical health (<0.01), psychological health (<0.05), social 
+health (<0.05), and environmental health (<0.05) – had a significant mean difference in all three 
+groups. All three aspects of cognitive failure, forgetfulness (<0.05), distractibility (<0.05), and false 
+triggers (<0.01) had a significant mean difference in scores for all three groups.
+CONCLUSION: Yoga practice was effective, followed by ayurveda and the control group in reducing 
+stress and improving sleep, cognitive function, and quality of life.
+Keywords:
+Ayurveda, cognitive, insomnia, Nasya Karma, quality of life, sleep, stress, yoga
+Introduction
+I
+nsomnia can be described as dissatisfaction 
+with rest quality, difficulty falling asleep, 
+frequent night arousals, and arousing prior 
+to the morning or the desired time.[1,2] Most 
+reports recommend predominance rates of 
+insomnia disorder at 5% to 15%.[3‑5] Insomnia 
+could be an ongoing issue in 31% to 75% 
+of patients, with more than two‑thirds 
+reporting side effects for at least 1 year.[1,5] 
+It is additionally associated with daytime 
+fatigue, languor, impedance in cognitive 
+execution, and mood changes. Insomnia 
+differs from sleep deprivation as it is 
+challenging to rest despite having adequate 
+opportunities.[1] Given the expanded work 
+weight and social challenges in an advanced 
+Address for 
+correspondence: 
+Kanika Verma, 
+Department of Yoga 
+and Life Sciences, 
+Swami Vivekananda 
+Yoga Anusandhana 
+Samsthana (S‑VYASA), 
+Bengaluru, India. 
+E‑mail: kanika.yog@ 
+gmail.com
+Received: 12‑10‑2022
+Accepted: 24‑11‑2022
+Published: 31-05-2023
+Department of Yoga 
+and Life Sciences, 
+Swami Vivekananda 
+Yoga Anusandhana 
+Samsthana (S‑VYASA), 
+Bengaluru, Karnataka, 
+1Department of 
+Panchkarma, Uttarakhand 
+Ayurved University, 
+Dehradun, Uttarakhand, 
+India
+Original Article
+Access this article online
+Quick Response Code:
+Website:
+www.jehp.net
+DOI:
+10.4103/jehp.jehp_1489_22
+How to cite this article: Verma K, Singh D, 
+Srivastava A. Comparative impact of yoga and 
+ayurveda practice in insomnia: A randomized 
+controlled trial. J Edu Health Promot 2023;12:160.
+This is an open access journal, and articles are 
+distributed under the terms of the Creative Commons 
+Attribution‑NonCommercial‑ShareAlike 4.0 License, which 
+allows others to remix, tweak, and build upon the work 
+non‑commercially, as long as appropriate credit is given and 
+the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+[Downloaded free from http://www.jehp.net on Friday, October 20, 2023, IP: 103.5.133.82]
+Verma, et al.: A comparative efficacy of yoga module & nasya karma in insomnia
+2	
+Journal of Education and Health Promotion | Volume 12 | May 2023
+society, many people cannot get adequate sleep and 
+endure sleep disturbance.[6‑8] A detailed study shows 
+that around 30% of grown��ups show some sleep issues.[9] 
+Different measurements can be utilized to characterize 
+sleep, such as sleep quality (e.g., fulfilled with sleep), 
+sleep amount (e.g., add up to sleep time, sleep period 
+time, time in bed), and daytime languor  (e.g., the 
+likelihood of falling asleep but alert).[10] An agreement 
+that disturbed sleep significantly hinders physical 
+and mental well‑being has come.[11] For example, 
+destitute sleep has been connected with a lifted hazard 
+for cardiovascular illness, diabetes, hypertension, 
+mortality, obesity, pain, neurocognitive dysfunction, 
+and psychiatric disarranges.[12‑16] Outstandingly, both 
+sleep and stress‑responsive physiological frameworks 
+are transiently and functionally controlled by the 
+biological process, and it has been well established 
+that sleep incorporates a close relationship with the 
+stress‑responsive physiological frameworks.[17‑20] The 
+lack of sleep might impact bodily reactions to stress.[21,22] 
+Poor sleep may be an imperative hazard factor for 
+stress‑related diseases, including cardiovascular 
+illnesses and temperament disorders.[21] Besides this, 
+insomnia is often associated with cognitive impairment, 
+such as poor memory, attention, concentration, and 
+performance of simple tasks.[23] Also, insomnia and 
+its associated conditions worsen their quality of 
+life.[24] Clinical observations of psychosomatic patients 
+indicate that their distorted somatopsychic functioning 
+necessitates their practice of yoga‑like therapy.[25] It 
+is emphasized that physical yogic exercise is meant 
+to prepare the body for mental practices such as 
+samadhi.[26] Mindfulness meditation is increasingly 
+incorporated into mental health interventions, and its 
+theoretical concepts have influenced basic research on 
+psychopathology.[27] Yoga is restorative management 
+for psychophysiological effects. It incorporates a 
+comprehensive approach to physical, mental, and 
+spiritual well‑being.[25] Components of yoga have 
+been explored for their viability and its practice as 
+a comprehensive multi‑component discipline.[25,28,29] 
+Sleep and its modifications and management have 
+also been explained well in ayurveda. Nidrä is one of 
+the three pillars capable of supporting a healthy life. 
+The heart is the seat of cetanä. When it is secured by 
+thomas (numbness, haziness), all living creatures tend 
+to fall asleep. The viewpoints of emotional well‑being, 
+nourishment, emaciation, strength and weakness, 
+virility, cognition, life, and death depend upon ideal 
+sleep.[30] In persons whose Kapha has diminished and 
+vätta or pitta has expanded and those whose intellect 
+and body are distressed by illness or bodily injury, 
+sleep does not be satisfactory, resulting in nidränäç or 
+sleep disorder.[31] Many herbal drugs that overcome 
+sleep‑related disorders are mentioned. Brahmi 
+tail (Bacopa monnieri) is used for Abhyanga because 
+of its sedative and medhya properties.[32] The present 
+study has novelty as it aimed to compare the potential 
+appropriateness and adequacy of a basic yoga module 
+with Nasya Karma to alleviate stress and insomnia and 
+consequently their cognitive function and quality of 
+life. These practices require little preparation that can 
+be practiced individually on an everyday premise by 
+patients with insomnia.
+Material and Methods
+Study design and sample size
+It was an open‑label, randomized controlled trial. There 
+were three groups in total, one for the yoga group (G‑1), 
+the second for the ayurveda group  (G‑2), and the 
+third for the control group (G‑3). Computer‑generated 
+randomization was performed. Participants were 
+randomly equally allocated to three groups, yoga 
+group  (G‑1), ayurveda group  (G‑2), and control 
+group (G‑3). All the groups were assessed on the first 
+day before the start of the yoga regime and the 48th day. 
+The sample size was calculated based on the previous 
+study (Bankar et al., 2013) on the beneficial effects of yoga 
+on insomnia.[33] The effect size and its equivalent of partial 
+eta square with alpha 0.05 and power 0.9 with three 
+groups and three measurements are used to estimate the 
+sample size. The optimal sample size estimated is 100. 
+With the assumption of attrition rate (~20%) during the 
+study, the total sample size planned is 120.
+Study setting and participants
+For the present clinical study, both male and female 
+participants were screened based on DSM‑5. The 
+participants were recruited from the out‑patient 
+department  (OPD) of the Panchakarma Dept. of 
+Ayurveda University. The study’s participants were 
+included based on the inclusion and exclusion criteria 
+below.
+Participant selection criteria
+Participants from 18 to 45  years were included in 
+the study, fulfilling DSM‑V criteria for insomnia, 
+willing to participate, and physically fit for the yoga 
+module and the Nasya procedure. Patients had an 
+allergy to oil application primarily through the nasal 
+route; any severe respiratory ailments (URTI, allergic 
+rhinitis, sinusitis, asthma); any severe psychiatric 
+disorder  (schizophrenia, mania, bipolar disorders, 
+OCD); chronic illness (diabetes mellitus, hypertension); 
+taking medications such as alpha‑blockers, beta‑blockers, 
+corticosteroids, ace inhibitors, and statins, drug 
+withdrawal syndromes (barbiturates, tranquilizers); 
+substance abuse such as alcohol ingestion and withdrawal; 
+endocrine or metabolic disorders (hypothyroidism or 
+hyperthyroidism); and pregnant and lactating women 
+were excluded.
+[Downloaded free from http://www.jehp.net on Friday, October 20, 2023, IP: 103.5.133.82]
+Verma, et al.: A comparative efficacy of yoga module & nasya karma in insomnia
+Journal of Education and Health Promotion | Volume 12 | May 2023	
+3
+Study intervention
+Yoga Group  (G‑1): The yoga session included 
+physical activity, relaxation, regulated breathing, and 
+philosophical aspects. It was an integrated approach 
+to yoga, derived from principles in ancient texts 
+emphasizing that yoga should promote health at all 
+levels. The session was for 60 minutes daily, 6 days a 
+week. The yoga practices followed the approved protocol 
+based on a paper by Dr. Manjunath and Dr. Shirley 
+Telles, “Influence of Yoga & Ayurveda on self‑rated sleep 
+in a geriatric population.”
+Yoga Nidrä – 1 day a week. Jal ëeti – 3 days in a week.
+Ayurveda Group (G‑2): Patients were administered 
+in this group’s Nasya  (Pratimarça) procedure. As 
+Pratimarça Nasya was a daily regimen, each sitting 
+included two drops in each nostril for 48 days, regularly 
+in the morning and evening.
+Control Group  (G‑3): This group followed the 
+conventional medical treatment. Pre‑post‑intervention 
+data were collected. Figure 1 CONSORT flow diagram
+Data collection
+Data were collected from the selected participants 
+through four questionnaires as Pittsburgh Sleep Quality 
+Index (PSQI), Perceived Stress Scale (PSS), cognitive 
+failure questionnaire (CFQ), and WHO Quality of Life 
+Scale‑Brief (WHOQOL‑Brief). Details about the nature of 
+the study’s intervention were explained to participants, 
+and informed consent was taken from them.
+The PSQI questionnaire measures the quality and sleeps 
+patterns. It has seven domains measuring “good” to 
+“poor” sleep: subjective sleep quality, sleep latency, sleep 
+duration, sleep disturbances, habitual sleep efficiency, 
+daytime dysfunction, and sleep medication last month. 
+The client rates each of these seven domains of sleep. 
+Scoring is based on a 0 to 3 scale. Scoring 3 depicts the 
+extreme negative on the Likert Scale. A total sum of “5” 
+or greater indicates a “poor” sleeper.[34]
+The PSS is a widely used instrument for measuring 
+stress. Stressful life events are closely associated with 
+the onset of insomnia and are mediated by certain 
+predisposing personality factors. Insomniacs, compared 
+to controls, tend to be more discontent, both as children 
+and as adults, have less satisfying inter‑personal 
+relations, and have relatively poor self‑concepts, 
+leading to inadequate coping mechanisms for dealing 
+with stress.
+All the items on this scale are easy to respond to, and 
+alternatives are simple to grasp. All questions are general 
+and are relatively free of content specific to any group. 
+It consists of 25 items scored on a 5‑point Likert scale 
+ranging from 0 (never) to 4 (very often). The questions 
+in the PSS ask about thoughts and feelings in the last 
+month.[35]
+Assessed for eligibility
+Inclusion criteria
+• Patient fulfilling DSM-5 criteria for
+insomnia.
+• Age – 18 to 45 years.
+• Patients willing to complete our
+treatment schedule.
+• Patient physically fit for the Yoga
+Module
+Randomization (n = 120)
+Allocation
+Yoga Group (n = 40)
+48 days Yoga practices i.e.,
+consisting of yoga postures,
+breathing practices, relaxation
+and meditation
+Ayurveda group (n = 40)
+48 days Nasya (Pratimarça)
+procedure
+Control group (n = 40)
+Conventional Treatment
+Follow up
+Lost to follow up (n = 2)
+Lost to follow up (n = 3)
+Lost to follow up (n = 3)
+Analyzed
+Analyzed (n = 37)
+Outcomes
+Stress, cognitive failure, sleep
+quality and quality of life
+Analyzed (n = 37)
+Outcomes
+Stress, cognitive failure, sleep
+quality and quality of life
+Analyzed (n = 38)
+Outcomes
+Stress, cognitive failure, sleep
+quality and quality of life
+Analysis
+Follow up
+Allocation
+Enrollment
+Figure 1: CONSORT Flow Diagram
+[Downloaded free from http://www.jehp.net on Friday, October 20, 2023, IP: 103.5.133.82]
+Verma, et al.: A comparative efficacy of yoga module & nasya karma in insomnia
+4	
+Journal of Education and Health Promotion | Volume 12 | May 2023
+The CFQ is used to measure standard cognitive errors. 
+The questionnaire was designed to assess the frequency 
+of lapses in three areas, perception, memory, and 
+motor function and was proposed by the authors to 
+tap a single factor coined “cognitive failures.” It is a 
+5‑point Likert scale ranging from 0 (never) to 4 (very 
+often). Respondents were asked to assess the number of 
+cognitive failures within the past 4 weeks before filling 
+out the questionnaire.[36]
+For measurements of subjective quality of life (QoL), the 
+WHOQOL‑Brief was used. The WHOQOL‑Brief (Field 
+Trial Version) includes four domains and two items 
+scored individually about overall perception of quality 
+of life and health. The four domain scores are scaled 
+positively. Higher scores indicate a higher quality of 
+life. Three items of the WHOQOL Brief must be reversed 
+before scoring.[37]
+Data extraction and analysis
+The data extraction was performed on the first day and 
+the 48th day for the yoga, ayurveda, and control groups. 
+After the pre‑ and post‑intervention data collection, 
+data were checked for normality, and appropriate 
+statistical tests were applied. The Kolmogorov–Smirnov 
+Z test checked the normality of data. The Statistical 
+Package for Social Sciences (SPSS version 23, SPSS, 
+Inc., Chicago, IL) is used for analysis. All quantitative 
+variables were measured as mean, standard deviation, 
+and standard error. Proportions and frequencies were 
+described for categorical variables and compared using 
+the Chi‑square test. All applied statistical tests were 
+two‑sided and performed at a significance level of 
+P < 0.05. ANOVA (One‑way) was applied to explore 
+the between‑ and within‑group differences among three 
+study groups. Post hoc analysis, Bonferroni test, was 
+performed for multiple comparisons in groups.
+Ethical consideration
+Ethical permission was taken from the Institutional 
+Ethical Committee (IEC). An ethical certificate number 
+is RES/IEC‑SVYASA/195/2021.
+Results
+Results were analyzed as per protocol analysis. A total 
+of 112 participants were analyzed, and the drop‑out 
+rate was 6.66%. In the yoga, ayurveda, and control 
+groups, 38, 37, and 37 participants were available 
+post intervention, respectively. Table 1 describes the 
+participant’s sociodemographic characteristics. It 
+showed that the mean age of participants was matched, 
+and there was no statistically significant difference. 
+Sociodemographic classifications were described in the 
+table as per modified Kuppuswamy and Udai Pareekh’s 
+scale.[38]
+Stress and sleep quality
+Results showed a significant association of selected 
+variables such as gender  (<0.05), habitat  (<0.001), 
+occupation  (<0.05), marital status  (<0.05), and 
+socioeconomic status  (<0.01) with sleep quality. 
+Table 1: Sociodemographic characteristics of participants
+Variables 
+Categories 
+Yoga Group 
+(n=40) 
+Frequency %
+Ayurveda 
+Group (n=40) 
+Frequency %
+Control Group 
+(n=40) 
+Frequency %
+Sleep 
+Quality (P)
+Age (Mean±SD)
+34.6±7.07
+32.15±6.94
+31.8±7.24
+Gender
+Male
+26 (65)
+22 (55)
+25 (62.5)
+<0.05*
+Female
+14 (35)
+18 (45)
+15 (32.5)
+Educational Qualification
+Up to 12th standard
+5 (12.5) 
+4 (10)
+9 (22.5)
+0.21
+Graduation 
+22 (55)
+21 (52.5)
+20 (50)
+Post‑ Graduation
+13 (32.5)
+15 (37.5)
+11 (27.5)
+Habitat
+Urban
+35 (87.5)
+31 (77.5)
+32 (40)
+<0.001**
+Rural
+5 (12.5)
+9 (22.5)
+8 (20)
+Marital status
+Married
+32 (40)
+21 (52.5)
+24 (60)
+<0.05*
+Single
+6 (15)
+10 (25)
+13 (32.5)
+Separated
+2 (5)
+9 (47.5)
+3 (7.5)
+Occupation
+Government job
+10 (25)
+5 (12.5)
+8 (20)
+<0.01**
+Private job
+22 (55)
+26 (65)
+12 (30)
+Self‑employed
+1 (2.5)
+3 (7.5)
+11 (27.5)
+No occupation
+7 (17.5)
+6 (15)
+9 (22.5)
+Socioeconomic Status
+Lower 
+‑
+‑
+<0.001**
+Upper Lower
+3 (7.5)
+4 (10)
+2 (5)
+Lower Middle
+33 (82.5)
+31 (77.5)
+29 (72.5)
+Upper middle
+4 (10)
+5 (12.5)
+9 (22.5)
+Upper
+‑
+‑
+‑
+‑
+Note Chi‑Square’ test, P value significant as * represents <0.05 and ** represents <0.01. SD, standard deviation
+[Downloaded free from http://www.jehp.net on Friday, October 20, 2023, IP: 103.5.133.82]
+Verma, et al.: A comparative efficacy of yoga module & nasya karma in insomnia
+Journal of Education and Health Promotion | Volume 12 | May 2023	
+5
+Table 2 depicts the descriptive statistics for stress and 
+sleep quality variables in yoga, ayurveda, and control 
+groups. It can be noted that the post‑intervention 
+mean ± SD for a perceived stress test was the lowest in 
+the yoga group (11.73 ± 1.96), followed by the ayurveda 
+group (16.51 ± 4.49) and control group (17.91 ± 4.62). 
+Accordingly, yoga practice reduced the stress level of 
+insomnia patients more than the ayurveda and control 
+groups.
+Simultaneously, participants’ sleep quality was also 
+improved in the yoga group (4.63 ± 2.28), followed by the 
+ayurveda group (9.18 ± 3.80) and control group (11.86 ± 6.54). 
+The lowest mean value can be observed in the yoga group. 
+Table 3 describes the results of the ANOVA (one‑way) 
+test. All groups have observed that stress variables had 
+significant mean differences (F‑26.275, P value 0.011). 
+Participants’ sleep quality also had a significant mean 
+difference (F‑24.271, P value 0.021) in all groups.
+Table 2: Descriptive statistics for stress, sleep, cognitive failure, and quality of life variables in yoga, ayurveda, 
+and control groups
+Dependent 
+Variable
+(I) Groups
+n
+Mean
+Std. 
+Deviation
+Std. Error
+95% Confidence Interval for Mean
+Lower Bound
+Upper Bound
+PSS
+1
+38
+11.7368
+1.96846
+0.31933
+11.0898
+12.3839
+2
+37
+16.5135
+4.49457
+0.73890
+15.0149
+18.0121
+3
+37
+17.9189
+4.62108
+0.75970
+16.3782
+19.4597
+Total
+112
+15.3571
+4.67860
+0.44209
+14.4811
+16.2332
+PSQI
+1
+38
+4.6316
+2.28297
+0.37035
+3.8812
+5.3820
+2
+37
+9.1892
+3.80670
+0.62582
+7.9200
+10.4584
+3
+37
+11.8649
+6.54541
+1.07606
+9.6825
+14.0472
+Total
+112
+8.5268
+5.42095
+0.51223
+7.5118
+9.5418
+WHOQOL‑Brief
+General Health
+1
+38
+7.9211
+1.14801
+0.18623
+7.5437
+8.2984
+2
+37
+7.0811
+1.32032
+0.21706
+6.6409
+7.5213
+3
+37
+6.5946
+1.38362
+0.22747
+6.1333
+7.0559
+Total
+112
+7.2054
+1.38940
+0.13129
+6.9452
+7.4655
+Physical 
+Health
+1
+38
+29.1053
+3.02056
+0.49000
+28.1124
+30.0981
+2
+37
+26.1351
+3.72799
+0.61288
+24.8922
+27.3781
+3
+37
+22.7297
+4.05277
+0.66627
+21.3785
+24.0810
+Total
+112
+26.0179
+4.44381
+0.41990
+25.1858
+26.8499
+Psychological 
+Health
+1
+38
+24.2368
+3.01738
+0.48948
+23.2451
+25.2286
+2
+37
+21.6486
+3.19910
+0.52593
+20.5820
+22.7153
+3
+37
+18.8378
+4.00356
+0.65818
+17.5030
+20.1727
+Total
+112
+21.5982
+4.05916
+0.38355
+20.8382
+22.3583
+Social Health
+1
+38
+12.1842
+1.81369
+0.29422
+11.5881
+12.7804
+2
+37
+10.7297
+2.06355
+0.33925
+10.0417
+11.4178
+3
+37
+9.9730
+1.89277
+0.31117
+9.3419
+10.6041
+Total
+112
+10.9732
+2.12009
+0.20033
+10.5762
+11.3702
+Environment 
+Health
+1
+38
+32.8684
+3.48875
+0.56595
+31.7217
+34.0151
+2
+37
+28.8378
+5.51520
+0.90669
+26.9990
+30.6767
+3
+37
+25.5135
+4.65845
+0.76585
+23.9603
+27.0667
+Total
+112
+29.1071
+5.48931
+0.51869
+28.0793
+30.1350
+Cognitive Failure 
+Forgetfulness
+1
+38
+10.2632
+3.20206
+0.51944
+9.2107
+11.3156
+2
+37
+15.1351
+3.35958
+0.55231
+14.0150
+16.2553
+3
+37
+18.8649
+6.57927
+1.08163
+16.6712
+21.0585
+Total
+112
+14.7143
+5.80529
+0.54855
+13.6273
+15.8013
+Distractibility
+1
+38
+10.8158
+3.76940
+0.61148
+9.5768
+12.0548
+2
+37
+14.5676
+3.64799
+0.59973
+13.3513
+15.7839
+3
+37
+17.0541
+6.81072
+1.11968
+14.7832
+19.3249
+Total
+112
+14.1161
+5.54709
+0.52415
+13.0774
+15.1547
+False triggers
+1
+38
+11.0789
+3.07897
+0.49948
+10.0669
+12.0910
+2
+37
+15.5135
+4.66441
+0.76682
+13.9583
+17.0687
+3
+37
+17.5405
+7.42965
+1.22143
+15.0634
+20.0177
+Total
+112
+14.6786
+5.95965
+0.56313
+13.5627
+15.7945
+Note: PSS, Perceived Stress Scale; PSQI, Pittsburgh Sleep Quality Scale; WHOQOL‑Brief, WHO Quality of Life Scale‑Brief; Std., standard; Sig., significant. 
+Groups: 1, Yoga; 2, Ayurveda; 3, Control
+[Downloaded free from http://www.jehp.net on Friday, October 20, 2023, IP: 103.5.133.82]
+Verma, et al.: A comparative efficacy of yoga module & nasya karma in insomnia
+6	
+Journal of Education and Health Promotion | Volume 12 | May 2023
+Quality of life
+Table 2 also describes the participants’ quality of life 
+scores under sub‑heads of general health, physical health, 
+psychological health, social health, and environment 
+health in all groups. In the yoga group, general health 
+scores (7.92 ± 1.14) were nearly similar to those in the 
+ayurveda group (7.08 ± 1.32) but higher than those in 
+the control group (6.54 ± 1.38).
+Physical health scores were the highest in the 
+yoga group  (29.10  ±  3.02) compared to the 
+ayurveda (26.13 ± 3.72) and control groups (22.72 ± 4.05). 
+The psychological, social, and environmental health 
+scores of participants were improved in the yoga 
+group compared to the ayurveda and control 
+groups [Table 2].
+All five aspects, general health (F‑10.220, P value 0.038), 
+physical health (F‑29.087, P value 0.001), psychological 
+health (F‑23.23, P value 0.021), social health (F‑12.808, 
+P value 0.045), and environmental health (F‑23.849, 
+P value 0.013) had a significant mean difference in all 
+three groups.
+Cognitive function
+The cognitive Failure questionnaire has been 
+divided into three aspects  –  forgetfulness, 
+distractibility, and false triggers. Post‑intervention 
+mean scores for forgetfulness were the lowest 
+in the yoga group  (10.2632  ±  3.20206) compared 
+to the ayurveda  (15.1351  ±  3.35958) and control 
+groups (18.8649 ± 6.57927). Distractibility scores were 
+also the lowest in the yoga group (10.8158 ± 3.76940) 
+compared to other groups. The table also depicted the 
+lower and upper bounds with a standard error for all 
+outcomes in each group [Table 2].
+All three aspects, forgetfulness  (F‑32.477, P  value 
+0.011), distractibility (F‑15.095, P value 0.020), and false 
+triggers (F‑14.340, P value 0.001), had significant mean 
+Table 3: Mean differences for stress, sleep, cognitive failure, and quality of life in yoga, ayurveda, and control 
+groups
+Sum of Squares
+Mean Square
+F
+Sig.
+PSS
+Between Groups
+790.346
+395.173
+26.275
+<0.01**
+Within Groups
+1639.368
+15.040
+Total
+2429.714
+PSQI
+Between Groups
+1005.078
+502.539
+24.271
+<0.05*
+Within Groups
+2256.842
+20.705
+Total
+3261.920
+WHOQOL‑Brief
+General Health
+Between Groups
+33.838
+16.919
+10.220
+<0.05*
+Within Groups
+180.439
+1.655
+Total
+214.277
+Physical health
+Between Groups
+762.764
+381.382
+29.087
+<0.01**
+Within Groups
+1429.201
+13.112
+Total
+2191.964
+Psychological health
+Between Groups
+546.592
+273.296
+23.231
+<0.05*
+Within Groups
+1282.328
+11.764
+Total
+1828.920
+Social health
+Between Groups
+94.939
+47.469
+12.808
+<0.05*
+Within Groups
+403.981
+3.706
+Total
+498.920
+Environment health
+Between Groups
+1018.102
+509.051
+23.849
+<0.01*
+Within Groups
+2326.612
+21.345
+Total
+3344.714
+Cognitive Failure
+Forgetfulness
+Between Groups
+1396.840
+698.420
+32.477
+<0.05*
+Within Groups
+2344.017
+21.505
+Total
+3740.857
+Distractibility
+Between Groups
+740.808
+370.404
+15.095
+<0.05*
+Within Groups
+2674.683
+24.538
+Total
+3415.491
+False triggers
+Between Groups
+821.233
+410.616
+14.340
+<0.01**
+Within Groups
+3121.196
+28.635
+Total
+3942.429
+PSS, Perceived Stress Scale; PSQI, Pittsburgh Sleep Quality Scale; WHOQOL‑Brief, WHO Quality of Life Scale‑Brief; Std., standard; significant mean difference; 
+* represents <0.05 and ** represents <0.01. Sig., significant. Groups: 1, Yoga; 2, Ayurveda; 3, Control
+[Downloaded free from http://www.jehp.net on Friday, October 20, 2023, IP: 103.5.133.82]
+Verma, et al.: A comparative efficacy of yoga module & nasya karma in insomnia
+Journal of Education and Health Promotion | Volume 12 | May 2023	
+7
+differences in scores for all three groups [Table 3]. Post 
+hoc analysis was also applied for multiple comparisons, 
+values which show a significant difference in all 
+groups [Tables 4‑6].
+Discussion
+Acute insomnia is considered an emotional disorder. It is 
+associated with specific personality traits in patients.[2,3] 
+Table 4: Multiple comparisons for stress and sleep quality in all groups
+Dependent Variable
+(I) Groups
+(J) Groups 
+MD (I‑J)
+Std. Error
+Sig.
+95% Confidence Interval
+Lower Bound
+Upper Bound
+PSS
+1
+2
+‑4.77667*
+0.89570
+<0.01**
+‑6.9546
+‑2.5988
+3
+‑6.18208*
+0.89570
+<0.05*
+‑8.3600
+‑4.0042
+2
+1
+4.77667*
+0.89570
+<0.01**
+2.5988
+6.9546
+3
+‑1.40541
+0.90165
+0.366
+‑3.5978
+0.7870
+3
+1
+6.18208*
+0.89570
+<0.01**
+4.0042
+8.3600
+2
+1.40541
+0.90165
+0.366
+‑0.7870
+3.5978
+PSQI
+1
+2
+‑4.55761*
+1.05093
+<0.01**
+‑7.1129
+‑2.0023
+3
+‑7.23329*
+1.05093
+<0.05*
+‑9.7886
+‑4.6780
+2
+1
+4.55761*
+1.05093
+<0.05*
+2.0023
+7.1129
+3
+‑2.67568*
+1.05792
+<0.05*
+‑5.2480
+‑0.1034
+3
+1
+7.23329*
+1.05093
+<0.01**
+4.6780
+9.7886
+2
+2.67568*
+1.05792
+<0.05*
+0.1034
+5.2480
+Note: Post hoc analysis, Bonferroni test for multiple comparisons. PSS, Perceived Stress Scale; PSQI, Pittsburgh Sleep Quality Scale; Std., Standard; Significant 
+mean difference; * represents <0.05 and ** represents <0.01. Sig., significant, MD Mean Difference. Groups: 1, Yoga; 2, Ayurveda; 3, Control
+Table 5: Multiple comparisons for quality of life in all groups
+Dependent Variable
+(I) Groups
+(J) Groups 
+Mean Difference (I‑J)
+Std. Error
+Sig.
+95% Confidence Interval
+Lower Bound
+Upper Bound
+WHOQOL‑Brief
+General Health
+1
+2
+0.83997*
+0.29716
+<0.05*
+0.1174
+1.5625
+3
+1.32646*
+0.29716
+<0.01**
+0.6039
+2.0490
+2
+1
+‑0.83997*
+0.29716
+<0.05*
+‑1.5625
+‑0.1174
+3
+0.48649
+0.29913
+0.320
+‑0.2409
+1.2138
+3
+1
+‑1.32646*
+0.29716
+<0.01** 
+‑2.0490
+‑0.6039
+2
+‑0 0.48649
+0.29913
+0.320
+‑1.2138
+0.2409
+Physical health
+1
+2
+2.97013*
+0.83632
+<0.01**
+0.9366
+5.0036
+3
+6.37553*
+0.83632
+<0.01**
+4.3420
+8.4090
+2
+1
+‑2.97013*
+0.83632
+<0.01**
+‑5.0036
+‑0.9366
+3
+3.40541*
+0.84187
+<0.05*
+1.3584
+5.4524
+3
+1
+‑6.37553*
+0.83632
+<0.05*
+‑8.4090
+‑4.3420
+2
+‑3.40541*
+0.84187
+<0.05*
+‑5.4524
+‑1.3584
+Psychological health
+1
+2
+2.58819*
+0.79218
+<0.01**
+0.6620
+4.5144
+3
+5.39900*
+0.79218
+<0.01**
+3.4728
+7.3252
+2
+1
+‑2.58819*
+0.79218
+<0.01**
+‑4.5144
+‑0.6620
+3
+2.81081*
+0.79744
+<0.01**
+0.8718
+4.7498
+3
+1
+‑5.39900*
+0.79218
+<0.001**
+‑7.3252
+‑3.4728
+2
+‑2.81081*
+0.79744
+<0.001**
+‑4.7498
+‑0.8718
+Social health
+1
+2
+1.45448*
+0.44464
+<0.05*
+0.3734
+2.5356
+3
+2.21124*
+0.44464
+<0.001**
+1.1301
+3.2924
+2
+1
+‑1.45448*
+0.44464
+<0.05**
+‑2.5356
+‑0.3734
+3
+0.75676
+0.44759
+0.281
+‑0.3316
+1.8451
+3
+1
+‑2.21124*
+0.44464
+<0.001**
+‑3.2924
+‑1.1301
+2
+‑0.75676
+0.44759
+0.281
+‑1.8451
+0.3316
+Environment
+1
+2
+4.03058*
+1.06705
+<0.001**
+1.4361
+6.6251
+3
+7.35491*
+1.06705
+<0.001**
+4.7604
+9.9494
+2
+1
+‑4.03058*
+1.06705
+<0.01**
+‑6.6251
+‑1.4361
+3
+3.32432*
+1.07414
+<0.01**
+0.7126
+5.9361
+3
+1
+‑7.35491*
+1.06705
+<0.01** 
+‑9.9494
+‑4.7604
+2
+‑3.32432*
+1.07414
+<0.05*
+‑5.9361
+‑0.7126
+Note: post hoc analysis, Bonferroni test, for multiple comparisons. WHOQOL‑Brief, WHO Quality of Life Scale‑Brief; Std., Standard; significant mean difference; 
+*represents <0.05 and ** represents <0.01. Sig., significant; MD, mean difference; LB, lower bound; UB, upper bound. Groups: 1, Yoga; 2, Ayurveda; 3, Control
+[Downloaded free from http://www.jehp.net on Friday, October 20, 2023, IP: 103.5.133.82]
+Verma, et al.: A comparative efficacy of yoga module & nasya karma in insomnia
+8	
+Journal of Education and Health Promotion | Volume 12 | May 2023
+As yoga aims to bring consensus between mind and 
+body,[26,27] this study assessed the effectiveness of a 
+basic set of yoga exercises, requiring little preparation 
+that patients can practice individually on an everyday 
+premise with insomnia. The study compared the results 
+with ayurveda and standard care. This randomized 
+control trial describes yoga as a helpful therapy 
+for acute insomnia patients. After an intervention, 
+participants in the yoga group improved global sleep 
+quality, subjective sleep quality, wake‑after‑sleep onset, 
+daytime dysfunction, and sleep efficiency compared 
+with ayurveda and standard care. In the same group, 
+we also found stress reduction and improved cognitive 
+function and quality of life. Because of physiopathology, 
+insomnia is associated with increased psychological 
+symptoms, cognitive dysfunction, perceived stress, and 
+poor quality of life as precipitating and perpetuating 
+factors.[39,40] Increasing melatonin levels and anxiety 
+reduction affect sleep quality and confirm yoga’s 
+effectiveness in stress reduction.[41] Morning yoga 
+exercise enhances night parasympathetic drive and more 
+curative sleep. In addition, the probable mechanisms 
+were linked to the cognitive structuring effects of the 
+yoga practice.[42] Consistently, studies have reported 
+improvement in objective sleep quality, even measuring 
+by polysomnography and sleep diary.[43,44] Yoga reduces 
+stress and improves general health in the young 
+population by reducing sympathetic activity.[45] Another 
+trial with a mindfulness program for stress reduction 
+suggested significant effects on stress, anxiety, and 
+cognitive emotion regulation (P < 001).[46] Even yoga 
+was safe and effective in improving sleep quality and 
+life in older adults.[47] One week of residential yoga 
+training program reduced the occupational stress in the 
+participants aged 40–59.[48] A quasi‑experimental study 
+states the effectiveness of yoga in coping with stress 
+and anxiety and enhancing happiness in professional 
+students.[49]
+According to ayurveda, an individual’s nature (Prakriti 
+in Sanskrit) could consist of different doshas, with one 
+dosha being predominant in some cases. Ayurveda looks 
+at several aspects of an individual›s lifestyle.[50] The 
+present study found improvement in sleep quality 
+and reduction in stress with improvement in cognitive 
+function and, ultimately, the quality of life in the ayurveda 
+group compared to standard therapy. However, the 
+scores were not like those of yoga practice but improved 
+compared to standard therapy. Therefore, the role of 
+ayurveda cannot be neglected in patients with insomnia. 
+Previous studies have come up with biochemical, 
+hematological, and physiological variations in different 
+Prakriti, and sleep is also considered to be influenced 
+by psychological factors.[51] Studies also claimed its 
+effectiveness in enhancing memory and cognitive 
+functions.[52,53] Few studies suggested the failure of 
+short‑term effects of Bacopa monnieri supplementation 
+to improve sleep patterns and quality of life in 
+comparison to the placebo in adults with insomnia.[54] 
+In contrast, another trial on healthy adults identified 
+mood‑enhancing effects and reduced cortisol levels, 
+evincing a physiological mechanism for cognitive stress 
+reduction with supplementation of Bacopa monnieri. It 
+was evidenced that Bacopa monnieri supplementation 
+Table 6: Multiple comparisons for cognitive function in all groups
+Dependent Variable
+(I) Groups
+(J) Groups 
+Mean Difference (I‑J)
+Std. Error
+Sig.
+95% Confidence Interval
+Lower Bound
+Upper Bound
+Forgetfulness
+1
+2
+‑4.87198*
+1.07104
+<0.05*
+‑7.4762
+‑2.2678
+3
+‑8.60171*
+1.07104
+<0.05*
+‑11.2059
+‑5.9975
+2
+1
+4.87198*
+1.07104
+0.060
+2.2678
+7.4762
+3
+‑3.72973*
+1.07816
+<0.05*
+‑6.3513
+‑1.1082
+3
+1
+8.60171*
+1.07104
+<0.001**
+5.9975
+11.2059
+2
+3.72973*
+1.07816
+<0.05*
+1.1082
+6.3513
+Distractibility
+1
+2
+‑3.75178*
+1.14409
+<0.001**
+‑6.5336
+‑0.9699
+3
+‑6.23826*
+1.14409
+<0.05*
+‑9.0201
+‑3.4564
+2
+1
+3.75178*
+1.14409
+<0.05*
+0.9699
+6.5336
+3
+‑2.48649
+1.15169
+0.099
+‑5.2868
+0.3138
+3
+1
+6.23826*
+1.14409
+<0.001**
+3.4564
+9.0201
+2
+2.48649
+1.15169
+0.099
+‑0.3138
+5.2868
+False triggers
+1
+2
+‑4.43457*
+1.23591
+<0.01**
+‑7.4397
+‑1.4295
+3
+‑6.46159*
+1.23591
+<0.01**
+‑9.4667
+‑3.4565
+2
+1
+4.43457*
+1.23591
+<0.001**
+1.4295
+7.4397
+3
+‑2.02703
+1.24412
+0.318
+‑5.0521
+0.9980
+3
+1
+6.46159*
+1.23591
+<0.001**
+3.4565
+9.4667
+2
+2.02703
+1.24412
+0.318
+‑0.9980
+5.0521
+Note: Post hoc analysis, Bonferroni test, for multiple comparisons. PSS, Perceived Stress Scale; PSQI, Pittsburgh Sleep Quality Scale; WHOQOL‑Brief, WHO 
+Quality of Life Scale‑Brief; Std., Standard; significant mean difference; * represents <0.05 and ** represents <0.01. Sig., significant; MD, mean difference; LB, 
+lower bound; UB, upper bound. Groups: 1, Yoga; 2, Ayurveda; 3, Control
+[Downloaded free from http://www.jehp.net on Friday, October 20, 2023, IP: 103.5.133.82]
+Verma, et al.: A comparative efficacy of yoga module & nasya karma in insomnia
+Journal of Education and Health Promotion | Volume 12 | May 2023	
+9
+produced some adaptogenic and nootropic effects.[55] A 
+systematic review of six randomized controlled trials 
+observed that Bacopa improves memory‑free recall 
+and cognitive abilities in studies across the cognitive 
+domains.[56] Evidence from animal trials has consistently 
+suggested its anxiolytic or antidepressant effects.[57,58] One 
+trial has explored its safety and efficacy in enhancing 
+cognitive performance in participants with age 65 or 
+more.[59]
+After discussing studies with yoga and ayurveda practice 
+in reducing stress and improving sleep quality, cognitive 
+function, and quality of life, it needs to emphasize 
+that the present study’s results with yoga practice 
+are consistent with previous studies. However, the 
+availability of limited literature with similar efficacy of 
+ayurveda emphasized further research for its acceptance 
+in reducing stress and improving sleep quality, cognitive 
+function, and quality of life.
+Strength and limitations
+The present study compared the two interventions (Yoga 
+and Nasya karma) individually with the control group in 
+the same population. The sample size was also adequate, 
+and the drop‑out rate was meager compared to other 
+studies in the same intervention. However, it was an 
+open‑label trial. Subjective questionnaires were used to 
+measure and compare the results.
+Conclusion
+The study concluded that yoga as a holistic treatment 
+could bring significant changes in insomnia patients 
+and help with various psychosocial and cognitive 
+parameters, which can ultimately help alleviate stress 
+and improve the quality of life compared to ayurveda 
+and standard therapy. A vital advantage of the yoga 
+intervention is its recognition and acceptance as a health 
+practice, which should also add to the attractiveness of 
+such a treatment for insomnia patients.
+Declaration of patient consent
+The authors certify that they have obtained all appropriate 
+patient consent forms. In the form the patient(s) has/
+have given his/her/their consent for his/her/their 
+images and other clinical information to be reported in 
+the journal. The patients understand that their names 
+and initials will not be published and due efforts will 
+be made to conceal their identity, but anonymity cannot 
+be guaranteed.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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subfolder_0/Complexity Biology based Information Structures can explain.txt

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+Cosmos and History: The Journal of Natural and Social Philosophy, vol. 10, no. 1, 2014 
+ 
+ 
+COMPLEXITY BIOLOGY-BASED INFORMATION 
+STRUCTURES CAN EXPLAIN SUBJECTIVITY, 
+OBJECTIVE REDUCTION OF WAVE PACKETS, 
+AND NON-COMPUTABILITY 
+Alex Hankey  
+ 
+ 
+ 
+Abstract: 
+Background: how mind functions is subject to continuing scientific discussion. A simplistic 
+approach says that, since no convincing way has been found to model subjective experience, 
+mind cannot exist. A second holds that, since mind cannot be described by classical physics, it 
+must be described by quantum physics. Another perspective concerns mind’s hypothesized 
+ability to interact with the world of quanta: it should be responsible for reduction of quantum 
+wave packets; physics producing ‘Objective Reduction’ is postulated to form the basis for mind-
+matter interactions. This presentation describes results derived from a new approach to these 
+problems. It is based on well-established biology involving physics not previously applied to the 
+fields of mind, or consciousness studies, that of critical feedback instability.  
+Methods: ‘self-organized criticality’ in complexity biology places system loci of control at 
+critical instabilities, physical properties of which, including information properties, are 
+presented. Their elucidation shows that they can model hitherto unexplained properties of 
+experience.  
+Results: All results depend on physical properties of critical instabilities. First, at least one 
+feed-back or feed-forward loop must have feedback gain, g = 1: information flows round the 
+loop impress perfect images of system states back on themselves: they represent processes of 
+perfect self-observation. This annihilates system quanta: system excitations are instability fluctuations, 
+which cannot be quantized. Major results follow:  
+1. Information vectors representing criticality states must include at least one attached information 
+loop denoting self-observation.  
+2. Such loop structures are attributed a function, 'registering the state’s own existence', 
+explaining  
+ 
+a. Subjective ‘awareness of one’s own presence’  
+ 
+b. How content-free states of awareness can be remembered (Jon Shear)  
+ 
+c. Subjective experience of time duration (Immanuel Kant)  
+ 
+d. The ‘witness’ property of experience – often mentioned by athletes ‘in the zone’ 
+www.cosmosandhistory.org  
+237 
+ 
+COSMOS AND HISTORY 
+238 
+ 
+e. The natural association between consciousness and intelligence 
+This novel, physically and biologically sound approach seems to satisfactorily model 
+subjectivity.  
+Further significant results follow:  
+1. Registration of external information in excited states of systems at criticality reduces external 
+wave-packets: the new model exhibits ‘Objective Reduction’ of wave packets.  
+2. High internal coherence (postulated by Domash & Penrose) leading to a. Non-separable 
+information vector bundles. b. Non-reductive states (Chalmers' criterion for experience)  
+3. Information that is: a. encoded in coherence negentropy; b. non-digitizable, and therefore c. 
+computationally without digital equivalent (posited by Penrose).  
+Discussion and Conclusions: instability physics implies anharmonic motion, preventing 
+excitation quantization, and totally different from quantum physics of simple harmonic motion 
+at stability. Instability excitations are different from anything hitherto conceived in information 
+science. They model aspects of mind never previously treated, including genuine subjectivity, 
+objective reduction of wave-packets, and inter alia all properties given above.  
+KEYWORDS: Complexity; Information structures; Subjectivity; Objective Reduction of Wave 
+Packets; Roger Penrose; Alan Chalmers  
+INTRODUCTION  
+In the early 1990’s, after consulting myself, publisher Keith Sutherland recruited 
+Professor Jonathan Shear to help him found the Journal of Consciousness Studies, thus 
+bringing a new channel of publication to the field of consciousness research. 
+Sutherland had been stimulated by Penrose’s monumental book, The Emperor’s New 
+Mind, strongly arguing that analysis of the halting problem, and other aspects of 
+computational theory, implied that human information processing was not 
+computable (1). This point developed the suggestion by Penrose’s Oxford colleague, J. 
+Lucas, that metamathematical theorems imply the existence of consciousness, a point 
+supported by Penrose, based on his experience of mathematical intuition, and its role 
+in guiding discovery in mathematics.  
+The rest is history: in 1994, David Chalmers published his magnificent JCS paper 
+(2), amplified in his book, The Conscious Mind (3), which became the reference point for 
+all subsequent work in the field, from Jon Shear’s book of papers, ‘Consciousness the 
+Hard Problem’ (4), in which Chalmers refuted all objections to his proposals, to the 
+Penrose and Hameroff collaboration (5) now dominating the field. Key points made by 
+Chalmers were, inter alia, (A) to deny conscious experience as an ingredient of creation 
+is inadmissible i.e. the subjective aspect of mind, with its sense of ‘self’, whatever that 
+may mean, is undeniable. (B) Consciousness needs to be admitted as an a priori 
+ingredient of creation, as fundamental as the electron or matter-energy. (C) Since 
+reductive explanations of consciousness had failed, any explanation should be non-
+ 
+ALEX HANKEY 
+239 
+reductive in nature, and (D) the brain must support special information states with a 
+‘Dual Aspect’: in addition to ordinary information content, they must possess an 
+additional aspect permitting them to support subjective experience. Chalmers’s points, 
+including several others in addition to these four, have served as the anvil, on which all 
+work in the field has since been forged.  
+Chalmers’s main point (1) was that the existence and nature of experience IS the 
+hard problem. It can be restated as follows: all of us, when we experience anything, 
+carry a ‘sense of our own presence’, of which we may be more or less strongly aware at 
+different times. When we recall a story from our life, our memory includes a ‘sense of 
+our own presence’ at the events we describe e.g. when our name was called out in a 
+roll call in class at school and we replied, ‘Present!’, our response affirmed our ‘sense of 
+our own presence’ in class.  This factor both affirms the non-triviality of subjective 
+experience, and identifies what is needed to explain it: something that carries a sense 
+of being in ‘Time present’ (as TS Eliot puts it) (6). That is what is really required.  
+A largely unrecognized problem is that Chalmers’s points have not been 
+sufficiently rigorously implemented. The general attitude on how to represent states of 
+experience in physical terms is exemplified by the tacit point in the many books by 
+Amit Goswami (7): since classical physics cannot represent conscious experience, 
+quantum physics must be used to do so (sotto voce: quantum theory is all that is 
+available). Goswami waxes eloquent on all that can supposedly be achieved using 
+quantum theory, but that approach fails to take into account that standard quantum 
+theory is used to represent matter, so to use it to try to represent states of experience fails to 
+distinguish between object and subject in any fundamental way. It trivializes Chalmers’s points.  
+Similarly, quantum theory is basically reductive in nature (states of many particles 
+are represented as products) - one reason why physics likes it. Though Chalmers states 
+that a non-reductive theory is required to represent experience (1), in practice, no one has 
+proposed an intrinsically non-reductive theory to do so. All uses of quantum theory, 
+including the latest Hameroff-Penrose proposals (5), fail to provide the inherently non-
+reductive information states required to properly fulfil Chalmers’s requirement: no 
+reason is given for the chosen states to be anything other than states of objective 
+matter!  
+This paper proposes to remedy these defects in current theory by adopting a 
+radically different approach based on theories of regulation emerging from complexity 
+biology, The supposed seat of conscious experience, the brain, is the ultimate regulator 
+of the body, so its complexity states constitute an obvious place to start a search for 
+possible physical states serving as the basis for experience. Indeed, conscious 
+experience may be considered the highest level of overall control in the brain, which 
+ 
+COSMOS AND HISTORY 
+240 
+provides many inputs to induce it to take appropriate action, but leaves final decisions 
+in the experiencer’s hands. Biologically speaking, this is precisely the place to start,   
+Complexity biology is remarkable for the obscurity of its new concepts: fractality, 
+edge of chaos, and self-organized criticality. Their biological rationale is not given. 
+‘Criticality’, the central concept, may be very simply stated, however: organisms prefer 
+their regulatory systems loci of control to be at critical feedback instabilities. Since 
+conscious experience is at the locus of control of the whole organism, feedback instability 
+becomes the physical condition of choice to consider as a possible basis for experience.  
+When Norbert Wiener first proposed his revolutionary new theory of control in 
+Cybernetics (8), he pointed out that all control requires feedback, which entails the 
+possibility of feedback instability, a mathematical ‘singularity’, with mathematical 
+physics as different from the physics of ordinary matter as is conceivable. Next, we list 
+various properties of feedback instabilities, in preparation for their use to explain 
+fundamental properties of experience in the following section.  
+METHODS  
+Instability only happens when the potential well for system restorative forces is not 
+described by the usual Hook’s Law form y = ax2, but rather y = axp, where p > 2 or 
+even p > 4,, making the well flat at its minimum. Energy levels are not evenly spaced: 
+system oscillations are neither simple harmonic, nor quantizable. Quantum theory breaks down. 
+(I)  
+Instead of being oscillations with well-defined frequencies independent of 
+amplitude, as in all quantum systems, frequencies are highly amplitude dependent, 
+and unpredictable. Excitations cannot be separated into a set of fixed frequency 
+oscillators – the idea of harmonic analysis in terms of normal modes does not hold. 
+Instead, the system becomes subject to long range correlations, representing a new 
+kind of ordering principle. (II) 
+Many authors have recognized that living organisms seem to possess abnormally 
+low entropy (9). Analysis of correlations at critical instabilities offers a rigorous reason for 
+this to hold: correlations endow a system with a form of order i.e. negative entropy. (III)  
+More importantly, if a system possess long range coherence, its excited states 
+cannot be separated into, or reduced to, mutually independent states, as in normal 
+mode analysis. Such a system is therefore non-reductive. Chalmers’s important point, (C) 
+above, is satisfied, now by the physics itself, not merely supposedly, in the philosophy. 
+(IV)   
+Next, consider the nature of the feedback leading to the instability. Critical 
+feedback occurs when a particular loop, possibly part of a complex system of loops, 
+ 
+ALEX HANKEY 
+241 
+attains of feedback gain, g, of precisely g = 1. But when information travels round a 
+(possibly multi-channel) loop with g = 1, the information returning to a given point is 
+unchanged, it constitutes a faithful reproduction of the information that started. In a 
+profound sense, the loop represents a self-observing system. (V)  
+ 
+Comments: a. A more labored, but better proof may be obtained by considering 
+how changes in the physics as g approaches the value 1 from below. b. The above 
+example is not at all the same as that of a video-camera looking in a mirror, or a lady 
+doing her make-up, or like looking at oneself between two mirrors, with an infinite set 
+of images receding into the distance, or slowly bending out of sight, due to the tiny 
+angle between the planes of the mirrors. It constitutes a completely new and original 
+definition, not previously proposed.  
+Since a flow of information brings a system with intelligent understanding, 
+‘knowledge’, a system that is ‘self-observing’ due to a loop of circulating information, 
+becomes a potential candidate for a ‘system with self-knowledge’. (VI) 
+This idea that a system at a critical instability forms a ‘self-observing system’ may 
+seem naïve, but, for the following reason, it is highly non-trivial: it provides an 
+explanation, complementary to (I) and (III) above, for why such systems are non-
+quantizable. In quantum theory, the quantum theory of observation states that a 
+process of observation annihilates quanta. A ‘self-observing system’ would annihilate all system 
+quanta by means of the process of self-observation. That is the dynamic reason why no quanta 
+are found in such systems, and they are not quantizable (VII)  
+Now consider the nature of excitations at critical instabilities: they are not simple 
+harmonic oscillations but complex, correlated mixtures known as critical fluctuations. 
+Their physics is responsible for all the properties of critical points. They cannot be 
+represented in a Hilbert Space, as is normally the case in quantum theory, for states in 
+Hilbert Spaces are, in principle, separable into individual states that can may 
+subsequently become superimposed. This luxury is not the case for critical 
+fluctuations, which are irreducible mixtures, inherently non-reductive members of a 
+different kind of mathematical ‘space’, called a ‘Banach Space’. (VIII) 
+Now consider information properties of such states: (a) they are mixtures, meaning 
+that they automatically have non-zero information; they are not like quantum 
+information vectors, each with zero intrinsic meaning, like letters of the alphabet. More 
+importantly (b) they carry the critical, g = 1, ‘self-observing’ information loop as an 
+irreducible aspect of their information properties. We therefore propose to represent 
+them as a vector bundle <===== with an added information loop: O. In other 
+words: <===== + O      <=====O. (IX)  
+ 
+COSMOS AND HISTORY 
+242 
+Criticality states are located at ‘The Edge of Chaos’ meaning that they are 
+adjacent to a region containing many bifurcations. (X)  
+RESULTS  
+Now let us apply the above properties of systems at critical feedback instabilities to 
+derive different aspects of conscious experience. Instability physics is completely 
+different from stability, so many new possibilities may emerge. First, consider how 
+information structure (IX) applies to experience.  
+The information structure of the critical fluctuations (IX) carries information 
+content in the vector mixture bundle <=====, and also the information loop O, 
+representing a process of self-observation potentially yielding self-knowledge (VI). In 
+the 1980’s, dictionary definitions of consciousness was ‘possessing self-knowledge’, so 
+this seems promising.  
+ 
+We therefore hypothesize that: The loop may be attributed a function, 'registering the state’s 
+own existence', analogous to humans ‘being aware of their own presence’ during experience.  
+ 
+The hypothetical nature of this statement is important to understand. The idea that 
+these states may represent experience is not deductive, but inductive. It represents an 
+entirely new departure in scientific thought. The reasoning offered in this section 
+serves to justify this hypothesis 
+The role of the loop can also be understood by considering the approach to pure 
+consciousness in meditation, described in detail by Shear and others. In self-
+transcending meditation systems, the content of the mind is allowed to die away, until 
+one is left in a state of pure self-awareness. This can be represented by the sequence: 
+ 
+<=====O    <====O    <===O    <==O    <=O    <O 
+The zero vector at end right has zero information content, but the information 
+loop is still present, indicating the system is in a state of pure self-observation, or self-
+knowledge. But this is precisely how pure consciousness is traditionally described: 
+sensory, affective, mental and intellectual aspects of awareness have died away, and all 
+that remains is a pure ‘sense of one’s own presence’. This is exactly what the 
+information loop, O, was intended to represent. In other words, the analysis of pure 
+consciousness as experienced in meditation, illustrates how the vector bundle 
+<=====, combined with an information loop O, represents an information state 
+carrying information, together with a ‘sense of the experiencing subject’s own 
+presence’. According to Shear, the universal, trans-cultural experience of such states is 
+ 
+ALEX HANKEY 
+243 
+not of unconsciousness, or sleep, but of heightened awareness, 'Pure Consciousness', in 
+which awareness of 'Self' alone remains.   
+To summarize, information states for excitations of critical feedback instabilities, 
+<=====O, possess precisely the aspects required to represent experience. Chalmers’ 
+deeply insightful requirement of ‘Dual Aspect Information States of Consciousness’ is 
+satisfied in a highly non-trivial way – the ‘Dual Aspect’ for subjectivity is precisely 
+represented by the information loop!  
+A further implication of the analysis of <O as the aspect of <=====O remaining 
+in the state of pure consciousness, is that the information loop <O is responsible for 
+the inner experience of the passage of time, first attributed to the mind’s inner sense by 
+the great German philosopher, Immanuel Kant. This is plausible, because at the 
+singularity the loop is essentially infinitesimal. The information rotates around it 
+effectively at infinite frequency generating a continuity of experience of time passing. 
+To contemporary neuroscience, this experience presents a paradox, for scanning of 
+cortices takes place at regular intervals, yet inner experience is one of a continuous 
+flow of time passing. This conflict is resolved by the model attributing the subjective 
+sense of time to the loop <O, rather than to changes in the external information 
+content represented by <=====.  
+Finally, the theory of meditation from the ancient tradition of Yoga states that 
+experience has two aspects, one involved in experience, and the other a witness, 
+uninvolved in it. The Mundaka Upanishad likens experience to two birds in a tree: the 
+first pecks the fruit, while the second looks on the roles of <===== and <O. The role 
+of meditation is said to be to strengthen the witness <O, until that dominates 
+experience and the sense of Being is no longer overshadowed by activity (10). Clearly, 
+in the model, the role of meditation is to grow the experience of <O, and diminish 
+experience of <=====. It allows neuroplasticity to convert <=====O into <=O. 
+The proposal for representing experience by criticality states thus yields an accurate 
+model of the long-term effects of regular meditation.  
+Point VII, that a g = 1 loop annihilates quanta, i.e. reduces wave packets, means 
+that the proposal includes a new form of objective reduction of wave packets, similar to, but 
+different from the OR proposed by Penrose: similar in that mathematical singularities 
+are identified as the root cause, but different in that the singularities are caused by 
+feedback singularities rather than quantum gravity ones. Critical feedback systems 
+reduce all wave-packets, even external ones fed into the system. When the system 
+registers information in excited states, the same non-linearity reduces external wave-
+packets, yielding a model for the OR of the wave packet by consciousness.  
+ 
+COSMOS AND HISTORY 
+244 
+Intelligence: a vitally important aspect of subjective awareness is its apparently 
+integral ability to take decisions and make choices. It is difficult to imagine being 
+aware without the accompanying sense of likes and dislikes, and the inclinations to 
+choose the former and reject the latter. How can the experiencing subject make such 
+choices? The present model suggests a way. A critical system is at the ‘Edge of Chaos’ 
+(X), so brief incursions into the chaos region are possible to make selected trajectories 
+pass on a chosen side of a given bifurcation point. Choice thus becomes possible, 
+providing a plausible basis for the universally experienced connection between 'self-
+awareness' and the 'ability to make decisions' that characterizes conscious experience. 
+IMPLICATIONS FOR COGNITIVE SCIENCE  
+States of experience are cognitive states, so if dual aspect vector mixture bundles, 
+<=====O, represent states of experience, they must also be cognitive states, and form 
+the basis for a new approach to cognitive science. But what kind of cognition does this form of 
+cognitive science support? Certainly not the digital, reducible, form in video recorders 
+and films based on digital encoding, for as we have seen the physics of the states is 
+non-reductive.  
+The long-range correlations offer a means to estimate the quantity of information 
+encoded into the vector mixture states, for correlations create order, which translates 
+into negative entropy, a standard measure of information content. We therefore 
+propose (III, above) that criticality states support a new kind of information: system-
+wide correlational, negentropy information.  
+This has several significant consequences:  
+1. The extreme dynamic, fluid nature of correlations in such systems, their 
+correlational information cannot be validly presented by fixed classical entities, 
+like digits. It represents a 'subtle form of information' with no digital equivalent. It 
+cannot be digitized.  
+2. Furthermore, any information processing undergone by such information must be 
+unrelated to digital processing, and cannot be represented digitally. This property 
+which Penrose spent ten years or so trying to establish through meta-mathematics 
+seems to fall out of the hypothesized structure, simply by virtue of the definition of 
+the class of systems (instabilities), the kind of excitations (inherently non-separable 
+mixtures), and the class of information that they can support (coherence 
+information, carried by internal system correlations). Penrose’s thesis in ‘The 
+Emperor’s New Mind’ (1), and its sequel (11), is completely supported, no laborious 
+hundred page proof seems to be required.  
+3. Consciousness is associated with high levels of correlation, as first, Domash (12), 
+and second, Penrose (1), have conjectured. Objections overruled them: quantum 
+ 
+ALEX HANKEY 
+245 
+correlations do not exist at the temperatures required to support life. Our proposal 
+resolves this conflict: correlations are not quantum mechanical, but long-range 
+criticality correlations.  
+These points lay the groundwork for considering criticality excitations as cognitive 
+states. The states are not digitizable, and their information is not reductive, rather it is 
+correlational, non-reductive, system spanning, and holistic. But to what could holistic 
+information refer? Here again, Immanuel Kant provides the key (13) in his concept of the 
+‘transcendental unity of apperception’: the nature of apperception is to ‘grasp the 
+whole’, and to see things in terms of Gestalts, as later generations of German cognitive 
+scientists put it. Viewed as cognitive states, criticality forms the basis for a biophysical theory of 
+Gestalt Cognition that can be realized in nervous systems because neuronal networks can 
+support critical instabilities.  
+IMPLICATIONS FOR NEUROSCIENCE  
+Neuroscience has long been dominated by McCullough’s conjecture, that neuronal 
+states of firing and not firing are equivalent to digital states one and zero respectively, 
+implying that they only use digital information. Now, however, the questions are, first, 
+how can neuronal networks support instability states, and, second, why should they do 
+so? The answers are straightforward.  
+1. There is a well-known isomorphism between neural nets and spin glasses, meaning 
+that neural nets are capable of phase transition behaviors, and accompanying 
+critical point phenomena of arbitrary complexity, such as tricritical points (14), 
+and higher order critical points (15,16).  
+But why should these be necessary?  Therein lies answer  
+2. Kauffman (17) found that genetic networks only function effectively at ‘The Edge of 
+Chaos’, meaning that they contain critical instabilities. But there is no limit to 
+the complexity of critical instabilities that genetic networks may contain. 
+Ayurveda’s Tridosha system of overall organism regulation (18) suggests that a 
+1-to-3-furcation coordinates overall system function, requiring a tricritical 
+point. Various 1-to-5-furcations, as in fingers and toes, or Ayurveda’s five 
+subdoshas, require higher order critical points.  
+In order to control organism function precisely, its regulatory systems must be 
+capable of modeling such mathematical singularities accurately. Their control systems must 
+support higher order critical points. The neural net-spin glass isomorphism uniquely qualifies 
+neuronal networks to do so. Hence, even an organism as simple as C. Elegans contains 
+a network of neurons. Why? Because it can model and regulate its genetic network 
+with all its complex critical instabilities! That is the fundamental reason why neuronal 
+networks were selected to regulate genetic networks. 
+ 
+COSMOS AND HISTORY 
+246 
+EXPERIMENTAL VERIFICATION  
+Experimental support for some of the above proposals seems to exist. Freeman (19) 
+cites evidence that, in the EEG, wave packets representing thoughts satisfy self-organized 
+criticality, the fundamental principle of complexity biology supporting criticality. This 
+seems to indicate that states of mental experience satisfy criticality, confirming our proposal, 
+though further work is needed to verify this. The criticality approach provides a theory 
+justifying Freeman's suggestion. 
+The idea that experience information is registered as correlations also has strong 
+circumstantial evidence: it provides a theory (to be published separately) for 
+Sheldrake’s ‘Seventh Sense Communication’, recounted in his books, ‘Dogs that 
+Know when their Masters are Coming Home’ (20), and ‘The Sense of Being Stared 
+At’ (21). Sheldrake calls direct information transfer between mentally attuned minds a 
+‘seventh sense’ (20). Such information transfer can be modeled as a form of ‘quantum 
+teleportation’ of information between coherent states in different minds – i.e. it 
+becomes available when information is registered in correlations. Seventh Sense 
+Communication therefore provides direct evidence for correlational encoding of 
+information.   
+Finally, the idea that minds register ‘holistic information’ as gestalts is illustrated by 
+Sheldrake’s story of ’Nkosi the African Grey parrot. ’Nkosi can accurately call out the 
+names of images viewed by her mistress in another room (20). Only gestalt image 
+encoding can provide a plausible explanation for such seventh sense visual information 
+transfer. Significantly, the story implies that the gestalt image encoding was established before 
+dinosaurs, from which birds are descended, diverged from reptiles, from which mammals come. It is 
+very ancient.  
+(Another reason for encoding images as gestalts is that criticality physics exhibits 
+scale invariance, so the encoded images are scale free and can be recognized 
+independently of distance – very necessary for an animal needing to distinguish friend 
+and foe, family from predator.)  
+DISCUSSION 
+Many if not most of the fundamental properties of experience have been derived from 
+the properties of critical instabilities in complexity biology. Instability physics is totally 
+different from the physics of stability. That previously unexplained properties of 
+biological systems should be explainable in terms of critical instabilities occurring in 
+complexity biology is not surprising. That they should explain so many demonstrated 
+and hypothesized properties of conscious experience is remarkable – even compelling.  
+ 
+ALEX HANKEY 
+247 
+To clarify the key point that information structures of criticality states must include 
+information loops, consider the following analogy, the generality of which provides a 
+‘proof by illustration’. A fluid system at its ‘critical Reynolds number’ shows a similar 
+instability in its system of flow vectors, which are no longer exactly stable, but carry the 
+possibility of a tiny vortex forming at each point in the fluid, the presence of which 
+causes instability. To denote a flow vector at such an instability, we add an unmanifest 
+loop to it, indicating its potential to form a vortex loop.  
+All such fluid systems can be regarded as information systems, in which the fluid 
+flow carries information. By analogy, at critical feedback instabilities, flows round 
+feedback loops causing the instabilities should be included in descriptions of each 
+system state. Information vector mixtures denoting criticality states should therefore include attached 
+information loops. QED 
+Now consider the implications of the theory for philosophies of mind such as 
+Cartesian duality or embodiment. Clearly, critical fluctuations at feedback instabilities 
+considered as Dual Aspect Information States of Experience, are completely distinct 
+from states of matter. Descartes rightly observed that mind as experienced by human 
+beings is in complete contrast to matter. Criticality based models of states of mind 
+preserve Descartes’ distinction between Mind and Matter:  
+• 
+Matter forms stable systems represented by excitations of systems of simple 
+harmonic oscillators that are simply quantizable e.g. ordinary quantum 
+fields.  
+• 
+Excitations of 'Mind', information states of experience, are represented by 
+excitations of anharmonic oscillators with potential well exponents > 2 or 
+even 4.  
+In the approach proposed here, phenomena in complexity biology are explicitly used to 
+model the mind-body connection. The machinery of conscious experience is linked to 
+structures considered the most complex in biology, probably in the entire natural 
+world. This seems natural: biology’s most sophisticated patterns of organization are 
+used to model its most complex (epi)phenomena. The proposed model thus effectively 
+confines ‘mind’ to the world of biology, as it should.  
+That the structure to which mind is proposed to couple is integral to all systems of 
+biological regulation is also appropriate: regulation requires feedback, and all feedback 
+contains the possibility of critical feedback instability. Indeed, Norbert Wiener (8) 
+identified feedback instability as the most significant innovation in physical theory 
+added by his account of regulation and control. But apparently no one has previously 
+considered their information properties, let alone how they may related to experience, 
+as proposed here.  
+ 
+COSMOS AND HISTORY 
+248 
+Subjectivity is deeply connected to intelligence and control. That feedback 
+instabilities and their (non)quantum properties should offer the key to understanding 
+experience is satisfying. Stability is characteristic of ‘matter’, to which instability seems, 
+in contrast, an irrelevant complication.  
+Convinced materialists may, possibly rightfully, claim that they have no need of 
+‘Mind’ to understand a purely material universe, as they understand the world of 
+perception. However, instability states seem to play a special role in supporting 
+‘experience’ in precisely the ways defined by Chalmers (1). The simple and 
+straightforward emergence of many properties of mind and subjective experience 
+previously only hypothesized brings confidence in the proposal.  
+CONCLUSIONS  
+A hitherto unsuspected, new form of information, ‘experience information’ has been 
+defined by considering information properties of excitations of a system at criticality – 
+critical fluctuations. Many reasons have been given for equating it with information 
+used cognition by experiencing subjects. Chiefly, the information loop(s), integral to its 
+information vector mixtures, can model the ‘sense of one’s own presence’ intrinsic to 
+subjective experience. Whether or not this is really the case for actual states of 
+experience should be subject to further theoretical and experimental investigation. 
+That self-organized criticality should apply to EEG wave packets associated with 
+mental cognition thus seems natural and appropriate. Freeman’s approach may play a 
+guiding role in helping form useful hypotheses for further research.  
+The theoretical work presented here provides prima facie reasoning for how all 
+this happens: information states built out of criticality excitations carry at least one g = 
+1 information loop associated with feedback instability. Interpretation of such loops as 
+perfect self-observing systems, suggests a physiological basis for the subjective sense of 
+being present in every situation, and thus for the sense of ‘self’ integral to human 
+experience. The proposed models may therefore account for the sense of subjectivity 
+accompanying human experience.  
+The occurrence of the g = 1 loops at loci of control adopted by complex 
+biosystems under self-organized criticality seems intuitively correct. It leads to another 
+serendipitous property of the proposed model: systems of the required complexity are 
+found exclusively in biosystems, and not in the world of ordinary matter, explaining 
+experience’s restriction to the world of biology.  
+The use of critical feedback instabilities from biological complexity to model 
+‘experience’ seems to show definite promise, and merits further work. It does not fully 
+explain the presence of the experiencing subject, however. That must still be taken as a 
+ 
+ALEX HANKEY 
+249 
+fundamental aspect in the universe, beyond explanation, as Chalmers (1) took pains to 
+emphasize.  
+In summary, the proposed theory seems to fit well in the following ways.  
+1. Complexity seems the right place in biology to find a solution to the problems of 
+experience and subjective intelligence, as the most complex phenomena in biology.  
+2. ‘Experience’ and ‘mind’ are based at the apex of the regularity hierarchy where 
+self-organized criticality must operate, so criticality is the condition of choice to 
+analyse.  
+3. In control theory, Wiener’s feedback singularity is the place where any radically 
+new and different property of a physical system should be located.  
+4. Singularity presents an appropriate physical condition, instability, with 
+correspondingly different physics from stability, the condition for matter. This 
+confirms criticality as the condition of choice to locate mind and experience.  
+5. The model presents a physics of experience distinct from the physics of matter 
+preserving the intuitive distinction between ‘mind’ and ‘matter’.  
+6. The feedback loop integral to the new kind of information is appropriate to model 
+the sense of ‘self’ accompanying all experience.  
+7. Criticality’s occurrence at the edge of chaos allows choices to be made, thus linking 
+the ‘sense of self’ to active intelligence, as is commonly experienced. 
+8. The non-linear mathematics of the singularity corresponds to the essential non-
+linearity implied by the experiencing subject’s awareness of ‘self’. The essence of 
+subjectivity would seem to be ‘non-linearity’, a condition that should probably be 
+added to Chalmers’s list of the properties of experience. 
+9. A system that is essentially non-linear cannot be represented by linear models. The 
+mathematically singular feedback loop at critical instability is appropriate to do so.  
+10. Mathematical singularities at critical feedback instabilities at the apex of 
+complexity-based biological regulatory systems are therefore appropriate 
+mathematical, physical and biological conditions to model subjective experience.  
+ACKNOWLEDGEMENTS 
+I would like to acknowledge many conversations over the years with Jon Shear, Brian 
+Josephson, Madan Thangavelu, Judu Ilavarasu and John Hagelin, exceptionally 
+helpful inputs from Neil Hammeroff and Walter Freeman, and consultations with 
+ECG Sudarshan and Steven Weinberg to all of whom I am grateful for providing a 
+sounding board for my ideas. 
+ 
+ 
+ 
+COSMOS AND HISTORY 
+250 
+REFERENCES 
+1. Penrose R. The Emperor’s New Mind: concerning computers, minds and the laws of physics. 
+Oxford University Press, Oxford, 1999. 
+2. Chalmers D. Facing up to the Problem of Consciousness. J. Consc. Studies, 1995; 
+2(3):200-209. 
+3. Chalmers D. The Conscious Mind. Oxford University Press, Oxford, 1997.  
+4. Shear J. (Ed.) Explaining Consciousness the Hard Problem. Academic Press, London, 
+1997. 
+5. Penrose R. Hameroff N. Reply to criticism of the ‘Orch OR qubit’ – 
+‘Orchestrated objective reduction’ is scientifically justified. Physics of Life Reviews, 
+Volume 11, Issue 1, March 2014; 11(1): 104-112. 
+6. Eliot T.S. Burnt Norton in Four Quartets. Harcourt Books, New York, NY, 1971.  
+7. Goswami A. Reed R.E. and Goswami M. The Self Aware Universe. Penguin Putnam, 
+New York,1995. 
+8. Wiener N. Cybernetics of control and communication in the animal and the machine. M.I.T. 
+Press, 1948. 
+9. Ho M-W. The Rainbow and the Worm: The Physics of Organisms. World Sientific, 
+Singapore, 2008. 
+10. Yogi MM The Science of Being and Art of Living. Penguin, New York, 2001. 
+11. Penrose R. Shadows of the Mind, Oxford University Press, Oxford, 1994.  
+12. Domash L. Physics of Coherent States. MIU Press, Rheinweiler, 1975.  
+13. Kant I. The Critique of Pure Reason. (Pluhar W.S. (trans), Hackett, 1996. 
+14. Hankey A. Stanley H.E. Chang T.S. Geometric Predictions of Scaling at 
+Tricritical Points. Phys Rev. Lets. 29(5); 278-281. (1972).  
+15. Chang T.S. Hankey A. Stanley H.E. Generalized Scaling Hypothesis in 
+Multicomponent Systems. I. Classification of Critical Points by Order and Scaling 
+at Tricritical Points. Phys. Rev. B 8, 346–364 (1973). DOI: 10.1103/PhysRevB.8.346.  
+16. Hankey A. Chang T.S. Stanley H.E. Generalized Scaling Hypothesis in 
+Multicomponent Systems. II. Scaling Hyßpothesis at Critical Points of Arbitrary 
+Order. Phys. Rev. B 8, 1178–1184 (1973).  
+17. Kauffman S. At Home in the Universe. The search for the laws self organization and 
+complexity. Oxford University Press, Oxford, 1995. 
+18. Hankey A.  Establishing the Scientific Validity of Tridosha part 1: Doshas, 
+Subdoshas and Dosha Prakritis. Anc Sci Life. 2010 Jan-Mar; 29(3): 6–18. 
+19. Freeman W.  
+20. Sheldrake R. Dogs that Know when their Masters are Coming Home. Three Rivers Press, 
+1999.  
+21. Sheldrake R. The Sense of Being Stared At. Arrow Books, London, 2004. 

subfolder_0/Cross-Cultural Study on the Effects of 10 Days of Online Mind Sound Resonance Technique (Msrt) on State Anxiety, Stress, Quality of Sleep, and Mindfulness.txt

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+Research Article
+Cross-Cultural Study on the Effects of 10 Days of Online Mind Sound Resonance Technique 
+(Msrt) on State Anxiety, Stress, Quality of Sleep, and Mindfulness
+1
+Abstract
+Objectives: The purpose of this pilot randomized control trial study was to understand the effects of a 10-
+day online intervention of a yoga and chanting-based relaxation technique called Mind Sound Resonance 
+Technique (MSRT) on measures of anxiety, stress, sleep, and mindfulness. This study was conducted in 
+parallel within the United States and India. Two-hundred and ten participants were recruited for this 
+pilot study, fifty participants from India and one-hundred and sixty participants from the United States. 
+Participants were initially administered a series of questionnaires to assess measures of state anxiety, stress, 
+quality of sleep, and mindfulness. Each day, participants received a link at 9 AM local time containing 
+the practice video of MSRT. Upon completion of the 10-day intervention, participants were administered 
+the same series of questionnaires to assess any changes in the previously mentioned measures. Sixty-five 
+participants completed all portions of the study and were compensated. Data analysis was conducted, 
+showing no statistically significant differences after the intervention, including cross-cultural differences. 
+However, several sleep related questions showed statistically significant improvements in certain aspects 
+of sleep such as restfulness and an improvement in insomnia. Several confounding factors could have 
+contributed to the lack of statistically significant results. The findings of this pilot study suggest that further 
+refined research within the effectiveness of an online Mind Sound Resonance Technique intervention - 
+specifically on various aspects of sleep such as insomnia and quality of sleep - should be designed and 
+implemented. ASEAN Journal of Psychiatry, Vol. 22 (1): January – February 2021: 01 04
+Keywords: Mind Sound Resonance Technique (Msrt), Anxiety, Sleep, Mindfulnes
+Introduction
+Stress has become an increasingly prevalent issue in 
+the modern world. Starting from early ages, chron-
+ic stress levels among populations across the world 
+have been increasing. This includes populations as 
+young as undergraduates [1]. As a result of chronic 
+stress, several health problems tend to arise, such as 
+a weaker memory, worsened cognition and learning 
+abilities, weaker immune function, cardiovascular 
+disease, gastrointestinal complications, and endo-
+crine problems [2]. Along with stress, anxiety, sleep 
+deprivation, and insomnia are becoming more and 
+more prevalent [3].
+Previous studies have shown that yoga interventions 
+can have significant positive effects on psychologi-
+cal measures such as stress, mindfulness, quality of 
+life, quality of sleep, and compassion, among vari-
+ous other variables [4]. A 9-day yoga intervention 
+can improve vigilance, self-rated sleep, state anxiety, 
+and self-rated sleep within military personnel [5]. 
+Long-term yoga interventions showed improvements 
+in symptoms of anxiety, stress, and depression in 
+patients with clinical depression [6]. Mindfulness-
+based yoga practices are shown to improve quality 
+of sleep [7].
+Mind Sound Resonance Technique (MSRT) is a spe-
+cific mindfulness-based yoga practice focused on 
+calming the mind-body complex. Previous literature 
+has shown that MSRT has immediate effects on state 
+anxiety and cognitive functions within people suffer-
+ing from generalized anxiety disorder [8]. In addi-
+tion, long-term interventions of MSRT have shown 
+a reduction in the levels of stress, anxiety, fatigue, 
+and psychological distress [9]. Single-session inter-
+ 
+Chinmay Surpur, Elliott Ihm, Jonathan Schooler, H. R. Nagarathna, Judu Ilavarasu
+ 
+Yoga Bharati, University of California, Santa Barbara, SVYASA University, United States
+Cross-Cultural Study on the Effects of 10 Days of Online
+Mind Sound Resonance Technique (Msrt) on State
+Anxiety, Stress, Quality of Sleep, and Mindfulness
+4
+4
+ October-November
+ASEAN Journal of Psychiatry, Vol. 22 (S1), 
+2021: 01-0
+Cross-Cultural Study on the Effects of 10 Days of Online Mind Sound Resonance Technique 
+(Msrt) on State Anxiety, Stress, Quality of Sleep, and Mindfulness
+ASEAN Journal of Psychiatry, Vol. 22 (1), January - February 2021: 01-0
+2
+ventions of MSRT administered to medical students, 
+a population group known to have higher stress lev-
+els than the average person, showed improvements 
+in cognitive performance immediately after the in-
+tervention [10]. MSRT also has a direct impact on 
+stress by reducing sympathetic nervous activity and 
+increasing vagal dominance [11]. Finally, a study 
+done by Sharma et al. showed that a week-long inter-
+vention of MSRT added on to regular yoga practice 
+enhances sleep quality and reduces stress, pain and 
+anxiety levels in patients suffering from chronic mus-
+culoskeletal pain [12].
+The purpose of this study was to understand the ef-
+fects of a 10-day online intervention of MSRT and its 
+effects on perceived stress, state anxiety, quality of 
+sleep, and mindfulness scores. In addition, the relative 
+effects of MSRT on the previously stated measures 
+in spiritually and/or religiously inclined individuals 
+versus those who are not inclined to spirituality and 
+religion were studied. An online intervention was 
+chosen because the efficacy of an online yoga inter-
+vention has been shown by previous literature, where 
+the effects of Sukshma Vyayama, a yoga practice, 
+was administered to women with breast cancer and 
+results showed that AI-induced pain was significantly 
+reduced [13]. 
+The study was administered to participants between 
+the ages of 18-50 in the United States as well as in 
+India to understand the cross-cultural differences on 
+the proposed measures. This intervention was admin-
+istered via a pre-recorded video link on YouTube, us-
+ing the Qualtrics platform, between 6-10 PM local 
+time. Perceived stress, state anxiety, quality of sleep, 
+and mindfulness assessments were administered 24 
+hours prior to the 10-day intervention as well as 24 
+hours after the last practice session of the interven-
+tion. Data was also collected about each participant’s 
+level of spirituality, prior history with religion and 
+meditation or yoga practice, and quality of life. Our 
+hypothesis was that MSRT, consistently practiced for 
+10 days, would reduce state anxiety, levels of stress, 
+increase quality of sleep, and scores regarding mind-
+fulness. We also hypothesized that the magnitude of 
+the effects of MSRT on the measures  
+studied will be greater in spiritually and/or religious-
+ly inclined individuals [14].
+Methods
+UC Santa Barbara’s research pool as well as Yoga 
+Bharati’s outreach efforts via digital marketing were 
+used to recruit participants. One-hundred and eighty 
+participants within the age range of 18-70 years old 
+applied for the online research study. 130 partici-
+pants were recruited within the United States and 
+50 participants were recruited within India. The se-
+lection criteria for participants included individuals 
+who perceive an experience of high levels of stress. 
+Both genders were equally considered for the study. 
+Informed consent was obtained. Exclusion criteria 
+contained anyone on any medications for chronic 
+illnesses, anyone on tranquilizers, anyone who gets 
+good sleep, and anyone who have been doing MSRT, 
+any yoga, or any relaxation or mindfulness practice 
+in the last three months.
+MSRT Steps
+Participants listen to the peace chant (Maha mrutyun-
+jaya mantra) once. Participants then make a positive 
+affirmation (sankalpa) such as “I’m full of love”, 
+“I’m full of forgiveness”, “I’m free of anger”, etc.
+• 
+Participants chant the syllables “A” “U” “M” and 
+“AUM” 4 times out loud (ahata).
+• 
+Participants chant the syllables within their mind, 
+not out loud (anahata).
+• 
+Participants listen to the peace chant (Maha mru-
+tyunjaya mantra) 3 times.
+• 
+Participants then spend time in silence and are 
+encouraged to recollect the sound
+• 
+of “om” nine times within their mind (anahata).
+• 
+After nine times of “om” within their minds, par-
+ticipants are encouraged to stay in
+• 
+silence.
+• 
+Within this silence, participants recollect their 
+positive affirmation (sankalpa) nine times.
+Prior to administering the intervention, participants 
+were given a pre-assessment which contained ques-
+tions about their spiritual/religious background and 
+rate of practice, questions about their personal life, 
+and general background information, using qualtrics 
+as the data-collection platform. A pre-test containing 
+the Perceived Stress Scale (Cohen, 1983), Spielberg-
+er’s State-Anxiety Inventory (STAI), Sleep Rating 
+4
+Cross-Cultural Study on the Effects of 10 Days of Online Mind Sound Resonance Technique 
+(Msrt) on State Anxiety, Stress, Quality of Sleep, and Mindfulness
+ASEAN Journal of Psychiatry, Vol. 22 (1), January - February 2021: 01-0
+3
+Questionnaire (SRQ), and The Five Facet Mind-
+fulness Questionnaire (FFMQ) was administered 
+24-hours prior to the start of the intervention.
+The practice was sent to participants each morning 
+at 9 AM local time and were encouraged to practice 
+MSRT following the pre-recorded video link upload-
+ed on YouTube and hosted on Qualtrics between 6 
+PM - 10 PM each day. After the last session, partici-
+pants completed a post-test to assess any changes in 
+measures of perceived stress, state anxiety, quality of 
+sleep, and mindfulness.
+Results
+Out of 130 participants, 65 participants completed 
+the study. Upon applying the exclusion criteria, 47 
+participants’ (10 men and 37 women) data was used 
+for statistical analysis. The mean age of participants 
+was 43.07 years old.
+For the statistical analysis of the pre- and post-data 
+SPSS and Excel was used. Both UC Santa Barbara’s 
+team and Yoga Bharati’s team completed the statisti-
+cal analysis for the data collected both in the United 
+States and in India. This paper was written jointly 
+by UC Santa Barbara’s team and Yoga Bharati’s re-
+search team.
+Initial results showed no statistically significant dif-
+ference in any of the questionnaires as a whole. How-
+ever, within the Karolinska Sleep Questionnaire, four 
+specific questions showed a significant improvement:
+• 
+Difficulties falling asleep  (M = 2.089, SD = 1.42; 
+t(44) = 3.0, p = 0.004).
+• 
+Insufficient amount of sleep (M = 2.178, SD = 
+0.1.29; t(44) = 2.0, p = 0.05)
+• 
+Feeling exhausted when waking up (M = 1.689, 
+SD = 1.39; t(44) = 2.8, p = 0.008)
+• 
+Sleepiness during work (M = 1.33, SD = 1.10; 
+t(44) = 2.8, p = 0.008)
+Although the results did not show statistical signifi-
+cance, the testimonials go to show that MSRT was 
+clearly a relaxing experience for the participants. 
+Among people who said MSRT was relaxing experi-
+ence, they also commented saying “their awareness 
+improved”, “I was able to understand myself better”, 
+“I was afraid of quietude and now I began liking qui-
+etness”, “I experienced high vibrations in the body”. 
+Among people who said MSRT was a relaxing expe-
+rience, they commented- “I am more aware”, “I was 
+able to understand myself better”, “I was afraid of 
+quietude and now I began liking quietness”, “I expe-
+rienced high vibrations in the body” and “my sleep 
+quota reduced and relaxed”, “This intervention def-
+initely helped me learn how to calm my mind and 
+body at least to some extent every day. I noticed that 
+the relaxation we so strive for can become a habit. 
+This experience will definitely inform my yoga/med-
+itation pursuits in the future”.
+Discussion
+The KSQ showed that there are some questions which 
+showed related statistically significant improvements 
+in aspect of sleep. In addition, the testimonials pro-
+vided by the participants were overwhelmingly posi-
+tive. Further studies must be done to remove some of 
+the discovered confounds. There is promising future 
+research studying specifically on various aspects of 
+sleep alone, rather than including anxiety, stress, and 
+mindfulness as well to create a more pointed study on 
+the effects of Mind Sound Resonance technique on 
+sleep. There were some issues with the study which 
+can be addressed in a subsequent research project. 
+The researchers could not ensure that the participants 
+practiced daily. The researchers were unable to ensure 
+that participants actually followed along with all as-
+pects of the intervention. Feedback from participants 
+indicated that several questions used in the ques-
+tionnaires were misunderstood due to the confusing 
+nature of the questions. Besides from the pitfalls of 
+the study, some suggestions for a future study could 
+help in strengthening the study itself. Implementing 
+a 6-week intervention rather than 10-day intervention 
+could have a more significant impact on participants. 
+It is also important to have a large subject pool when 
+conducting research online.
+Conclusion
+While none of the results showed statistically sig-
+nificant improvements in mindfulness, anxiety, and 
+mindfulness, there was an improvement in some 
+sleep-related questions. There is promising future 
+research studying specifically on various aspects of 
+4
+Cross-Cultural Study on the Effects of 10 Days of Online Mind Sound Resonance Technique 
+(Msrt) on State Anxiety, Stress, Quality of Sleep, and Mindfulness
+ASEAN Journal of Psychiatry, Vol. 22 (1), January - February 2021: 01-0
+4
+sleep alone, rather than including anxiety, stress, and 
+mindfulness as well to create a more pointed study 
+on the effects of Mind Sound Resonance technique 
+on sleep.
+Acknowledgements
+Yoga Bharati would like to acknowledge SVYASA 
+University, and specifically Dr. H.R. Nagarathna, for 
+their support in constructing this pilot study.
+References
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+Correspondence author: Chinmay Surpur, Yoga Bharati, University of California, Santa Barbara, SVYASA University, United 
+States
+Email: [email protected]
+Received: 22               2021 
+4
+October 
+Accepted:  
+  2021
+ November
+25

subfolder_0/Development and Validation of Integrated Yoga Module for Obesity in Adolescents.txt

@@ -0,0 +1,434 @@
+Int J Yoga. 2018 Sep-Dec; 11(3): 231–238.
+doi: 10.4103/ijoy.IJOY_38_17
+PMCID: PMC6134747
+PMID: 30233117
+Development and Validation of Integrated Yoga Module for Obesity in
+Adolescents
+Sunanada Surendra Rathi, Nagarathna Raghuaram, Padmini Tekur, Ruchira Rupesh Joshi, and
+Nagendra Hongasandra Ramarao
+Yoga and Life Sciences Department, SVYASA, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Sunanada Surendra Rathi, Yoga Initiative Centre, Chiranjiv Foundation,
+404, Pinnacle Pride, Sadashiv Peth, Tilak Road, Pune - 411 030, Maharashtra, India. E-mail:
+[email protected]
+Received 2017 Jul; Accepted 2017 Sep.
+Copyright : © 2018 International Journal of Yoga
+This is an open access journal, and articles are distributed under the terms of the Creative Commons
+Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the
+work non-commercially, as long as appropriate credit is given and the new creations are licensed under the
+identical terms.
+Abstract
+Background:
+Obesity is a growing global epidemic and cause of noncommunicable diseases. Yoga is one of the
+effective ways to reduce stress which is one of the causes of obesity. Nowadays, children in adolescent
+age are more prone to get obese due to lack of physical activity making them more sedentary.
+Aim:
+To identify the design and validation of Integrated Approach of Yoga Therapy Module (IAYTM) for
+obesity in adolescents. Materials and Methods: First phase – IAYTM for obesity was designed based on
+the literature review of classical texts and recently published research articles. Second phase –
+Designed IAYTM was validated by 16 subject matter (yoga) experts. Content-validity ratio (CVR) was
+analyzed using Lawshe's formula.
+Results:
+Yoga practices were designed for Integrated Yoga Module for Obesity in Adolescents. Yoga practices
+with CVR ≥0.5 and which were validated by 16 yoga experts and approved in faculty group discussion
+were included in final Integrated Yoga Therapy Module.
+Conclusion:
+The yoga practices were designed and validated for IAYTM for obesity in adolescents.
+Keywords: Adolescence, integrated approach of yoga therapy, obesity, validation
+Introduction
+Obesity
+2
+Obesity (body mass index [BMI] >30 kg/m ) is more common in women than men. The risk of obesity
+starts at a BMI of 25 kg/m 
+ and it is much lower (23 kg/m ) in southeastern countries that contain
+genetic predisposition to metabolic disorders. East Asian countries use lower values of BMI.[ ] Obesity
+increases the likelihood of diseases such as heart disease, type 2 diabetes, obstructive sleep apnea,
+cancer, and osteoarthritis.[ ] Researchers consider obesity as one of the most serious public health
+problems of the 21  century.[ ] International organizations such as the WHO, UNICEF, and CARE
+consider obesity as one of the most neglected public health problems in the society.[ ] It is commonly
+caused by a combination of excessive food intake, lack of physical activity, and genetic susceptibility.
+[ ] Therefore, it can be prevented through a combination of social changes and personal choices.
+Adolescent obesity
+The prevalence of overweight and obesity in children has dramatically increased over the past two
+decades.[ ] In 2010, 43 million children were obese and this number is expected to reach 60 million by
+2020. Of the approximately 45 million, 35 million live in the developing countries. Obese children are
+likely to remain so in adulthood and are at greater risk of developing noncommunicable diseases such
+as diabetes, hypertension, cardiovascular diseases, and cancers.[ ] Two systematic review articles[ ]
+and one clinical review article[
+] suggest that yoga has beneficial effects on mental and physical
+health in children and adolescents.
+Yoga modules to control obesity
+Yoga has emerged as one of the evidence-based practices widely used across the globe. Over 10 million
+Americans practice yoga for health reasons in 2002 and the number has increased to 13 million in
+2007.[
+] Several schools of yoga have come up different modules of yoga practices that have
+shown a range of positive benefits on BMI in adults and children. A randomized controlled trial on 72
+obese adult males resulted in improvement in BMI, hip circumference, waist circumference, and skin-
+fold thickness. Fourteen weeks of integrated yoga-based lifestyle change included yogic diet, asana,
+pranayama, relaxation techniques, meditation, and yogic counseling.[
+] Yoga/meditation users with
+normal BMI appeared to be more satisfied with their body weight and shape than nonyoga/meditation
+users.[
+] Studies provide strong evidence that the modified Qigong breathing exercise can
+significantly reduce or even suppress the sense of hunger on an empty stomach. Qigong practice
+typically involves moving meditation, coordinating slow flowing movement, deep rhythmic breathing,
+and calm meditative state of mind. Qigong is now practiced throughout China and worldwide for
+recreation, exercise and relaxation, preventive medicine and self-healing, alternative medicine, and
+cultivation. Stomach pH was increased by 3 and intestinal pressure was reduced by 12 mmHg in the
+experimental group and did not change significantly in the control group. The breathing exercise
+provides comfort in different circumstances, such as lack of regular meals, limited volume or caloric
+diet, and even during temporary complete absence of food in therapeutic fasting which is useful in
+obesity.[
+]
+In a randomized controlled trial on yoga practice for reducing the male obesity and weight-related
+psychological difficulties, it has been proved that the yoga practice is effective for obesity control for
+adult male in an urban setting. Improvement in anthropometric and psychological parameters was
+observed in that study.[
+] The 12-week yoga intervention had positive effects on anthropometric and
+self-reported variables in women with abdominal obesity. Sixty women with abdominal obesity (waist
+circumference ≥88 cm; BMI ≥25) were randomly allocated in a 2:1 ratio to either yoga intervention (n
+= 40) or a waiting list (n = 20). Intergroup significant differences in the waist/hip ratio, body weight,
+BMI, body fat percentage, body muscle mass percentage, mental and physical well-being, self-esteem,
+subjective stress, body awareness, and trust in bodily sensations were observed.[
+]
+Mindfulness-based interventions may be both physically and psychologically beneficial for adults who
+are either overweight or obese. Fifteen studies measuring posttreatment outcomes of mindfulness-based
+interventions in 560 individuals were identified in an review article.[
+] Average weight loss was 4.2
+kg. Overall effects were large for improving eating behaviors, medium for depression, anxiety, and
+eating attitudes, and small for BMI and metacognition outcomes. Therapeutic effects for BMI, anxiety,
+2
+21
+2
+2
+3
+st
+4
+5
+6
+7
+8
+9
+11
+12,13
+14
+15
+16
+17
+18
+19
+eating attitudes, and eating behaviors remained significant. Another RCT study of a 12-month
+computerized mindfulness-based intervention for obese patients with binge eating disorder support that
+mindfulness work as de-automation element and a moderator of motivation to exercise which can lead
+to the reduction of impulsive eating and also to an increase in levels of physical activity.[
+]
+Few studies has been conducted on quality of life for the obese people. A short-term yoga-based
+lifestyle intervention study, including asana, pranayama, relaxation techniques, lectures, group support,
+nutrition awareness program, and individualized advice, had positive effect on the overall health the
+obese people.[
+]
+These studies have designed and used different yoga modules for obesity. However, there is no
+validated yoga module for obesity in adolescents. Therefore, this study has been designed to propose a
+validated yoga module for obesity in adolescent with practices of breathing and loosening, asana,
+pranayama, and relaxation techniques.
+Yoga is a voluntary and mindful technique that has positive impact on obesity at physical and
+psychological levels. Yoga has effect on serum leptin and serum ghrelin; there two hormones have been
+recognized to harbor major influence on the energy balance mechanism. Leptin is a mediator of long-
+term regulation of energy balance, suppressing food intake and thereby inducing weight loss.[
+] A
+study states that voluntary exercise leads to the maintenance of a lower body weight and leaner
+composition, as well as to improved leptin action, independent of fat mass.[
+] Moderated meditation
+analyses showed that higher levels of mindfulness were associated with better-perceived quality of life
+through lower body shame.[
+] Similar effect on serum leptin by yoga is expected as yoga is a
+voluntary and mindful technique to get control over mind and body.
+Yoga in adolescence
+Studies suggest that school-based yoga may provide unique benefits beyond participation in physical
+practice of yoga under expert supervision was helpful in achieving optimum level of self-adjustment in
+adolescent students.[
+] However, to the best of our knowledge, there are no studies on the effect of
+yoga on obesity in adolescence. Hence, this study was designed to provide Integrated Approach of
+Yoga Therapy module (IAYTM) for obesity in adolescents.
+Validation
+Validation using content–validity ratio (CVR) developed by Lawson is a tool to check product, service,
+or system meets requirements and specifications fulfilling its intended purposes.[
+] As there are many
+different modules of yoga for obesity used by different investigators from different parts of the globe, it
+was felt that there is a need to have a validated common protocol for obesity which we plan to use in a
+study on yoga for obesity in adolescents. Hence, the present study for validation was planned and
+implemented.
+Materials and Methods
+The designing, validation, and feasibility of Integrated Yoga Therapy Module (IYTM) for obesity [
+Figure 1] were carried out in the following steps:
+20
+21
+22
+23
+24
+25,26
+27
+Figure 1
+Flowchart of steps in the development for obesity in adolescents
+Step 1: The need of the adolescents with obesity were enlisted [Table 1].
+Table 1
+Need of adolescents with obesity
+Step 2: The basis of integrated approach to yoga therapy to achieve these goals was understood by
+studying several yoga texts by the researcher under the guidance of senior yoga masters. This was
+complemented by the present day scientific understanding that obesity is not only a physical problem
+but has also deep roots in the mind and emotions. Abdominal obesity has been suggested to be
+associated with perturbations of the regulation of the hypothalamic-pituitary-adrenal axis. In a study on
+51-year-old men (n = 284), salivary cortisol concentrations were determined on repeated occasions
+over a random working day and perceived stress was reported in parallel which results that perceived
+stress-dependent cortisol values were strongly related to perturbations of other endocrine axes as well
+as abdominal obesity.[
+] Excessive stress affects biosynthesis of physiological processes and causes an
+imbalance in cognition and emotions also which results in metabolic disorders such as obesity.[
+]
+During stress corticotrophin-releasing hormone and norepinephrine are released which has impact on
+hypothalamo–pitutary axis leading to behavioral and peripheral changes. This leads to release of large
+quantity of glucocorticoids inhibiting action of insulin on skeletal muscles and adipose tissues which is
+the cause of metabolic disorder such as obesity.[
+] This supports that mind and body has strong
+interaction in pathophysiology of obesity. It proves that along with physical causes, disturbances or
+problems in mind and emotions are also major contributing factors of obesity pathophysiology.
+Attention bias for food could be a cognitive pathway to overeating in obesity. The study results
+demonstrate that state differences in health versus palatability mind-sets can cause attenuated attention
+bias for high-calorie food cues in participants with higher eating restraint which can cause bias
+attention for food.[
+]
+The concept of how obesity as a mind–body problem occurs was formulated based on the descriptions
+of five aspects of human existence (Pancha Kosha Viveka)[
+] and the downward causation of stress-
+induced diseases (Adhija Vyadhi). It states that human being exists at five different layers of existence
+(Annamaya – body, Pranamaya – vital energy, Manomaya – mind, and Vijnaanamaya – intellect, and
+Anandamaya Kosha – soul) which are interconnected and has counterimpact on each other also. Stress
+at mind disturbs Prana and results in abnormalities at body level called disease. Obesity also has root
+28
+29
+30
+31
+32
+cause as mental stress along with other physical causes. Hence, treatment of obesity includes working
+on all Koshas (body, mind, Prana, and intellect). IAYTM for obesity in adolescents also is designed on
+the basis of Pancha Kosha model.
+We then went on to compile the corrective techniques described in many texts (Patanjali yoga sutra,
+Hath Yoga Pradipika, Hatharatnavali, Bhagavad Gita) which offer a reversibility model. Thus, a need-
+based table of practices for long-term holistic change at all the five aspects of personality[
+] was
+prepared. Publications (books and published articles) on yoga for obesity were also reviewed to prepare
+the list of all practices used in all these studies This yielded forty practice items that are tabulated in 
+Table 2.
+Table 2
+Basis for development of module
+Step 3: Validation of the module for obesity: Validation of the 40-item module was carried out by
+arranging a focused group discussion faculty group discussion (FGD) by inviting sixteen subject matter
+expert (SMEs), that included five Doctor of Medicine in Yoga, eight Doctorates (PhD) in Yoga with
+minimum experience of 4–5 years in the field of yoga, and three yoga therapists (MSc in yoga)
+involved continuously for >7 years in teaching the IAYT techniques to obese participants of all ages.
+These 16 SMEs marked the content validity on a three (0–2)-point scale, viz., not necessary – 0, useful
+but not essential – 1, and essential – 2. After validation, data were analyzed using Lawshe's CVR.[
+]
+Statistical analysis
+33,34
+35
+Sixteen SMEs validated all the 40 practices. Lawshe's CVR was calculated for all the 40 items using
+the formula CVR = (n  − N/2)/(N/2),[
+] wherein n  = number of SME panelists indicating “essential”
+and N = total number of SME panelists. As per Lawshe's significance table, the value of CVR for 16
+SMEs = 0.5 which means all items with CVR >0.5 are valid and essential for the module.
+Results
+Step 1: We presented the list of the needs of adolescents with obesity to FGD; the final
+comprehensive list of 11 items evolved is tabulated in Table 1
+Step 2: Table 2 shows basis of development of the module with five yogic personality domains
+and 15 categories of practices; the benefits each component would offer is also tabulated
+Step 3: Table 3 shows the list of 54 items that evolved all groups of practices.
+e
+36
+e
+Table 3
+List of 54 items that evolved all groups of practices
+CVR was calculated for physical and breathing practices only. Among them, 33 yoga practices [Table 4
+] with CVR ≥0.5 were included in designed IYTM. Others practices such as diet, meditation,
+counseling and lectures on yoga were discussed in faculty group discussion (FGD) meeting and were
+approved by all participants. Hence, those were also included in IYTM.
+Table 4
+IYTM practices with content validity ratio ≥0.5 and focused group discussion approved
+practices
+Discussion
+This study developed a validated module of integrated yoga as a prelude to an RCT for obese
+adolescents. The content validity was assessed in four steps. After enlisting the needs of obese
+adolescents at their physical, mental, emotional, spiritual, and behavioral levels, 15 categories of yoga
+practices under five domains with yogic scriptural basis (Annamaya – physical, Pranamaya – vital
+energy, Manomaya – mental and emotional, Vijnanamaya – intellectual, and Anandamaya – spiritual
+and behavioral) was tabulated. As a next step, 54 items of actual yoga practices were selected and
+subjected to assessment by 16 subject experts in a focussed group discussion meeting. Then, the CVR
+was calculated to develop the final list by retaining all those items with CVR >0.5.
+Advances in technology has resulted in children spending their leisure time in television, mobiles, and
+ipads resulting in sedentary lifestyle and childhood obesity since last two decades.[
+] Low levels of
+physical activity are definitely promoted by an automated and automobile-oriented environment that is
+37,38
+39
+conducive to sedentary lifestyle.[
+] Hence, weight management by changing sedentary lifestyle of
+adolescents through yoga practices was the goal of designing IAYT module for obesity in adolescents.
+Urbanization leads to consumption of huge amount of food items at home and at restaurants, plus
+consumption of high-calorie food such as high-fat, low-fiber foods, and intake of sweetened beverages
+that have been shown to promote obesity.[
+] Urbanization is only the external cause of overeating.
+The root cause of overeating is a form of stress resulting from demanding situations in the academic
+and personal lifestyle among adolescents. Regular practice of yoga, especially relaxation techniques,
+reduces the risk of overeating. Meditation trains the mind to search for happiness form inside instead of
+searching outwardly. It also make the mind to enjoy eating healthy food. The control over mind
+decreases the cravings toward junk and fast food resulting in proper intake of high-fiber and less-fat
+diet.
+Yoga practices with CVR <0.5 was removed from IAYTM [Table 5]. The reason for their CVR <0.5
+could be these practices are not focused and not having direct impact on adolescent obesity. The
+principle of selection of yoga practices is physical exercise along with relaxation of mind. However,
+few texts on Hatha yoga lay more emphasis on improving health through different yogic practices.[
+]
+This module for obesity in adolescents reduces weight as it provides exercise effect to different parts of
+body, especially arms, abdomen, hip, and thigh region. Muscle work out in body region reduces
+adipose tissues leading to weight loss. It offers enough work out to burn excessive calories that results
+in proper balance of calorie intake and energy expenditure. Yoga practices provide deep relaxation to
+internal body systems which is essential to regain normal functioning of the system. Yoga also
+strengthens the mind determination to adhere to healthy lifestyle.
+Table 5
+IYTM practices with content validity ratio <0.5
+Practices of Manomaya Kosha such as Bhajans (devotional music) and lecture on Bhaktiyoga releases
+stress in mind with relaxation. Practices of Vijnanamaya Kosha such as lecture on Jnana yoga and
+counseling help to motivate children in right direction towards success and their goal of life by clearing
+the intellectual complexes and conflicts. Activity like Karmayoga trains their mind to do work with the
+sense of duty and not as the burden of life which leads to relaxed mind.
+These yoga practices makes IAYTM unique from other yoga modules.
+39
+40,41
+42
+Conclusion
+The yoga practices for IAYTM were designed as per yoga texts and the experience of yoga
+experts
+The designed IAYTM was validated by 16 yoga experts by using Lawshe's content validity
+formula.
+Strength and limitations
+This study provides a validated yoga module for obesity in adolescents. We did not conduct other
+validity and reliability tests for obesity in adolescents. Furthermore, all the panelists of SMEs were
+from the same school of Yoga (S-VYASA, Bangalore, Karnataka, India). Further study can be planned
+with reliability test on yoga module for obesity in adolescents.
+Financial support and sponsorship
+Rathi foundation, Pune supported this study.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgment
+We would like to thank Mr. Ramkumar Rathi for his support to the study.
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subfolder_0/Development and initial standardization of Ayurveda child personality inventory.txt

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+7/29/2016
+Development and initial standardization of Ayurveda child personality inventory
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296431/?report=printable
+1/7
+J Ayurveda Integr Med. 2014 Oct­Dec; 5(4): 205–208.
+doi:  10.4103/0975­9476.146562
+PMCID: PMC4296431
+Development and initial standardization of Ayurveda child personality inventory
+S. P. Suchitra, Arati Jagan, and H. R. Nagendra
+Department of Life Sciences, SVAYSA, Yoga University, Bangalore, Karnataka, India
+Address for correspondence: HR Nagendra, Swami Vivekananda Yoga Anusandhana Samsthana (S­VYASA), Eknath Bhavan, No.19,
+Gavipuram Circle, Kempegowda Nagar, Bangalore ­ 560 019, Karnataka, India E­mail: [email protected]
+Received 2013 Oct 11; Revised 2013 Dec 18; Accepted 2013 Dec 24.
+Copyright : © Journal of Ayurveda and Integrative Medicine
+This is an open­access article distributed under the terms of the Creative Commons Attribution­Noncommercial­Share Alike 3.0 Unported, which
+permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
+Abstract
+Background:
+Ayurveda inventories for prakriti (constitution) have been developed and validated for adults. Children,
+however, require different categories of quarter and questions, for example, to assess the intelligence, the
+questions can be related to their scholastic performances.
+Objective:
+To develop and standardize an inventory to assess the prakriti of the children, and to compare with Child
+Personality Questionnaire (CPQ).
+Materials and Methods:
+A 135­item Ayurveda child personality inventory (ACPI) scale was developed on the basis of translation of
+Sanskrit verses describing vataja (A), pittaja (B), and kaphaja prakriti (C) characteristics and by taking the
+opinions of experts (ten Ayurveda experts and three psychologists). Study was carried out in Maxwell public
+school, Bangalore. The scale was administered on parents of children of the age group 6­12 years. CPQ was
+administered on children of the age group 8­12 years.
+Results:
+The ACPI was associated with excellent internal consistency. The Cronbach's alpha for A, B, and C scales
+were 0.77, 0.55, and 0.84, respectively, and the Split­half reliability scores were 0.66.0.39 and 0.84,
+respectively. Factor validity coefficient scores on each items was above 0.5. Scores on vataja, pittaja and
+kaphaja scales were inversely correlated. Items of V, P, and K scales showed significant correlation (values
+ranging from 0.39 to 0.84) with subscales of CPQ, which indicates that Eastern and Western psychology
+concept have good correspondence.
+Conclusions:
+The prakrti of the children can be measured consistently by this instrument. Scores on V and P scale showed
+good correlation with the anxiety primary scale of CPQ.
+Keywords: Prakriti, vata, pitta, kapha, tridosha
+INTRODUCTION
+Ayurveda, the ancient life science, is an aspect of Vedic lore most closely connected to Rigveda and
+Atharvaveda. It is centered on the principles of Panchamahabhuta (space, air, fire, water, and earth) and
+tridosha­vata, pitta, and kapha. Tridosha are the metabolic principles (maintains all the functions in the body
+7/29/2016
+Development and initial standardization of Ayurveda child personality inventory
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296431/?report=printable
+2/7
+as breathing, memory, digestion, intelligence, and nourishment).[1,2,3,4,5,6,7,8,9]
+Western psychologists, Carl Jung and HJ Eysenik classify the personality of an individual based on
+temperament, behavior and characteristics such as ‘introvert’, ‘extrovert’ as a dimension of personality,
+which HJ Eysenik extended this to include dimensions of neuroticism and psychoticism.[10]
+In contrast, Ayurveda classics[1,2,3,4,5,6,7,8,9] propose a comprehensive outlook of personality,
+encompassing physical­physiological aspects like color of the eyeball, texture of hair, appetite, sleep,
+behavior, attitudes and interests, memory, intelligence, mental stamina of an individual based around
+tridosha, recognizing that tridoshas physiological characteristics also influence mental and behavioral
+qualities. Further, the texts suggests seven types of personality (vata, pitta, kapha, vata­pitta, vata­kapha,
+pitta­kapha, and sama) determined by predominance of a single, pair, or all of the dosha.
+Ayurveda considers the balanced state (sama) of tridosha as health. Person with predominance of single and
+double doshas will always be afflicted by one or��more diseases.[1] Accordingly, Ayurveda recommends
+specific diet and daily regime for different types of personalities for the prevention of health.
+Statistical model of dosha prakriti based on analysis of a questionnaire has been developed.[11]. An analysis
+of tridosha physiology, linking it to process of cellular physiology has been carried out.[12,13] Similarly a
+genetic basis of tridosha constitution has been postulated.[14,15,16] Importance of dosha in health and
+treatment methods have been discussed.[17]. A study comparing the Ayurveda personality concepts and
+Western psychology concepts is available.[18] However, a simple and standardized instrument to assess the
+prakriti of children according to Ayurvedic comprehensive concepts is not available. Hence, the present
+investigation was carried out to develop Ayurveda child Personality inventory (ACPI).
+MATERIALS AND METHODS
+Ethical clearance was approved by research board of SVYASA (Yoga university). The ACPI was developed
+based on 522 Sanskrit characteristics from 9 authoritative ancient texts describing characteristics typical of
+vataja, pittaja, and kaphaja prakriti. Item reduction was carried out by deleting the repeated items,
+ambiguous items, and by selecting those items specifically suitable for children. A total of 155 items in
+Sanskrit, and translation in English, were presented to 10 Ayurveda experts. They were asked to judge the
+correctness of each statement and to check: (1) whether any of the items were repeated or if any item should
+be added? (2) whether the features of vataja, pittaja and kaphaja prakriti selected for the scale are correct,
+and (3) if the constructed items were in acceptable translation of the Sanskrit in the original texts. As per their
+suggestions, 147 items were retained and some of the items were changed and refined.
+Based on the final Sanskrit statements, 165 questions of ACPI were framed by the researcher. The scale was
+again presented to ten Ayurveda experts and three psychologists, who reviewed the format of this scale and
+recommended a dichotomous scoring (0 and 1), which was adopted in the final ACPI. Suggestions in the
+phrasing of questions were incorporated. A total of 158 questions that were agreed by all Ayurveda experts
+and psychologists were retained. Initially, scale was answered by parents of 60 children. Item difficulty level
+was analyzed.
+The final ACPI has 135 items ­ out of this, 45 items for vataja prakriti (A­scale) 44 items for pittaja prakriti
+(B­scale) and 46 items for kaphaja prakriti (C­scale) subscales. The scale was to be answered by the parents
+of the children [Supplementary 1].
+Supplementary 1
+Ayurveda Child Personality Inventory for Parents
+Data collection and analysis
+For testing the reliability and validity, the scale was administered on parents of the children who were the
+students of Maxwell public school in Bangalore, of both sex with an age range of 6­12 years.
+The final 135 items of ACPI was administered on parents of 230 children (122 boys and 108 girls). Child
+7/29/2016
+Development and initial standardization of Ayurveda child personality inventory
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296431/?report=printable
+3/7
+Personality Questionnaire[19] (CPQ) was administered on 30 children of either sex with an age range of 8­
+12 years.
+The statistical package for social sciences (SPSS, version 10) was used for data analysis. The data were
+analyzed for reliability. The split­half and Cronbach's alpha tests were applied for reliability analysis.
+Pearson's correlation analysis was done to check the degree of association between vata, pitta, and kapha
+scores. Principal component analysis (factor analysis) was done to check the validity.
+RESULTS
+Content validity
+All the 10 Ayurveda experts, who served as judges, agreed for 158 questions.
+Item difficulty level
+This is defined as the presence of a said symptom expressed as the percentage of children who score positive
+to that item.[20] The results obtained from the administration of ACPI on parents of 60 children showed 136
+items that had less coefficient than 0.9 (answered, yes, by the most) and below 0.3 (answered, yes, by the
+less volunteers) were retained.
+Internal consistency
+An analysis of the data collected from 230 parents of the children showed the Cronbach's alpha for V, P, and
+K scales, which were 0.77, 0.55, and 0.84, respectively. The Split­half reliability for V, P, and K scales were
+0.65, 0.34, and 0.84, respectively. This shows that the three scales have good internal consistency.
+Correlations
+The subscales (vata, pitta, and kapha) correlated significantly (negatively) with each other [Table 1].
+Factor analysis
+Factor analytic coefficient (by principle component analysis) obtained for each items in the scale for all V, P,
+and K scales for total score was more than 0.5 [Supplementary 2].
+Supplementary 2
+Principle component analytic coefficients of each item
+Correlation with Child Personality Questionnaire
+Vata and pitta scale scores positively correlated with A (warm hearted vs reserved), D (excitable vs
+phlegmatic), E (dominant vs obedient), H (venturesome vs shy), N (shrewd vs forthright), 0 (guilt prone vs
+self­assured), Q4 (tense vs relaxed) subscales of CPQ. Negatively correlated with B (bright vs dull), C
+(emotionally stable vs affected by feelings), G (conscientious vs expedient), I (tender minded vs tough
+minded), J (internally restrained vs vigorous), Q3 (controlled vs undisciplined self­conflict) subscales of
+CPQ.
+Similarly, kapha scale scores positively correlated with B, C, G, I, J, Q3 subscales of CPQ. Negatively
+correlated with A, D, E, H, N, O, Q4 subscales of CPQ [Table 2].
+DISCUSSION
+The present study has described the development and initial standardization of 136 items, parents rating, the
+ACPI as an instrument to assess the personality (prakriti) of the children.
+Corelation between vataja, pittaja, and kaphaja scale scores was negative, suggesting discriminative validity.
+The reliability of subscales was supported by Cronbach's alpha coefficient and Split­half analysis. This
+provided the evidence of homogeneity of items.[21,22,23] The validity of items of subscales was supported
+by Principle component analysis. Corelation with modern CPQ revealed significant relationship between
+7/29/2016
+Development and initial standardization of Ayurveda child personality inventory
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296431/?report=printable
+4/7
+Eastern and Western personality concepts (p). Statistical significance suggests that vata and pitta prakriti
+people are extravert and vulnerable to anxiety[22] [Table 2].
+Applying the inventory to children, further validated the concept of prakriti. Among selected sample, 40%
+were vata­pitta, 30%were pitta­kapha, 10% were kapha, 7% were vata, 8%were sama, and 5% were pitta [
+Table 3].
+Increased score in kapha in early age, and pitta, vata in later stages supported convergent validity [Table 4].
+Measuring the prakriti of an individual is important aspect of maintaining one's health as the equilibrium state
+of three dosha is considered as health.[1,2,3,4,5,6,7,8,9] One can prevent vulnerability for the somatic and
+psychological diseases by following different regime and personality development methods for different
+dosha. For example, person with predominance of vata should avoid bitter, spice, astringent taste foods, and
+should consume sweet, sour taste foods. The treatment modalities are also different for different prakrti.
+[1,2,3,4,5,6,7,8,9] Though published scales are available to assess the prakriti of an individual, they have
+been standardized for adult age group. However, children require different mode of questions. Hence, ACPI
+can be potentially used to identify the predominant dosha in children and thus help to plan suitable regime at
+an early age to maintain the health.   Studies should be conducted on larger sample and norms should be
+established. The present scale has the limitation mainly because of parent influence, at the same time the
+comprehensive approach of analyzing prakriti and paper­pencil mode are the strength of this work.
+CONCLUSIONS
+An ACPI is a consistent and valid instrument. Tridosha measure may point out to lifestyle management to
+prevent the disease and main the health of the children. Researchers can employ this instrument to assess the
+effect of Yoga, personality development program on the prakriti of the children.
+ACKNOWLEDGMENT
+The authors thank Dr. Kishore Kumar, NDI (CCRAS unit), Bangalore, Dr. Uma Hirisave NIMHANS,
+Bangalore, Dr. Arati Jagnnath, SVYASA, Bangalore and Ayurveda experts in Hubli Ayurveda College, for
+their support and participation in the study.
+Footnotes
+Source of Support: Nil
+Conflict of Interest: None declared.
+REFERENCES
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+New Delhi: Choukamba Publications; 1997. pp. 759–61.
+2. Hastry KA, editor. Sushruta Samhita: Hindi Vyakhya, Sharirasthana Chapter 4 Verses 63­75. 15th ed.
+New Delhi: Choukamba Publications; 2002. pp. 38–9.
+3. Sharma S, editor. Ashtanga Sangraha: Sanskrit Commentary, Sharirasthana Chapter 8 Verses 9­16. 1st ed.
+Varanasi: Choukamba Publications; 2006. pp. 328–29.
+4. Shastri P Ashtanga Hradaya: Sanskrit Commentary. 2nd ed. Varanasi: Choukamba Publications; 2002. pp.
+402–04. Sharira sthana 3 (85­94)
+5. Shastri P, editor. Ashtanga Hradaya: Sanskrit Commentary, Sharirasthana Chapter 3 Verses 85­94. 2nd ed.
+Varanasi: Choukamba Publications; 2002. pp. 402–04.
+6. Krishnamurthy KH, editor. Bhela Samhita: English Commentary, Vimanasthana Chapter 4 verses 54­56.
+1st ed. Varanasi: Choukamba Publications; 2000. pp. 183–5.
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+10th ed. Varanasi: Chaukamba Smaskrita Bhavan; 2002. p. 103.
+8. Pandit PS. Sharangadhara Samhita: Samskrita Vyakhya. 6th ed. Varanasi: Chaukamba Orientalia; 2005.
+pp. 73–4. prathama khanda 6 (21­23)
+7/29/2016
+Development and initial standardization of Ayurveda child personality inventory
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296431/?report=printable
+5/7
+9. Pandit HT, editor. Harita Samhita: Hindi Vyakhya. 1st ed. Varanasi: Chaukamba Krishnadas Academy;
+2005. pp. 32–34.
+10. Misched W. Introduction to Personality. New York: Holt. Rinehart and Winston. Inc; 1976.
+11. Joshi RR. A biostatistical approach to ayurveda: Quantifying the tridosa. J Altern Complement Med.
+2004;10:879–89. [PubMed: 15650478]
+12. Hankey A. The Scientific Value of Ayurveda. J Altern Complement Med. 2005;2:221–5.
+[PubMed: 15865485]
+13. Hankey A. A test of the systems analysis underlying the scientific theory of Ayurveda Tridosa. J Altern
+Complement Med. 2005;11:385–90. [PubMed: 15992219]
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+and the concept of Prakriti in Ayurveda. J Altern Complement Med. 2005;11:349–53. [PubMed: 15865503]
+15. Patwardhan B, Bodeker G. Ayurvedic genomics: Establishing a genetic basis for mind­body typologies.
+J Altern Complement Med. 2008;14:571–6. [PubMed: 18564959]
+16. Prasher B, Negi S, Aggarwal S, Mandal AK, Sethi TP, Deshmukh SR, et al. Indian Genome Variation
+Consortium, Mukerji M. Whole genome expression and biochemical correlates of extreme constitutional
+types defined in Ayurveda. J Transl Med. 2008;6:48. [PMCID: PMC2562368] [PubMed: 18782426]
+17. Mishra L, Singh BB, Dagenais S. Healthcare and disease management in Ayurveda. Altern Ther Health
+Med. 2001;7:44–50. [PubMed: 11253416]
+18. Dube KC, Kumar A, Dube S. Personality types in Ayurveda. Am J Chin Med. 1983;11:25–34.
+[PubMed: 6660210]
+19. Rutherford B, Cattell R. Hand book for the children's personality questionnaire. Illinois: Indian economy
+edition; Institute of Personality and Ability testing. 1999
+20. Nunnaly JC. Psychometric Theory. 2nd ed. New York: Mc­Grow­Hill; 1978.
+21. AK Singh. Tests, Measurements and Research Methods in Behavioral Sciences. 5th ed. Patna: Bharati
+Bhavan Publishers and Distributers; 2006.
+22. Anastasi A, Urbina S. Psychological Testing. 7th ed. Upper Saddle River: Pearson Education; 2005.
+23. Freeman FS. Theory and Practice of Psychological Testing. 3rd ed. New Delhi: Surjeet Publications;
+2006.
+Figures and Tables
+Table 1
+Pearson correlation among subscales
+Table 2
+7/29/2016
+Development and initial standardization of Ayurveda child personality inventory
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296431/?report=printable
+6/7
+Pearson's correlation coefficient with CPQ
+Table 3
+Mean dosha scores for three different diagnostic groups
+Table 4
+Mean scores in different age groups
+7/29/2016
+Development and initial standardization of Ayurveda child personality inventory
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296431/?report=printable
+7/7
+Articles from Journal of Ayurveda and Integrative Medicine are provided here courtesy of Elsevier

subfolder_0/Development of a simplified yogic measure (bhramari time) of lung function in normal children– a correlational study.txt

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+SENSE, 2014, Vol. 4 (4), 7-13 
+ 
+ 
+                           
+ 
+ 
+       UDC: 233.852.5Y: 616.2 
+© 2014 by the International Society for  
+ 
+                         
+ 
+ 
+        Original Scientific Paper 
+Scientific Interdisciplinary Yoga Research 
+ 
+ 
+ 
+Development of a simplified yogic measure (bhramari time) of lung function in 
+normal children - a correlational study 
+ 
+Vikas Rawat1, Rajesh S.K., Raghuram Nagarathna 
+University Vivekananda 
+Bangalore, India 
+ 
+Abstract: Yoga being accepted for use in schools there is a need for developing a scientifically acceptable 
+standardized tool to assess the progress of their practices that can be used in yoga classes for children. 
+The present study was designed to validate the acceptability of bhramari time (BHT) by checking its 
+correlation with Peak expiratory flow rate (PEFR) in healthy South Indian Children. Three hundred and 
+eighty six healthy school children who attended yoga based Personality Development Camp were 
+recruited for the study. Sample consist of 229 males and 157 females with a mean age of 12.78 years 
+(SD=1.69). Anthropometric measurements, BHT and PEFR were recorded. As hypothesized, BHT was 
+significantly and positively correlated with PEFR (r=.35, p<0.01), Height (r=.29, p<0.01), 
+Weight(r=.17, p<0.01) and Age (r=.22, p<0.01). Our study suggests that BHT can be recommended for 
+use in mass camps as an acceptable scientifically validated yogic tool in young population to assess the 
+progress of their practices in each class. 
+ 
+Key words: yoga, bhramari time, lungs function  
+ 
+ 
+Introduction  
+ 
+Yoga in its original form consists of a system of physical, psychological and ethical practices; although of 
+ancient origin, it transcends cultures and languages (Nagarathna, Nagendra, 2001). The popularity of yoga 
+is evident with emerging interest and research in the therapeutic applications of yoga in prevention and 
+management of psycho-physical conditions. Further, estimated prevalence of practicing Yoga has doubled 
+from 1997 to 2002, corresponding to 10.4 million adults in the U.S (Barnes, Powell-Griner, McFann, 
+Nahin, 2004). Recent studies suggest that implementation of yoga is acceptable and feasible in a 
+secondary school setting and has the potential of playing a protective or preventive role in maintaining 
+mental health (Khalsa et al, 2012). Further, findings suggest that a school-based yoga intervention is 
+acceptable to youth, teachers, and school administrators in serving chronically stressed and disadvantaged 
+youth (Mendelson et al, 2010). Research literature suggests that yoga improves children’s physical and 
+mental well-being as it helps them improve their resilience, mood, and self-regulation skills pertaining to 
+emotions and stress (Hagen, Nayar, 2014).  
+ 
+Furthermore, yoga training improves lung function, strength of inspiratory and expiratory muscles as well 
+as skeletal muscle strength and endurance of students (Mandanmohan, Jatiya, Udupa, Bhavanani, 2003). 
+Several studies have shown that regular yoga practice increases the vital capacity, timed vital capacity, 
+maximum voluntary ventilation, breath holding time and maximal inspiratory and expiratory pressures 
+(Vedala, Mane & Paul, 2014). Yoga training has shown positive effect on improving lung function and 
+exercise capacity in patients with chronic obstructive pulmonary disease (Raub, 2002). Pulmonary 
+                                                 
+1 Corresponding author: [email protected] 
+functions and diffusion capacity in patients of bronchial asthma before and after yogic intervention has 
+shown increased respiratory stamina (Soni, Singh, Munish, Singh, 2012). 
+ 
+Measurements of ventilator function is useful for assessment of physical fitness in children and adults and 
+also for diagnosis and follow up during management of conditions with increased airway resistance, such 
+as asthma, chronic bronchitis, and emphysema (Petty, 2006). Peak expiratory flow rate (PEFR) which is a 
+measure of the maximum flow achieved during an expiration delivered with maximal force starting from 
+the level of maximal lung inflation (Pedersen, 1997) recording is an essential measure in the evaluation of 
+ventilator function. Various types of instruments including hand held mini PFR meters are available to 
+measure PEFR (Holcroft, Eisen, Sama, Wegman, 2003). A simple, but reliable, method of measuring the 
+ventilator function of the lungs has long been sought.  
+ 
+Yoga lays emphasis on manipulation of breath movement (Pranayama), which contributes to positive 
+neurophysiologic responses (Vialatte, Bakardjian, Prasad, Cichocki, 2009). Yoga breathing exercises, as 
+an adjunct treatment improves pulmonary functions in both normal volunteers (Mandanmohan, Jatiya, 
+Udupa, Bhavanani, 2003) and in patients with bronchial asthma (Vedala, Mane & Paul, 2014). Yogic 
+breathing technique called Bhramari Pranayama (Bhpr), engages in producing a pulsating constant low 
+pitch sound imitating the buzzing of female bumble bee (Rajesh, Ilavarasu, Srinivasan, 2014).  
+ 
+With yoga being accepted for use in schools there is a need for developing a scientifically acceptable 
+standardized tool to assess the progress of their practices that can be used in yoga classes for children that 
+keeps their interest going. Bhramari time that involves measuring the slow exhalation time while making 
+a low pitched humming sound like that of a female honey bee has been used in our yoga based personality 
+camps for children and adults over many years as a tool to assess the progress of the practices. The 
+present study was designed to validate the acceptability of bhramari time by checking its correlation with 
+PEFR in healthy South Indian Children. 
+ 
+Methods 
+ 
+Participants 
+Three hundred and eighty six healthy school children who attended yoga based Personality Development 
+Camp in summer holidays in the serene campus of SVYASA University, Bengaluru were randomly 
+selected from a pool of 625 children. Children with a history of asthma, a recent history of respiratory 
+infection with or without persistent cough within the past two weeks and those with any major disability 
+or illness were excluded from the study. Participants in this study had no formal training in yogic 
+techniques.  
+ 
+Consent and ethical clearance 
+Signed informed consent was obtained from the parent or guardian of the child at the time of registration 
+after they had read the proposal of this simple non interventional study that involves non invasive data 
+collection. All procedures were reviewed and accepted by the institutional ethical committee of SVYASA 
+University. The children were explained in detail about the nature of the study and the voluntary nature of 
+participation and were not provided with any incentives for their participation.  
+ 
+Measurements 
+ 
+Demographic data 
+The weight (KG) was recorded using a standard electronic weighing scale. The participants were asked to 
+remove as much outerwear as possible. Further they were asked to remove the shoes and step up onto the 
+weighing scale and stand still over the center of the scale with body weight evenly distributed between 
+both feet. Standing height (cm) was measured without shoes and without traction using standard scale. 
+Procedure for bhramari time measurement  
+The procedure was performed in a spacious room during the morning hours between 9 AM to 11 AM in 
+the month of April Between third to fifth days after the inauguration of the camp. Bhramari breathing 
+technique: The term Bhramari is Sanskrit word signifies a female bee.  This is a pranayama technique 
+wherein after a deep inhalation the participant exhales through the nasal airways with the mouth closed, 
+emulating the buzzing of bumblebees in a constant low pitch (Rajesh, Ilavarasu & Srinivasan, 2014). 
+Subjects sat on a comfortable cushion on the floor of the experimental room, in a crossed leg posture 
+keeping the spine erect, with eyes-closed and  practiced three rounds of bhramari pranayama which was 
+taught to them in the classes on pranayama for three days before the child was taken up for the study. The 
+purpose and technique of the Bhramari breathing time was explained to the child followed by 
+demonstration of the correct manner of performing. They were closely observed to ensure that they 
+maintained the procedure correctly. Three trials were performed and the time duration of the exhalation 
+was measured using a stop watch. The best of the three readings was taken as the final Bhramari Time 
+(BHT). 
+Procedure for PEFR Measurement 
+A mini PEFR meter (Clement Clarke) was used to check the PEFR of these children. The purpose and 
+technique of performing PEFR was explained along with a demonstration of the correct manner of 
+performing the test. When subjects had understood the method and were able to perform correctly, they 
+were made to give the test in the standing position. They were closely observed to ensure that they 
+maintained an airtight seal between their lips and the mouthpiece of the instrument (Holcroft, Eisen, 
+Sama, Wegman, 2003). The highest value of the three readings was recorded as the final PEFR value. 
+ 
+Data analysis  
+ 
+All statistical analyses were performed using the Statistical Package for Social Sciences (version 16.0). 
+Pearson correlations were used to examine the association between height, weight, PFR and BHT. 
+Independent-samples t-tests were performed to compare groups. 
+ 
+Results 
+ 
+Three hundred ninety one subjects who satisfied the inclusion and exclusion criteria included in the study. 
+Five students were excluded due to missing data. Final sample consist of 229 males and 157 females. 
+Table I shows detail demographic profile. Participants age ranged from 9 to 16 years with a mean age of 
+12.78 years (SD=1.69). Table II gives Distribution of Weight, Height, Peak Expiratory Flow Rate (PEFR) 
+and Bhramari Time (BHT) in different Age groups. BHT, PEFR, height and weight increased 
+progressively with age. Table III shows the zero-order correlations on all variables. As hypothesized, 
+BHT was significantly and positively correlated with PEFR (r=.35, p<0.01), Height (r=.29, p<0.01), 
+Weight(r=.17, p<0.01) and Age (r=.22, p<0.01). Further, PEFR had significant positive correlation with 
+Height (r=.64, p<0.01), Weight (r=.53, p<0.01) and Age (r=.53, p<0.01). 
+Independent-samples t-tests were performed to determine whether statistically significant differences 
+existed in height, weight, PFR and BHT between boys and girls. Table IV shows the gender differences. 
+The average values of BHT for all age groups ranged from 3 to 34 sec for boys and 5 –26 seconds for 
+girls. The PEFR values for boys ranged between 160 – 510 L/min and girls between 160 –410 L/min. 
+Gender wise analysis has shown no difference in any variables except on PFR. Boys scored significantly 
+higher PEFR than girls.  
+ 
+ 
+ 
+ 
+Table 1. Demographic details  
+ 
+N 
+Age 
+Weight 
+(Kg) 
+Height 
+(Cm) 
+PFR 
+(L/min) 
+BHT 
+(Sec) 
+386 
+12,78±1,69 
+43,39±11,70 
+149,80±12,20 
+291,30±62,75 
+13,13±4,98 
+ 
+Table 2. Distribution of Weight, Height, Peak Flow Rate and Bhramari Time in different Age groups.  
+ 
+Age 
+N 
+Weight 
+(Kg) 
+Height 
+(Cm) 
+PFR 
+(L/min) 
+BHT 
+(Sec) 
+9 
+10 
+26,75±4,53 
+135,30±11,75 
+216,00±33,73 
+9,60±2,84 
+10 
+32 
+31,82±7,85 
+134,45±8,52 
+236,25±44,49 
+11,00±2,95 
+11 
+46 
+35,74±8,31 
+140,33±8,41 
+262,39±44,93 
+12,59±4,42 
+12 
+71 
+39,40±9,40 
+145,43±9,92 
+271,30±50,99 
+12,78±4,79 
+13 
+93 
+46,96±11,37 
+152,27±8,92 
+295,65±51,92 
+12,91±5,27 
+14 
+71 
+47,10±9,46 
+156,04±8,36 
+317,83±56,28 
+14,17±5,14 
+15 
+45 
+52,95±8,27 
+161,27±9,56 
+334,09±63,33 
+14,14±5,41 
+16 
+18 
+51,30±9,92 
+161,56±5,65 
+357,78±79,52 
+15,28±5,95 
+ 
+Table 3. Zero-order between Bhramari Time, Peak Flow Rate, Height, Weight and Age (N=386)  
+ 
+  
+PFR 
+Height 
+Weight 
+Age 
+BHT 
+.35** 
+.29** 
+.17** 
+.22** 
+PFR 
+  
+.64** 
+.52** 
+.53** 
+Height 
+  
+  
+.74** 
+.68** 
+Weight 
+  
+  
+  
+.57** 
+**. Correlation is significant at the 0.01 level (2-tailed).  
+ 
+Table 4. Comparison of boys and girls on all variables 
+ 
+Gender 
+N 
+Weight 
+Height 
+PEFR 
+BHT 
+Age 
+Boys 
+229 
+43,39±12,43 
+149,91±13,15 
+297,60±66,69 
+13,18±5,31 
+12,66±1,69 
+Girls 
+157 
+43,37±10,56 
+149.64±10,67 
+282,10±55,45
+** 
+13,06±4,48 
+12,97±1,68 
+**p=0,02 
+ 
+ 
+Discussion 
+ 
+This study sets out to examine the relationship between PEFR and Bhramri Time among school children 
+in order to establish the utility of this yogic tool for use in mass programs and by individuals as a test of 
+their progress in the practice of yoga. The significant relationship between Bhramri Time and PEFR 
+confirmed our primary hypothesis. Further, the relationship between Bhramri Time and Anthropometric 
+data also has shown significance. Height had the strongest relationships with other variables. Overall, the 
+study showed that in healthy children PEFR (Ebomoyi, Iyawe, 2005) and BHT significantly increases 
+with height, weight and age, which is in agreement with the report of other studies. 
+PEFR is a measure of a dynamic factor during exhalation as it takes into account the rate of movement of 
+air in and out of the lungs and is considered the best single index of ventilatory function (Pedersen, 1997). 
+Unfortunately, it is time consuming, fatiguing, difficult to obtain acceptable data by novices and needs a 
+good instrument (although simple and portable). BHT is a useful test that is cost effective as it needs no 
+instruments and acceptable while teaching yoga to children in a school or a camp environment because of 
+the playful nature of the test  that promotes self encouragement  to continue the practices. 
+Potential limitations of this research must also be considered. We have used only PEFR using a mini 
+PEFR instrument which is a measure of forced expiratory volume in first second (FEV1) while BHT is a 
+measure of slow vital capacity (SVC). It would have been ideal to compare all   measures of lung function 
+using a spirometer to establish the utility of the BHT. Secondly, the sample included was healthy young 
+children in a yoga camp environment which may be difficult to generalize for all children and adults. 
+ 
+Conclusion  
+ 
+Despite these limitations, the present study confirmed our primary hypothesis i.e. BHT correlated 
+positively with PEFR. To our knowledge, this is the first study to understand the relationship between 
+BHT and PEFR. BHT can be enhanced by training. Practice of yoga based breathing practice can increase 
+pulmonary function which in turn leads to enhancement of BHT (Vedala, Mane, Paul, 2014). Our study 
+suggests that BHT can be recommended for use in mass camps as an acceptable scientifically validated 
+yogic tool in young population to assess the progress of their practices in each class. Studies comparing 
+BHT with other variables of lung function may be carried out in future to confirm the validity and 
+reliability of this observation. 
+ 
+ 
+References:  
+ 
+1. Barnes, P. M., Powell-Griner, E., McFann, K., & Nahin, R. L. (2004). Complementary and alternative medicine use among 
+adults: United States, 2002. Advance data, (343), 1-19. 
+2. Ebomoyi M.I., & Iyawe V.I. (2005)  Variations of peak expiratory flow rate with anthropometric determinants in a population  
+of healthy adult Nigerians, Nigerian Journal of Physiological Sciences, 20(1-2), 85-89. 
+3. Hagen I., & Nayar U.S. (2014). Yoga for Children and Young People's Mental Health and Well-Being: Research Review and 
+Reflections on the Mental Health Potentials of Yoga. Frontiers in Psychiatry, 5:35.  
+4. Holcroft, C. A., Eisen, E. A., Sama, S. R., & Wegman, D. H. (2003). Measurement characteristics of peak expiratory flow. 
+Chest, 124, 501-510. 
+5. Jatiya, L., Udupa, K., & Bhavanani, A. B., with Mandanmohan. (2003). Effect of yoga training on handgrip, respiratory 
+pressures and pulmonary function. Indian journal of physiology and pharmacology, 47(4), 387-392. 
+6. Khalsa, S. B. S., 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. Journal of Behavioral Health Services and 
+Research, 39(1), 80-90. 
+7. Mendelson, T., Greenberg, M. T., Dariotis, J. K., Gould, L. F., Rhoades, B. L., & Leaf, P. J. (2010). Feasibility and 
+preliminary outcomes of a school-based mindfulness intervention for urban youth. Journal of Abnormal Child Psychology, 38(7), 
+985-994. 
+8. Nagarathna, R., & Nagendra, H.R. (2001). Integrated Approach of Yoga Therapy for positive health. Bangalore: Swami 
+Vivekananda Yoga Prakashana; 
+9. Petty, T. L. (2006). The history of COPD Early historical landmarks. International Journal of COPD, 1(1), 3-14. 
+10. Pedersen, O. F. (1997). The Peak Flow Working Group: physiological determinants of peak expiratory flow. The European 
+respiratory journal. Supplement, 24, 11S-16S. 
+11. Rajesh, S.K., Ilavarasu, J.V., & Srinivasan, T.M. Effect of Bhramari Pranayama on response inhibition: Evidence from the 
+stop signal task. International Journal of Yoga, 7:138-41 
+12. Raub, J. A. (2002). Psychophysiologic effects of Hatha Yoga on musculoskeletal and cardiopulmonary function: a literature 
+review. Journal of alternative and complementary medicine (New York, N.Y.), 8(6), 797-812. 
+13. Soni, R., Singh, K., Munish, K., & Singh, S. (2012). Study of the effect of yoga training on diffusion capacity in chronic 
+obstructive pulmonary disease patients: A controlled trial. International Journal of Yoga, 5(2), p.123. 
+14. Vedala, S.R., Mane, A.B., & Paul, C.N. (2014). Pulmonary functions in yogic and sedentary population. International 
+Journal of Yoga; 7:155-9 
+15. Vialatte, F. B., Bakardjian, H., Prasad, R., & Cichocki, A. (2009). EEG paroxysmal gamma waves during Bhramari 
+Pranayama: a yoga breathing technique. Consciousness and cognition, 18(4), 977-988. 
+ 
+ 
+Received: August 3, 2014 
+Accepted: September 1, 2014 
+ 

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+© 2021 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow	
+1
+Development, validation, and 
+feasibility of a school‑based short 
+duration integrated classroom yoga 
+module: A pilot study design
+Atul Sinha, Sony Kumari, Mollika Ganguly
+Abstract:
+BACKGROUND: The practice of yoga is proven to have physical, cognitive and emotional benefits 
+for school children. Despite this many schools do not include yoga in their daily schedule. The 
+reasons cited are lack of time and resources. To overcome these problems the present study aimed 
+to develop and validate a short duration Integrated classroom yoga module. The design guidelines 
+were that it should be possible to practice in the classroom environment and that it could be led by 
+the class teacher. In this way the module would overcome the problem of both time and resource.
+MATERIALS AND METHODS: The study had two main 
+ phases. In the first phase, selected ICYM 
+practices based on the literature review were validated by 21 subject matter experts using Lawhse’s 
+content validity ratio (CVR) formula. In the second phase, a pilot study using a paired sample prepost 
+measurement design was carried out on 49 
+ high  school children. The study was conducted in June 
+2019. The intervention period was 1 month, and the test variables were physical fitness, cognitive 
+performance, self‑esteem, emotional well‑being, and personality characteristic.  
+ Paired sample t‑test was 
+the analysis tool and the software used was the Statistical Package for the Social Science version 26.
+RESULTS: In the Lawshe’s CVR analysis, 17 out of the 24 practices tested were rated by experts 
+as essential as was the overall module (CVR score ≥0.429). In the pilot study, there were significant 
+differences in the postmean scores compared to premean scores, for all the 4 EUROFIT physical 
+fitness testing battery tests  (P  <  0.02), all the three scores of the Stroop 
+  color‑word naming 
+task (P < 0.001) and the Rosenberg self‑esteem scale (P < 0.008).
+CONCLUSION: ICYM was validated and found feasible by the present 
+ study. It was found to have a 
+statistically significant impact on physical fitness, cognitive performance, and self‑esteem variables. 
+However, a randomized control trial with a longer intervention period is needed to strengthen the 
+present study.
+Keywords:
+Children’s cognitive function, children’s physical fitness, children’s psychosocial well‑being, classroom 
+yoga, school‑based yoga
+Introduction
+D
+espite awareness of the benefits of 
+school‑based yoga, most schools 
+either have not incorporated the practice 
+of yoga in the school curriculum or have 
+done so sub‑optimally, usually one 
+class a week. The reasons range from 
+lack of time, a packed curricular and 
+
+co‑curricular schedule and the need for 
+resources such as yoga rooms, yoga mats, and 
+trained yoga instructors. If a solution can be 
+found to overcome the problems associated 
+with including yoga in the daily school 
+schedule, it will benefit children immensely.
+The yogic vision of education is to lay the 
+foundations of character and personality 
+Address for 
+correspondence:
+Dr. Sony Kumari,
+Department of Yoga 
+and Humanities, Swami 
+Vivekananda Yoga 
+Anusandhana Samsthana, 
+19 Eknath Bhavan, 
+Gavipuram Circle, 
+Kempe Gowda Nagar, 
+Bengaluru ‑ 560 019, 
+Karnataka, India. 
+E‑mail: sonykarmanidhi@
+gmail.com
+Received: 17‑06‑2020
+Accepted: 02-10-2020
+Published: 20-05-2021
+Department of Yoga 
+and Humanities, Swami 
+Vivekananda Yoga 
+Anusandhana Samsthana, 
+Bengaluru, Karnataka, 
+India
+Original Article
+Access this article online
+Quick Response Code:
+Website:
+www.jehp.net
+DOI:
+10.4103/jehp.jehp_674_20
+How to cite this article: Sinha A, Kumari S, 
+Ganguly M. Development, validation, and feasibility 
+of a school-based short duration integrated classroom 
+yoga module: A pilot study design. J Edu Health 
+Promot 2021;10:148.
+This is an open access journal, and articles are 
+distributed under the terms of the Creative Commons 
+Attribution‑NonCommercial‑ShareAlike 4.0 License, which 
+allows others to remix, tweak, and build upon the work 
+non‑commercially, as long as appropriate credit is given and 
+the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+Sinha, et al.: Validation of integrated classroom yoga module
+2	
+Journal of Education and Health Promotion | Volume 10 | April 2021
+based on self‑transformation.[1] Yoga is a system of 
+disciplines for furthering an integrated development 
+of multiple aspects of the individual’s personality. 
+Through asanas  (physical postures) the body is 
+maintained in a steady and supple state. By the practice 
+of pranayama (breathing exercises) emotional stability, 
+self‑confidence and self‑control are developed. Through 
+dhyana (meditation) the turbulent mind is stilled. The 
+practice of yoga creates a balance in the personality.[2]
+Over the last three decades, modern research has 
+demonstrated positive results of yoga on children. 
+Serwacki and Cook‑Cottone[3] reviewed 12 preliminary 
+studies of yoga in schools and found that yoga had a 
+positive effect on cognitive performance, emotional 
+well‑being, anxiety and negative behavior. Physical 
+fitness was shown to be positively associated with yoga.[4]
+Another factor for considering school‑based yoga is its 
+possible role in promoting 
+ health  literacy. Studies have 
+found a correlation between health literacy and health 
+promotion. A study by Karimi et al., 2019[5] defined 
+health literacy as the degree to which people are able 
+to choose, understand, process, communicate, and get 
+information for their health. They hypothesized that 
+health literacy aids correct decision making regarding 
+disease prevention, health promotion and for improving 
+quality of life. The authors conducted a randomized 
+controlled study with adolescents where the intervention 
+comprised the dissemination of the PBL health literacy 
+program. They found that the average level of health 
+literacy in the intervention group increased significantly, 
+specifically in the self‑efficacy dimension. Another study 
+with adolescents by Bayati et al., 2018[6] found a direct 
+significant correlation of health literacy with all the 
+dimensions of health‑promotion. A study with students 
+found a significant relationship between adopting health 
+promoting lifestyle and aspects of spiritual growth, stress 
+management and general quality of life.[7] An aspect 
+of school‑based yoga is the dissemination of self‑care 
+knowledge. Hyde, 2012[8] says that school‑based yoga 
+as critical‑emancipatory pedagogy, effectively uses 
+national standards for physical education, health and 
+safety and social‑emotional learning to provide self‑care 
+knowledge and skills to students and teachers. Hence, 
+yoga may be considered beneficial from the perspective 
+of health literacy too.
+The problems of the packed school schedule, time and 
+resources come 
+ in the way of incorporating yoga in 
+the daily school schedule. We hypothesize that a short 
+duration integrated classroom yoga module (ICYM) 
+can potentially overcome the problem of time and 
+resources. The 
+ short  duration would make it possible 
+to be practiced in the first period of the day without 
+impinging materially on the time for academic lessons. 
+Further, the class‑teacher can lead the practice in the 
+limited spaces of the classroom environment. This 
+ensures that no additional resources will be required. 
+Traditional texts of yoga too support its practice in the 
+classroom. Yogabhakti Saraswati says that children 
+enter the class with different states of mind. Yoga in the 
+classroom helps to harmonize their minds and create the 
+right balance between excitement and alertness.[2] The 
+objective of this study was to develop a validated short 
+duration ICYM and confirm its feasibility and efficacy 
+with a pilot study design.
+Materials and Methods
+The present study adopted a phased methodology 
+to develop, validate and confirm 
+ the feasibility and 
+efficacy of the school‑based short duration ICYM. In 
+the first phase, yoga practices were selected based on a 
+review of ancient and contemporary literature on yoga. 
+In the second phase, the content validity of the selected 
+practices was assessed by a panel of 21 subject matter 
+experts. The content validity was calculated using 
+Lawshe’s content validity ratio (CVR) formula.[9] In the 
+third phase, the validated ICYM was developed. In the 
+fourth phase a pilot study was conducted to confirm 
+the feasibility and ascertain the efficacy of the module. 
+Figure 1 shows the four phases adopted in the study. 
+The study was approved by the Institutional ethics 
+committee of 
+ S‑VYASA  University (reference number: 
+RES/IEC‑SVYASA/145/2019).
+Designing integrated classroom yoga module 
+based on literature review
+Ancient and contemporary texts of yoga were reviewed 
+to develop the content of the module. The ancient texts 
+reviewed were Patanjali yoga sutra,[10] Hatha yoga 
+pradipika,[11] Gheranda Samhita,[12] Siva Samhita,[13] 
+Svetasvatara Upanishad,[14] and Brhdaranyaka 
+Figure 1: Phases in developing a validated school‑based integrated classroom 
+yoga module
+Sinha, et al.: Validation of integrated classroom yoga module
+Journal of Education and Health Promotion | Volume 10 | April 2021	
+3
+Upansidhad.[15] The contemporary texts reviewed were 
+Light on Yoga,[16] Asana Pranayama Mudra Bandha[17] 
+and Integrated yoga therapy for positive health.[18] At an 
+overall level, these texts make out a compelling case for 
+making yoga integral to children’s education.
+According to Niranjanananda[1] the purpose of education 
+is to develop a fully integrated personality by laying 
+the foundations of character and personality. He 
+elaborates on this theme by stating that there are two 
+main ingredients to achieve this objective. The first is the 
+development of discrimination between what is worthy 
+and what is not and the second is the development of a 
+spiritual attitude in order to face life with courage and 
+fortitude. Being self‑transformative, yoga aids in the 
+development of discrimination and a spiritual attitude. 
+Satyananda[2] says that yoga has immense benefits for 
+children. It gently massages the endocrine glands whose 
+proper functioning is critical for growing bodies. Regular 
+practice of yoga brings about emotional stability and 
+enhances self‑confidence, self‑awareness and self‑control.
+Patanjali yoga sutra says that only a still mind is capable 
+of concentration and higher perception. It advises 
+constant practice and an attitude of nonattachment 
+to bring the mind under control. Asanas  (physical 
+postures) make the body firm and still. It lessens 
+the natural restlessness of the body making it easier 
+for the mind to concentrate. Pranayama  (breathing 
+exercises) removes rajas (uncontrolled restless activity) 
+and tamas (uncontrolled dullness) to make the mind 
+sattvic (controlled gentle steadiness). This in turn makes 
+the mind fit for concentration. Dharana (concentration) 
+and Dhyana (meditation) trains the mind to focus on 
+one subject effortlessly.[10] Hatha yoga pradipika states 
+that asanas  (physical postures) steadies the body, 
+makes it supple, induces relaxation and facilitates 
+free low of prana  (vital energy). The practice of 
+pranayama (breathing exercises) increases pranic force 
+and balances the mind. The left and right hemispheres 
+of the brain are balanced to allow both the logical and 
+intuitive faculties to function.[11] Gheranda Samhita says 
+yoga calms the mind and brings the whole personality 
+under control, moderation and balance.[12] According 
+to Siva samhita yoga helps to develop an attitude of 
+cheerfulness, enthusiasm and courage.[13]
+Modern research has corroborated many of the 
+claims made by ancient texts of yoga. Studies have 
+shown that yoga had a beneficial effect on physical 
+fitness.[19] It improved musculoskeletal health.[20] It 
+impacted cardiopulmonary health positively,[21‑23] and 
+improved neuromuscular health.[23‑25] Studies have 
+associated yoga with significant improvements in 
+memory, attention and executive function.[26‑28] Yoga 
+enhanced self‑esteem,[29,30] and improved self‑efficacy, 
+self‑regulation and self‑adjustment.[31‑33] Yoga helped 
+improve mood state, depression, anger and anxiety.[34‑36] 
+Ferreira‑Vorkapic et al.[37] reviewed nine randomized 
+control trial studies and found positive effects of yoga 
+on mood indicators, tension, anxiety, self‑esteem and 
+memory. Yoga had a positive impact on three types 
+of response patterns called gunas. A study showed an 
+increase in 
+ sattva (controlled gentle steadiness) and 
+reduction in rajas (uncontrolled restless activity) and 
+tamas  (uncontrolled dullness).[38] Om chanting has 
+been shown to activate the neural region, increase 
+oxygenation, give psychological relaxation, relieve stress 
+and provide vigor.[39,40] Pradhan and Derle[41] reported 
+that chanting Gayatri mantra improved attention.
+The ancient and contemporary literature on yoga were 
+scanned to identify and evaluate practices beneficial for 
+physical fitness, cognitive performance and emotional 
+well‑being of children. Only practices that could be 
+performed in the confined spaces of the classroom 
+environment were evaluated. Table 1 lists the selected 
+practices of asanas (physical postures), Table 2 lists the 
+selected practices of pranayama (breathing exercises), 
+and Table 3 lists the selected dhyana (meditation) and 
+mantra (chanting) practices and summarizes their benefits 
+as referred in yoga texts. The literature review found that all 
+14 asanas selected impacted physical fitness, 11 asanas were 
+associated with cognitive performance and 6 with emotional 
+wellbeing. Of the 7 pranayama practices (breathing exercises) 
+selected, 5  had a positive effect on physical fitness and all 7 
+were beneficial for cognitive and emotional well‑being. The 
+3 dhyana (meditation) and mantra (chanting) practices were 
+found to promote cognitive performance and emotional 
+well‑being.
+Validation of Integrated classroom yoga module 
+by subject matter experts
+The 24 practices selected from literature review were 
+incorporated in 4 alternate sets of yoga module. These 
+sets were meant to be rotated from 1 day to the next. 
+A questionnaire was prepared for yoga experts. They 
+were required to validate the practices on a three‑point 
+scale:
+1.	 Not essential: Has no role in improving physical 
+fitness, cognitive performance, emotional wellbeing 
+or personality characteristics of school children
+2.	 Useful but not essential: Useful but not important in 
+improving physical fitness, cognitive performance, 
+emotional well‑being or personality characteristics 
+of school children
+3.	 Essential: Very important for improving physical 
+fitness, cognitive performance, emotional wellbeing 
+or personality characteristics of school children.
+The questionnaire further required them to rate the yoga 
+module as a whole on its ability to achieve the objectives 
+Sinha, et al.: Validation of integrated classroom yoga module
+4	
+Journal of Education and Health Promotion | Volume 10 | April 2021
+of impacting physical fitness, cognitive performance, 
+emotional wellbeing and personality characteristics of 
+school children. The rating was on a three‑point scale.
+1.	 Not at all
+2.	 Moderately
+3.	 Very much.
+Open ended suggestions for improvement of the module 
+were also solicited in the questions.
+The experts were selected based on convenience 
+sampling. 21 yoga experts responded to the questionnaire. 
+Lawshe’s CVR formula was the statistical tool employed 
+to analyze the data.[9]
+Designing a validated integrated classroom yoga 
+module
+Definition of Integrated classroom yoga module
+The premise worked on was that a short duration 
+yoga module, amenable to be led by the class teacher 
+and possible to practice in the limited spaces of the 
+classroom environment would encourage schools to 
+incorporate yoga in their daily schedule. ICYM was 
+thus conceived as a 12‑min integrated yoga module 
+to be practiced in the limited spaces of the classroom 
+environment. It could be led by the class teacher after 
+a 1‑week training in the practice and a working theory 
+of yoga.
+The integrated module included different limbs of yoga 
+namely asanas (physical postures), pranayama (breathing 
+exercises), dhyana (meditation) and mantra (chanting). 
+The design was based on three predefined criteria:
+1.	 It should be an integrated yoga module
+2.	 It should be possible to practice the module in the 
+limited spaces of the classroom environment
+3.	 The choice of practices should have the ability to 
+impact physical fitness, cognitive performance, 
+emotional well‑being and personality characteristics 
+of school children.
+Table 1: Asanas (physical postures) selected from literature review
+Asanas (physical postures)
+Benefits
+Textual references
+Sideways bending/twisting
+Katichakrasana
+Tones upper body; corrects posture; relieves stress
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+TirikayaTadasana
+Exercises and balances side muscles
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+ArdhakatiChakrasana
+Stimulates sides and spine; improves liver function
+Positive Health. Nagarathna and Nagendra (2011)
+Parsvakonnasana
+Tones lower body; increases peristaltic activity
+Light on Yoga. Iyengar (2012)
+Forward and backward bending
+Prasarita Padohastasana + 
+Ardhachakrasana
+Develops lower body muscles; improves flexibility, 
+increase blood flow to head region
+Light on Yoga. Iyengar (2012)
+Padahastasana + 
+Ardhachakrasana
+Tones abdomen; improves digestive health; 
+improves metabolism, improves concentration
+Light on Yoga. Iyengar (2012)
+Positive Health. Nagarathna and Nagendra (2011)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Padahastasana + 
+Hastauthanasana
+Tones abdomen; improves digestive health; 
+improves metabolism, improves concentration
+Light on Yoga. Iyengar (2012)
+Positive Health. Nagarathna and Nagendra (2011)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Stretching
+Tadasana
+Lightness; mental agility; physical and mental 
+balance; tones nerves
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+ParivrittaTrikonasana
+Tones lower body; invigorates abdominal organs; 
+stimulates nervous system
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Gaumukhasana
+Tones upper body; regulates endocrine system; 
+regulates prana flow; steadies body and calms 
+mind, increases energy and awareness
+Hatha Yoga Pradipika. Muktibodhananda (1985)
+Gheranda Samhita. Niranjananda (2012)
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Ardhachandrasana
+Strengthens lower body and abdomen; improves 
+digestion; improves balance
+Gheranda Samhita. Niranjananda (2012)
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Balancing
+Vrkshasana
+Improves balance; strengthens lower body; 
+promotes kidney health
+Gheranda Samhita. Niranjananda (2012)
+Light on Yoga. Iyengar (2012)
+Garudasana
+Strengthens and loosens body; tones nerves, 
+develops concentration
+Gheranda Samhita. Niranjananda (2012)
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Veerbhadrasana Pose III
+Creates harmony and balance; tones abdomen; 
+gives vigour; improves concentration
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Sinha, et al.: Validation of integrated classroom yoga module
+Journal of Education and Health Promotion | Volume 10 | April 2021	
+5
+Designing a validated Integrated classroom yoga module
+The validated practices were incorporated in the ICYM. 
+From the open‑ended suggestions given by experts we 
+thought it useful to include a positive affirmation practice. 
+Another suggestion incorporated was to slow down the 
+pace of the practice to ensure that children were not tired. 
+The parameters followed to design the module were:
+1.	 The module duration was 12 min
+2.	 Two sets were to be made meant to be practiced on 
+alternate days to provide variety and derive more 
+benefits
+3.	 The practice was to start with dhyana (meditative 
+silence) to harmonize the mental state of the cohort
+4.	 The asanas (physical postures) that followed would 
+comprise side bending or twisting, forward and 
+backward bending, stretching and balancing to 
+ensure that the whole body was exercised
+5.	 The 
+asanas 
+were 
+to 
+be 
+followed 
+by 
+pranayama 
+(breathing 
+exercises)
+6.	 At the tail end, there was dhyana (meditative silence) 
+and OM chanting to relax the body and mind. The 
+module 
+ ended  with a positive 
+ affirmation.
+The ICYM module is presented in Table 4.
+Pilot study to confirm the feasibility of integrated 
+classroom yoga module
+Design
+The aim of the pilot study was to test the feasibility 
+and efficacy of the validated ICYM in a school setting. 
+The design was a paired sample prepost measurement 
+of means of physical fitness, cognitive performance, 
+self‑esteem, emotional well‑being, and personality 
+characteristic variables.
+Table 2: Pranayama (Breathing exercises) selected from literature review
+Pranayama (breathing exercises)
+Benefits
+Textual reference
+Bhastrika
+Stimulates cerebral region; strengthens nervous 
+system; oxygenates blood; stimulates heart; 
+detoxification; unblocks prana movement; 
+stimulates metabolism; lowers stress; induces 
+clarity of thought and improves concentration
+Hatha Yoga Pradipika. Muktibodhananda (1985)
+Gheranda Samhita. Niranjananda (2012)
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Ujjai
+Relaxes; develops psychic sensitivity; 
+internalises the senses; calms the mind; 
+promotes cardio and digestive health
+Hatha Yoga Pradipika. Muktibodhananda (1985)
+Gheranda Samhita. Niranjananda (2012)
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Yogic breathing (abdominal)
+Relaxed and comfortable breathing; gives 
+vitality and calmness; clarity of thought
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Positive Health. Nagarathna and Nagendra (2011)
+Nadi Shudhi
+Purifies nadis; increases prana capacity; 
+eliminates bodily disorders; makes breathing 
+rhythmic; soothes nerves; stills the mind; 
+balances brain hemispheres; improves 
+concentration
+Hatha Yoga Pradipika. Muktibodhananda (1985)
+Gheranda Samhita. Niranjananda (2012)
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Positive Health. Nagarathna and Nagendra (2011)
+Sheetali and Sadanta
+Cools the body and mind; keeps teeth and 
+gums healthy; harmonises the endocrine 
+system; reduces BP; encourages flow of prana; 
+gives vigour; gives inner tranquillity
+Hatha Yoga Pradipika. Muktibodhananda (1985)
+Gheranda Samhita. Niranjananda (2012)
+Light on Yoga. Iyengar (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Positive Health. Nagarathna and Nagendra (2011)
+Bhramari
+Awakens psychic sensitivity; relieves anxiety; 
+alleviates anger; reduces BP; helps in throat 
+ailments; creates healing capacity
+Hatha Yoga Pradipika. Muktibodhananda (1985)
+Gheranda Samhita. Niranjananda (2012)
+Asana Pranayama Mudra Bandha. Satyananda (2009)
+Positive Health. Nagarathna and Nagendra (2011)
+Table 3: Dhyana (meditation) and mantra (chanting) practices shortlisted from literature review
+Meditation/Chanting
+Benefits
+Textual reference
+Dhyana (meditation)
+Mauna
+Control over mind; stillness, one 
+pointedness, continuous awareness; deep 
+relaxation; reduced metabolic rate; light 
+and expansive feeling
+Patanjali Yoga Sutra. Vivekananda (1986)
+Hatha Yoga Pradipika. Muktibodhananda (1985)
+Gheranda Samhita. Niranjananda (2012)
+Positive Health. Nagarathna and Nagendra (2011)
+Mantra (chanting)
+OM and Gayatri 
+Mantras
+Steadies the senses and quietens the mind; 
+balances the emotions; purifies the mind
+Svetasvatara Upanishad. Tejomayananda (2011)
+Brhadaranyaka Upanishad. Madhavananda (1934)
+Positive Health. Nagarathna and Nagendra (2011)
+Sinha, et al.: Validation of integrated classroom yoga module
+6	
+Journal of Education and Health Promotion | Volume 10 | April 2021
+Participants
+The participants for the present study were selected 
+from an urban campus of the multi‑campus Samsidh 
+Mount Litera Zee School group in Bengaluru, India. 
+The participants were selected randomly from Grades 
+7–10. A grade‑wise quota was predecided, and equal 
+gender ratio was fixed. The selection of participants 
+was made blindly and randomly by drawing from 
+paper slips. The inclusion criteria were: (i) participants 
+must be from Grades 7–10 and (ii) of both genders. The 
+exclusion criteria were: (i) any history of major physical 
+illness or surgery in the past 2 months, (ii) any mental 
+illness and (iii) any condition where physical activity 
+was contraindicated.
+Intervention
+The intervention period was 1 month, with 5 days a 
+week of practice in the beginning of the first period of the 
+school day. The class teachers were trained by qualified 
+yoga instructors over daily 1 h sessions for 7 days. The 
+training included an overview of the discipline of yoga 
+and its various limbs. The benefits of each practice were 
+conveyed to them. Each yoga exercise was demonstrated 
+and practiced. Teachers had to lead mock sessions. 
+A video of the module was also given to the teachers. 
+Every 2 weeks, there was a top‑up training session 
+conducted for the teachers.
+Ethics
+The study was approved by the Institutional ethics 
+committee of S‑VYASA University (reference number: 
+RES/IEC‑SVYASA/145/2019). The school administration 
+was briefed in writing and verbally on the details of 
+the study and the intervention. Informed consent was 
+obtained from the school administration.
+Assessment
+The participants were assessed for physical fitness, cognitive 
+performance, self‑esteem, emotional well‑being and 
+personality characteristic. Four tests from EUROFIT physical 
+fitness testing battery were conducted.[42] The Stroop 
+color-word naming task was used to measure cognitive 
+performance.[43] Rosenberg self‑esteem scale[44] and WHO‑5 
+well‑being index[45] were utilized to measure emotional 
+well‑being. Sushruta child personality inventory (SCPI)[46] 
+was employed to measure child personality characteristic.
+EUROFIT physical fitness testing battery
+Flamingo balance test
+Participants balanced on a narrow wooden bar on their 
+preferred leg. The free leg was flexed at the knee. Number 
+of falls in 60 s was recorded.
+Sit and reach flexibility test
+Participants were made to sit on the floor with both legs 
+stretched, touching the base of a measuring table with 
+Table 4: Integrated classroom yoga module: Set 1 and Set 2 practiced on alternate days
+Set 1
+Set 2
+Yoga practice
+Time
+Description
+Yoga practice
+Time
+Description
+Dhyana (Meditative silence)
+1 min
+Sit straight with eyes closed. 
+Attention on breathing. Watch 
+your thoughts flowing
+Dhyana (Meditative silence)
+1 min
+Sit straight with eyes closed. 
+Attention on breathing. Watch 
+your thoughts flowing
+Asanas
+Asanas
+Katichakrasana
+1 min
+20 rounds
+Ardhakatichakrasana
+1 min
+Hold for7 counts on each side
+Hastauthanasana/
+Padahastasana
+1 min
+3 rounds backward‑forward 
+bending. On 4th round hold for 
+7 counts on backward bend 
+and then on forward bend
+Ardhachakrasana/
+Padahastasana
+1 min
+3 rounds of backward‑forward 
+bending. On 4th round hold 
+for 7 counts on back bend 
+and then
+Tadasana
+1 min
+3 rounds of up and down 
+followed by 1 round of holding 
+for 10 counts
+Gaumukhasana (standing)
+1 min
+Hold on each side to the 
+count of 10
+Vrkhsasana
+1 min
+Hold on each side for 10 
+counts
+Garudasana
+1 min
+Hold on each side for 10 
+counts
+Pranayama
+Pranayama
+Yogic breathing (abdominal)
+1 min
+10 rounds
+Yogic breathing (abdominal)
+1 min
+10 rounds
+Nadi Shudhi
+2 min
+6 rounds
+Nadi Shudhi
+2 min
+6 rounds
+Bhramari
+1 min
+6 rounds
+Bhramari
+1 min
+6 rounds
+OM chanting
+1 min
+6 rounds
+OM chanting
+1 min
+6 rounds
+Dhyana
+1 min
+Mentally recap the practices. 
+Attention on breathing
+Dhyana
+1 min
+Mentally recap the practices. 
+Attention on breathing
+Affirmation
+Affirmation
+I am a powerful soul
+0.5 min 3 rounds
+I am a loveful soul
+0.5 min
+3 rounds
+Closing
+0.5 min Rub palms, massage eyes, 
+face, neck. With a few blinks 
+open eyes
+Closing
+0.5 min
+Rub palms, massage eyes, 
+face, neck. With a few blinks 
+open eyes
+Total timing
+12 min
+Total timing
+12 min
+Sinha, et al.: Validation of integrated classroom yoga module
+Journal of Education and Health Promotion | Volume 10 | April 2021	
+7
+their 
+ spine erect. The table had a measuring scale. The 
+initial reading on the measuring scale was taken at the 
+point where the tip of the longest finger touched. They 
+were then asked to stretch fully without bending their 
+legs. The final reading where the tip of the longest finger 
+reached was taken and the distance of stretch calculated 
+by subtracting the initial (non stretch reading) from the 
+final (full stretch) reading.
+Sit ups trunk strength
+Participants were required to lie on their back with knees 
+bent; thighs kept 
+ at right angle to the torso and feet flat 
+on the ground. Their hands were kept behind their head. 
+Participants performed sit‑ups from this position and 
+returned to the initial position. The number of sit‑ups in 
+30 s was recorded. Incomplete sit‑ups were not counted.
+10 × 5‑m shuttle run agility test
+Cones were kept at a distance of 10 m. At the word ‘Go’ 
+the participants ran to the cone 10 m away and back five 
+times without stopping. At the end of the fifth round, 
+the timing was recorded using a stopwatch.
+Stroop color‑word naming task
+The Stroop color‑word task measures the executive 
+function involving word, color and an interference naming 
+response. The test consists of three pages. The first page 
+tests how fast the participant can read out words (correct 
+number of words read in 45 s). The second page tests how 
+fast the participant can call out the colors (correct number 
+of colors called in 45 s). The third page tests the speed 
+with which the participant can name the color of the ink 
+and disregard the word printed in that color ink (correct 
+number of ink colors called in 45 s). The test in effect 
+measures the participant’s control over neuropsychological 
+functions involved in color and word naming responses.[39] 
+The test extracts three scores, namely Stroop word score, 
+Stroop color score and Stroop color‑word score.
+Rosenberg self‑esteem scale
+The Rosenberg self‑esteem scale is a self‑report scale. 
+It is a 10‑item scale measuring both positive and 
+negative feelings associated with global self‑esteem. The 
+instrument uses a 4‑point Likert scale.
+WHO‑5 well‑being index
+The WHO‑5 well‑being index is a self‑report scale. It 
+has 5 items measuring positive feelings associated with 
+emotional well‑being. The instrument uses a 6‑point 
+Likert scale.
+Sushruta child personality inventory
+The SCPI is a self‑report scale measuring personality 
+characteristic. It has 54 items and uses a binomial Yes/
+No scale. The scale is based on the concept that the mind 
+is always in a dynamic equilibrium between three types 
+of response patterns called gunas. The three patterns are 
+Sattva (controlled gentle steadiness), Rajas (uncontrolled 
+restless activity) and Tamas (uncontrolled dullness).[47] 
+Well‑being is disturbed when Rajas and Tamas become 
+dominant.
+The raw data were analyzed using the Statistical Package 
+for the Social Science (SPSS) version 26, IBM, USA.
+Results
+Results of validation of Integrated classroom yoga 
+module by subject matter experts
+The ICYM was evaluated by subject matter experts (n = 21). 
+The qualification of the experts was Ph.D., (Yoga) 13, 
+MD (Yoga Therapy) 1, M.Sc., (Yoga) 2, Yoga instructors 
+certification course 5. The mean number of years’ 
+experience in teaching yoga was M = 19.9 (8.57) and the 
+range was 4–40. The characteristics of the expert panel are 
+given in Table 5. To test content validity of subject matter 
+expert ratings, Lawshe’s CVR analysis was undertaken. 
+Tables 6‑9 gives the results of content validity for the 
+24 yoga practices proposed. For a panel size of 21 the 
+CVRcrit was calculated at 
+ 0.429. A CVR score ≥CVRcrit 
+would constitute sufficient evidence to validate that 
+practice. Conversely a CVR score <CVRcrit would indicate 
+insufficient evidence to validate that practice. Out of the 14 
+asanas (physical postures) 12 had a CVR score ≥CVRcrit. 
+Out of the 7 pranayama practices (breathing exercises), 3 
+cleared the content validity test with CVR score ≥CVRcrit. 
+1 dhyana (meditation) and 1 mantra (chanting) practice 
+cleared the content validity test with a CVR score ≥CVRcrit. 
+The overall module also cleared the content validity test 
+with a CVR score ≥CVRcrit indicating that the overall 
+module was rated by experts as capable of achieving its 
+objectives.
+Results of pilot study to confirm feasibility and 
+efficacy of Integrated classroom yoga module
+Participants for the pilot study were selected randomly 
+from grades 7–10. The sample size achieved was N = 49. 
+The mean age was M = 13.63 (1.014), range = 12–16 years 
+and gender ratio B:G = 23:26 [Table 5]. A paired sample 
+t‑test was conducted to test the hypothesis that yoga 
+Table 5: Characteristics of subject matter experts 
+(n=21)
+Characteristic
+Number
+Qualification
+Ph.D. (Yoga)
+13
+M.Sc. (Yoga)
+2
+MD (Yoga)
+1
+Yoga instructors certification
+5
+Experience
+Mean (SD)
+19.90 (8.57)
+Range
+4‑40 years
+SD=Standard deviation
+Sinha, et al.: Validation of integrated classroom yoga module
+8	
+Journal of Education and Health Promotion | Volume 10 | April 2021
+intervention with the validated ICYM would result in 
+statistically significant differences in postintervention 
+means compared to preintervention means for physical 
+fitness, cognitive performance, self‑esteem, emotional 
+well‑being, and personality characteristic variables. The 
+intervention period was 1 month, with 5 days a week of 
+practice. The preassessment was done in the middle of July 
+2019 and the postassessment in the middle of August 2019.
+EUROFIT physical fitness testing battery
+The paired sample t‑test was associated with 
+statistically significant differences in postintervention 
+means compared to preintervention means with 
+small‑to‑medium effect 
+ sizes for all four tests, namely 
+balance, flexibility, strength, and agility.
+Flamingo balance test: T  (48) = 3.03, P  =  0.004, 
+Cohen’s d = 0.43.
+Sit and reach flexibility test: T (48) = 2.52, P = 0.015, 
+Cohen’s d = 0.36.
+Sit ups trunk strength test: T (48) = 2.55, P = 0.014, 
+Cohen’s d = 0.36.
+10 × 5 m shuttle run agility test: T (48) = 2.61, P = 0.012, 
+Cohen’s d = 0.37.
+Table 8: Validated meditation and chanting practices using Lawshe’s content validity ratio (n=21)
+Dhyana (Meditation) and Mantra (chanting)
+ne
+N/2
+CVR (ne‑N/2)/N/2
+CVRcrit
+Select/reject
+Mauna
+19
+10.5
+0.810
+0.429
+Select
+OM mantra
+19
+10.5
+0.810
+0.429
+Select
+Gayatri mantra
+12
+10.5
+0.143
+0.429
+Reject
+n=Total number of panellists, ne=Total number of essentials (2) for each practice, CVR=Content validity ratio, CVRcrit=Minimum value for acceptance based on 
+binomial probabilities for panel size
+Table 6: Validated asanas (physical postures) using Lawshe’s CVR (n=21)
+Asana (physical posture)
+ne
+N/2
+CVR (ne‑N/2)/N/2
+CVRcrit
+Select/reject
+Katichakrasana
+15
+10.5
+0.810
+0.429
+Select
+TirikayaTadasana
+13
+10.5
+0.429
+0.429
+Select
+ArdhakatiChakrasana
+17
+10.5
+0.619
+0.429
+Select
+Parsvakonnasana
+15
+10.5
+0.429
+0.429
+Select
+PrasaritaPadohastasana + ardhachakrasana
+14
+10.5
+0.333
+0.429
+Reject
+Padahastasana + ardhachakrasana
+16
+10.5
+0.524
+0.429
+Select
+Padahastasana + hastauthanasana
+18
+10.5
+0.714
+0.429
+Select
+Tadasana
+17
+10.5
+0.619
+0.429
+Select
+ParivrittaTrikonasana
+16
+10.5
+0.524
+0.429
+Select
+Gaumukhasana
+16
+10.5
+0.524
+0.429
+Select
+Ardhachandrasana
+14
+10.5
+0.333
+0.429
+Reject
+Vrkshasana
+19
+10.5
+0.810
+0.429
+Select
+Garudasana
+16
+10.5
+0.524
+0.429
+Select
+Veerbhadrasana Pose III
+16
+10.5
+0.524
+0.429
+Select
+n=Total number of panellists, ne=Total number of essentials (2) for each practice, CVR=Content validity ratio, CVRcrit=Minimum value for acceptance based on 
+binomial probabilities for panel size
+Table 7: Validated pranayama practices (breathing exercises) using Lawshe’s content validity ratio (n=21)
+Asana (physical posture)
+ne
+N/2
+CVR (ne‑N/2)/N/2
+CVRcrit
+Select/Reject
+Bhastrika
+11
+10.5
+0.048
+0.429
+Reject
+Ujjai
+9
+10.5
+−0.143
+0.429
+Reject
+Yogic breathing (abdominal)
+18
+10.5
+0.714
+0.429
+Select
+Nadi Shudhi
+19
+10.5
+0.810
+0.429
+Select
+Sheetali
+12
+10.5
+0.143
+0.429
+Reject
+Sadanta
+10
+10.5
+−0.048
+0.429
+Reject
+Bhramari
+19
+10.5
+0.810
+0.429
+Select
+n=Total number of panellists, ne=Total number of essentials (2) for each practice, CVR=Content validity ratio, CVRcrit=Minimum value for acceptance based on 
+binomial probabilities for panel size
+Table 9: Validation of overall integrated classroom yoga module module (n=21)
+Overall rating of Yoga module
+ne
+N/2
+CVR (ne‑N/2)/N/2
+CVRcrit
+Will Yoga module achieve objective
+Can achieve objective
+16
+10.5
+0.524
+0.429
+Yes
+n=Total number of panelists, ne=Total number of essentials (2) for each practice, CVR=Content validity ratio, CVRcrit=Minimum value for acceptance based on 
+binomial probabilities for panel size
+Sinha, et al.: Validation of integrated classroom yoga module
+Journal of Education and Health Promotion | Volume 10 | April 2021	
+9
+Stroop color‑word naming task
+The paired sample t‑test was associated with 
+statistically significant differences in postintervention 
+means compared to preintervention means with 
+medium‑to‑large effect sizes for all three scores namely 
+word, color and color‑word.
+•	 Word score: T  (48) = 5.41, P  =  0.001, Cohen’s 
+d = 0.77
+•	 Color score: T (48) = 4.24, P = 0.001, Cohen’s d = 0.61
+•	 Color‑word score: T (48) = 4.39, P = 0.001, Cohen’s 
+d = 0.63.
+Rosenberg self‑esteem scale
+The paired sample t‑test was associated with a 
+statistically significant difference in postintervention 
+mean compared to preintervention mean with small 
+effect size.
+t (48) = 2.75, P = 0.008, Cohen’s d = 0.39.
+The paired sample t‑test was associated with statistically 
+insignificant effect for the following variables:
+WHO‑5 well‑being index
+•	 t (48) = 0.63, P = . 532, Cohen’s d = 0.09.
+SCPI:
+•	 Sattva score: T (48) = 0.07, P = 0.947., Cohen’s d = 0.01
+•	 Rajas score: T (48) = 1.92, P = 0.061, Cohen’s d = 0.27
+•	 Tamas score: T (48) = 1.88, P = 0.067, Cohen’s d = 0.27.
+Summary of results of the pilot study
+The yoga intervention with ICYM gave statistically 
+significant differences in means for physical fitness, 
+cognitive performance and self‑esteem variables. The 
+effect sizes ranged from small to medium in physical 
+fitness measures, medium to large in the cognitive 
+performance measure and small in the measure of 
+self‑esteem. The differences in means for emotional 
+well‑being and child personality characteristic variables 
+were insignificant. It can be concluded that ICYM 
+is feasible in improving physical fitness, cognitive 
+performance, and self‑esteem [Tables 10 and 11].
+Discussion
+Traditional literature on yoga makes a compelling 
+case for its inclusion in education. It is seen as 
+self‑transformational impacting every facet of the 
+personality to build intelligence, personality, and 
+character. Modern research lends support to the claims 
+made by traditional texts. Despite mounting evidence, 
+yoga finds it difficult to get included in the school 
+curriculum in any meaningful manner. The stated 
+barriers are a paucity of time and need for resources. 
+The aim of this study was to develop a validated short 
+duration (12 min) ICYM for benefiting school children 
+in physical fitness, cognitive performance, self‑esteem, 
+emotional well‑being and personality characteristic 
+variables. It was hypothesized that a short duration ICYM 
+would solve the problem of time and resource and could 
+potentially be included in the daily school schedule. 
+Current studies on classroom yoga have tested mostly 
+nonstandard yoga module designs, provided limited 
+details of the intervention or suffered from sub‑optimal 
+days per week of practice. An uncontrolled pilot study 
+by Butzer et al.[48] used a 30‑min classroom yoga module 
+practiced once a week. A study by Chen and Pauwels[49] 
+Table 10: Age and gender of pilot sample (n=49)
+Characteristic
+Number
+Age (years)
+13.63 (1.014)
+Age range
+12‑16
+Gender ratio (B:G)
+23:26
+Age is group mean (SD). SD: Standard deviation
+Table 11: Variables of scales tested: Paired sample t‑test
+Variable
+n=49
+Pre
+Post
+t
+P
+Cohen’s d
+EUROFIT physicalfitness testing battery
+Flamingo balance test
+7.37 (6.366)
+5.12 (5.270)
+3.03
+0.004
+0.43
+Sit and reach flexibility test
+13.08 (4.983)
+14.94 (6.105)
+2.52
+0.015
+0.36
+Sit ups trunk strength test
+19.18 (4.777)
+21.12 (5.540)
+2.55
+0.014
+0.36
+10 × 5 m shuttle run agility test
+15.79 (1.964)
+16.33 (1.527)
+2.61
+0.012
+0.37
+Stroop color ‑ word naming task
+Word score
+92.92 (13.156)
+98.59 (13.233)
+5.41
+0.001
+0.77
+Color score
+58.53 (11.616)
+65.82 (9.901)
+4.24
+0.001
+0.61
+Color ‑ word score
+32.14 (10.454)
+37.51 (9.520)
+4.39
+0.001
+0.63
+Rosenberg self‑ esteem scale
+27.78 (3,454)
+29.10 (3.435)
+2.75
+0.008
+0.39
+WHO‑5 well‑being index
+16.59 (4.286)
+17.00 (3.953)
+0.63
+0.532
+0.09
+Sushruta child personality inventory
+Sattva Score
+13.63 (2.118)
+13.65 (1.877)
+0.07
+0.947
+0.01
+Rajas Score
+8.82 (2.297)
+8.29 (2.000)
+1.92
+0.061
+0.27
+Tamas Score
+6.94 (2.025
+6.35 (1.964)
+1.88
+0.067
+0.27
+Pre‑ and Post are Group Means (SD). SD=Standard deviation
+Sinha, et al.: Validation of integrated classroom yoga module
+10	
+Journal of Education and Health Promotion | Volume 10 | April 2021
+used a 5‑15 min yoga‑based activity module. Mische 
+Lawson, Cox and Blackwell studied a 10‑min yoga‑based 
+reflex integration module.[50] The current research on 
+short‑duration classroom yoga is clearly inadequate. 
+There is a need for a methodologically sound study with 
+a validated short duration classroom yoga module.
+ICYM was designed based on a thorough review of 
+traditional yoga literature. The module integrated 
+asanas  (physical postures), pranayama  (breathing 
+exercises), dhyana  (meditative practice), and 
+mantra (chanting). The module was validated by yoga 
+experts. The analysis tool used was Lawshe’s CVR 
+formula. Only practices rated essential were included 
+in the final module. The entire module was also rated 
+essential by the experts. The methodology used in the 
+module validation phase of this study was consistent 
+with earlier researches on yoga module development 
+and validation. Isha et al.,[51] developed and validated 
+a yoga module for heart disease. A study by Kakde 
+et al.,[52] validated a yoga module on Parkinson’s disease. 
+Patil et al.[53] developed and validated a yoga module for 
+chronic lower back pain. A yoga module for children 
+with intellectual disabilities was validated by Pise et al.,[54]
+The pilot study was conducted in an urban campus of the 
+multi‑campus Samsidh Mount Litera Zee School group 
+in Bengaluru, India (n = 49). It found that the module 
+was well accepted by both teachers and students. There 
+was no problem in practicing the module in the limited 
+spaces of the classroom environment. A paired sample 
+t‑test showed that the differences in postintervention 
+means compared to preintervention means were 
+significant for physical fitness, cognitive performance 
+and self‑ 
+ esteem variables but insignificant for emotional 
+well‑being and child personality variables. The effect 
+sizes ranged from small to medium in physical fitness 
+measures, medium to large in the cognitive performance 
+measure and smallin the measure of self‑esteem. It was 
+concluded that ICYM has a statistically significant impact 
+on physical fitness, cognitive performance and self‑esteem 
+measures of school children. These 
+ findings  corroborate 
+earlier researches on the effect of yoga on physical 
+fitness, cognitive performance and self‑esteem although 
+with longer duration yoga modules. Two randomized 
+controlled Indian studies conducted on school children 
+found that integrated yoga practice improved physical 
+fitness as measured by the EUROFIT testing battery. 
+Improved BMI, speed, balance and strength were 
+reported in one study.[4] Improved balance, reaction 
+time, flexibility, strength, and agility were reported in the 
+other study.[14] Two Indian studies with school children 
+reported improvement in executive function as a result 
+of yoga intervention. Purohit and Pradhan[55] reported 
+significant differences in the yoga group for Stroop 
+Color‑Word Task, Digit Span Test and part‑A of TMT. 
+A study by Telles et al.,[4] found that yoga intervention 
+improved executive function as measured by the Stroop 
+Color‑Word task. Bhardwaj and Agrawal[29] assessed the 
+effect of yoga on the level of self‑esteem in preadolescents 
+school‑going children in a randomized controlled study. 
+The scale used was the Indian adaptation of Battle’s 
+self‑esteem inventory for children. The yoga group 
+showed a significant increase in the level of overall, 
+general and social self‑esteem. In another study with 
+school children, Sethi et al.,[56] showed a significant 
+increase in self‑esteem scores.
+The methodology used in the pilot phase of the study was 
+consistent with earlier researches that tested feasibility 
+of customized yoga modules. Bhat et al.,[57] conducted 
+a pilot study for a yoga module to treat Obsessive 
+compulsive disorder with 17 patients. Patil et al.[53] tested 
+the feasibility of a module for chronic lower back pain 
+with 12 patients. A module for depression was tested 
+with 7 patients.[58] Hariprasad et al.[59] conducted a pilot 
+study on a module for the elderly with 10 elders.
+The present study is unique since it has developed 
+a validated school‑based short duration classroom 
+yoga module. The interventions used in earlier studies 
+were nonstandard. The strengths of the study are (i) 
+the ICYM was developed methodically based on 
+ancient and contemporary yoga literature; (ii) it was 
+an integrated module incorporating physical postures, 
+breathing practices, meditative practices, chanting and 
+affirmation; (iii) The selected practices were validated 
+by a sufficient number of subject matter experts and 
+the responses were analyzed using a sound statistical 
+tool; (iv) and importantly the validated module was 
+subjected to a pilot study using a paired sample pre–post 
+measurement design. The pilot study found that the 
+module was efficacious in impacting physical fitness, 
+cognitive performance, and self‑esteem variables. 
+The weaknesses of the study were: (i) the sample size 
+of the pilot study was small (n = 49); (ii) the period 
+of intervention was 1 month, which is short; (iii) No 
+follow‑up study was conducted to ascertain long‑term 
+benefits and (iv) the module was tested only with high 
+school children. Its effect on smaller children is thus 
+unknown. Future studies could be undertaken using a 
+randomized control trial design with larger sample size 
+and a longer period of intervention. The module could 
+be tested with smaller children to understand its efficacy 
+across age groups.
+Acknowledgments
+This study was a part of one of the author’s Ph.D., thesis. 
+The study was self‑funded and there was 
+ no  conflict 
+of interest. We would like to acknowledge the 
+willing cooperation of the Samsidh Mount Litera Zee 
+School management, principal, teachers, staff, and 
+Sinha, et al.: Validation of integrated classroom yoga module
+Journal of Education and Health Promotion | Volume 10 | April 2021	
+11
+the 
+ enthusiastic students. Without their cooperation, 
+this study would not have been possible.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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subfolder_0/Does short-term lemon honey juice fasting have effect on lipid profile and body composition in healthy individuals..txt

@@ -0,0 +1,443 @@
+Short communication
+Does short-term lemon honey juice fasting have effect on lipid profile
+and body composition in healthy individuals?
+Prashanth Shetty a, A. Mooventhan b, *, Hongasandra Ramarao Nagendra c
+a Department of Nutrition and Herbology, SDM College of Naturopathy and Yogic Sciences and Hospital, Ujire, India
+b Department of Research and Development, S-VYASA University, Bengaluru, Karnataka, India
+c S-VYASA University, Bengaluru, Karnataka, India
+a r t i c l e i n f o
+Article history:
+Received 8 April 2015
+Received in revised form
+10 May 2015
+Accepted 18 May 2015
+Available online 18 May 2016
+Keywords:
+Body composition
+Fasting
+Lemon honey juice
+Lipid profile
+a b s t r a c t
+Fasting is one of the fundamental treatments of naturopathy. Use of lemon and honey for various me-
+dicinal purposes were documented since ancient days but there is a lack of evidence on short-term
+effects of lemon honey juice fasting (LHJF). Hence, we aim at evaluating the short-term effect of LHJF
+on lipid profile and body composition in healthy individuals. A total of 50 healthy subjects were recruited
+and they received 300-ml of LHJ, 4 times a day for four successive days of fasting. Assessments were
+performed before and after the intervention. Statistical analysis was performed by student's paired t-test
+with the use of Statistical Package for the Social Sciences (SPSS) version-16. Our study showed significant
+reduction in weight, body mass index (BMI), fat mass (FM), free FM (FFM), and total serum triglycerides
+(TSTGs) with insignificant reduction in fat percentage and total serum cholesterol compared to baseline.
+Within group analysis of females showed similar results, unlike males. Our results suggest that LHJF may
+be useful for reduction of body weight, BMI, FM, FFM, and TSTG in healthy individuals, which might be
+useful for the prevention of obesity and hypertriglyceridemia.
+© 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
+Fasting is an important treatment modality of naturopathy,
+based on providing rest to the digestive system, diverting vital en-
+ergy otherwise utilized to digest food to the process of healing body
+and mind [1]. Plasma level of Vitamin-C status is inversely related to
+body mass and degree of obesity [2]. Low plasma levels of Vitamin-C
+are reported to be associated with the increased body mass index
+(BMI), central fat distribution, increased all-cause mortality, the risk
+of myocardial infarction, and gallbladder disease [3]. Whereas
+increased Vitamin-C intake was reported to be associated with
+higher high-density lipoprotein cholesterol (HDL-C) levels in
+women and prevention of coronary heart disease (CHD) [4].
+The antioxidant content of honey is found to be equivalent to
+that of the fruits and vegetables [5] and helps reduce lipids in
+normal as well as hyperlipidemic individuals [6]. Lemon honey
+juice fasting (LHJF) is a commonly used treatment modality in
+naturopathic hospitals in obesity, hypertriglyceridemia, dyslipide-
+mia, alcoholic liver disorders, etc. but there is a lack of evidence
+showing its effects on body composition and lipid profile, especially
+in short interval. This preliminary study aims at evaluating the
+short-term physiological changes of LHJF on body composition,
+total serum triglycerides (TSTGs), and total serum cholesterol
+(TSCH) in healthy individuals.
+2. Materials and methods
+2.1. Subjects
+Fifty participants (32 females) aged 18e29 years were recruited
+from a residential campus of the college of naturopathy and yogic
+sciences. Study protocol was approved by the institutional ethics
+committee and written informed consent was obtained from the
+participants. Sample size was not calculated based on any previous
+studies. Participants who met the following inclusion and exclusion
+criteria were recruited for the study.
+* Corresponding author. Department of Research and Development, S-VYASA
+University, #19, Eknath Bhavan, Gavipuram Circle, Kempe Gowda Nagar, Bengaluru,
+Karnataka, India.
+E-mail address: [email protected] (A. Mooventhan).
+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.2016.03.001
+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 7 (2016) 11e13
+2.1.1. Inclusion criteria
+Both genders, willing to participate in the study.
+2.1.2. Exclusion criteria
+Participants with a history of any systemic diseases or regular
+medication for any disease; females during menstruation and
+pregnancy; active in any exercise/sports program.
+2.2. Study design
+This was a single group study with pre- and post-design. In this
+preliminary study, baseline assessments were done (n ¼ 50) before
+the intervention. Forty-four participants completed the study and
+contributed to the second assessment after 4-day of intervention.
+The reason for dropouts in study group (n ¼ 6) was unwillingness to
+continue fasting due to personal problem (n ¼ 5) and abdominal
+pain (n ¼ 1).
+2.3. Assessments
+Assessments were done before and after 4-day of intervention.
+Body composition was measured using TANITA body composition
+analyzers SC-330 (Japan) which is an automatic instrument.
+TANITA is used to measure body composition especially when
+monitoring modest changes in fat [7]. The measurement was taken
+by asking the participants to stand barefoot and erect on the foot
+plate of the analyzer. TSTG and TSCH were measured by an insti-
+tutionally qualified and well experienced technician with the use of
+BA-4545 semi-auto biochemistry analyzers (India).
+2.4. Intervention
+Participants were asked to gather in the hall, where fasting
+therapy was administered. To prepare and during fasting, the par-
+ticipants were kept away from daily routine to avoid interference
+by thoughts and emotions. The participants received 300-ml of LHJ
+(half lemon and a teaspoon of honey with 290-ml of water), 4-times
+(8.00e8.30-am, 11.30e12.00-am, 3.00e3.30-pm, and 6.30e7.00-
+pm) a day for four successive days of fasting [8]. The participants
+were staying together in allotted hall under observation from 6 am
+to 8 pm and then asked to go back to their residential hostel and
+kept under observation. We used Western Ghats of Karnataka
+(Dharmasthala) honey, which is dark yellow color multifloral
+honey, has mixed flavor and aroma. Its physiochemical analysis
+was: pH ¼ 3.48, ash (%) ¼ 0.60, moisture (%) ¼ 15.54, acidity (meq/
+kg) ¼ 20.0, total sugar (%) ¼ 75, protein (mg/g) ¼ 0.80, phenol (mg/
+g) ¼ 0.67, alkaloid (%) ¼ 10.6. This honey was reported to have good
+quality and can be used in traditional medicine [9]. Drinking water
+(whenever thirsty) was allowed during the fasting period, and the
+participants were instructed to avoid any vigorous physical activ-
+ities to avoid the risk of hypoglycemia [10]. On day-5, the fast was
+broken with 300-ml of sweet lime juice (morning) followed by fruit
+diet (papaya 200-g) at afternoon, raw diet (sprouts 50-g and raw
+vegetables 100-g, and fruit salad 100-g) at night, and normal
+routine boiled diet from the next day [8].
+2.5. Data analysis
+Data were statistically analyzed using SPSS for Windows,
+Version 16.0. Chicago, SPSS Inc. Descriptive analysis was done for
+demographic variables of the study group (n ¼ 44) and sub-groups
+(male [n ¼ 14] and female [n ¼ 30]). Student's paired samples t-test
+was performed to analyze baseline and post assessments of both
+study-group and sub-groups. P < 0.05 was considered as significant.
+3. Results
+Of 50 participants, 44 successfully completed the study. Data
+assessment was done before and after intervention. Demographic
+variables were age in years (both genders [20.68 ± 1.95], male
+[20.71 ± 1.59], female [20.67 ± 2.12]), and height in centimeters
+(both genders [162.43 ± 8.45], male [171.79 ± 6.74], female
+[158.07 ± 4.86]). Baseline and post assessments of study-group
+(n ¼ 44) and sub-group (male [n ¼ 14] and female [n ¼ 30]) are
+in Tables 1 and 2, respectively.
+Our study showed significant reduction in weight, BMI, fat mass
+(FM), free FM (FFM), muscle mass (MM), total body water (TBW),
+and TSTGs in study-group compared to baseline (Table 1). In sub-
+group analysis, significant reduction in weight, BMI, FM, FFM,
+MM, TBW, and TSTG in females were observed similar to study
+group, whereas in males, significant reduction was observed only in
+weight, BMI, FFM, and MM (Table 1). Though there were no sig-
+nificant reductions in fat percentage and TSCH, a trend toward
+reduction was observed (Tables 1 and 2).
+4. Discussion
+Our study showed a significant reduction in weight, BMI, FM,
+FFM, MM, TBW, and TSTG in study-group compared to baseline.
+Significant reduction in weight and BMI might attribute reduction
+of FM and FFM during fasting. Reduction in weight might possibly
+be due to LHJ as well, due to its Vitamin-C content, which was
+shown to have an association with weight loss [2]. Reduction in
+FM (significant) and fat% (insignificant) and TSTG (significant)
+compared to baseline indicates fat utilization during fasting
+because adipose tissue triglyceride mobilization during fasting is
+an important adaptive response and it is the major source of
+body's energy during food deprivation. This result might be
+attributed to the effect of fasting on plasma insulin concentration
+which was reported to have an inverse correlation to antilipolytic
+activity in adipose tissue during fasting [11] or due to the effect of
+Vitamin-C, an essential factor for biosynthesis of carnitine, useful
+for subsequent fat oxidation by shuttling long chain fatty acids
+across the mitochondrial membrane [2] or due to the effect of
+honey, which has lipid-lowering property in normal and hyper-
+lipidemic participants [6].
+Significant reduction in FFM such as MM and TBW indicates the
+utilization of muscle tissues and body fluids for energy requirement
+during the latter period of fasting where normal food intake was
+restricted. Though normal food intake was restricted, none of the
+participants reported any adverse effects except mild tiredness and
+mild giddiness in few subjects, which indicates the safety of short-
+term LHJF among healthy individuals.
+Table 1
+Baseline and post assessment of study group (n ¼ 44) (Students paired-t-test).
+Variables
+Baseline
+Post treatment
+t
+P
+Weight (kg)
+54.28 ± 12.93
+52.11 ± 12.65
+13.334
+<0.001
+BMI (kg/m2)
+20.46 ± 3.57
+19.64 ± 3.54
+11.749
+<0.001
+Fat (%)
+17.26 ± 8.30
+16.69 ± 8.97
+1.565
+0.125
+FM (kg)
+9.93 ± 7.46
+9.33 ± 7.84
+2.999
+<0.01
+FFM (kg)
+44.35 ± 7.68
+42.78 ± 7.30
+6.337
+<0.001
+MM (kg)
+42.10 ± 7.32
+40.60 ± 6.94
+6.300
+<0.001
+TBW (kg)
+31.16 ± 6.08
+30.09 ± 6.05
+5.758
+<0.001
+TSTG (mg/dL)
+95.50 ± 30.65
+78.18 ± 20.44
+3.889
+<0.001
+TSCH (mg/dL)
+147.77 ± 24.91
+143.07 ± 23.63
+1.646
+0.107
+All values are as mean ± SD. BMI: Body mass index, FM: Fat mass, FFM: Free fat mass,
+MM: Muscle mass, TBW: Total body water, TSTG: Total serum triglycerides, TSCH:
+Total serum cholesterol, SD: Standard deviation.
+P. Shetty et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 11e13
+12
+Total serum cholesterol reduced (not statistically significant)
+compared to baseline, which indicates LHJF may be useful to
+maintain TSCH level. This result is supported by a previous study on
+the administration of ascorbic acid in individuals with TSCH level
+<200 mg/dl, where it did not produce the consistent effect [4].
+Vitamin-C accounted for 35e75% of antioxidant power of food
+[12] and thus was shown to have protective effect on lipid-peroxide
+induced endothelial injury [13] and oxidative damage which are
+believed to play a key role in cardiovascular disease, cancer initia-
+tion, inflammatory diseases, neurologic disorders, and aging pro-
+cess in general [12].
+In sub-group analysis reduction in variables such as FM, TBW,
+and TSTG were observed in both genders, but were significant only
+in females, indicating LHJF might be more beneficial to females
+than males in reducing FM and TSTG, which in turn might be useful
+for prevention of major diseases such as obesity, hypertension, and
+other cardiovascular diseases. The previous studies on the intake of
+Vitamin-C in American men and women appeared to benefit only
+women [13,14] and were associated with a reduced risk of death
+from CHDs in Finnish women and not in men [13,15]. These evi-
+dences support the gender difference results of this study.
+4.1. Limitations of the study
+We did not measure HDL, LDL to obtain complete lipid profile;
+hormones such as plasma insulin and norepinephrine, which are
+shown to play an important role in the lipolysis in various studies
+[11]. Due to the absence of a control group, the result of our study
+may not primarily be attributed to the effect of LHJ during fasting.
+Disproportionate number of males with that of females could be of
+the limitation.
+4.2. Strengths of the study
+Intervention is cost effective and short duration of the inter-
+vention makes it easily acceptable, adaptable, and feasible to
+practice even at home. No serious adverse effect was found. The
+intervention might possibly be used as a preventive measure for
+the modern public health problems such as obesity, hyper-
+triglyceridemia, etc. Further studies (randomized control trials)
+with the larger sample size are required to warrant these effects
+and to evaluate the mechanism behind the effect of LHJF on lipid
+profile and body compositions, in healthy as well as in various
+disease conditions.
+5. Conclusion
+The result of our study suggests that 4-day of LHJF may be
+considered as an effective and safe method in reducing body
+weight, BMI, FM, and TSTG in healthy individuals, which might be
+useful in prevention of obesity and hypertriglyceridemia.
+Source of support
+Nil.
+Conflict of interest
+None declared.
+References
+[1] Rastogi R. Current approaches of research in naturopathy: how far is its evi-
+dence base? J Homeopath Ayurvedic Med 2012;1:107.
+[2] Horowitz JF, Coppack SW, Paramore D, Cryer PE, Zhao G, Klein S. Effect of
+short-term fasting on lipid kinetics in lean and obese women. Am J Physiol
+1999;276(2 Pt 1):E278e84.
+[3] Johnston CS. Strategies for healthy weight loss: from vitamin C to the glycemic
+response. J Am Coll Nutr 2005;24:158e65.
+[4] Aasheim ET, Hofsø D, Hjelmesaeth J, Birkeland KI, Bøhmer T. Vitamin status in
+morbidly obese patients: a cross-sectional study. Am J Clin Nutr 2008;87:
+362e9.
+[5] Simon JA, Hudes ES. Relation of serum ascorbic acid to serum lipids and li-
+poproteins in US adults. J Am Coll Nutr 1998;17:250e5.
+[6] Hegazi AG, Abd El-Hady FK. Influence of honey on the suppression of human
+low density lipoprotein (LDL) peroxidation (in vitro). Evid Based Complement
+Altern Med 2009;6:113e21.
+[7] Al-Waili NS. Natural honey lowers plasma glucose, C-reactive protein, ho-
+mocysteine, and blood lipids in healthy, diabetic, and hyperlipidemic subjects:
+comparison with dextrose and sucrose. J Med Food 2004;7:100e7.
+[8] Wouters EJ, Van Nunen AM, Geenen R, Kolotkin RL, Vingerhoets AJ. Effects of
+aquajogging in obese adults: a pilot study. J Obes 2010. pii: 231074.
+[9] Naveen GH, Shetty P, Goutham MP, Ganesh PB, Chethan R, Sangram P. Effect of
+naturopathic based fasting therapy on liver enzymes, electrolytes, fasting
+blood glucose, weight and perceived stress among healthy individuals e a
+randomized controlled trial. Int J Yoga Allied Sci 2014;3:103e11.
+[10] Ramnath S, Venkataramegowda S. Physicochemical and pollen analysis of
+western ghats honey of Karnataka, South India. Int J Sci Nat 2012;3:831e5.
+[11] Al-Arouj M, Bouguerra R, Buse J, Hafez S, Hassanein M, Ibrahim MA, et al.
+Recommendations for management of diabetes during Ramadan. Diabetes
+Care 2005;28:2305e11.
+[12] Johnston CS, Dancho CL, Strong GM. Orange juice ingestion and supplemental
+vitamin C are equally effective at reducing plasma lipid peroxidation in
+healthy adult women. J Am Coll Nutr 2003;22:519e23.
+[13] Naidu KA. Vitamin C in human health and disease is still a mystery? an
+overview. Nutr J 2003;2:7.
+[14] Rimm EB, Stampfer MJ, Ascherio A, Giovannucci E, Colditz GA, Willett WC.
+Vitamin E consumption and the risk of coronary heart disease in men. N Engl J
+Med 1993;328:1450e6.
+[15] Knekt P, Reunanen A, J€
+arvinen R, Sepp€
+anen R, Heli€
+ovaara M, Aromaa A.
+Antioxidant vitamin intake and coronary mortality in a longitudinal popula-
+tion study. Am J Epidemiol 1994;139:1180e9.
+Table 2
+Baseline and post assessment of study group male (n ¼ 14) and female (n ¼ 30)
+(Students paired-t-test).
+Variables
+Gender
+Baseline
+Post
+treatment
+t
+P
+Weight (kg)
+Male
+62.48 ± 18.23
+60.10 ± 17.54
+9.804
+<0.001
+Female
+50.47 ± 7.17
+48.39 ± 7.35
+9.852
+<0.001
+BMI (kg/m2)
+Male
+21.09 ± 5.22
+20.30 ± 5.02
+10.290
+<0.001
+Female
+20.17 ± 2.53
+1.934 ± 2.65
+8.599
+<0.001
+Fat (%)
+Male
+12.80 ± 8.73
+11.58 ± 10.36
+1.211
+0.247
+Female
+19.35 ± 7.35
+19.09 ± 7.26
+1.036
+0.309
+FM (kg)
+Male
+9.35 ± 11.03
+8.54 ± 12.11
+1.413
+0.181
+Female
+10.20 ± 5.28
+9.71 ± 5.01
+3.932
+<0.001
+FFM (kg)
+Male
+53.13 ± 7.83
+51.56 ± 6.15
+2.355
+<0.05
+Female
+40.27 ± 2.37
+38.68 ± 2.73
+7.688
+<0.001
+MM (kg)
+Male
+50.45 ± 7.46
+48.94 ± 5.86
+2.388
+<0.05
+Female
+38.20 ± 2.25
+36.71 ± 2.60
+7.506
+<0.001
+TBW (kg)
+Male
+38.14 ± 6.08
+37.32 ± 5.30
+1.620
+0.129
+Female
+27.91 ± 1.93
+26.72 ± 2.17
+8.412
+<0.001
+TSTG (mg/dL)
+Male
+100.57 ± 32.38
+83.71 ± 19.28
+1.842
+0.088
+Female
+93.13 ± 30.08
+75.60 ± 20.76
+3.465
+<0.01
+TSCH (mg/dL)
+Male
+153.14 ± 24.26
+147.57 ± 27.66
+0.804
+0.436
+Female
+145.27 ± 25.22
+140.97 ± 21.70
+1.551
+0.132
+All values are as mean ± SD. BMI: Body mass index, FM: Fat mass, FFM: Free fat mass,
+MM: Muscle mass, TBW: Total body water, TSTG: Total serum triglycerides, TSCH:
+Total serum cholesterol, SD: Standard deviation.
+P. Shetty et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 11e13
+13

subfolder_0/EMOTIONAL IMPACT FOLLOWING THE TSUNAMI IN ENDOGENOUS PEOPLE AND MAILAND SETTLERS IN THE ANDAMAN ISLANDS.txt

@@ -0,0 +1,123 @@
+70 
+LETTER TO THE EDITOR 
+A, Lalitha MK, et al. Surgical presentation of 
+melioidosis in India. Natl Med J India 1999;12:59­
+61. 
+5. Jesudason MV, Anbarasu A, John TJ. Septicaemic 
+melioidosis in a tertiary care hospital in south India. 
+Indian J Med Res 2003;117:119-21. 
+Udayakumar Navaneethan, 
+A.C. Ramesh Kumar, G. Ravi 
+Postgraduate in Internal medicine, 
+Madras Medical College and 
+Govt Gen Hospital, 
+Chennai-3, India. 
+Correspondence 
+Dr. Navaneethan Udayakumar 
+ Postgraduate in Internal medicine, 
+ Madras Medical College and 
+ Govt Gen Hospital, 
+Chennai-3, India. 
+E-mail: [email protected] 
+EMOTIONAL IMPACT 
+FOLLOWING THE TSUNAMI IN 
+ENDOGENOUS PEOPLE AND 
+MAINLAND SETTLERS IN THE 
+ANDAMAN ISLANDS 
+Sir, 
+A survey conducted a month after the 
+tsunami in December 2004 in the Andaman 
+islands compared the emotional impact and 
+coping in endogenous people (EP) and 
+second-generation mainland immigrants (ML; 
+from Tamil Nadu, Andhra Pradesh and West 
+Bengal), as the groups differed in (i) social 
+organization 
+(EP 
+constituting 
+close 
+communities under a ‘captain’, ML having the 
+family as the main (unit), and (ii) religion (EP 
+mainly Christians, ML mainly Hindus). The 
+groups were comparable with respect to 
+education, socio-economic status, age-range 
+(25 to 55 years), tsunami-related loss and 
+trauma (though this was not directly 
+measured). The immigrants constitute 
+approximately 70% of the population and are 
+well integrated. Out of 1800 persons 
+approached, 500 completed a survey of 
+symptoms and 68 completed an additional 
+survey of coping strategies. Of the 500, 54% 
+were endogenous people. Respondents rated 
+the intensity of four symptoms that are 
+commonly reported by disaster survivors,[1] 
+viz, fear, anxiety, disturbed sleep, and 
+sadness using a 10 cm analog scale. 
+The ML group had higher levels for all four 
+indicators (p<.001). The mean values and 
+standard deviations for ML versus EP group, 
+respectively were: (i) for fear: 5.7 ± 3.0 cm 
+versus 4.4 ± 2.9 cm; (ii) for anxiety: 6.2 ± 
+2.9 cm versus 4.4 ± 2.8 cm; (iii) for disturbed 
+sleep: 5.0 ± 3.6 cm versus 3.9 ± 3.0 cm; and 
+(iv) for sadness: 7.2 ± 2.5 cm versus 5.5 ± 
+2.8 cm. 
+Following a major disaster the coping 
+strategies used have an important effect on 
+physical and mental health.[2] An exploratory 
+analysis of coping strategies based on the 
+sub-sample of 68 showed comparable 
+numbers selected specific strategies as first 
+choice, viz. interpersonal contact or using 
+religious practices. The groups differed in 
+their second choice, the largest number of 
+the EP group selecting interpersonal contact 
+while the ML group selected denial 
+strategies, especially alcohol (p<.001,χ2). 
+These differences may have contributed to 
+the higher levels of distress in the ML 
+Indian J Med Sci, Vol. 60, No. 2, February 2006 
+71 
+INDIAN JOURNAL OF MEDICAL SCIENCES 
+compared to the EP group, as the ‘stress 
+buffering’ effect of religious beliefs and social 
+support are recognized.[3] However other 
+factors may also have contributed, such as 
+previous traumatization, education, support 
+received, ways of expressing distress or 
+scoring the analog scales and individual 
+vulnerability. 
+This study showed that in the Andaman 
+Islands affected by the tsunami, people of 
+different origins had different coping 
+strategies and levels of distress, which may 
+be relevant for their rehabilitation. The ML 
+group may be in particular need of 
+intervention to reduce their distress and 
+improve their coping. 
+ACKNOWLEDGMENT 
+The study formed part of a project funded by the 
+Government of the Andaman and Nicobar Islands and 
+the state Government of Karnataka which is gratefully 
+acknowledged. 
+REFERENCES 
+1. 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. 
+2. Scott MJ, Stradling SG. Counselling for post­
+traumatic stress disorder. Sage Publications: 
+London; 2001. 
+3. Lawler KA, Younger JW, Piferi RL, Jobe RL, 
+Edmondson KA, Jones WH. The unique effects of 
+forgiveness on health: an exploration of pathways. 
+J Behav Med 2005;28:157-67. 
+ShirleyTelles, Manoj Dash, Naveen K. V. 
+Swami Vivekananda Yoga Research Foundation, 
+Bangalore, India 
+Correspondence 
+Shirley Telles, 
+SVYASA, # 19, Eknath Bhavan, 
+K.G. Nagar, Bangalore 19, India 
+E-mail: [email protected] 
+Indian J Med Sci, Vol. 60, No. 2, February 2006 

subfolder_0/Effect Of One Month Residential Yoga Program On Measuring The Positive And Negative Attitude ..txt

@@ -0,0 +1,641 @@
+Voice of Research, Vol. 3 Issue 4, March 2015, ISSN 2277-7733 |  11
+ “Psychology Today” magazine, reports that the average person
+generates 25,000 to 50,000 thoughts per day. Beginning in
+1952 with Norman Vincent Peale’s book, “The Power of
+Positive Thinking,” a large school of thought has developed
+around the idea that happiness and unhappiness are largely by
+products of thoughts and that “negative thinking” results in a
+variety of psychological and physiological disorders. The remedy,
+according to these thinkers, is to exercise control over your
+thoughts to achieve health, serenity, an enhanced sense of well-
+being and increased personal effectiveness at work and at home.
+Attitudes are organized collections of thoughts about a
+particular issue. To think positively, you need to eliminate
+certain negative thinking patterns that nearly everyone indulges
+in at least some of the time. These include the four major
+types of negative thinking filtering, personalizing, cadastres
+prizing and polarizing. Filtering refers to psychologically
+screening out the encouraging aspects of complex scenarios.
+Personalizing means automatically blaming yourself every time
+something bad happens. Cadastre phasing’s expecting the
+worst possible outcome in any situation, and polarizing is a
+type of black-and-white thinking that defines failure as any
+result short of perfection
+Emotion is a common component in persuasion, social
+influence, and attitude change. Much of attitude research
+emphasized the importance of affective or emotion
+components. Emotion works hand-in-hand with the cognitive
+process, or the way we think, about an issue or situation.
+Emotional appeals are commonly found in advertising, health
+campaigns and political messages. Recent examples include
+no-smoking health campaigns and political campaign
+advertising emphasizing the fear of terrorism. Attitudes and
+attitude objects are functions of cognitive, affective and
+cognitive components. Attitudes are part of the brain’s
+associative networks, the spider-like structures residing in long
+term memory that consist of affective and cognitive nodes.
+By activating an affective or emotion node, attitude change
+may be possible, though affective and cognitive components
+tend to be intertwined. In primarily affective networks, it is
+more difficult to produce cognitive counterarguments in the
+resistance to persuasion and attitude change.
+In terms of research methodology, the challenge for researchers
+is measuring emotion and subsequent impacts on attitude.
+Since we cannot see into the brain, various models and
+measurement tools have been constructed to obtain emotion
+and attitude information. Measures may include the use of
+physiological cues like facial expressions, vocal changes, and
+other body rate measures. For instance, fear is associated with
+raised eyebrows, increased heart rate and increase body tension
+Other methods include concept or network mapping, and
+using primes or word cues in the era .
+The effects of attitudes on behaviors is a growing research
+enterprise within psychology. Icek Ajzen helped develop two
+prominent theoretical approaches within this field: the theory
+of reasoned action and, its theoretical descendant, the theory of
+planned behavior. Both theories help explain the link between
+attitude and behavior as a controlled and deliberative process.
+Russell H. Fazio proposed an alternative theory called
+“Motivation and Opportunity as Determinants” or MODE.
+Fazio argues that motivation can modify our deliberative
+attitude-related behavior, only if the opportunity presents itself.
+Yoga suggests attitudes to cultivate for removing the mental and
+emotional blocks that veil the joy of the true Self. Each of these
+can be the subject of meditation and contemplation as well as
+being practiced in daily life. Attitudes meditations are foundations
+for the subtler meditations. Correlations were obtained between
+scores on the. Yoga Attitude Scale and improvement in a group
+of 20 psychoneurotic patients undertaking yoga therapy of 4-6
+weeks duration. A significant positive correlation was found
+between the improvement in social and vocational disability and
+scores on the Yoga Attitude Scale at intake. However, during
+treatment and follow-up, there was a significant change in the
+attitude towards yoga - it became more positive.
+Correlations were also performed between improvement and
+change in attitude over the 5-month study period. Significant
+positive correlation was seen only on personal distress.
+EFFECT OF ONE MONTH RESIDENTIAL YOGA PROGRAM ON
+MEASURING THE POSITIVE AND NEGATIVE ATTITUDE
+Ashwini H. R.
+Research Scholar, SVYAS University, Bangalore.
+Sony Kumari
+Assistant Professor, SVYAS University, Bangalore.
+Abstract
+The Effectiveness of  One Month Residential Yoga Program on Measuring the Positive and Negative Attitude among 50 participants was
+examined. The participants were divided into two groups -Yoga and Control group. Yoga Group comprising of  both Male and Female attended one
+month Residential yoga program where they followed a strict schedule of  10 hours per day. Result indicated that Yoga Program contributed
+significantly in improving positive attitude and reducing in negative attitude in healthy volunteers.  Positive thinking can lead to positive attitudes
+and peace of mind. Much of your behavior depends on your attitudes. If your attitudes are negative, you can expect to be vulnerable to addictions
+and psychosomatic disorders, and the resulting lack of  focus and concentration may degrade every area of  your life. A positive attitude can be
+developed by monitoring and disciplining your thoughts on a moment-by-moment basis.
+Keywords: yoga, attitude, psychology
+YOGA AND ATTITUDE
+Voice of  Research
+Volume 3, Issue 4
+March 2015
+ISSN 2277-7733
+12  |  Voice of Research, Vol. 3 Issue 4, March 2015, ISSN 2277-7733
+Improvement in the other symptoms of neurosis i.e. anxiety,
+depression, features, vegetative symptoms of neurosis i.e.
+anxiety, depression, features, vegetative symptoms and the
+other neurotic features i.e. hysteria, obsessions-compulsions
+and phobia did not show any relationship with the patient’s
+attitude towards yoga.
+Method
+The Subjects in study were taken from one month Residential
+yoga program and control Group. The subjects comprised of
+50 participants. 25(Yoga Group) participants both male and
+Female aged 20 to 45 years. Control group comprised of 25
+Participants Both Male and Female raged 22 to 45 Years.
+Measure
+Positive and Negative Affects Scale (PANAS) to assess these
+specific emotional states in one Month Residential Yoga Program
+Participants. It is taken in individuals before and after yoga.
+Watson, Clark, and Tellegen (1988) developed the Positive
+and Negative Affect Schedule (PANAS), which consists of
+two 10-item scales for PA and NA, Respectively in addition to
+the two original higher order scales the PANAS-X measures
+10 specific affects: Fear, Sadness, Guilt, Hostility, Shyness,
+Surprise, Joviality, Self-Assurance, Attentiveness, and Serenity.
+PANAS-X provides for mood measurement at two different
+levels. That is personality and emotionality PANAS-X scales
+shows significant discriminate validity when correlated with
+peer-judgments.
+Procedure
+Om Meditation: a type of meditation using the syllable om
+chanting mentally to achieve a state of alert full rest (Telles,
+Nagarathna and Nagendra,(1995). The person seated in any
+comfortable meditative posture goes on repeating the syllable
+Om mentally leading to effortless flow of a single thought in
+the mind.
+Yoga practice: yoga practices formulated based on the
+requirements of  the patients developed by SVAMI
+VIVEKANANDA 
+YOGA 
+ANUSANDHANA
+SAMSTHANA YIC (One month residential Yoga
+Instructed Course).
+Pranayama: Pranayama is a state of voluntarily regulated
+breathing while the mind is directed to the flow of breath
+to the flow of breath or prana.A typical cycle of the slow
+type breathing involves the phases of inhalation, exhalation;
+there are different kinds of pranayama varying according to
+the durations of the phases in the breathing cycles, and the
+nostrils used.
+Cyclic Meditation: This has included a combination of both
+stimulating and relaxing or calming practices (Nagendra and
+Nagarathna 1997) its basis from traditional text. Studies on
+this meditation have shown that this technique, which is a
+combination of yoga postures interspersed with relaxation,
+reduces arousal more than relaxation alone
+Trataka:One of theKriya (cleansing technique) mentioned in
+yogic texts to remove impurities of the ophthalmic tract and
+to attain mental stability (DHARANA).
+Results & Discussion
+Table 1
+Means And SDs of Scores on The Measure of Emotional
+Competence by Yoga And Control Groups Before and After
+Intervention. This explains the comparison between pre and
+post assessment on negative attitude of Experimental Group.
+Note: Wilcoxon Test showed that amongst 10 negative
+attitude ,Yoga group showed significant reduction in distressed
+(p>0.05).
+Table 2 - This explains the comparison between pre and post
+assessment on positive attitude of Experimental Group.
+Note: In within group comparison (Yoga group) Wilcoxon test
+did not show any significant improvement in positive attitude
+Table 3 - This explains the comparison between pre and post
+assessment on negative attitude of group.
+Variable 
+ 
+Mean=+SD 
+% change 
+of mean 
+P value 
+Afraid 
+Pre 
+Post 
+2.231=+1.1066 
+2.654=+1.3840 
+15.93 
+085 
+Scared 
+Pre 
+Post 
+2.269=+1.1509 
+2.731=+1.4576 
+16.91 
+171 
+Nervous 
+Pre 
+Post 
+2.385=+1.2673 
+2.538=+1.2722 
+6.02 
+596 
+jittery 
+Pre 
+Post 
+2.231=+1.2746 
+2.423=+1.2385 
+0 
+689 
+irritable 
+Pre 
+Post 
+2.192=+1.2335 
+2.846=+1.6172 
+22.97 
+130 
+hostel 
+Pre 
+Post 
+2.731=+1.4016 
+2.615=+1.2985 
+4.43 
+697 
+guilty 
+Pre 
+Post 
+2.154=+1.3173 
+2.269=+1.4016 
+5.06 
+718 
+ashamed 
+Pre 
+Post 
+2.038=+.8237 
+2.538=+1.5028 
+19.70 
+260 
+upset 
+Pre 
+Post 
+2.577=+1.2704 
+2.885=+1.657 
+10.67 
+307 
+distressed 
+Pre 
+Post 
+2.577=+1.2704 
+3.385=+1.3879 
+23.87 
+001* 
+Variable 
+ 
+Mean=+SD 
+% change 
+of mean 
+P 
+value 
+active 
+Pre 
+Post 
+3.038=+.9992 
+3.308=+1.1232 
+8.88 
+400 
+alert 
+Pre 
+Post 
+3.115=+.9089 
+2.923=+1.0554 
+6.16 
+380 
+attentive 
+Pre 
+Post 
+2.923=+.7442 
+3.000=+1.2000 
+2.63 
+783 
+determined 
+Pre 
+Post 
+3.192=+.7494 
+2.885=+1.1073 
+9.61 
+314 
+enthusiastic 
+Pre 
+Post 
+3.000=+.9798 
+3.192=+1.0961 
+6.4 
+445 
+excited 
+Pre 
+Post 
+3.000=+1.0583 
+2.885=+1.2434 
+3.83 
+.824 
+inspired 
+Pre 
+Post 
+3.000=+.9381 
+3.231=+1.1767 
+7.7 
+385 
+interested 
+Pre 
+Post 
+2.923=+1.0168 
+3.346=+1.2944 
+14.47 
+119 
+proud 
+Pre 
+Post 
+3.346=+1.0175 
+2.923=+1.0168 
+12.64 
+491 
+strong 
+Pre 
+Post 
+3.423=+.9454 
+3.154=+1.2229 
+7.85 
+309 
+Variable 
+ 
+Mean=+SD 
+% change 
+of mean 
+P 
+value 
+Afraid 
+Pre 
+Post 
+3.542=+1.3181 
+2.792=+1.2151 
+21.17 
+023* 
+Scared 
+Pre 
+Post 
+3.125=+1.4540 
+2.958=+1.5737 
+5.34 
+655 
+YOGA AND ATTITUDE
+Voice of Research, Vol. 3 Issue 4, March 2015, ISSN 2277-7733 |  13
+Note: Within group comparison was done by using Wilcoxon
+Test where the result showed significant improvement in the
+attitude afraid in Control Group.
+Table 4 -  This explains the comparison between pre and post
+assessment on positive attitude of group.
+Note: Within group comparison was done by using Wilcoxon
+Test where the result showed significant improvement in the
+attitude active in Control Group.
+Table 5 - This explains the comparison between the group
+(Yoga and Control).MannWhitney (Between group)
+Note: In between group comparison Yoga group showed
+significant improvement in the negative attitude such as afraid,
+nervous, irritable, ashamed and upset.
+In a previous, open-armed observational study on 312
+participants of a weeklong free yoga camp for promotion of
+positive health through integrated yoga practices showed
+significant reduction in negative affect and increase in positive
+affect scores on modified version of PANAS questionnaire.;
+The current study reveals that in a within group comparison
+Yoga Group showed a significant reduction in negative attitude,
+distressed (p> .001) whereas no changes was observed in positive
+attitude.; In control group negative attitude afraid was reduced
+significantly (p>.023) and positive attitude active, increased
+significantly with p > .05.; In between group comparison yoga
+group showed significant reduction in negative attitude such
+afraid (p>.05), nervous (p>.05), irritable (p>.05), ashamed (p>
+.05), and upset (p>.05).; In positive attitude result betweens
+group did not show any significantly improved in yoga group
+after one month of intervention.; Yoga intervention has shown
+significant change in reducing negative attitd ude an improvement
+in positive attitude in healthy volunteers.
+Reference
+Allport, G. W., Vernon, P. E., &Lindzey, G. (1960).
+Eagly, A. H., &Chaiken, S. (2007). The advantages of an inclusive
+definition of attitude. Social Cognition, 25(5), 582-602.
+Kirill Zdorov. (2000). Mastering the Perverse: State Building
+and Language” Purification” in Early Soviet Russia. Slavic
+Review, 133-153.
+Marano, H. E. (2004). A nation of  wimps. Psychology
+Today, 37(6), 58-70.
+Forsyth, D. M., Poppe, K., Nash, V., Alarcon, R. D., & Kung,
+S. (2010). Measuring changes in negative and positive
+thinking in patients with depression. Perspectives in
+psychiatric care, 46(4), 257-265.
+Dillard, J. P., & Peck, E. (2000). Affect and Persuasion
+Emotional 
+Responses 
+to 
+Public 
+Service
+Announcements. Communication Research, 27(4), 461-495.
+Ajzen, I., &Fishbein, M. (1977). Attitude-behavior relations:
+A theoretical analysis and review of empirical
+research. Psychological bulletin, 84(5), 888.
+Mathew Anad , DrJagatheesanAlagesan , Dr S Prathap Effect
+of  Yoga Therapy in rehabilitation of drug Addicts
+Volume ;2 issue;7 July 2013 ISSN No 2277-8160
+Gupta, N., Khera, S., Vempati, R. P., Sharma, R., &Bijlani, R.
+L. (2006). Effect of yoga based lifestyle intervention on
+state and trait anxiety. Indian journal of  physiology and
+pharmacology, 50(1), 41.
+Malathi, A., Damodaran, A. S. H. A., Shah, N. I. L. E. S. H., Patil,
+N. E. E. L. A., & Maratha, S. R. I. K. R. I. S. H. N. A. (2000).
+Effect of yogic practices on subjective well being. Indian journal
+of  physiology and pharmacology, 44(2), 202-206.
+Bagozzi, R. P. (1993). An examination of the psychometric
+properties of measures of negative affect in the PANAS-X scales.
+Narasimhan, L., Nagarathna, R., &Nagendra, H. R. (2011). Effect
+of integrated yogic practices on positive and negative emotions
+in healthy adults.International journal of yoga, 4(1), 13.
+Vadiraja, H. S., Rao, M. R., Nagarathna, R., Nagendra, H. R., Rekha,
+M., Vanitha, N.&Rao, N. (2009). 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, 17(5), 274-280.
+Nagarathna R, Nagendra HR. 3rd ed. Bangalore: Swami
+Vivekananda Yoga Prakashana; 2006. Integrated approach
+of yoga therapy for positive health.
+Nervous 
+Pre 
+Post 
+3.500=+1.4446 
+3.375=+1.6101 
+3.57 
+758 
+jittery 
+Pre 
+Post 
+2.708=+1.5737 
+2.708=+1.3667 
+0 
+951 
+irritable 
+Pre 
+Post 
+3.333=+1.3726 
+3.292=+1.4590 
+1.23 
+828 
+hostel 
+Pre 
+Post 
+3.000=+1.3831 
+2.875=+1.5126 
+4.16 
+704 
+guilty 
+Pre 
+Post 
+3.167=+1.4646 
+3.458=+1.4136 
+9.18 
+542 
+ashamed 
+Pre 
+Post 
+3.167=+1.4646 
+2.917=+1.6659 
+7.89 
+639 
+upset 
+Pre 
+Post 
+3.708=+1.2676 
+3.167=+1.2039 
+14.59 
+172 
+distressed 
+Pre 
+Post 
+2.583=+1.529 
+2.667=+1.6594 
+3.25 
+947 
+Variable 
+ 
+Mean=+SD 
+% change 
+of mean 
+P value 
+active 
+Pre 
+Post 
+2.917=+1.2129 
+2.958=+1.3345 
+1.38 
+.048* 
+ 
+alert 
+Pre 
+Post 
+2.958=+1.5458 
+3.708=+1.2676 
+20.22 
+088 
+attentive 
+Pre 
+Post 
+3.375=+1.2091 
+2.958=+1.3667 
+14.09 
+207 
+determined 
+Pre 
+Post 
+2.625=+1.2790 
+3.333=+1.4039 
+21.24 
+073 
+enthusiastic 
+Pre 
+Post 
+3.083=+1.2129 
+3.375=+1.3126 
+8.65 
+307 
+excited 
+Pre 
+Post 
+2.917=+1.1757 
+2.792=+1.2151 
+4.47 
+750 
+inspired 
+Pre 
+Post 
+2.958=+1.5737 
+3.458=+1.3181 
+14.45 
+263 
+interested 
+Pre 
+Post 
+3.250=+1.1516 
+3.208=+1.4136 
+1.30 
+ 
+935 
+proud 
+Pre 
+Post 
+3.042=+1.3667 
+2.917=+1.4116 
+4.28 
+809 
+strong 
+Pre 
+Post 
+3.250=+1.3593 
+3.375=+1.2091 
+3.70 
+649 
+Variable 
+P value 
+Variable 
+P value 
+Afraid pre 
+614 
+active pre 
+268 
+Afraid post 
+.006* 
+Active post 
+.580 
+Scared pre 
+713 
+alert pre 
+037 
+Scared post 
+.073 
+Alert post 
+.837 
+Nervous pre 
+103 
+attentive pr 
+796 
+Nervous post 
+.017* 
+Attentive post 
+.066 
+Jittery pre 
+527 
+Determined pre 
+270 
+jittery post 
+.638 
+Determined post 
+.064 
+irritable pre 
+263 
+Enthusiastic pre 
+618 
+Irritable post 
+.016* 
+Enthusiastic post 
+.684 
+Hostel pre 
+487 
+excited pre 
+723 
+Hostel post 
+.959 
+Excited post 
+.533 
+guilty pre 
+019 
+inspired pre 
+535 
+Guilty post 
+.053 
+Inspired post 
+.886 
+ashamed pre 
+480 
+interested pr 
+695 
+Ashamed post 
+.027* 
+Interested post 
+.318 
+upset pre 
+329 
+Proud pre 
+332 
+Upset post 
+.020* 
+Proud post 
+.561 
+Distressed pre 
+220 
+strong pre 
+693 
+Distressed post 
+.420 
+Strong post 
+.737 
+YOGA AND ATTITUDE

subfolder_0/Effect of Adjunct Tele-Yoga on Clinical Status at 14 Days in Hospitalized mild and Moderate COVID-19 Patients a Randomized Controlled Trial..txt

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+Page 1/19
+Effect of Adjunct Tele-Yoga on Clinical Status at 14
+Days in Hospitalized mild and Moderate COVID-19
+Patients: a Randomized Controlled Trial
+Vijaya Majumdar 
+(
+
+[email protected]
+)
+Swami Vivekananda Yoga Anusandhana Samsthana
+Manjunath N K 
+Swami Vivekananda Yoga Anusandhana Samsthana
+Nagarathna R 
+Swami Vivekananda Yoga Anusandhana Samsthana
+Suryanarayan Panigrahi 
+Swami Vivekananda Yoga Anusandhana Samsthana
+Muralidhar Kanchi 
+Narayana Health City
+Sarthak Sahoo 
+Narayana Health City
+Hongasandra R Nagendra 
+Swami Vivekananda Yoga Anusandhana Samsthana
+Adithi Giridharan 
+Swami Vivekananda Yoga Anusandhana Samsthana
+Mounika Reddy 
+Swami Vivekananda Yoga Anusandhana Samsthana
+Rakshitha Nayak 
+Swami Vivekananda Yoga Anusandhana Samsthana
+Research Article
+Keywords:
+Posted Date: March 22nd, 2022
+DOI: https://doi.org/10.21203/rs.3.rs-1361039/v1
+License:
+
+
+This work is licensed under a Creative Commons Attribution 4.0 International
+License.
+ 
+Read Full License
+Page 2/19
+Abstract
+Background: We tested if tele-yoga intervention could aid in better clinical management for hospitalized
+patients with mild to moderate COVID-19 when complemented with the standard of care.
+Methods: This was a randomized controlled trial conducted at the Narayana Hrudalaya, Bengaluru, India
+on hospitalized patients with mild to moderate COVID-19 infection, enrolled between May 31st and July
+22, 2021. Patients (n=225) were randomized in 1:1 ratio [adjunct tele-yoga (n = 113), or standard of care
+(n = 112)]. Adjunct yoga group received intervention in tele-mode within 4 hours post-randomization until
+14 days along with the standard of care. The primary outcome was clinical status at 14th-day post-
+randomization assessed with a 7-category ordinal scale. The trial included 11 secondary outcomes,
+including 28-day mortality.
+Results: As compared with standard of care alone, the proportional odds of having a higher score on the
+seven-point ordinal scale at day 14 was ~1.9 for the adjunct tele-yoga group (95% CI, 1.18-3.18). CRP and
+LDH levels were comparatively reduced in the adjunct tele-yoga group 5th day post-randomization. CRP
+reduction was also observed as a potential mediator for the improvement of clinical outcomes in the
+adjunct tele-yoga group. There were no significant differences between the treatment groups concerning
+the duration of hospitalization, all-cause mortality at day 28; log-rank P = 0.144, and other outcomes.
+Conclusion: The observed clinically relevant outcomes in COVID-19 patients at day 14 contest the use of
+tele-yoga as a complementary treatment in hospital settings.
+Introduction
+The rapid global spread of the Corona virus-related pneumonia outbreak, which was described first in
+December 2019, has led to the evolution of one of the most extensive pandemics in human history so
+far.1–3 Though, the mainstay of treatment for patients with COVID-19 pneumonia remains symptomatic
+and supportive care,4–6 the devaststating impact of the pandemic led to a parallel unprecedented quest
+of identifying new and/or repurposed pharmacological treatments.5–10 Unfortunately, the initial
+indications from these studies were disappointing which further aggravated the search of strategies
+based on complementary and alternative medicine.5–11 Amidst this uncertainty, several key clinicians and
+scientitists identified and proposed the adjunct potential of yoga for enhancing the effectiveness of
+standard of care with respect to Covid management in acute settings.12 Authors emphasized the
+relevance of certain practices of yoga and meditation in helping reduce the severity of COVID-19 disease,
+including its collateral effects and sequelae,12 further underlined with the immunomodulatory, anti-
+inflammatory and stress modulatory potential of yoga.13–15 Hence, we conducted this clinical trial to
+address the necessity of testing the effectiveness of adjuvant tele-yoga to the standard of care in
+improving the clinical outcomes for adults hospitalized with COVID-19. This trial was supported under a
+special call announced by the Department of Science and Technology, Government of India under the
+scheme, Science and Technology of Yoga and Meditation (SATYAM).16
+Page 3/19
+Design And Amendments
+The protocol was approved by the institutional ethics committee from each site and conducted in
+compliance with the Declaration of Helsinki. The study protocol was approved for funding by Deparment
+of Science and Technology, Government of India (Appendices no. I and IV). Additionally the study was
+also approved in a high level committee meeting conducted by Governemnt of Karnatake, India to ensure
+control and mangament of COVID-19 outbreak. All patients or legally authorized representatives provided
+the written informed consent. Given the uncertainty an in the recruitment and random allocation of the
+study subjects in chaotic hospital settings amidst the pandemic, the trial was initially planned as a non-
+randomized one. and their presumed lack of was initially planned as a non-randomized clinical trial
+wherein an integrative yoga based supportive care was planned to be administrated as an adjunct
+intervention for hospitalized COVID-19 patients. However, the protocol was amended on 14th May 2020,
+on the basis of emerging feasibility of conducting a randomized trial as emphasized by the clinicans and
+its supeioir design.The study was registered at clinical trial registry of India (CTRI/2020/09/027915).
+Participants:
+Given a significant proportion of requirement of timely hospitalization and mangament of Covid 19
+patients, we recruited hospitalized COVID-19 patients in this trial. Those with moderate disease along with
+the presence of comorbidities, or those with initially mild disease but experiencing worsening of
+symptoms or depletion of oxygen saturation were referred and managed at the Mazumdar Shaw Medical
+Center, Narayana Hrudalaya, Bengaluru, India. Laboratory confirmed SARS-CoV-2 cases defined as mild or
+moderate according to FDA guidance were included with following eight symptoms:17 fever, cough, sore
+throat, malaise, headache, muscle pain, gastrointestinal symptoms, and shortness of breath with exertion.
+Additionally we also included the moderate disease definition od respiratory rate ≥ 15 < 30 and/or partial
+90–94%.18 In line with prior reports, this trial enrolled patients with mild and moderate COVID-19 who
+were receiving no more than 4 liters per minute of supplemental oxygen.19 Notable exclusion criteria
+included a peripheral oxygen saturation of 93% or less while breathing ambient air, a ratio of the partial
+pressure of arterial oxygen to the fraction of inspired oxygen of less than 300, a respiratory rate of at least
+30 breaths per minute, and a heart rate of 125 or more beats per minute. Full eligibility criteria are listed in
+eTable 2 in Supplement 3.
+Outcomes:
+We used the 7-category ordinal scale used that has been used in different COVID-19 therapeutic trials.7,20
+The primary outcome was clinical status at day 14th post- randomization, assessed with a 7-category
+ordinal scale (the COVID Outcomes Scale) recommended by the World Health Organization.20 The scale
+consisted of 7 mutually exclusive categories: 1, death; 2, hospitalized, receiving extracorporeal membrane
+oxygenation (ECMO) or invasive mechanical ventilation; 3, hospitalized, receiving noninvasive
+mechanical ventilation or nasal high-flow oxygen therapy; 4, hospitalized, receiving supplemental oxygen
+without positive pressure or high flow; 5, hospitalized, not receiving supplemental oxygen; 6, not
+Page 4/19
+hospitalized and unable to perform normal activities; and 7, not hospitalized and able to perform normal
+activities. To distinguish between categories 6 and 7, study personnel assessed the patient’s performance
+of usual activities with questions consistent with validated health status measures.21
+Patients who were discharged from the hospital were contacted by tele-phone for assessment of the
+COVID Outcome Scale at 7, 14, and 28 days after randomization. Complete information on the inclusion
+and exclusion criteria is provided in the Supplementary Appendix. All the patients provided written or
+electronic informed consent before randomization.The secondary outcome set included: scores on the
+COVID Outcomes Scale at days 7, and 28 post-randomization; all-cause all-location mortality at 28 days
+post-randomization, duration of days at hospital, 5th day changes postrandomization for viral load
+expressed as cyclic threshold (Ct), and inflammatory markers and perceived stress scores at day 14
+postrandomization. Other auxillary markers were HbA1c, blood hemogram, kidney function markers, etc.
+All protocol amendments were authorized and approved by the institutional review board or independent
+ethics committee.
+Clinical and Laboratory Monitoring:
+Assessments:
+Data were collected daily, from randomization until day 14, in the patient proformas. For patients who
+were discharged before day 14, a structured tele-phone call to the patient or the patient’s family was
+conducted on or after day 14 by an interviewer who was unaware of the assigned trial group in order to
+assess vital status and return to routine activities.. All samples were processed by PCR for genes N and E
+of SARS-CoV-2. Demographic, clinical, laboratory, and radiology data from patients’ medical records were
+collected by the research team. The data were evaluated by a trained team of physicians. The date of
+disease onset was defined as the day when the symptom was noticed. Data on symptoms, vital signs,
+laboratory values on biomarkers of disease progression, biomarkers [C-reactive protein (CRP), D-Dimer,
+Interleukin 6 (IL-6), ferritin, and Lactate dehydrogenase (LDH)], and treatment measures during the
+hospital stay were collected. Patient assessments included physical examination, respiratory status
+(respiratory rate, type of oxygen supplementation, blood oxygen saturation, and radiographic findings),
+adverse events, and concomitant medications. On study days 1, and 5, blood samples were obtained for
+measurement of blood cell counts, serum creatinine, glucose, total bilirubin, and liver transaminases, and
+inflammatory biomarkers. Perceived stress was assessed using Perceived Stress Scale 10 (PSS-10).22
+Site investigators assessed clinical status daily from day 1 through day 14 or hospital discharge on a 7-
+point ordinal scale. In case of over a day change in the scores observed for the clinical status worse
+scores of the hospitalized patients were documented. A final assessments on clinical status were done on
+the day 28 personally for hospitalized patients or through tele-phonic interview for already discharged
+patients.
+Intervention:
+Page 5/19
+We built a yoga protocol adjusted to isolated patients and staff, including deliervry through tele- (videos)
+as well as in person intervention. Clinical guidelines were followed up for treating patients via tele-yoga
+and hands on techniques in cooperation with the medical heads of departments. Instructional short
+videos were prepared in different languages constituting the intervention. At day 1 hands on intervention
+was carried out in the COVID wards through teams of certified yoga therapists in personal protective
+suites, within 4 hours of randomization. Those who were discharged before 14 days post-randomization,
+tele-yoga sessions were continued from their home settings. The practices of yoga were included based
+on the reported effects on strengthening of the respiratory muscles, and respiratory function
+[development of awareness of expansion and contraction of the airways, continuous and rhythmic
+breathing, reported to aid in thorough oxygenation of the lungs etc] and also known to reduce
+inflammation. (For details on the intervention see the appendices I and V). These exercises were followed
+by quick relaxation and subsequent 10 minutes of pranayama (breathing exercises), consisting of right
+nostril breathing/and alternate nostril breathing and Brahmari. The practice sessions ended with guided
+relaxation with a resolve. Patients received daily tele–yoga intervention with relaxation/meditative
+practices for twice for day.
+Standard of Care:
+Standard of care was based on the recommendations of the Indian Council of Medical Research, which
+was updated as per the evolving evidence generated in drug trials and international consensus
+guidelines.23,24 Overall, it included antibiotic agents, antiviral agents, corticosteroids, vasopressor support,
+and anticoagulants at the discretion of the clinicians.
+Randomization
+Randomization was done in permuted blocks of 4 in sequences created by the unblinded research staff in
+Microsoft Excel version 19.0 who provided masked allotment to the yoga traners. Owing to the nature of
+the intervention, blinding was not possible, but outcome measures were blinded for the randomisation
+groups. Eligible patients were randomly assigned in a 1:1 ratio to receive either standard of care or
+adjunct yoga. Allocation assignment was concealed from investigators and patients.
+Statistical analysis:
+Analysis was performed with SPSS version 23 [IBM Corp., (N.Y., USA]. The total intent-to-treat (ITT)
+sample size of 230 patients with a 1:1 randomization of adjunct tele–yoga to standard of care provides
+approximately 80% power to detect a 15% difference between treatment groups in time cumulative
+hospital discharge (i.e.,with or without limiting abilities) rates of 80% in the adjunct tele–yoga group and
+75% in standard of care group, at 14th day postrandomization, using a two-sided 5% alpha. The trial was
+analyzed by comparing patients randomized to adjunct tele- yoga vs those randomized to standard of
+care, with the placebo group serving as the referent. The primary outcome was analyzed with a
+multivariable proportional odds model with age, and sex. Further adjustments with baseline
+(prerandomization) COVID Outcomes Scale category, and duration of acute respiratory symptoms are
+reported as posthoc analysis. Results are presented with corresponding 95% confidence intervals For
+Page 6/19
+patients who were discharged prior to 14 days after randomization, primary outcome ascertainment was
+completed by tele-phone calls. Patients who could not be reached by tele-phone for the primary outcome
+assessment at day 14 had the COVID Outcomes Scale score carried forward from a day 7 follow-up call if
+such a call was successfully completed or had a category 6 score (not hospitalized and unable to
+perform normal activities) imputed if no prior follow-up calls were successfully completed. For patients
+who remained hospitalized 14 days after randomization, primary outcome ascertainment was completed
+by medical record review.
+Given the deviation from normality for the study variables, analysis of covariance was done using the
+rank transformation to study the influence of adjunct tele-yoga intervention on biomarker levels at day
+from postrandomization.
+Heterogeneity of treatment effect by prespecified baseline characteristics was evaluated by adding an
+interaction term between randomized group assignment and the baseline characteristic of interest in the
+primary model. Baseline characteristics evaluated in heterogeneity of treatment effect analyses included
+baseline COVID Outcomes Scale category, and duration of symptoms prior to randomization, age, sex,
+and race/ethnicity.
+All-cause mortality was estimated using the Kaplan-Meier product limit method. Adjunct tele–yoga group
+was compared with the standard of care group using the log-rank test, and the mean estimates and 95%
+CIs were provided.
+We also used the paramed- command in SPSS to perform mediation analysis by fitting a linear regression
+model to the outcomes with yoga yreatment and the mediators included were the covariates and then
+fitting a regression model to the mediator (linear or logistic depending on the mediator) including
+treatment as a covariate.
+Post Hoc Analyses
+We also conducted sensitivity analyses of the primary end point (1) adjusting for day 1 clinical score; and
+(2) adjusting for duration of symptoms. Additionaly we also performed a post-hoc analysis that was
+stratified by CRP and LDH levels. We also calculated and comapared the proportions of patients with a 1-
+point or greater improvement, no change or worsening of clinical status at days 7, 14, and 28.
+Page 7/19
+Table 1
+Baseline Patient Characteristics
+Variable
+Overall
+(n = 
+225)
+Tele–
+yoga
+(n = 113)
+Control
+(n = 112)
+P value
+Age, median IQR
+43 (35–
+53)
+42 (35-
+53.5)
+43 (36–52)
+0.657
+Gender
+ 
+ 
+ 
+;
+Female
+102
+(45.33)
+51
+(45.13)
+51 (45.54)
+1.00
+Male
+123
+(54.67)
+62
+(54.87)
+61 (54.46)
+ 
+Coexisting conditions
+ 
+ 
+ 
+ 
+Hypertension, n (%)
+47
+(20.89)
+21
+(18.58)
+26 (23.21)
+0.416
+Diabetes, n (%)
+85
+(37.78)
+42
+(37.17)
+43 (38.39)
+0.891
+Coronary artery disease, n (%)
+15
+(6.67)
+5 (4.43)
+10 (8.93)
+0193
+Hypothyroidism, n (%)
+25
+(11.11)
+14
+(12.39)
+11 (9.82)
+0.672
+COPD, n (%)
+3 (1.33)
+3 (2.65)
+0 (0)
+0.222
+Asthma, n (%)
+2 (0.89)
+0 (1.73)
+2 (1.80)
+0.244
+Symptoms
+ 
+ 
+ 
+ 
+Fever/chills, n (%)
+158
+(70.22)
+73
+(64.61)
+85 (75.89)
+0.080
+Cough, n (%)
+163
+(72.44)
+82
+(72.57)
+81 (72.32)
+1.000
+Sore throat, n (%)
+28
+(12.44)
+16
+(10.71)
+12 (14.16)
+0.545
+Nausea/Vomiting, n (%)s
+13
+(5.78)
+7 (6.19)
+6 (5.36)
+1.000
+General weakness, n (%)
+92
+(40.89)
+48
+(42.48)
+44 (39.28)
+0.685
+Breathlessness, n (%)
+105
+(50.72)
+44
+(41.90)
+61 (59.80)
+0.006**
+Page 8/19
+Variable
+Overall
+(n = 
+225)
+Tele–
+yoga
+(n = 113)
+Control
+(n = 112)
+P value
+Headache, n (%)
+57
+(25.33)
+34
+(30.09)
+23 (20.54)
+0.125
+Diarrhea, n (%)
+11
+(5.31)
+4 (3.81)
+7 (6.86)
+NS
+Previous medication use — no. (%)
+ 
+ 
+ 
+ 
+Glucocorticoid
+7 (3.03)
+5 (4.35)
+2 (1.67)
+NS
+ACE inhibitor
+12
+(5.19)
+7 (6.19)
+5 (4.46)
+NS
+Angiotensin II–receptor antagonist
+8 (3.46)
+3 (2.61)
+5 (4.35)
+NS
+Baseline ordinal Covid outcome score — no. (%)
+ 
+ 
+ 
+ 
+3.Hospitalized, receiving non-invasive mechanical
+92
+(40.89)
+54
+(47.79)
+38 (33.93)
+0.60
+4.Hospitalized, receiving supplemental oxygen
+without positive pressure or high flow; requiring
+low-flow supplemental oxygen;
+125
+(55.56)
+57
+(50.44)
+68 (60.71)
+ 
+5. Hospitalized, not receiving
+supplemental oxygen
+8 (3.56)
+2 (1.77)
+6 (5.36)
+ 
+Ct value
+28.00
+(22.5–
+32.00)
+27.00
+(22.50–
+30.00)
+28.0
+(22.50–
+33.00)
+0.125
+Inflammatory markers
+ 
+ 
+ 
+ 
+C-reactive protein, mg/l
+24.82
+(8.09–
+63.67)
+28.16
+(8.43–
+65.46)
+26.71
+(8.47–
+67.40)
+0.854
+Ferritin, mg/dl
+196
+(81.85–
+421)
+179
+(82.30-
+404.50)
+203(77.40–
+441)
+0.616
+D-dimer, ng/ml
+167
+(94.00-
+242.00)
+170 (94–
+245)
+179 (95–
+250)
+0.953
+LDH, U/L
+302
+(241–
+392)
+296
+(226.50–
+355)
+319 (248-
+436.94
+0.057
+IL-6, mg/dL
+37.65
+(11.27–
+80.02)
+31.89
+(11.93–
+79.99)
+39.76
+(10.21–
+76.15)
+0.808
+Page 9/19
+Variable
+Overall
+(n = 
+225)
+Tele–
+yoga
+(n = 113)
+Control
+(n = 112)
+P value
+Haemogram
+ 
+ 
+ 
+ 
+Hb (g/dL)
+13.50
+(12.20–
+14.60)
+13.6
+(12.10–
+14.70)
+13.2
+(12.20-
+14.45)
+0.406
+ALC (×109/L)
+/L)a
+1.27
+(0.87–
+1.92)
+1.21
+(0.84–
+1.86)
+1.34
+(0.88–
+1.95)
+0.472
+AMC (×109 /L)
+0.46
+(0.29–
+0.74)
+0.45
+(0.28–
+0.72)
+0.50
+(0.32–
+0.77)
+0.343
+ANC (×109 /L)
+4.23
+(2.85–
+6.71)
+4.17
+(2.91–
+6.64)
+4.39
+(2.73–
+6.83)
+0.606
+PSS
+19 (15–
+24)
+20 (16–
+25)
+19 (13.25-
+23)
+0.023*
+For continuous variables, median and IQR (Interquartile range) have been presented due to the non-
+normality of the data. Correspondingly, Mann-Whitney tests were used to assess if differences between
+the study groups were statistically significant. For categorical variables, Chi-square/Fisherʼs exact tests
+were used to check if there were any association between the groups. Ct, cyclic threshold value; ALC,
+absolute lymphocyte count; AMC, absolute monocyte count; ANC, absolute neutrophil count; PSS,
+Perceived stress scale.
+Results
+During the 60-days of enrollment period, 326 patients were screened; 66 (20.24%) patients were excluded
+for being hospitalized for more than 48 hours at the time of screening, 24 (7.36%) had tested negative for
+RT-PCR at day 0 (baseline) for coronavirus disease 2019. Further, 11 eligible patients refused to
+participate (2.76%) (see Fig. 1, Trial Profile.). Hence, out of 236 eligible patients, 225 could be randomized,
+113 were randomized to the adjunct tele–yoga and 112 were randomized to the standard of care group.
+The last outcome assessment was on July 31st 2021. Overall the median age of the participants was 43
+years (IQR, 35–53 years), 54.67% were male, 32.43% had diabetes, 20.89% had hypertension, and 6.67%
+had coronary artery disease. Demographics and baseline disease characteristics of participants in both
+groups are presented in Table 2; there was an equal distribution of age, gender, days before onset of
+symptomsa, comorbidities, and inflammatory markers between the study arms (Tables 2 and S2). Overall,
+70.22% of the patients presented with perceived or objective fever, 72.44% presented with cough, 12.44%
+presented with sore throat, 25.33% presented with headache and 50.72% presented with breathlessness
+with no remarkable differences between groups. The median duration of symptoms prior to
+Page 10/19
+randomization was 3 days (IQR, 2–4 days) in both the groups. There were no differences in vital signs, or
+full blood count also between the groups (Table S2). Of 113 patients in the adjunct yoga group, 29 (76%)
+were discharged before 7 days post-randomization, hence, were continued with tele–yoga sessions till
+14th.
+Primary Outcome:
+The primary outcome (status on the seven-point ordinal scale at day 14) was assessed in all patients who
+were still hospitalized on day 14th or were tele-phonically interviewed if had been discharged earlier (see
+the Supplementary Appendix and Fig. S2). The distribution of patients’ scores on the seven-level ordinal
+scale at 14 days is shown in Fig. 2. Patients randomized to the adjunct tele–yoga group had significantly
+higher odds of a better clinical status distribution on the 7-point ordinal scale compared with those
+randomized to standard care (odds ratio, 1.94, 95% CI = 1.18–3.18) (Fig. 2). Sensitivity analyses of the
+primary end point adjusting for day 1 clinical status score, and symptom duration using the intention-to-
+treat population produced no significant difference (Table S3). The results for the primary outcome were
+not different across the prespecified subgroups (Table S4).
+Secondary Outcomes:
+There were significant differences between the adjunct tele–yoga and standard care groups in terms of
+improvement in clinical status at 7th day (partially adjusted for age odds ratio, 3.61; 95% CI, 2.11–6.05; P 
+< 0.001) but the outcome on 28th day was not significant (adjusted odds ratio,, 95% CI = 1.03–3.44)
+(Table S5). At day 5, there was significant reductions in CRP (p = 0.001) and LDH levels (P = 0.029) in the
+adjunct yoga group compared to the standard of care alone (Fig. 3 and Table S6). There were no
+significant differences between the treatment groups in duration of hospitalization (Fig. 3). The Kaplan-
+Meier estimates of all-cause mortality at day 28 were 1.80% vs 5.40% for standard of care; log rank P = 
+0.144; adjusted hazard ratio [HR], 0.26; 95% CI, 0.05–1.30). (Figure S3)
+Exploratory outcomes:
+Since we could establish significant reductions in CRP and LDH at day 5 from post-randomization in the
+adjunct yoga group compared to the standard of care group alone, we further tested for their mediating
+effects on the intervention (Table 2). The analyses indicated CRP as potential mechanistic mediator of
+adjunct yoga on the improved clinical status at 14th day post intervention. There was also differences
+between proportions of subjects with atleast 1 unit change in outcomes at day 7 from basleine between
+adjunct tele-yoga as compared to the standard of care groups. However, the distributions were not
+different for days 14 and 28 (Figure S4).
+Adverse Effects
+None of the 8 deaths through day 28 (5 [1%] in the standard of care, and 3 [2%] in the adjunct tele-yoga
+group occurred in the Covid 19 patients could be attributed to the tele-yoga intervention (Table S7). In the
+Page 11/19
+tele-yoga group, extension of hospitalization was 10.62%, whereasin the standard of care alone it was 21
+18.75%. Single cases each of sinus tachycardia, and pulmonary embolism was observed in the yoga
+group as compared to no cases in the standard of care.
+#Only hospitalized patients who were not receiving supplemental oxygen or who were receiving up to 4
+liters per minute of supplemental oxygen were eligible for the trial. Patients who had scores on other
+levels of the seven-level ordinal scale were not eligible. Adjusted for baseline age, sex, comorbidities
+(diabetes, hypertension, hypothyroid, ), he primary outcome (status on the seven-point ordinal scale at day
+14) was assessed in all patients who were still in the hospital on day 15 exactly and in outpatients (by
+means of tele-phone interview) as close to day 14 as possible.
+Primary outcome: Distribution n (%)
+Total
+Subjects
+(n = 225)
+Tele–
+yoga
+(n = 113)
+Standard of care (n = 
+112)
+7: Not hospitalized with no limitations on
+activities
+96 (42.67)
+52
+(46.02)
+44 (39.29)
+6: Not hospitalized but with limitations on
+activities
+87 (38.67)
+51
+(45.13)
+36 (32.14)
+5: Hospitalized, not receiving supplemental
+oxygen
+27 (12.00)
+7(6.19)
+20 (17.86)
+4: Hospitalized, receiving supplemental
+oxygen
+6 (2.67)
+1 (0.88)
+5 (4.46)
+3: Hospitalized, receiving noninvasive
+ventilation
+or high-flow nasal cannula
+2 (0.89)
+1 (0.88)
+1 (0.89)
+2: Hospitalized, receiving mechanical
+ventilation
+3 (1.33)
+1 (0.88)
+2 (1.79)
+1: Death
+4 (1.78)
+0 (0.00)
+4 (3.57)
+Proportional Odds Ratio (OR, 95%CI)
+1.94 (1.18–3.18) P = 0.01
+Model is adjusted for age and gender
+ 
+Table 2
+Indirect, direct and total effects of the mediation models on COVID-19 outcomes at 14 days post-
+randomization
+Page 12/19
+ 
+Effect size
+Proportion mediated
+Direct effect of the adjunct tele-yoga
+vs. standard of care
+Adjunct yoga
+0.41(0.03–0.78)
+-
+Total effect of the model
+0.54 (0.17–0.91)
+-
+Indirect (mediating) effects
+ 
+ 
+LDH
+-0.01 (-0.10-0.04)
+Not significant
+CRP
+0.06 (0.05–0.16)*
+11.11%
+Discussion
+This study is a pioneer clinical trial that investigated the short-term acute interventional benefits of
+adjunct tele–yoga practice for clinical management of hospitalized COVID-19 patients. We could
+establish a ~ 1.9-fold improvement in the clinical status at 14th day post-randomisation, in mild and
+moderate hospitalized COVID-19 patients (Odds Ratio = 1.94, 95% CI = 1.18–3.18) as compared to those
+with only standard of care. The odds of improvement with yoga intervention were higher at the 7th day
+(Odds ratio = 3.61, 95% CI = 2.13–6.10. However, the effectiveness of the intervention was not found to be
+sustained at 28th day post-randomization (Odds Ratio 1.70, 95% CI = 0.97–2.99), P = 0.07). Since,
+patients had several coexisting diseases and were subjected to a diverse medication regimen, the
+complementary effects of tele-yoga could have been influenced by the heterogeneity of the sample and
+its treatment. However, when analyzed in the post hoc subgroup analysis, adjunct yoga was found to be
+effective across all the strata of covariates. Concerning influence of the intervention on mortality related
+outcomes, no benefit could be observed for the adjunct yoga interevention with respect to mortality (adj
+HR 0.26; 95% CI, 0.05–1.30).
+We could establish support for the primary end points with the observed secondary improvement in
+crucial biomarkers in the tele-yoga group compared to the standard of care at 5th day post-randmization,
+CRP (P = 0.001) and LDH (P = 0.029). Both CRP and LDH have been reported as prognostic markers of
+deterioration in COVID 19 patiants including mild/non severe cases as well.25,26 We could also establish a
+mediation effect of CRP modulation underlying effectiveness of tele-yoga intervention (~ 11% proportion
+mediation on on the observed improved outcome of clinical status at day 14). This inflammation
+reducing effect of yoga well aligns with the physiological modulation of vagal tone, one of the widely
+reported effects of yoga and meditation.12,13 The anti-inflamamroty potentisl of yoga could serve as a
+step forward in the fight against other serious forms of infectious diseases with a dominant inflammatory
+component, as proposed for malaria, HIV/ AIDS, and SARS, among others. COVID-19.
+Page 13/19
+We could not observe a significant effect of adjunct tele-yoga on perceived stress scale in COVID 19
+patients (P = 0.69). We speculate that the failure to obtain the desired effect on stress and sevral other
+variables could be due to the primarily virtual mode of the delivery of the intervention and the short
+duration of intervenion. However, the beneficial clinical outcomes observed in the study hold special
+significance in the present era with reimerging and recurring viral infections.27,28 Overall the findings of
+this study support the exploratory notions of several researchers and clinicians that certain meditation,
+yoga asana (postures), and pranayama (breathing) practices may be effective adjunctive means of
+treating SARS-CoV-2 infection.12 The findings also pave the foundation for the clinical implementation of
+tele–yoga-based adjunct interventions in hospital settings for the management of infectious diseases. A
+previous study on yoga had also reported it to be effective as an adjunct to anti-tuberculosis treatment
+(ATT) in patients with pulmonary tuberculosis by reducing the symptom scores, sputum conversion on
+microscopy, and improvement in the lung capacity and radiographic pictures.29
+This clinical exploration is one of the earliest to be reported amongst several other concomitant attempts
+to establish the efficacy of aditional systems of medicine, against the combat of COVID-19, well reflected
+by 67 such registered in the Clinical Trial Registry of India (CTRI).30 Hence, given the lack of available
+findings from clinical trials on COVID 19 and Yoga based interventions, the findings of this trial could not
+be presented with comparisons.
+The study has several strengths. One of the strengths of the study is the inclusion of WHO criteria for
+assessing the benefit on clinical status for patients hospitalized with mild and moderate coronavirus
+disease 2019 (COVID-19). This is the first report wherein yoga-based intervention was provided in a tele–
+mode to Covid 19 patients. This was done to prevent health care employees from being infected.
+Importantly, the trial included inflammatory markers as study outcomes, wherein an anti-inflammatoty
+mediating influence of yoga intervention could be established improving the outcomes of hospitalized
+mild to moderate COVID patients. A key feature of the trial was the early implementation of treatment
+within 7 days of symptom onset (median duration of 3 days) which has been considered important for
+the treatment protocol, in particular antivirals like remdesivir.
+The trial was limited to hospitalized Covid 19 patients which restricts the generalizability of the findings
+to other populations involving home-base care. The assessments were limited to 28 days post
+randomization, reporting long-term outcomes of trial participants should have been considered. Given the
+nature of intervention, the study used an open-label design, which could have led to biases in patient care
+and reporting of data. Though prespecified for days 14, and other than clinical status and subjective
+outcomes, other laboratory parameters could not be routinely collected due to logistic challenges.
+Overall we could observe clinically relevant effects among hospitalized patients with mild to moderate − 
+19, contesting the use of tele-yoga as a complmentary treatment for patients with this disease. However,
+the positive signal found in this small scale trial warrants the conduction of larger trials using tele-yoga
+for the treatment of COVID-19.
+Page 14/19
+Declarations
+Data availability:
+The datasets generated and/or analysed during the current study are not publicly available  due to
+privacy or ethical restrictions but are available from the corresponding author on reasonable request.
+Author Contributions:
+Vijaya Majumdar and Manjunath N K take responsibility for the integrity of the data and the accuracy of
+the data analysis. Concept and design: Nagarathna R, Mannjunath NK, Vijaya Majumdar. Acquisition,
+analysis, or interpretation of data: Suryanarayan Panigrahi, Sarthak Sahoo, Adithi Giridharan, Mounika
+Reddy, Rakshitha Nayak and Vijaya Majumdar, Drafting of the manuscript: Vijaya Majumdar and
+Manjunath NK, Critical revision of the manuscript for important intellectual content: Manjunath NK,
+Nagarathna R, Muralidhar Kanchi, Hongasandra R Nagendra. Statistical analysis: Vijaya Majumdar,
+Obtained funding: Vijaya Majumdar, Manjunath NK, and Nagarathna R, Administrative, technical, or
+material support.
+Funding/Support:
+This study was sponsored by Department of Science and Technology,under the scheme SATYAM of
+Government of India
+Conflict of Interest Disclosures: 
+Authors declare no conflict of interest
+Additional Contributions:
+We thank the patients who participated in this study, their families, and all participating investigators as
+well as their clinical and nursing staff.
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+2020.
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+hospitalized COVID-19 patients at a tertiary care government hospital in Delhi, India. J Med Virol.
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+PMC8251427.
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+patients: a multicenter nested case-control study. BMC Med. 2020;18(1):168. Published 2020 Jun 3.
+doi:10.1186/s12916-020-01633-7
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+PMC7150905.
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+Lancet. 2021;398(10317):2126-2128.
+29. Visweswaraiah, N. K., & Telles, S. (2004). Randomized trial of yoga as a complementary therapy for
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+30. Umesh C, Ramakrishna KK, Jasti N, Bhargav H, Varambally S. Role of Ayurveda and Yoga-Based
+lifestyle in the COVID-19 Pandemic - A Narrative Review [published online ahead of print, 2021 Jul
+19]. J Ayurveda Integr Med. 2021;10.1016/j.jaim.2021.07.009. doi:10.1016/j.jaim.2021.07.009
+Figures
+Figure 1
+Trial Profile
+Page 18/19
+Figure 2
+Clinical Status on the Coronavirus Disease (COVID) Outcomes Scale 14 Days post Randomization
+Page 19/19
+Figure 3
+Biomarker levels at day 5 post randomization
+Supplementary Files
+This is a list of supplementary files associated with this preprint. Click to download.
+SupplementrayDataCovidStudyfinal16.03.2022.docx

subfolder_0/Effect of Residential Yoga Camp on Psychological Fitness of Adolescents A Cohort Study.txt

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+Journal of Clinical and Diagnostic Research. 2018 Aug, Vol-12(8): VC07-VC11
+7
+DOI: 10.7860/JCDR/2018/36839.11872
+Original Article
+Psychiatry/Mental 
+Health Section
+Effect of Residential Yoga Camp 
+on Psychological Fitness of 
+Adolescents: A Cohort Study
+Astha Choukse1, Amritanshu Ram2, HR Nagendra3
+ABSTRACT
+Introduction: Discovering and promoting ways that improve 
+adolescents’ psychological fitness has been a recurrent 
+concern in the field of health and psychology. Adolescence, as 
+a period of transition, is highly prone to have mental health risks 
+and unhealthy behaviour patterns. Thus, it is the right time to 
+promote healthy practices to prevent problems of health and 
+behaviour in adulthood. As Yoga provides practical solutions for 
+mental health, we anticipated that exposure to it should improve 
+psychological fitness among adolescents.
+Aim: To evaluate the effectiveness of short term residential yoga 
+intervention on psychological constructs in adolescents.
+Materials and Methods: A pre, post-yoga interventional study 
+was carried out in a 10 day residential camp. Three independent 
+cohorts of adolescents from India, in three batches (1, 2 and 3), 
+with sample size of 148 (87 boys and 61 girls), 167 (122 boys 
+and 45 girls) and 195 (121 boys and 74 girls), respectively were 
+examined. A holistic integrated yoga module with eight hours of 
+yoga sessions per day was given as an intervention. Emotional 
+Intelligence (EI), emotional regulation strategies, Clinical anger 
+and self-concept parameters were studied using psychometric 
+scales like Schutte Emotional Intelligence Scale (SEIS), Cognitive 
+Emotion Regulation Questionnaire (CERQ-short), Clinical Anger 
+Scale (CAS) and Self-concept Scale respectively. Authorised 
+scales and software were used for assessments and analyses. 
+Results: Significant (p<0.05) improvements in EI, emotional 
+regulation and anger management were observed in all the 
+three batches. However, no significant improvement was 
+found in self-concept in either of the cohorts. The observation 
+of the results of assessed outcome measures in all the three 
+batches confirms the positive effect of Yoga intervention on 
+psychological fitness. The pattern of changes was consistent 
+across all three batches. 
+Conclusion: Residential Yoga camp improves the psychological 
+fitness among adolescents. Even short term courses are 
+effective and induce positive behavioural signatures. 
+INTRODUCTION
+According to World Health Organisation, 1.2 billion of the world 
+population is between the age of 10 and 19 years and are classified 
+as adolescents [1]. This group of individuals are undergoing a 
+stage of distinct and formative biological, physiological and social 
+transition [2]. 
+Especially in low and middle-income countries, many psychological 
+and substance-use disorders reach a peak in this stressful time 
+span of adolescence [3]. According to National Survey on Child 
+and Adolescent Well-being (NSCAW II) in USA, high rates of 
+mental health problems are seen in teens of all ages [4], increasing 
+health problems among young adults [5]. Academic pressures, 
+peer pressure, problems with bullying, addiction to social media 
+has serious implications for mental and physical well-being of 
+adolescents, leading to impaired performance and may contribute 
+to the overall growth retention [6-8]. Improving the transition during 
+adolescence is one of the priority areas to enhance health care for 
+young adults [9].
+Adolescence is the best time for teaching strategies of self-control 
+and self-regulation [3]. It is also a phase that is more amenable to 
+learning and more receptive to corrective changes if provided by 
+intervention programs to improve their mental health. 
+Yoga as holistic intervention in which each pupil can find his/her 
+unique trajectory of change and improvement is now considered 
+as an important intervention for promoting psychological health 
+[10]. Yoga shows a reduction in anxiety, depression, psychological 
+distress in high risk adolescents [11]. Studies also report positive 
+correlation of yoga with self-concept and well-being in adolescents 
+[12,13]. Residential yoga program for young adults has shown 
+positive effects on perceived stress and quality of life [14]. Meditation 
+sessions in schools have beneficial effects across physiological, 
+psychosocial, and behavioural outcomes [15]. Additional studies 
+of school-based yoga interventions also suggest positive effects of 
+yoga on several factors such as concentration, attention, mood, 
+anxiety, working memory, anger and self-esteem [16-21]. Many 
+reviews suggests that yoga is generally effective at improving 
+physical and mental health in children and adolescents [22-25].
+In the available yoga research studies on adolescents, the yoga 
+intervention of 3-4 months duration is used in the school setting as 
+part of curriculum or before/after school hours with yoga sessions 
+ranging from 2 to 3 hours per week for a homogeneous sample. 
+Most of them were conducted with special education, high-risk 
+samples, and small sample size. According to a literature review, 
+residential yoga intervention studies are very few [26].
+An important research question in this area relates to whether 
+yoga offers any benefits for student psychological fitness in a 
+setting different than school setting. Thus, the present study is to 
+explore effect of short term residential yoga intervention program 
+on psychological fitness of adolescents. An objective was also to 
+examine the effects of residential yoga on psychological fitness 
+across different age groups. The present study is a part of a mega 
+study to assess overall fitness among adolescents registered 
+in the Clinical Trials Registry of India bearing the trail number 
+CTRI/2018/02/011709. 
+Keywords:	Anger, Emotional intelligence, Emotional regulation, Self-concept
+Astha Choukse et al., Effect of Residential Yoga Camp on Psychological Fitness of Adolescents	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2018 Aug, Vol-12(8): VC07-VC11
+8
+MATERIALS AND METHODS
+Design: It is a pre-post yoga interventional study carried out in a 
+residential setting (Residential Yoga Camp for high school children). 
+Three independent cohorts (Batch 1, 2 and 3) of adolescents 
+underwent yoga intervention program in the same setting with same 
+guidelines as consecutive studies during April 1-10 (batch 1), April 
+11-20 (Batch 2) and April 21-30 (Batch 3) in year 2016. The duration 
+of the study was 10 days with 8 hours per day of classroom yoga 
+sessions. All other components were kept consistent and similar 
+as far as possible like teachers, living conditions, daily routine and 
+dietary plan. This study was conducted in the campus of Swami 
+Vivekananda Yoga Anusandhana Samsthana (SVYASA) Yoga 
+University, Bengaluru, India. 
+Participants: The participants of the study included adolescent 
+children studying in English Medium Schools who registered for 
+a yoga camp in summer holidays. Healthy adolescents of both 
+genders, between the age of 9 and 16 years participated in the 
+study. The participants were divided into three batches depending 
+on the registration. Batch wise sample size was 148 (87 boys and 
+61 girls), 167 (122 boys and 45 girls) and 195 (121 boys and 74 
+girls) in batch 1, 2, and 3 respectively. Since, the Age range 9-16 
+is wide considering the rapid changes during adolescents, the 
+participants were divided into juniors (9-12 years) and seniors (13-
+16 years) to evaluate changes. Age wise sample were (93 juniors 
+and 55 seniors), (90 juniors and 77 seniors) and (112 juniors and 83 
+seniors) in batch 1, 2 and 3 respectively. 
+They were further randomly divided into smaller groups of 12-15 
+participants which made it easy to implement the intervention. Each 
+smaller group was supervised by two teachers for better monitoring. 
+All teachers have bachelor degree in yoga and were trained on the 
+implementation of the intervention to ensure uniformity. 
+Since, the study was conducted as a yoga camp during summer 
+holidays, the sample was heterogeneous representative sample 
+in nature with subjects from different family backgrounds, socio-
+economic status, cultures and traditions, faiths and different 
+academic status (school boards such as state, ICSC, CBSE etc.,). 
+Subjects with single parents, acute or chronic health problems, on 
+medication, having attended any residential yoga program in the 
+last three months were excluded. 
+Ethical 
+approval 
+was 
+obtained 
+from 
+the 
+Institutional 
+Ethical 
+Committee 
+of S-VYASA with reference number RES/IEC-SVYASA/64/2015. 
+A signed informed consent from parents and a signed informed 
+assent from all participants were obtained after explaining the study 
+in detail prior to screening. 
+Intervention: The modified version of Integrated Yoga Module 
+(IYM), based on Pancha kosha model (five layers of existence) as 
+explained in Taitairiya Upanishad, comprised of yogic techniques 
+that benefit each of the koshas (Gross body-Annamaya Kosha, 
+Energy body - Pranamaya Kosha, Emotional Body - Manomaya 
+Kosha, Intellectual Body - Vijnanamaya Kosha and Bliss Body-
+Anandamaya Kosha). The module was designed referring to 
+various yogic texts on yoga for children and in consultation with 
+subject experts. The module was specially designed for the retreat 
+with suitably modified yogic techniques to address the needs of 
+psychological health development. 
+The yoga module included Asana, Pranayama, Relaxation, 
+Meditation and also Jnana Yoga (yama niyama concepts) and Bhakti 
+Yoga (prayers and chantings). The bhakti yoga sessions included 
+chanting and singing while jnana yoga sessions included lectures, 
+creativity like role-playing, story-telling, parables, journaling-diary 
+entry etc., to drive yama niyama concepts and yogic concept of 
+food. Few friendly competitions were kept between groups to 
+encourage participation and team building.
+The 8 hour class room yoga sessions consisted of roughly 2 hours 
+of Asana practices, 2 hours of Jnana Yoga sessions, 1 hour each 
+of Pranayama (breathing exercises coupled with body movements), 
+Meditation, Relaxation and Bhakti Yoga. The sessions were 
+designed with a mix of events to make the program interesting. 
+Detailed schedule is given below in [Table/Fig-1].
+Assessment: Assessment of psychological fitness parameters 
+were done using following psychometric tools:
+• 
+Schutte Emotional Intelligence Scale (SEIS): This self-reported 
+scale is based on Salovey and Mayer's (1990) original model 
+of EI. This is a 33-item scale with test-retest reliability of 0.78 
+for total scale scores. Each item has a 5-point Likert's rating 
+from 1 (strongly disagree) to 5 (strongly agree). Some item has 
+reverse coding. The total score ranges between 33 to 165, 
+high score indicates more characteristic EI [27].
+• 
+Cognitive Emotion Regulation Questionnaire (CERQ-short): This 
+18 item self-report questionnaire comprises of nine domains 
+(Self-blame, 
+Other-blame, 
+Rumination, 
+Catastrophising, 
+Positive refocusing, Refocus on planning, Positive reappraisal, 
+Putting into perspective and Acceptance) independent from 
+one another. Each item has a 5-point Likert's rating from 1 
+(almost never) to 5 (almost always). Each domain has different 
+scoring, high score represents often used of cognitive coping 
+strategy. Cronbach’s alpha reliability coefficient ranged from 
+0.73 to 0.81 [28]. 
+• 
+Clinical anger Scale (CAS): This 21 item scale is designed to 
+measure different symptoms of clinical anger. Each item has a 
+4-point Likert's rating from 0 (I feel fine) to 3 (I feel completely 
+miserable). The total score ranges between 0 to 63, high 
+score represents high clinical anger. This scale has reliability 
+coefficients of 0.94 (males and females together) [29].
+• 
+Self-Concept: This 30 item self-report scale comprises of five 
+domains that make up an adolescent’s self-concept: 1) Athletic 
+Competence; 2) Conduct/Morality; 3) Peer Acceptance; 4) 
+Physical Appearance; 5) Scholastic Competence. Each item 
+has a 5-point rating from 1 (strongly disagree) to 5 (strongly 
+Time
+Session
+Details
+5am
+-
+Wake Up
+5:30am to 5:45am
+Session 1
+Morning prayer
+5:45am to 6:45am
+Session 2
+Asana practice (physical postures)
+6:45am to 7:30am
+Session 3
+Meditation (om meditation, cyclic meditation)
+7:30am to 8:15am
+-
+Breakfast
+8:15am to 9.00am
+Session 4
+Social works (altruistic group activities)
+9.00am to10:00 am
+-
+Bath and wash
+10:00am to11:00am
+Session 5
+Lectures on concepts of Yoga (yama niyama 
+concepts) 
+11:00am to12:00pm
+Session 6
+Pranayama practice
+12:00pm to 1:00pm
+-
+Lunch
+1:00pm to 2:00pm
+Session 7
+Relaxation (Deep relaxation technique, 
+Quick relaxation technique, Instant relaxation 
+technique) 
+2:00pm to 3:30pm
+Session 8
+Indoor activities (parables, creativity, 
+chanting)
+3:30pm to 4:30pm
+Session 9
+Asana practice 
+4:30pm to 5.00pm
+-
+Evening tea, snacks 
+5.00pm to 6:15pm
+-
+Free time 
+6:15pm to 7:15pm
+-
+Dinner
+7:15pm to 8:30pm
+Session 10
+Happy assembly 
+8:30pm to 9.00pm
+Session 11
+Tranquilling pranayama and meditation 
+9.00pm to 9.15pm
+-
+Milk, snacks 
+9.15pm to 9:30pm
+Session 12
+Diary writing
+9:30pm
+-
+Sleep 
+[Table/Fig-1]: Daily schedule of intervention.
+www.jcdr.net	
+Astha Choukse et al., Effect of Residential Yoga Camp on Psychological Fitness of Adolescents
+Journal of Clinical and Diagnostic Research. 2018 Aug, Vol-12(8): VC07-VC11
+9
+agree). Some item has reverse coding. High score indicates 
+positive self-concept [30].
+Socio-Demography Measures: Children and parents completed a 
+short demographic questionnaire in order to obtain descriptive data 
+for the sample. Screening sheet was filled by parents and children. 
+Variables included are age group, gender, handedness, family type, 
+sibling hierarchy, father’s age, mother’s age etc.
+Data collection was done on the first (pre-data) and last day (post-
+data) of the program, in small group settings by trained staff. The 
+investigator and two teachers were available to clear doubts and 
+provide unbiased guidance during the data collection. 
+statistical Analysis
+To maintain the confidentiality, the data sheets were coded and 
+names and other personal identifiers were omitted during data 
+entry. Analysis was done using SPSS (Version 19.0). Change over 
+time was evaluated using the paired sample t-test. The results of the 
+tests were deemed to be significant if probability values were less 
+than 0.05 whereas trends (p<0.1) have also been highlighted.
+RESULTS
+The recruited study sample included adolescents with a mean age 
+of 11.84±1.77, 12.22±1.82 and 12.06±1.82 in Batches 1, 2 and 
+3 respectively. Gender ratio in Batch 1 of 148 {87 (58.78%) boys 
+and 61 (41.22%) girls}, Batch 2 of 167 {122 (73.05%) boys and 
+45 (26.94%) girls} and Batch 3 of 195 {121 (62.05%) boys and 74 
+(37.94%) girls}. All three batches were evaluated for the effects of 
+a ten day holistic IYM on SEIS, CERQ-short-form, CAS and Self-
+Concept scale. 
+In the present study, overall scores of SEIS in Batch 1 (123.59 to 
+129.86 with p<0.001), Batch 2 (122.27 to 126.04 with p=0.002) 
+and Batch 3 (123.63 to 126.15 with p=0.032) increased significantly 
+in all three batches. Scores of CERQ kids in Batch 1 (51.83 to 57.11 
+with p<0.001), Batch 2 (55.79 to 60.10 with p<0.001) and Batch 
+3 (54.15 to 58.62 with p<0.001) increased significantly in all three 
+batches. Self-Concept has not shown significant change in any of 
+the batches. Significant decrease was seen in the scores of CAS 
+in Batch 1 (13.59 to 10.94 with p<0.001), Batch 2 (16.23 to 14.09 
+with p=0.008) and Batch 3 (14.61 to 12.51 with p=0.003) which 
+was a positive change [Table/Fig-2].
+The analysis was also carried out separately for juniors and seniors 
+in each batch as detailed below. 
+The sub-factor analyses within juniors in different batches indicate, 
+significant increase in scores of SEIS in Batch 1 juniors, and trend 
+of increase was seen in Batch 2 juniors and Batch 3 juniors. Scores 
+of CERQ kids in juniors increased significantly in all three batches. 
+Self-Concept has not shown significant change in juniors in any of 
+the batches. Significant decrease was seen in the scores of CAS 
+in Batch 1 juniors and decrease was seen in juniors of Batch 2 
+and Batch 3 but not significant. Reduction in clinical anger was a 
+positive change [Table/Fig-3].
+The sub-factor analyses within seniors in different batches indicates, 
+there was a significant increase in the scores of SEIS in seniors 
+in Batch 1 and Batch 2 and non-significant increase was seen in 
+Batch 3 seniors. Scores of CERQ in seniors increased significantly 
+in all three batches. Self-Concept has not shown significant change 
+in seniors in any of the batches. Significant decrease was seen in 
+the scores of CAS in seniors in all the three batches. Reduction in 
+clinical anger was a positive change [Table/Fig-4].
+DISCUSSION
+The present study demonstrated the positive effects of short 
+term integrated yoga module program on psychological fitness in 
+residential setting within summer break. Results suggest that yoga 
+is an acceptable practice in residential camp by adolescents. 
+Present study showed significant improvement in EI. Yoga practices 
+may significantly influence the process of self-awareness and 
+self-control [31]. Previous research indicates improved EI through 
+Variables
+Batch 1 (n=148) Mean±SD
+p-value
+Batch 2 (n=167) Mean±SD
+p-value
+Batch 3 (n=195) Mean±SD
+p-value
+Pre-
+Post-
+Pre-
+Post-
+Pre-
+Pos-
+Emotional Intelligence
+123.59±16.09
+129.86±19.30
+<0.001*
+122.27±15.62
+126.04±17.98
+0.002*
+123.63±17.40
+126.1518.98
+0.032*
+Emotional regulation 
+strategies
+51.83±10.68
+57.11±13.59
+<0.001*
+55.79±10.15
+60.10±11.02
+<0.001*
+54.15±10.47
+58.62±12.47
+<0.001*
+Self-concept
+103.36±12.99
+103.64±14.70
+0.766
+101.89±14.10
+101.58±14.66
+0.724
+103.04±13.06
+102.13±14.67
+0.315
+Clinical anger
+13.59±10.44
+10.94±10.68
+<0.001*
+16.23±10.77
+14.09±11.52
+0.008*
+14.61±10.59
+12.51±10.54
+0.003*
+Variables
+Batch 1 (n=93) Mean±SD
+p-value
+Batch 2 (n=90) Mean±SD
+p-value
+Batch 3 (n=112) Mean±SD
+p-value
+Pre-
+Post-
+Pre-
+Post-
+Pre-
+Post-
+Emotional Intelligence
+121.46±17.21
+128.77±20.33
+<0.001*
+121.32±16.77
+124.21±16.76
+0.078
+120.52±18.50
+123.76±20.30
+0.068
+Emotional regulation 
+strategies
+52.20±11.52
+58.65±13.31
+<0.001*
+55.09±10.97
+59.02±10.87
+0.002*
+52.48±10.66
+58.42±13.59
+<0.001*
+Self-concept
+103.51±12.86
+103.26±15.16
+0.836
+102.62±14.75
+100.72±15.10
+0.115
+104.02±14.26
+102.35±15.81
+0.209
+Clinical anger
+14.74±10.56
+12.48±11.18
+0.023*
+15.58±10.49
+15.31±11.68
+0.759
+14.17±10.60
+13.23±10.55
+0.308
+Variables
+Batch 1 (n=55) Mean±SD
+p-value
+Batch 2 (n=77) Mean±SD
+p-value
+Batch 3 (n=83) Mean±SD
+p-value
+Pre-
+Post-
+Pre-
+Post-
+Pre-
+Post-
+Emotional Intelligence
+127.26±13.29
+131.74±17.42
+0.026*
+123.38±14.18
+128.18±19.21
+0.007*
+127.82±14.88
+129.39±16.60
+0.265
+Emotional regulation 
+strategies
+51.20±9.18
+54.53±13.79
+0.049*
+56.61±9.11
+61.35±11.13
+<0.001*
+56.41±9.82
+58.88±10.84
+0.040*
+Self-concept
+103.11±13.29
+104.31±14.02
+0.480
+101.03±13.36
+102.58±14.16
+0.218
+101.71±11.18
+101.82±13.07
+0.926
+Clinical anger
+11.67±10.06
+8.36±9.32
+<0.001*
+16.97±11.10
+12.01±11.06
+<0.001*
+15.19±10.63
+11.53±10.50
+0.001*
+[Table/Fig-2]: Paired sample t-test for three cohorts.
+*indicates p<0.05; SD: Standard deviation
+[Table/Fig-3]: Paired sample t-test for juniors.
+*indicates p<0.05; SD: Standard deviation 
+[Table/Fig-4]: Paired sample t-test for seniors.
+*indicates p<0.05; SD: Standard deviation
+Astha Choukse et al., Effect of Residential Yoga Camp on Psychological Fitness of Adolescents	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2018 Aug, Vol-12(8): VC07-VC11
+10
+10
+20 minutes of meditation over eight weekly sessions in graduate 
+students [32]. Evidence suggests increased self-awareness, EI, and 
+social skills in response to sitting meditation in youth [15]. 
+Significant change was seen in overall emotion regulation and 
+strategies. Pranayama, breathing practices, chanting and meditation, 
+yama-niyama concept driven creativity and games especially 
+designed for emotional development may have accounted for 
+these positive changes and enhanced coping abilities in the present 
+study. Results of present study on emotion regulation is in line with 
+previous study done on 159 students with yoga based intervention 
+in classroom setting [33]. 
+Self-concept didn’t change although, some sub-domains of it did 
+change. Long and more periodic intervention maybe required to 
+change self-concept. 
+In the present study, significant reduction in CAS in Batch 1 (13.59 
+to 10.94 with p<0.001), Batch 2 (16.23 to 14.09 with p=0.008) 
+and Batch 3 (14.61 to 12.51 with p=0.003) shows reduction in 
+cognitive, physiological, social, and behavioural symptoms due to 
+anger. In present study, specially designed yoga module given in 
+residential setting may have accounted for significant improvement 
+in anger management and other significant positive psychological 
+changes. Improved anger control through yoga module while 
+in one previous RCT, insignificant changes in anger control and 
+many of the psychological parameters were seen within groups 
+and between groups with semester long intervention in school 
+curriculum in adolescents [13]. In another RCT, no changes were 
+seen in emotional and behavioral functions within yoga group as 
+well as between groups [34]. Small sample size and inadequate 
+dose of intervention (only 18 hours in 12 weeks) may be reason for 
+no changes. All these limitations were well taken care in present 
+study in the form of well-organised integrated yoga module and the 
+intervention was repeated with three independent cohorts with large 
+sample sizes (Batch 1-148, Batch 2-167, Batch 3- 195) . Positive 
+findings of another study on psychological measures done in adults 
+with 5 day residential yoga program supports the positive findings 
+in the present study [35]. 
+The sub-factor analysis between age groups indicates similar 
+changes in EI in both juniors and seniors. Similar positive significant 
+changes were seen in emotion regulation in both juniors and seniors 
+and consistent in all three batches. Self-concept has not shown any 
+significant changes in both juniors and seniors in any of the batches. 
+Clinical anger scores were reduced in both age groups but more 
+(significant) in seniors showing better anger control in seniors. Results 
+of all parameters are consistent in all the three batches showing 
+the consistency and confirmed effect of the Yoga intervention. 
+Pranayama, meditation and Jnana Yoga activities may help them 
+to look for the positive side of events, think positive and respond 
+responsibly. Multi-component nature of yoga and intervening effect 
+of each technique on various koshas makes it complex to precisely 
+assign the effect on any particular parameter. According to sage 
+Patanjali, practice of yogic postures leads to expansion of mind and 
+ceasing of dualities [36]. Practice of pranayama gives better clarity 
+on thoughts. Meditation and Relaxation work on cellular activity or 
+metabolic activities. Jnana Yoga sharpens the mind while Bhakti 
+yoga calms down the mind.
+The positive outcomes in the study are generally consistent with 
+previous studies of yoga, meditation in school settings, although 
+the use of different outcome measures and research designs 
+precludes a precise comparison [37,38]. The results showed 
+significant improvement in all assessed outcome measures except 
+self-concept in all three consecutive studies and reflects a positive 
+change. Since, this is residential setting and participants were from 
+many different cities (diverse data), it was not practically feasible to 
+have active control group. So, three independent cohorts with large 
+and matched sample size were done with same intervention to test 
+the repeatability and consistency of the effect. Consistent similar 
+trend of results in all three cohorts confirms the positive effect of 
+given integrated yoga module in adolescents. 
+The strength of the study lies in including heterogeneous 
+representative samples with relatively bigger sample size. Multiple 
+components in the yoga module can be seen as limitation as well 
+as the strength. Limitation in terms of not able to assign the effect 
+to any particular component of module. It is a strength because 
+of strictly following the comprehensive integrated holistic approach 
+of Yoga as said in the classical texts. The integrated approach to 
+yoga comprises of yogic postures (asanas), breathing techniques 
+(pranayama), relaxations (guided relaxation techniques), meditations 
+(guided meditations), knowledge points (Jnana Yoga) and prayers 
+and chanting (Bhakti Yoga). Guided relaxation techniques such as 
+deep relaxation technique, quick relaxation technique and instant 
+relaxation technique also include postures and body movements 
+and breathing techniques that provide flexion and extension 
+to muscles. Guided meditations include different postures and 
+concepts of focusing which warrants establishing certain physical 
+postures with hand gestures (mudras).
+In Yogic parlance, concept of human existence comprises of five 
+layers-the gross body, the energy body, the emotional body, the 
+intellectual body and the bliss body.  Integrated approach to yoga 
+is employing specific yogic techniques to address all the layers of 
+existence in order to get holisticity or overall health. 
+The integrated module of yoga especially designed for yoga camp 
+for adolescence was very well accepted by the children and received 
+complements from the parents too. Maintaining uniformity in 
+execution of intervention and overall conducting of program across 
+the three batches acts as a replication of the study. The similar 
+results/trends in each batch not only confirm the effectiveness 
+of the program in establishing the psychological fitness among 
+adolescents but also nullifies the lacuna arising due to absence of 
+active control group. 
+LIMITATION  
+The absence of control may act as a limitation of the study. However, 
+by repeating the intervention thrice with three different batches, this 
+limitation was tried to overcome. As there were no indigenous scales 
+available to study the psychological parameters in the Indian setting, 
+the psychometric scales that were developed by Westerners, used 
+in the study. This may also be considered as another limitation of 
+the study. 
+CONCLUSION
+The 10 day Residential Yoga camp is effective in improving the 
+psychological fitness among adolescent children especially EI, 
+cognitive emotional regulation strategies and anger management. 
+The findings also highlight the potential of short term integrated yoga 
+in bringing significant improvements in psychological constructs 
+among adolescents. Further the study also demonstrates the 
+feasibility and effectiveness of residential integrated yoga program 
+for adolescents. 
+ACKNOWLEDGEMENTs
+The authors would like to extend their heartiest thanks and 
+appreciation to the University and its faculty, for allowing the study 
+to be conducted during the residential summer camp. The authors 
+thank all the participants and parents for their support. The authors 
+also thank Mrs. Alakamani, PhD for her critical comments on the 
+manuscript.
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+being: research review and reflections on the mental health potentials of yoga. 
+Front Psychiatry. 2014;5:35. 
+PARTICULARS OF CONTRIBUTORS:
+1.	 Research Scholar, Department of Yoga and Humanities, S-VYASA Yoga University, Bengaluru, Karnataka, India.
+2.	 Scientist, CAM Program, HCG Enterprise Ltd., Bengaluru, Karnataka, India.
+3.	 The Chancellor, S-VYASA Yoga University, Bengaluru, Karnataka, India.
+NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
+Dr. Astha Choukse,
+Research Scholar, S-VYASA Yoga University, # 19, Eknath Bhawan, Govipurum circle, Kempagowda Nagar,
+Bengaluru-560019, Karnataka, India.
+E-mail: [email protected]
+Financial OR OTHER COMPETING INTERESTS: None.
+Date of Submission: Apr 17, 2018
+Date of Peer Review: May 02, 2018
+Date of Acceptance: Jun 28, 2018
+Date of Publishing: Aug 01, 2018

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+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+1/16
+Int J Yoga. 2019 May-Aug; 12(2): 139–145.
+doi: 10.4103/ijoy.IJOY_29_18: 10.4103/ijoy.IJOY_29_18
+PMCID: PMC6521760
+PMID: 31143022
+Effect of Residential Yoga Camp on Psychosocial Fitness of
+Adolescents
+Astha Choukse, Amritanshu Ram,  and HR Nagendra
+Department of Yoga and Humanities, S-VYASA Yoga University, Bengaluru, Karnataka, India
+CAM Department, HCG Enterprises Ltd., Bengaluru, Karnataka, India
+Address for correspondence: Dr. Astha Choukse, S-VYASA Yoga University, Bengaluru Eknath Bhawan, No. 19,
+Gavipuram Circle, Kempegowda Nagar, Bengaluru - 560 019, Karnataka, India. E-mail:
+[email protected]
+Received 2018 May; Accepted 2018 Oct.
+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:
+Adolescence is a key phase of socialization, where improved psychosocial fitness helps to promote
+socioeconomic productivity in societies. Psychosocial fitness also has an impact on the academic
+performance, overall health, and quality of life, throughout life. The present study evaluates the effect of
+yoga intervention on psychosocial fitness among adolescents.
+Materials and Methods:
+A single group, pre and post yoga interventional study was carried out in three independent cohorts
+(batches 1, 2, and 3), having sample size of 148, 167, and 195 respectively. A 7-day integrated yoga
+intervention was given in a residential setting. Psychosocial assessments included social competence,
+empathy, altruism, parent relationship, and peer friendship. Data were collected from the participants and
+their parents using respective versions of the scales. While pre- and post-data were collected from all the
+adolescent participants, pre- and post-data from parents were collected for 340 and 43 parents only. The
+objective of the analyses was to evaluate the effect of the yoga program and check the consistency of these
+effects.
+Results:
+Significant changes (P < 0.05) were seen in social competence, empathy, and altruism in batches 2 and 3,
+whereas changes in batch 1 showed nonsignificant improvements. Analyses of the parental data indicated a
+significant improvement in parent relationship (P = 0.035) and also nonsignificant improvement in all
+other outcomes.
+1
+1
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+2/16
+Conclusion:
+Results suggested that yoga intervention might help in improving psychosocial fitness in adolescents. It
+also helped to demonstrate that administering yoga was acceptable and feasible in a residential setting.
+Keywords: Adolescents, empathy, parent relationship, psychosocial fitness, social competence, yoga
+Introduction
+Adolescence is a time of tremendous growth, potential and socioemotional development[1] along with
+considerable risk, during which social contexts exert powerful influences.[2] Psychosocial fitness is
+defined as developing a sense of personal identity which will continue to influence behavior and
+development for the rest of a person's life.[3] Psychosocial fitness among adolescents plays an important
+role, considering the need for social integration and the search for self-assertion and independence.[4] It is
+marked by a set of learned behaviors displayed by them in the interpersonal context and their performance
+level for the demands of a social situation. Adolescence is a crucial period of socialization that demands
+greater attention to the mental well-being, failing which may lead to mental health consequences that may
+remain throughout life and reduce the capacity of societies' socioeconomic productivity.[5] Appropriate
+psychosocial development of adolescent is an indicator of sound academic performance; physical health;
+and adequate social, emotional, and psychological health. Psychosocial fitness ultimately contributes in
+reducing the risk of psychosocial and behavioral problems, violence, crime, teenage pregnancy, and misuse
+of drugs and alcohol.[6] Psychosocial fitness includes how one feels and perceives about their societal
+relationships that has key factors such as empathy, social competence, altruism, and so forth.
+Empathy, a key component of all social functioning, is an effective cognitive ability to adopt the
+perspective of others in order to understand their feelings, thoughts, or actions.[7] Altruism is a
+motivational state, thought, and action with the ultimate goal of increasing other's welfare without
+considering one's own well-being.[8] Weak social competencies are thought to limit an adolescent's ability
+to establish and maintain friendships. Low levels of perceived social competence and negative parental
+interactions are associated with depressive symptoms.[9] During the adolescent period, their relationships
+with family and peers undergo dramatic changes and shifts. Strong positive relationships with both family
+and friends are vital for healthy social and emotional development.[10] The quality of the parent–child
+relationship affects the adolescent's self-concept, which in turn affects the adolescent's integration into the
+world of peers.[11]
+Literature on interventional studies, promoting psychosocial fitness are not many and are not focused to
+target adolescents, their caregivers, and community stakeholders.[6,12] A systematic review suggested that
+a multimodal and multidisciplinary group-based approach was found to be an effective interventional
+strategy.[13] One of the studies suggested psychosocial assets and well-being, which could be improved
+among adolescent girls through a brief school day program.[14]
+Since psychosocial fitness is largely to do with how we deal with the mind, yoga may play a role in its
+enhancements. Yoga is a science of mind control, delineated in historical Indian texts, and comprises of
+holistic multicomponent practices and considered as an effective intervention to promote the overall
+fitness. A number of studies have been done on adolescent mental health involving yoga as an intervention
+that has shown benefits[15,16,17] No studies thus far have assessed the psychosocial benefits of yoga on
+adolescents. Further, adolescence being at the crucial developmental stage, highly vulnerable to biological,
+psychological, social, and environmental factors and are in a period where they are more receptive to the
+corrective measures. This warrants considering their physical and psychological aspects while developing
+intervention programs/strategies to improve social health among adolescents. Considering the psychosocial
+benefits seen by the practice of yoga in other populations, there is enough to warrant an exploration in the
+adolescent population.
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+3/16
+The aim of the present study was to explore the efficacy of short-term integrated residential yoga
+intervention on parameters of psychosocial fitness in adolescents. The objective was to evaluate the effects
+of yoga through a single group pre- and post-design for each cohort. This included eliciting data from
+adolescents and their parents and engaging in subgroup analyses of different age groups.
+This study included secondary data of a registered study (CTRI/2018/02/011709) that evaluated physical,
+psychological, and social fitness among adolescents.
+Materials and Methods
+Participants
+The participants of the study included healthy adolescent children between the ages of 9 and 16 years,
+studying in English-medium schools. Participants with single parents, acute or chronic health problems, on
+medication, having attended any residential yoga program in the last 3 months were excluded from the
+study. They were selected from children who were registered to attend three 7-day residential summer
+yoga programs that naturally formed the three cohorts for the study. Children were screened for suitability
+and once their parents provided consent along with the children's assent, were subjected for the
+preassessment. Considering the rapid psychosocial changes during the adolescence, the participants were
+further subdivided into juniors (9–12 years) and seniors (13–16 years).
+Children from each batch were further randomly divided into smaller groups of 12–15 participants, with
+two teachers, which made it easy to implement the intervention. Teachers included undergraduates in yoga
+and were trained on the implementation of the intervention to ensure uniformity.
+Since the selection of participants was from a summer yoga camp during the summer break, there was
+good heterogeneity of the sample with respect to family backgrounds, socioeconomic strata, cultures,
+traditions, faiths, and academic backgrounds.
+Ethical approval was obtained from the Institutional Ethical Committee of S-VYASA with the reference
+number RES/IEC-SVYASA/64/2015.
+Assessment
+The psychosocial fitness was assessed by the outcome measures of social competence, empathy, altruism,
+parent relationship, and peer friendship. Data were collected from the adolescents before and after the
+intervention. Data of empathy, altruism, and parental and peer relationship, from the parents, were
+collected before and after 3 months of the intervention using the parent versions of the respective scales.
+This would help comparing the opinions of the parents with that of their children.
+The psychometric scales used are developed and validated by Child Trends[18,19] and they are (a) Social
+Competence Questionnaire – 9-item scale with Cronbach's alpha of 0.79; (b) Teen Empathy – 4-item scale
+with Cronbach's alpha 0.84; (c) Teen Altruism – 4-item scale with Cronbach's alpha 0.80; (d) Positive
+parent relationship – 6-item scale with Cronbach's alpha 0.92; and (e) Peer friendship – 5-item scale with
+Cronbach's alpha 0.91.
+Design
+The present study is a single group pre- and post-yoga interventional study carried out during a residential
+yoga camp for the adolescents. Data were collected from both children, as well as parents, using respective
+questionnaires. Three independent 10-day residential camps for personality development were organized
+during the summer by VYASA organization. While the duration of camp was 10 days, the yoga
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+4/16
+intervention schedule was followed from day 2 to day 8 across the three camps. Eligible adolescents
+underwent the same yoga intervention program with the instructors, living conditions, daily routine, and
+dietary plan.
+Intervention
+The modified version of Integrated Yoga Module, based on Pancha Kosha model (five layers of existence)
+as explained in Taittiriya Upanishad comprised of yogic techniques that benefit each of the Koshas (gross
+body – annamaya kosha; energy body – pranamaya kosha; emotional body – manomaya kosha; intellectual
+body – vijnanamaya kosha; and bliss body – anandamaya kosha). The module was based on various yogic
+texts, books on yoga for children, and was modified in consultation with the subject experts with more
+than 25 years of experience in conducting these camps.
+The yoga module included Asana, Pranayama, Relaxation, Meditation, and also Jnana yoga (Yama Niyama
+concepts) and Bhakti yoga (prayers and bhajans). The bhakti-yoga sessions included mantra chanting and
+singing, whereas Jnana yoga sessions included lectures, creativity such as role playing, storytelling,
+parables, journaling diary entry, and so forth to drive the Yama Niyama concepts and yogic concepts of
+food. Few competitive activities were organized between groups to encourage participation and team
+building. The sessions were administered in a manner that kept the program engaging and interesting to the
+selected age group. Details of the intervention are summarized in Table 1.
+Data extraction
+Data collection was done for the children on the 1  day (predata) and 9  day (postdata) of the camp, in
+small group settings by trained researchers. The investigators and two teachers were available to clear
+doubts and provide unbiased guidance during the data collection. Data collection from the parents was
+done on the 1  day (predata), when they came to drop their wards to the camp, and after 3 months
+(postdata) as a follow-up data, by sending the questionnaire through E-mail.
+All the recruited students completed the questionnaires before and after the intervention. A total of 340
+parental responses were collected before the intervention and only 43 parental responses were obtained
+after 3 months as a follow-up data (postdata). Post 3 months data obtained from parents served to evaluate
+if the yoga intervention had long-term and sustained effects on the social behavior. Only 43 pre- and post-
+parental data were available that made it difficult to draw strong conclusions on the parental opinions. The
+reasons for attrition in parental predata were (a) parents were not available at the commencement of the
+camp, (b) refusal to participate, and (c) lack of English language fluency. Several parents did not respond
+to the follow-up assessments despite repeated E-mail and reminders due to their preoccupations or
+disinterest. Hence, the analyses that involved data from adolescents and their parents were from 43
+participants.
+Data analyses
+To maintain confidentiality, the data sheets were coded and personal identifiers were omitted during the
+data entry. Analysis was done using SPSS Inc. SPSS for Windows, Version 16.0. Chicago, Change over
+time was evaluated using the paired samples t-test. The results of the tests were deemed to be significant if
+probability values were <0.05, whereas trends (P < 0.1) were also highlighted.
+Results
+The effect of a short-term residential yoga intervention was evaluated for its benefits on social
+competence, empathy, altruism, parent relationship, and peer friendship by a single-arm, pre- and post-
+study in three individual cohorts of adolescent children. The three cohorts comprised 148 (57.8% male)
+st
+th
+st
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+5/16
+(62.8% juniors), 167 (73.1% male) (53.9% juniors) and 195 (62.1% male) (57.4% juniors), with a mean
+age of 11.84 ± 1.77, 12.22 ± 1.82 and 12.06 ± 1.82, respectively. Demographic and anthropometric data are
+presented in Table 2.
+As seen in Table 3, comparing pre- and post-data for each of the cohorts showed that there were no
+significant changes, observed in the first batch, whereas the subsequent batches showed statistically
+meaningful changes in teen empathy. Social competence and altruism was significant in the third batch. An
+interesting observation was that while all changes, although nonsignificant, were in the positive direction,
+peer friendship had changed negatively.
+Analysis of the junior subgroup, as shown in Table 4, indicates that empathy significantly improved in all
+the three batches. Social competence improved significantly in the first batch and altruism improved
+significantly in the third batch. It was interesting to note that unlike the overall result, peer friendship had
+increased, although nonsignificantly in two of the three batches. All the other variables also showed a
+nonsignificant positive change.
+Analysis of the senior subgroup, as shown in Table 5, indicates that there were no significant positive
+changes in any of the outcomes in batch 1, but social competence and empathy changed positively in the
+subsequent batches. Altruism also showed a significant positive change in the third batch. Peer friendship
+showed a significant reduction in the first batch, which was not seen in the subsequent batches.
+Additional analyses compared (n = 340) predata of the outcomes between the adolescents and their parents
+(200 juniors), as seen in Table 6. There were significantly lower altruism and peer friendship and
+significantly higher parent relationship reported by parents when compared with their children.
+Changes in empathy, altruism, parent relationship, and peer friendship were compared between the
+responses received by the 43 adolescents and their parents, as shown in Table 7. It was interesting to note
+that the adolescents reported a significant change (P = 0.003) in altruism and the parents reported a
+significant change (P = 0.035) in parent relationship as a result of the yoga intervention.
+Discussion
+The objectives of this study were to evaluate the effects that a 7-day residential yoga intervention would
+bring on measures of psychosocial fitness in three independent cohorts through a single group pre- and
+post-study. The secondary objective was to compare if these effects were also observed by the parents.
+Statistically significant increase in measures of empathy, social competence, and altruism were
+inconsistent between the three cohorts and between the age groups, except for an increase in empathy,
+which was seen across all the three cohorts among juniors.
+Psychosocial fitness stems from empathy or being able to put oneself in another's situation in order to
+understand their feelings. This in turn impacts one's behavior and makes them better connect with their
+peers, parents, and surroundings at large. Altruism is also a resultant prosocial behavioral pattern of
+increased empathy,[20,21] and these patterns of psychosocial behavior define an individual's social
+competence. Building self-awareness is the key to developing skill of emotional appraisal and control,
+whereby positive social competencies might be achieved. Yoga, being the science of holistic well-being,
+comprises of practices that encourage internalization and development of self-awareness, and thereby,
+increase the capacity of self-control.[22] Yoga practices through a sequence of awareness building and
+relaxing practices evoke a deeper calming effect, which helps students get into a frame of mind, conducive
+to learning and is distinct from the effects of physical exercise alone.[16] The results of our study may
+suggest that 7 days of yoga practices may have only been adequate to show a change in empathy scores
+and a longer intervention might have been required to show consistent impact on the downstream
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+6/16
+behavioral patterns. Other studies have also indicated that Karma Yoga,[23] yoga practices, mindfulness,
+[24] and prayer[25] have an influence over the aspects of empathy, altruistic behavior, and social
+competence in adolescents.
+Variables of empathy, altruism, and peer and parental relationship are easily under or overestimated while
+using a self-reported instrument. Thus, parallel data of these variables were also sought from the parents. It
+is, however, known that the parents are not able to report accurately, certain aspects of their adolescent
+children's behavior.[26] Comparison of the corresponding adolescent and parent data provided rich
+information on the discrepancies of opinions held by each of them. Comparing baseline values between
+parents and their children, it was interesting to note that apart from having an agreement in scores of
+empathy, all other outcomes were significantly different. It was more interesting that parents opined that
+their children had very positive parental relationship and a very-low peer friendship, but their children
+thought otherwise. Noting these discrepancies, we further assessed the changes in these parameters
+resulting from the yoga intervention in both these populations.
+In the present study, adolescents reported only a trend of improvement (P = 0.095) in parental relationship
+as a result of the yoga intervention, but the parents reported a significant (P = 0.035) improvement, 3
+months after the intervention. However, unlike what was expected, the parameters of peer friendship
+reduced significantly (P = 0.031) in seniors of the first batch.
+A positive parent–child relationship is an essential component of adolescent development. During this
+transitional age, the concept and opinions of oneself grow stronger, taking precedence over that of their
+parents[27] and conflicts with parental ideologies emerge. Retaining a healthy relationship with parents
+and peers plays a crucial role in an individual's psychological and physical health.[28] Components of the
+intervention also comprised activities that were geared to provide calmness and balance to the mind
+(Pranayama, meditation) and promoted the quality of relationships and moral behavior (Yama Niyama) in
+adolescents.[29] This effect, as observed by the parents, 3 months after the intervention could suggest a
+sustained change in parental relationship as a result of yoga. The adolescent data, collected before and after
+a 7-day intervention, might not have been adequate to appraise the change. Furthermore, not having the
+exposure with the parents during this time might have made it nonconducive for its appraisal. The trend
+seen in the present study is in line with a previous randomized controlled trial[30] evaluating changes in
+socioemotional competencies, such as empathy and prosociality, as a result of a yoga program delivered
+twice a week for 12 weeks to 125 low socioeconomic adolescents.
+The point of reference for peer friendship during the predata was an established set of peers from their
+native setting, whereas the postdata elicited had a point of reference of peers from within the camp. This
+subtle disparity was appreciated more in seniors, which had resulted in a significant drop in scores of peer
+friendship, whereas in juniors there was a higher degree of adaptability indicated by a nonsignificant
+increase in peer friendship in the first and third batches.
+This was the first time that an interventional study of this scale, in adolescents had been attempted. The
+intervention being tested was also developed in a comprehensive manner, referring authentic Indian texts
+of yoga, modern-day literature of its interpretations, and modifying it through several iterations with
+subject experts in yoga, psychology, and adolescent health. An intervention that is focused on the holistic
+psychosocial development of adolescents, administered in the group setting has shown to be more effective
+in improving social skills, if there has been at least one medical health professional or an adolescent
+psychologist involved in its development.[13] This ensured that while the premise of yoga is grounded to
+its authentic roots, the practices themselves were able to elicit the interest of the selected age group.
+Qualitative feedback elicited from the adolescents and parents on all aspects of the camp was very good.
+Considering that other literature provided stronger evidence to the benefits of yoga among adolescents, an
+attempt was also made to evaluate a residential camp setting as a way to impart these practices to this age
+group. To provide a multidimensional intervention like yoga in such large numbers, the study employed
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+7/16
+close to 40 trainers who were rigorously trained and monitored for uniform quality of instruction. In
+addition, capture of parental data along with corresponding data from their children was a novel endeavor,
+although the results had not proven to be what was anticipated.
+The inconsistency in the results demonstrate that yoga being a multimodal set of activities, is heavily
+dependent on how well each person is able to internalize these practices and drive the change of mindset.
+The absence of a control group heavily undermined the conclusions drawn in this study. Considering this,
+the design was reworked at detecting the repeatability of the results. Contrary to our speculation, the
+internal validity of the results, by virtue of the inconsistency of results, was also poor. Adolescent data
+should have also been collected along with that of their parents, post 3 months to evaluate the sustained
+changes in the relationships. The controlled environment of the camp setting might have only provided the
+required information needed for the psychosocial improvement and evaluating the same after the
+participants had been given an opportunity to express it in their existing relationships would have provided
+a fairer comparison. Secondary qualitative data, in anticipation of a nonconclusive result, could have been
+premeditated, which would have given a rich feedback on the changes needed in the module and its
+implementation. Future studies, while having a more robust design, should not just be able to detect the
+effects but also identify possible predictors and mechanisms associated with improvement in psychosocial
+fitness. Long-term interventions, homogenous samples, and improved and focused interventions also
+remain as improvements in the future researches in this field.
+Conclusion
+Adolescence is a phase of emotional and psychosocial transition and yoga, a technique of mind control,
+which could potentially help in improving holistic personality. The efficacy of a 7-day yoga intervention in
+improving psychosocial fitness was evaluated and showed that the feeling of empathy increased
+significantly. There was a sporadic increase in altruism, social competence, and parent relationships in
+some cohorts while peer relationship deteriorated. Parents providing data on their children's perceived
+level of altruism, empathy, and relationship with parents and peers, before and after 3 months of
+intervention highlighted the discrepancy in their understanding of their children and also their ability to
+perceive the changes while the children could not. Design and implementation flaws, as a result of
+resources, limit from stating the findings of these studies as conclusive evidence but helps to plan more
+robust and intricate studies to assess the specific benefits of yoga and its mechanisms.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgment
+The authors would like to extend their heartiest thanks and appreciation to the University and its faculty
+for allowing the study to be conducted during the residential summer camp. The authors thank all the
+participants and parents for their support. The authors also thank Mrs. Alakamani, PhD for her comments
+on the manuscript.
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+Figures and Tables
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+10/16
+Table 1
+Summary of integrated yoga intervention program
+Name of the intervention session
+Duration
+Prayer session
+15 min
+Asana sessions: Standing postures, sitting postures, prone postures, inverted postures, supine postures
+2 h
+Meditation session: Om meditation, cyclic meditation
+45 min
+Pranayama session: Conscious breathing, sectional breathing, full yogic breathing, dynamic (Bhastrika,
+Kapalbhati), balancing (Anuloma-viloma), cooling (Shitli), tranquilizing (Bhramari)
+1 h
+Relaxation session: IRT, QRT, DRT
+1 h
+Lecture session: Yama Niyama concepts, physical adolescent health, emotional appraisal and control,
+prosocial behavior
+1 h
+Chanting and singing session: 18 verses from Bhagavad Gita, devotional songs, patriotic songs
+1 h
+Creativity sessions: Karma yoga (altruistic group activities), role modeling, parables, storytelling, diary
+writing, competitions
+2 h
+Game session: Yogic games, group awareness
+1 h
+Happy assembly: Cultural program
+1 h
+IRT=Instant relaxation technique, QRT=Quick relaxation technique, DRT=Deep relaxation technique
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+11/16
+Table 2
+Demographic and anthropometric measures
+Variables
+Mean±SD
+Batch 1
+Batch 2
+Batch 3
+Age
+11.84±1.77
+12.22±1.82
+12.06±1.82
+Father age
+43.54±4.63
+43.61±5.61
+43.56±4.40
+Mother age
+38.64±4.15
+38.12±3.87
+38.16±4.00
+Height
+148.26±12.81
+149.51±12.75
+150.5±13.29
+Weight
+43.42±13.20
+41.31±12.28
+44.03±12.35
+BMI
+18.80±3.82
+17.75±3.99
+18.8±4.98
+SD=Standard deviation, BMI=Body mass index
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+12/16
+Table 3
+Comparison of pre- and post-data of the three cohorts
+SD=Standard deviation
+Measures
+Batch 1 (n=148)
+Batch 2 (n=167)
+Batch 3 (n=195)
+Mean±SD
+P
+Mean±SD
+P
+Mean±SD
+Pre
+Post
+Pre
+Post
+Pre
+Post
+Empathy
+14.70±3.344
+15.05±3.841
+0.207
+14.32±3.014
+15.28±3.116
+<0.001
+13.97±3.341
+14.90±3.284
+Social
+competence
+33.21±6.702
+33.70±7.866
+0.363
+33.19±5.381
+34.06±6.816
+0.055
+32.43±6.513
+33.48±6.463
+Altruism
+13.15±3.786
+13.43±4.113
+0.355
+13.27±3.574
+13.78±3.419
+0.052
+12.87±3.498
+13.66±3.524
+Parent
+relationship
+23.61±4.827
+23.84±5.273
+0.606
+23.58±4.928
+23.89±4.885
+0.423
+23.66±4.168
+24.19±4.746
+Peer
+friendship
+20.62±4.278
+20.45±4.678
+0.663
+20.70±4.002
+20.43±4.109
+0.385
+20.03±4.323
+20.01±3.900
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+13/16
+Table 4
+Comparison of pre- and post-data of the three cohorts of juniors
+SD=Standard deviation
+Measures
+Batch 1 (n=93)
+Batch 2 (n=90)
+Batch 3 (n=112)
+Mean±SD
+P
+Mean±SD
+P
+Mean±SD
+Pre
+Post
+Pre
+Post
+Pre
+Post
+Empathy
+14.41±3.275
+15.12±3.557
+0.033
+13.90±2.860
+14.78±3.042
+0.029
+13.87±3.424
+14.65±3.427
+Social
+competence
+32.40±6.823
+33.83±6.882
+0.029
+32.51±5.707
+33.04±7.228
+0.465
+31.89±6.616
+32.63±6.710
+Altruism
+13.56±3.740
+13.82±3.776
+0.488
+12.82±3.740
+13.33±3.576
+0.199
+12.89±3.483
+13.63±3.521
+Parent
+relationship
+23.49±5.058
+24.10±4.632
+0.227
+23.48±5.383
+24.01±4.775
+0.361
+23.71±4.433
+24.21±4.973
+Peer
+friendship
+19.98±4.604
+20.62±3.785
+0.143
+20.16±3.940
+19.98±4.081
+0.682
+19.66±4.788
+19.71±4.060
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+14/16
+Table 5
+Comparison of pre- and post-data of the three cohorts of seniors
+SD=Standard deviation
+Measures
+Batch 1 (n=55)
+Batch 2 (n=77)
+Batch 3 (n=83)
+Mean±SD
+P
+Mean±SD
+P
+Mean±SD
+Pre
+Post
+Pre
+Post
+Pre
+Post
+Empathy
+15.18±3.432
+14.93±4.311
+0.607
+14.81±3.133
+15.86±3.119
+0.001
+14.12±3.240
+15.23±3.070
+Social
+competence
+34.58±6.318
+33.49±9.363
+0.248
+33.99±4.890
+35.25±6.135
+0.010
+33.16±6.339
+34.63±5.965
+Altruism
+12.45±3.795
+12.76±4.586
+0.544
+13.79±3.318
+14.31±3.168
+0.131
+12.84±3.539
+13.71±3.549
+Parent
+relationship
+23.82±4.448
+23.42±6.232
+0.640
+23.70±4.368
+23.75±5.040
+0.917
+23.59±3.806
+24.16±4.452
+Peer
+friendship
+21.71±3.436
+20.16±5.918
+0.031
+21.34±4.005
+20.96±4.105
+0.400
+20.53±3.569
+20.41±3.659
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+15/16
+Table 6
+Agreement between the parents and adolescents (n=340)
+Mean±SD
+P
+Parent data
+Adolescent data
+Empathy
+13.90±3.052
+14.26±3.278
+0.131
+Altruism
+12.31±3.339
+12.84±3.614
+0.023
+Parent relationship
+27.10±5.084
+23.41±4.762
+<0.001
+Peer friendship
+10.29±3.113
+20.45±4.177
+<0.001
+SD=Standard deviation
+1/27/2021
+Effect of Residential Yoga Camp on Psychosocial Fitness of Adolescents
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521760/?report=printable
+16/16
+Table 7
+Comparison of the change scores between parents and adolescents (n=43)
+Outcome measures
+Data description
+Parent data set
+Adolescent data set
+Mean±SD
+P
+Mean±SD
+P
+Predata
+Postdata
+Predata
+Postdata
+Empathy
+12.47±2.914
+12.93±2.772
+0.446
+14.12±3.52
+14.84±3.703
+0.171
+Altruism
+10.35±3.101
+11±3.867
+0.372
+12.3±3.827
+13.65±3.484
+0.003
+Parent relationship
+24.95±5.3
+27.05±3.879
+0.035
+23.19±4.36
+23.88±4.3
+0.095
+Peer friendship
+9.51±2.53
+9.56±3.026
+0.929
+20.37±4.37
+20.58±3.923
+0.708
+SD=Standard deviation
+Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow
+Publications

subfolder_0/Effect of Yoga Program on Quality of Life in Adolescent Polycystic Ovarian Syndrome A Randomized Control Trial..txt

@@ -0,0 +1,694 @@
+1 23
+Applied Research in Quality of Life
+The Official Journal of the International
+Society for Quality-of-Life Studies
+ 
+ISSN 1871-2584
+ 
+Applied Research Quality Life
+DOI 10.1007/s11482-012-9191-9
+Effect of Yoga Program on Quality of
+Life in Adolescent Polycystic Ovarian
+Syndrome: A Randomized Control Trial
+Ram Nidhi, Venkatram Padmalatha,
+Raghuram Nagarathna & Ram
+Amritanshu
+1 23
+Your article is protected by copyright and
+all rights are held exclusively by Springer
+Science+Business Media Dordrecht and The
+International Society for Quality-of-Life Studies
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+Effect of Yoga Program on Quality of Life
+in Adolescent Polycystic Ovarian Syndrome:
+A Randomized Control Trial
+Ram Nidhi & Venkatram Padmalatha &
+Raghuram Nagarathna & Ram Amritanshu
+Received: 24 February 2012 /Accepted: 13 September 2012
+# Springer Science+Business Media Dordrecht and The International Society for Quality-of-Life Studies
+(ISQOLS) 2012
+Abstract Polycystic Ovarian Syndrome (PCOS) is a common female endocrine
+disorder challenging feminine identity which is likely to impact their quality of life.
+The aim of this study was to evaluate the effect of yoga on PCOS specific quality of
+life in adolescent girls with PCOS. Ninety adolescent (15–18 years) girls from a
+residential college in Andhra Pradesh, who satisfied the Rotterdam criteria, were
+randomized into two groups. The yoga group (n037) practiced a holistic yoga
+module while the control group (n035) practiced a matching set of physical exercises
+(1 h/day, for 12 weeks). PCOS specific quality of life was measured at inclusion and
+after 12 weeks. Mann-Whitney on difference score showed that the changes in all
+domains were significantly different between the two groups (p<0.05) except for
+infertility (p00.675). Wilcoxn signed ranks test showed yoga group observed greater
+improvement in emotional disturbances (effect size; Y:1.52, E: 0.72), body hair
+(effect size; Y: 1.02, E: 0.32), weight (effect size; Y: 0.96, E: 0.33) and menstrual
+problem (effect size; Y: 1.24, E: 0.64) domain as compared to the exercise group.
+Yoga program for 12 weeks is significantly better than physical exercise in improving
+PCOS quality of life in adolescent girls with PCOS.
+Keywords Adolescent PCOS . PCOSQ . Yoga
+Introduction
+Polycystic Ovarian Syndrome (PCOS) affects 2.2 % to as high as 26 % (Michelmore
+et al. 1999; Chen et al. 2008) of the women of reproductive age. Recently we found a
+Applied Research Quality Life
+DOI 10.1007/s11482-012-9191-9
+Funding Agency Central Council for Research in Yoga and Naturopathy (C.C.R.Y.N.), ministry of health,
+Government of India, New Delhi.
+R. Nidhi (*): V. Padmalatha: R. Nagarathna: R. Amritanshu
+Division of Yoga and Life Sciences, SVYASA University, #19, Eknath Bhavan, Gavipuram Cirlce
+Kempegowdanagar, Bangalore 560 019, India
+e-mail: [email protected]
+Author's personal copy
+9.13 % prevalence of PCOS in south Indian adolescent girls (Nidhi et al. 2011 Aug). Its
+pathophysiology is most likely a combination of genetic disposition and environ-
+mental factors and is not completely understood (Dunaif and Thomas 2001; Legro
+and Strauss 2002). The three most bothersome symptoms commonly reported by
+affected women are excess hair growth, irregular or absent menstruation, and infer-
+tility (Kitzinger and Willmott 2002). As a result, PCOS women face challenges to
+their feminine identity which is likely to impact their quality of life. (Elsenbruch et al.
+2003). Adolescent PCOS girls who are at the height of feminine identity development
+and awareness of body image, would have an equal or possibly higher disturbance in
+quality of life as compared to adult women and hence cannot be overlooked.
+Research has shown a lower Health Related Quality of Life (HRQol) in women
+with PCOS when compared with healthy controls (Elsenbruch et al. 2003; Hahn et al.
+2005; Coffey et al. 2006; Ching et al. 2007). One study measuring the HRQoL of
+adult Indian women with PCOS found a high prevalence of psychological distress in
+over 50 % of the women as measured by the Goldberg’s General Health
+Questionnaire-28 (GHQ-28) (Sundararaman et al. 2008).
+The first published data to focus specifically on adolescents with PCOS and their
+HRQL were collected from a cohort of women in Boston, wherein the measure of
+HRQL used was The Child Health Questionnaire–Child Self-Report Form (CHQ-
+CF87) (Trent et al. 2002). Findings from this study demonstrated that adolescents
+with PCOS had lower HRQoL than their healthy counterparts.
+In 1998, Cronin et al. reported polycystic ovary syndrome health-related QoL
+questionnaire (PCOSQ) (Cronin et al. 1998) which is the only specific measure for
+assessing HRQoL in PCOS. Studies employing the PCOSQ consistently demonstrate
+that women with PCOS experience impairments of functioning related to all mea-
+sured domains: body hair, emotions, infertility, weight and menstrual problems
+(Schmid et al. 2004; McCook et al. 2005; Coffey et al. 2006; Ching et al. 2007).
+Though, there are variations which could be attributed to cultural differences. How-
+ever there are fewer data in adolescents with PCOS although this population repre-
+sents an enormous opportunity to intervene early.
+Lifestyle interventions have been suggested as the first-line treatment for PCOS,
+especially in adolescent age groups. A recent study on adolescents with PCOS,
+comparing the effect of metformin with placebo, in a lifestyle modification program
+combined with oral contraceptives (OC) suggested that the addition of metformin
+does not add improvement to PCOSQ scores above those observed with lifestyle
+modification and OC treatment (Harris-Glocker et al. 2010).
+Also, recently Thomson et al. (Thomson et al. 2010) observed improvements in
+quality of life (PCOSQ) and depression amongst overweight women with PCOS after
+a 20 weeks energy-restricted diet with and without exercise (aerobic only or com-
+bined aerobic-resistance exercise).
+Experts agree that Complimentary and Alternative Medicine (CAM) treatments
+may have beneficial effects in PCOS but well-designed studies are needed (Raja-
+Khan et al. 2011).Yogic life style, a form of holistic mind-body medicine, is found to
+be effective in improving the QOL in several chronic conditions such as chronic low
+backache (Tekur et al. 2010), osteoarthritis of knee joint (Ebnezar et al. 2011),
+fibromyalgia (da Silva et al. 2007), rheumatoid arthritis (Haslock et al. 1994) and
+cancer (Raghavendra et al. 2008).
+R. Nidhi et al.
+Author's personal copy
+However till the date there have been no published data on adolescent PCOS
+assessing the effects of yogic interventions. Thus the present study was planned to
+evaluate the effect of yoga on PCOS specific quality of life in adolescent girls with
+PCOS.
+Material and Methods
+Participants
+Adolescent girls aged 15–18 years and with a BMI>18.5 kg/m2 were enrolled from a
+residential college in Anantapur, Andhra Pradesh, India. We used Rotterdam
+diagnostic criteria (2/3 of the features) to identify subjects (Rotterdam ESHRE/
+ASRM-Sponsored_PCOS_Consensus_Workshop_Group 2004). The following
+were the definitions of the three features: Oligo/amenorrhea: absence of
+menstruation for 45 days or more and/or less than eight menses per year
+(Kumarapeli et al. 2008). Clinical hyperandrogenism: Modified Ferriman and
+Gallway (mFG) score of 6 or higher (Chen et al. 2008). Biochemical hyperandrogen-
+ism: Serum testosterone level of >82 ng/dl in the absence of other causes of Hyper-
+androgenism. Poly cystic ovaries: presence of >10 cysts, 2–8 mm in diameter, usually
+combined with increased ovarian volume of >10 cm3, and an echo-dense stroma in
+pelvic ultrasound scan (Franks et al. 1997).
+Exclusion criteria were: use of oral contraceptives/hormone treatment/insulin-
+sensitizing agents within previous 6 weeks, smoking, hyperprolactinemia, thyroid
+abnormalities, non-classic adrenal hyperplasia and prior experience of yoga. Those
+who satisfied the Rotterdam’s criteria for PCOS were then randomly assigned to two
+groups using a computer-generated random number table by the pre labelled sealed
+envelope method.
+The study was approved by the Institutional Ethical Committee of Swami Vive-
+kananda Yoga 4 Anusandhana Samsthana (SVYASA) University. Signed Informed
+consent was obtained from the college authorities, the student and one of the parents.
+Design
+This was a prospective, randomised, active interventional controlled trial in which 90
+participants were randomly divided into two study arms: one arm practiced yoga and
+the other arm practiced conventional physical exercises for the same duration.
+Methods
+Based on random number table participants were assigned to two interventions. Pre
+assessment was carried out a day before commencing the intervention and post
+assessment was done the day after. Two different halls in the college premises were
+allotted for yoga and control group practices. Both groups practiced their respective
+set of practices, one hour daily, 7 days a week for 12 weeks (total 90 sessio ns), under
+the supervision of trained instructors. The daily routine in the class consisted of
+lecture (5 min) followed by physical practices (40 min), pranayama (5 min) and
+Effect of Yoga Program on Quality of Life in Adolescent PCOS
+Author's personal copy
+relaxation (10 min). The instructors maintained the register of daily attendance and
+the reason for absence if any.
+Blinding and Masking
+Double blinding was not possible as this was an interventional study. The medical
+officer who assessed the questionnaires, ultrasonologist and the laboratory staff were
+all blind to the groups. Also the statistician who did the randomization and the final
+analysis was blind to the source of the data.
+Assessments
+Abdominal ultrasound scanning of the pelvis with special attention on ovaries was
+carried out by a certified postgraduate medical ultrasonologist using Philips HD
+11XE ultrasound system. Vaginal ultrasound scanning was not acceptable to the girls
+or the parents.
+Fasting sample of venous blood (10 ml) was analyzed at certified laboratories.
+Prolactin (PRL) estimates were done by Fully Automated Bidirectionally Interfaced
+Chemi Luminescent Immuno Assay (Abbot Park, IL) with CV below 10 %. Thyroid
+Stimulating Hormone (TSH) was measured by Ultra Sensitive Sandwich Chemi
+Luminescent Immuno Assay (Immulite, USA) with CV below 7 %.
+Polycystic Ovary Syndrome Questionnaire (PCOSQ), a questionnaire developed
+to measure the health-related quality of life (HRQoL) of women with polycystic
+ovary syndrome consists of a total of 26 items grouped into 5 domains: emotions (8
+items), body hair (5 items), weight (5 items), infertility (4 items), and menstrual
+problems (4 items). Each question is associated with a 7-point scale in which 7
+represents optimal function and 1 represents the poorest function. Scoring is done by
+dividing each domain total score by the number of items in the domain. A score of
+less than 5 for any domain indicates significant adverse impact.
+In year 2004, Jones et al. (Jones et al. 2004) showed that all PCOSQ dimen-
+sions were internally reliable with Cronbach’s a scores ranging from 0.70 to 0.97.
+Intra-class correlation coefficients to evaluate test & retest reliability were high (range
+0.89±0.95, P<18 0.001).
+Intervention
+The specific modules of intervention were developed by a team of experts that
+included a physiatrist, a gynaecologist and yoga therapy physician. Care was taken
+to match the lectures, practical classes and the type of relaxation technique used in the
+two modules.
+Yoga Intervention
+The concepts for the intervention were taken from traditional yoga scriptures (Patanjali
+yoga sutras, Upanishads and Yoga Vasishtha) that highlight a holistic approach to health
+management (Nagendra 2004). The practices consisted of asanas (yoga postures),
+pranayama, relaxation techniques, meditation, and lectures on yogic lifestyle and
+R. Nidhi et al.
+Author's personal copy
+stress management through yogic counselling. All girls received at least one session
+(about one hour each) of individualized counselling that was aimed at cognitive
+restructuring based on yoga philosophy.
+Pranayama included yogic breathing practices to achieve a slow rhythmic pattern
+of breathing with internal awareness. A prolonged easy, slow exhalation is the safest
+way to get mastery over the mind (Nagendra 2000).
+Meditation, considered to be a part of yoga, (antaranga yoga) is a valuable tool to
+calm down uncontrollable surge of negative emotions that may contribute to poor
+quality of life. Lectures and individual yogic counselling for stress management to
+bring about a notional correction were focused on ‘happiness analysis’ (Swami
+Lokeswarananda 1996).
+Control Intervention
+Table 1 shows the hour long module of practices for the control group that consisted
+of a set of physical movements, non-yogic safe breathing exercises followed by
+supine rest (without instructions) that were matched with the yoga module. One
+session of counselling was ensured for the students in the control group also. Care
+was taken by the counsellors not to introduce any of the yogic references during these
+sessions while maintaining the objective of the session to keep up with those of the
+yoga groups.
+Data Analysis
+All statistical analyses were performed using SPSS version 17.0. Kolmogorov–
+Smirnov test was used to check for normal distribution. As our objective was to
+compare the changes after yoga with that of exercise and the data were not normally
+distributed, non-parametric analysis was done by using Mann–Whitney U test to
+compare difference scores (delta change) between the two groups wherein difference
+score was calculated by subtracting pre from post values for each variable.
+Results
+Figure 1 describes the trial profile. The recruitment was carried out between Decem-
+ber 2009 and January 2011. Of 986 girls who agreed for clinical examination, 154
+girls with oligomenorrhea and/or hirsutism (as per the above said definitions) were
+asked to come for ultrasound and hormonal investigations. After the laboratory
+evaluations 90 girls who satisfied Rotterdam criteria of PCOS, were randomized into
+2 groups. Of these, there were total 18 dropouts, 8 in the yoga group and 10 in the
+control group because of less than 75 % attendance.
+The reasons (not confirmed) given for withdrawal were (a) sick leave and (b)
+unexpected events in the family. The final analysis was done on 72 participants, 37 in
+the yoga group and 35 in the control group.
+Table 2 shows the demographic data. Of the 90 girls recruited, 82.2 % (74/90) were
+of normal weight (BMI018.5 to 23) and only 17.78 % (16/90) were overweight
+Effect of Yoga Program on Quality of Life in Adolescent PCOS
+Author's personal copy
+(BMI>23) and 31.11 % (28/90) had mFG score ≥6. A total of 66.67 % (60/90) girls
+had their menstrual cycle length between 60 to 90 days.
+Wilcoxon signed ranks test (Table 3) showed yoga group observed greater improve-
+ment in emotional disturbances (Y: p<0.001, E: p<0.01), body hair (Y: p<0.001,
+E: p>0.05), weight (Y: p<0.001, E: p>0.05) and menstrual problem (Y: p<0.001,
+E: p<0.001) domain as compared to the exercise group. For infertility domain
+exercise group (E: p<0.01) showed significant improvement as compared to the
+non-significant change in yoga group (Y: p>0.05). Mann-Whitney on difference
+Table 1 Matched practices between yoga and control groups
+Yoga group
+Time
+Control group
+Time
+Group Lecture:
+8min
+Group Lecture:
+15min
+Lectures, in the form of cognitive
+restructuring based on the spiritual
+philosophy underlying yogic concepts.
+Lectures on conventional modern medical
+concepts about a healthy lifestyle
+including diet, exercise.
+Surya Namaskara (Sun Salutation)
+10min Brisk Walk
+15min
+Prone Asanas
+Prone Exercises
+Cobra Pose (Bhujangasana)
+1min
+Prone Head Lift
+1min
+Locust Pose (Salabhasana)
+1min
+Prone Leg Rising
+1min
+Bow Pose (Dhanurasana)
+1min
+Tiger Leg Stretch
+1min
+Standing Asanas
+Standing Exercises
+Triangle Pose (Trikonasana)
+1min
+Spread Leg Side Bending
+1min
+Twisted Angle Pose (Parsva-konasana)
+1min
+Spread Leg Twisted Bending
+1min
+Spread Leg Intense Stretch (Prasarita
+padottanasana)
+1min
+Spread Leg Forward Bend
+1min
+Supine Asanas
+Supine Exercises
+Inverted Pose (Viparita Karni)
+1min
+Straight leg raising
+1min
+Shoulder Stand (Sarvangasana)
+1min
+Straight Leg Supine Twist
+1min
+Plough Pose (Halasana)
+1min
+Cycling (Clockwise – Counter
+Clockwise)Bended knee Crunches
+1min
+Sitting Asanas
+Sitting Exercises
+Sitting Forward Stretch
+(Paschimottanasana)
+1min
+Spread Leg Forward Bend
+1min
+Fixed angle Pose (Baddha-konasana)
+1min
+Spread Leg Alternate Toe Touching
+1min
+Garland Pose (Malasana)
+1min
+Squat pose
+1min
+Guided relaxation (Savasana)
+10min Supine Rest
+10min
+Breathing Techniques (Pranayama)
+Normal Breathing
+8min
+Sectional Breathing (Vibhagiya-
+Pranayama)
+4min
+Forceful Exhalation (Kapala Bhati)
+2min
+Right Nostril Breathing (Suryanuloma
+Viloma)
+2min
+Alternate nostril breathing (Nadi suddhi)
+2min
+OM Meditation (OM Dhyana)
+10min
+R. Nidhi et al.
+Author's personal copy
+score showed that the changes in all domains were significantly different between the
+two groups (p<0.05) except for infertility (p00.675).
+Discussion
+This is the first randomised controlled trial comparing the effect of a 12 weeks yoga
+program with physical exercise on PCOS quality of life in adolescent PCOS. Present
+Screened (n=986)
+Unsuitable (n=832)
+Randomized (n=90)
+Control (n=45)
+Yoga (n=45)
+completed (n=37)
+completed (n=35)
+Drop Out 
+(n=10)
+Drop Out (n=8)
+Excluded (n=64)
+Presence of Clinical Symptoms (n=154)
+Clinical Examination
+Laboratory Evaluation
+Fig. 1 Trial profile
+Table 2 Demography of girls recruited in the study
+S.No.
+Variables
+Yoga (n042)
+Control (n043)
+1.
+Age, yrs (mean ± S.D.)
+16.22±1.13
+16.22±0.93
+2.
+Ht, m (mean ± S.D.)
+1.54±0.06
+1.56±0.05
+3.
+Wt, Kgs (mean ± S.D.)
+47.92±6.20
+51.14±7.39
+4.
+BMI, Kgs/m2 (mean ± S.D.)
+20.30±1.92
+21.22±2.99
+5.
+No. of girls with BMI≤23
+37
+34
+No. of girls with BMI>23
+5
+9
+6.
+mFG Score
+4.60±2.02
+4.20±2.13
+No. of girls with mFG score <6
+30
+32
+No. of girls with mFG score ≥6
+15
+13
+7.
+Menstrual Frequency in months (mean ± S.D)
+1.41±0.8
+1.47±0.87
+No. of girls with cycle length of 45 to <60 days
+9
+9
+No. of girls with cycle length of 60 to <90 days
+14
+16
+No. of girls with cycle length of ≥90 days
+19
+18
+Ht: Height, Wt: Weight, BMI: Body Mass Index, Mfg score: Modified Ferriman and Gallway Score for
+hirsutism
+Effect of Yoga Program on Quality of Life in Adolescent PCOS
+Author's personal copy
+study observed higher baseline values for weight domain as compared to the study by
+Ladson et al. (Ladson et al. 2011) on PCOS adolescents (aged 13–18 years) from
+United States. Although Ladson’s study enrolled girls with a BMI>27 kg/m2 in
+comparison to the present study where 82.2 % of PCOS girls were of normal BMI
+(≤23 kg/m2), the perception of Indian adolescents about their body weight and image
+appears to be different from the American adolescents. This is perhaps not surprising
+given that recent research has pointed out that measuring waist circumference along
+with BMI is important, as WC is more indicative of the total body fat and the amount
+of metabolically active visceral fat and therefore recognized as a more accurate
+measure of the metabolic risk (Haslam et al. 2006). This is why the Indian
+population with an increased possibility for hypertension, diabetes and
+dyslipidemia have lower BMI thresholds to reflect the risk for this population
+(Misra et al. 2009). Therefore central obesity, being considered unattractive in this
+age group could cause poor body image in spite of low BMI.
+The scores on infertility domain were lower in our study as compared to Ladson et
+al. (2011) study. Unlike other RCT where the girls were recruited from a hospital or a
+medical college because they were seeking help for their problem, subjects in our
+study were screened from a girl’s college where they were not previously diagnosed
+and hence they were not aware of the long term impact of PCOS on infertility. This
+might have caused a drop in the scores for infertility domain.
+The scores on the other three domains (emotion domain, body hair domain and
+menstrual problem domain) in our study were similar to that of Ladson’s (Ladson et al.
+2011) study. One of the limitations of the study could be the baseline differences for
+emotional, body hair and weight domain with control group having higher values. As
+this might have affected the hope for and trust in a personal change over the variables.
+The mechanism of action for yoga can be traced to Hypothalamic-pituitary-adrenal
+axis (HPA) and sympatho-adrenal activity. It has been shown that PCOS and the related
+metabolic syndromes, such as hyperandrogenemia, hyperinsulinemia and insulin resis-
+tance are associated with disturbed activity of the sympathetic nervous system (Mancia
+Table 3 Changes in PCOSQ domains post intervention [Yoga (Y)037, Exercise (E)035]
+Domains
+Groups
+Pre
+(mean ± SD)
+Post
+(mean ± SD)
+Within
+grp
+effect size
+Wilcoxon
+Signed
+Ranks test
+Between
+grp
+effect size
+Mann-Whitney
+on diff score (sig.)
+Emotional
+disturbances
+Y
+4.51±1.12
+2.51±1.00
+1.52
+0.000
+0.247
+0.001
+E
+3.92±1.03
+3.03±1.04
+0.72
+0.001
+Body Hair
+Y
+3.33±1.40
+2.02±1.16
+1.02
+0.000
+0.128
+0.002
+E
+2.70±1.31
+2.36±1.46
+0.32
+0.097
+Weight
+Y
+4.44±1.72
+2.92±1.53
+0.96
+0.000
+0.124
+0.018
+E
+3.79±1.48
+3.27±1.27
+0.33
+0.071
+Infertility
+Y
+2.14±0.89
+1.83±0.90
+0.31
+0.085
+0.16
+0.675
+E
+2.02±0.88
+1.58±0.61
+0.52
+0.002
+Menstrual
+problem
+Y
+4.86±1.40
+2.51±1.17
+1.24
+0.000
+0.262
+0.008
+E
+4.33±1.44
+3.20±1.36
+0.64
+0.000
+R. Nidhi et al.
+Author's personal copy
+et al. 2007). Increased sympathetic and decreased parasympathetic activity in PCOS
+has been documented through heart rate variability, a measure of cardiac autonomic
+control (Yildirir et al. 2006) and also through direct intra-neural recordings
+(Sverrisdottir et al. 2008). There are evidences proving efficacy of yoga in reducing
+cortisol levels (Kamei et al. 2000) and stress arousal by modulating sympathetic
+nerve activity (Vempati and Telles 2002) and sympathetic activity (Vempati and
+Telles 2002) in normal population. Also, it has been reported that, practicing inte-
+grated yoga as a means to manage and relieve both acute and chronic stress helps
+individuals overcome other co-morbidities associated with metabolic diseases and
+leads to improved quality of life (Michalsen et al. 2005 Dec; Oken et al. 2006).
+Therefore, we hypothesize that yoga may lead to significant improvement in quality of
+life of young PCOS girls by modulating sympathetic activity in addition to its physical
+activity effect.
+As a non-pharmacological form of treatment, yoga based interventions are
+effective in not only improving quality of life in PCOS but it may also prevent
+the long term morbidities. In a recent study, mind-body based program focusing
+on cognitive behaviour therapy, relaxation training, negative health behaviour
+modification, and social support components was associated with increased
+pregnancy rates for cycle 2 of IVF cycle (Domar et al. 2011 Jun). Also studies
+shown the beneficial effects of yoga as an intervention in increased insulin sensitivity
+in healthy male population (Chaya et al. 2008) and in reducing fasting blood glucose
+and improving lipid profiles in obesity and diabetes (Singh et al. 2004).
+Further, yoga is a cost-effective and enduring therapy. This treatment paradigm for
+PCOS in adolescents is promising for long-term prevention and ameliorating its ill
+effects. Pharmacological agents used extensively in the treatment of PCOS with
+mixed results, short term benefits and side effects such as nausea, diarrhoea and
+abdominal cramps, have triggered researchers and patients to seek help through
+alternative non pharmacological therapies. Yoga a non-pharmacological intervention
+is available as an adjuvant therapy or as a primary intervention to improve the
+response of modern medicine.
+Restriction to a highly selective age group and also the small sample size raises the
+question of generalizability of the conclusions of this study. And hence more studies
+are required on larger sample size and different age groups and ethnicities and also
+follow up studies are required with an intention to test the prolonged effects of these
+interventions.
+Conclusion
+Twelve weeks of a holistic yoga program in adolescent PCOS is significantly better
+than physical exercise program in improving selected measures quality of life.
+Acknowledgements
+We are thankful to the Central Council for Research in Yoga and Naturopathy
+(C. C.R.Y.N.), ministry of health, Government of India, New Delhi for funding this project.
+We would like to place on record our gratitude for the support provided by the Vice Chancellor,
+SVYASA University. We gratefully acknowledge the co-operation of the staff and administration of Sri
+Sai College in recruiting the students and carrying out the study.
+Effect of Yoga Program on Quality of Life in Adolescent PCOS
+Author's personal copy
+Declaration
+NR contributed to conception and design, or acquisition of data, or analysis and interpre-
+tation of data; PV have been involved in conception and revising the manuscript critically for important
+intellectual content; RN contributed to conception, design and revising the manuscript and AR have
+contributed to design, acquisition of data and analysis and all the authors have given final approval of
+the version to be published.
+Ethical Approval
+The study was approved by the Institutional Ethical Committee of Swami Vivekananda
+Yoga Anusandhana Samsthana (SVYASA) University (vide project # SVYASA0012/08).
+Conflict of Interest
+It is declared that none of the authors involved in this study have any conflict of
+interest and that all authors of this article have contributed to their fullest capacities.
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+Effect of Yoga Program on Quality of Life in Adolescent PCOS
+Author's personal copy

subfolder_0/Effect of Yoga on Psychological Functioning of Nursing Students A Randomized Wait List Control Trial.txt

@@ -0,0 +1,804 @@
+Journal of Clinical and Diagnostic Research. 2017 May, Vol-11(5): KC01-KC05
+1
+DOI: 10.7860/JCDR/2017/26517.9833
+Original Article
+Complementary/alterna­
+tive medicine section
+Effect of Yoga on Psychological 
+Functioning of Nursing Students: 
+
+A Randomized Wait List Control Trial
+INTRODUCTION
+As per a systematic review conducted till 2010, reported sources 
+of stress in nursing students are related to their academic activities 
+and clinical practice [1]. However, perceived stress was associated 
+more with the clinical practice than the academic demands, resulting 
+in more psychological symptoms [2] and also gastrointestinal 
+symptoms [3]. Considerably, nursing students have more stress and 
+anxiety than other students [4], especially more in female students 
+[5]. So, there is a need for physical activity and stress management 
+in nursing students to maintain their health [6].
+In our study, the following psychological variables; mindfulness, 
+self-compassion, empathy, resilience, and satisfaction with life were 
+included. Mindfulness is being aware of the present moment to 
+one’s own experiences [7]. Being mindful aids in stress management 
+[8]. According to Neff, self compassion is being warm and caring 
+at times of hardship, being kind to self, accepting suffering or 
+unpleasant experiences as it is and being non judgmental [9]. 
+Moving ahead, empathy is an essential professional quality a 
+student nurse should possess to provide quality health care to 
+the patients. In this study, empathy on cognitive dimension was 
+measured. Empathy can be defined as, “a predominantly cognitive 
+attribute that involves understanding of the patient’s experiences, 
+concerns, and perspectives with a capability to communicate this 
+understanding and an intention to help [10]”. In Congruent with the 
+professional requirement, many studies have reported that nursing 
+students have higher levels of empathy than other undergraduate 
+students [11-13]. Nevertheless, female nursing students are 
+more empathetic than male students [12,13]. Also, higher level of 
+empathy and resilience was reported in older nursing students [14]. 
+According to the American Psychological Association, resilience can 
+be defined as, “the process of adapting well in the face of adversity, 
+trauma, tragedy, threats or even significant sources of stress [15]”. 
+Substantially, resilience aids in the retention of students in the 
+academic program [16], and in their academic success [17] and, 
+this helps them to cope effectively with adversities in the clinical 
+setting [18]. Satisfaction with life is a subjective judgment about his 
+or her life [19]. However, nursing students have reported higher level 
+of life satisfaction [5] than compared to other students [20]. 
+Indeed, physical fitness is associated with perceived physical and 
+psychological health. Nursing students have reported poor to 
+moderate levels of physical fitness and this needs to be addressed 
+through appropriate intervention [21,22]. Yoga is an effective 
+practice to reduce stress [23] and improve psychological well being 
+[24,25]. Hence, the present study was designed to evaluate the 
+effectiveness of eight week yoga intervention to reduce perceived 
+stress and to enhance psychological well being among nursing 
+students.
+MATERIALS AND METHODS
+The present study was a randomized WLC trial. Total of 100 students 
+{1st and 2nd year General Nursing and Midwifery (GNM) and 1st to 
+3rd year BSc Nursing} were recruited from Kempegowda Institute 
+of Nursing, Bengaluru, Karnataka, India. In this study, female 
+students aged between 17-30 years and who were willing to learn 
+yoga were included. However, students who were diagnosed with 
+severe neurological or psychiatric illness, those students receiving 
+treatment for hormonal imbalance, recently underwent surgical 
+intervention, and regularly practicing yoga was excluded. The 
+Monali Devaraj Mathad1, Balaram Pradhan2, Rajesh K Sasidharan3
+Keywords:	Mindfulness, Nursing education, Perceived stress, Resilience, Self compassion
+ABSTRACT
+Introduction: Nursing students experience considerable 
+amount of stress to meet their professional demands. Yoga is 
+an effective practice to reduce stress and improve psychological 
+well being. However, improvement in psychological well being 
+aids in stress management.
+Aim: To evaluate the effectiveness of eight week yoga 
+intervention on psychological functioning of nursing students.
+Materials and Methods: This was a randomised Wait List 
+Control (WLC) trial, we recruited total 100 students from 
+Kempegowda Institute of Nursing, Bengaluru, Karnataka, India 
+and randomized them into two groups (yoga=50 and WLC=50 
+students). The following instruments were used to collect the 
+data, Freiburg Mindfulness Inventory (FMI), Self-Compassion 
+Scale- Short Form (SCS-SF), Connor–Davidson Resilience Scale 
+(CD-RISC), Satisfaction with Life Scale (SWLS), Jefferson Scale 
+of Empathy HPS-Version (JSE-HPS), and Perceived Stress Scale 
+(PSS). Data was analysed using Repeated Measures Analysis 
+of Variance (RM-ANOVA) followed by post-hoc Bonferroni 
+correction for all psychological variables.
+Results: The results of our study report that eight week yoga inter­
+vention was significantly effective in improving self compassion 
+and mindfulness among nursing students in experimental 
+group than compared to WLC group. Even though there were 
+improvements in resilience, satisfaction in life and perceived 
+stress, results were not statistically significant.
+Conclusion: Overall, results of the present study have 
+demon­
+strated impact of eight week yoga intervention on the 
+psychological functioning of nursing students. Yoga intervention 
+can be inculcated in the nursing education to meet demands of 
+the profession.
+Monali Devaraj Mathad et al., Effect of Yoga on Psychological Functioning of Nursing Students- A Randomized Wait List Control Trial	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2017 May, Vol-11(5): KC01-KC05
+2
+research study was carried out between May 2015 to July 2015. 
+After screening, students were randomly allocated into two groups. 
+Yoga group received yoga intervention for eight week {five days/
+week, one hour/day} and the WLC group continued their routine 
+work for the first eight week. After the completion of study, yoga 
+intervention was given to WLC group also.
+Sample Size 
+A priori computation of sample size using G* Power version 3.1.9.2, 
+revealed 64 participants were required with an effect size 0.347 [26] 
+at an alpha value of 0.05 and with an actual power of 0.80.
+Ethical Approval
+Approval of Institutional Ethics Committee was obtained for this 
+study {RES/IEC-SVYASA/59/2015} and informed consent was 
+obtained from all the students who were recruited for the research 
+study.
+Intervention
+The yoga intervention was based on integrated approach to yoga 
+therapy as designed by S-VYASA [27]. Details of yoga intervention 
+are described in the [Table/Fig-1]. 
+Assessments
+Data were collected using sociodemographic sheet and five self 
+reported questionnaires. 
+Sociodemographic sheet included name, age, religion, level of 
+education, and address.
+FMI: The FMI is a self report questionnaire to measure mindfulness. 
+This scale consists of 14 items and is very sensitive to change in 
+mindfulness. Each item has a 4-point Likert rating from 1 (Rarely) 
+to 4 (Almost always). The total score will range between14 to 56, 
+high score represents high mindfulness. This scale has a sound 
+psychometric properties and reported Cronbach’s alpha is 0.86 [28].
+CD-RISC 10: This is a brief, self report questionnaire to measure 
+resilience. In this study, 10 items scale was used. Response to each 
+item will be from 0 (not true at all) to 4 (true nearly all the time). The 
+range of total score is from 0 to 40. High score corresponds to high 
+resilience. This scale has a robust psychometric properties [29], 
+with Cronbach’s alpha=0.85 [30].
+SCS-SF: This is a self report questionnaire to measure self-
+compassion. In this study, we have used 12 items scale. Response 
+for each item will be between 1 (Almost never) to 5 (Almost always). 
+Scores can range from 12 to 60; one who scores high has high 
+level of self compassion. The SCS–SF is a reliable and valid tool to 
+assess self compassion with reported Cronbach’s alpha is ≥0.86. 
+This scale has a close correlation with the long form of SCS r ≥0.97 
+for all samples [31].
+SWLS: This is a short 5-item questionnaire to measure global 
+cognitive judgments of satisfaction with one’s life. This scale 
+requires about one minute to complete the test. Each item must be 
+scored on a 7-point Likert rating between 1 (Strongly Disagree) to 
+7 (Strongly Agree). This scale has a good psychometric properties 
+and can be widely used among wide range of age groups with 
+average alpha coefficient 0.85 [19]. Satisfaction with life scale also 
+focuses on emotional well being or underlying psychopathology of 
+an individual as the evaluation is based on his own criteria [32].
+JSE-HPS: This is a 20 item scale designed to measure empathy 
+(cognitive). Each item should be scored on a 7-point Likert rating 
+between 1 (Strongly Disagree) to 7 (Strongly Agree). The total score 
+will range between 20 to 140. High score corresponds to high level 
+of empathy. This scale has reported robust psychometric properties 
+with Cronbach’s alpha 0.78 and 0.93 among nursing students of 
+southeastern part of USA [33].
+PSS: This is a self reported questionnaire to assess perception of 
+stress in one’s day-to-day life. This is a 10-item questionnaire. Each 
+item should be rated on 5-point Likert scale 0 (Never) to 4 (Very 
+Often). High score represents high level of perceived stress. This 
+scale has reported adequate psychometric properties [34,35].
+Statistical Analysis
+Data were analysed using SPSS 16.0 version. RM-ANOVA 
+followed by post-hoc Bonferroni correction was performed for all 
+psychological variables with the level of significance at p<0.05. 
+RESULTS
+The trial profile of the study is depicted in the [Table/Fig-2]. For this 
+study, 100 students were recruited, 50 participants in each group 
+and there were 10 dropouts in each group. Finally, for analysis there 
+were 80 students left. 
+The age of all participants in the yoga group was 19.65±1.48 and in 
+the WLC group was 19.35±1.03. Characteristics of the participants 
+are reported in the [Table/Fig-3]. It is apparent from this table that 
+majority of the students belong to Hindu religion and their mother 
+tongue was kannada. In this study, all the participants were females, 
+single and were residing in the college hostel.
+Proceeding further, data was analysed using Repeated Measure 
+of Analysis of Variance (RM-ANOVA). Results are reported in the 
+Sl. No.
+Intervention
+Approximate 
+time for the 
+practice
+Schedule
+1
+Basic Instructions
+15 minutes
+First day
+2
+Breathing practices-
+Hands in and out breathing,
+Hand stretch breathing,
+Ankle stretch breathing,
+Leg raising (Alternative and both legs). 
+breathing,
+Tiger breathing,
+Rabbit (Shashanka) breathing
+10 minutes
+Daily-first week
+to 8th week
+3
+Loosening practices-
+Twisting, 
+Side bending, 
+Forward and backward bending 
+Jogging
+10 minutes
+Daily-first week
+to 8th week
+4
+Sun salutation
+(Suryanamaskara)
+10-12 minutes
+Daily-first week
+to 8th week
+5
+Asanas (postures)
+Standing posture-
+Half wheel posture (Ardhacakrasana)
+Foot palm posture (Padahastasana)
+Half waist rotation posture 
+(Ardhakaticakrasana)
+Tree posture (Vrkshasana)
+Triangle posture (Trikonasana)
+Sitting posture-
+Diamond posture (Vajrasana)
+Rabbit posture (Shashankasana)
+Spinal twist posture (Vakrasana/ 
+Ardhamatsendrasana)
+Camel posture (Ustrasana)
+Posterior stretch (Paschimottanasana)
+Supine asana
+Fish posture (Matsyasana)
+Shoulder stand posture (Sarvangasana)
+Prone asana
+Cobra posture (Bhujangasana)
+Grasshopper posture (Shalabhasana)
+Bow posture (Dhanurasana)
+10-15 minutes
+Daily-first week
+to 8th week
+6
+Quick Relaxation Technique (QRT)
+3 minutes
+Daily-first week
+to 8th week
+7
+Pranayama-
+Kapalabhati
+Nadishodana pranayama
+Bhramari chanting
+8-10 minutes
+Daily-From 2nd 
+week
+8
+Yogic games (Krida yoga)
+8-10 minutes
+Alternative days
+9
+Meditation
+5 minutes
+Once in a 
+month
+10 
+Lecture session 
+10 minutes
+Once in a 
+month
+[Table/Fig-1]: List of yoga practices in the yoga module.
+www.jcdr.net	
+Monali Devaraj Mathad et al., Effect of Yoga on Psychological Functioning of Nursing Students- A Randomized Wait List Control Trial
+Journal of Clinical and Diagnostic Research. 2017 May, Vol-11(5): KC01-KC05
+3
+[Table/Fig-2]: Trial profile.
+and self compassion among nursing students in yoga group than 
+compared to WLC group. Even though, we could not elicit statistical 
+significance the following improvements were witnessed among 
+participants of yoga group in contrast to WLC group. There was 
+improvement in resilience and perceived stress in yoga group but 
+not in WLC group. However, there was improvement in satisfaction 
+with life among both the groups. Contrary to our expectation, 
+decrease in the empathy was reported in both the groups, but 
+significant decrease was noticed in WLC group.
+Characteristics of the 
+participants 
+N (%)
+Yoga group 
+(40)
+WLC group
+(40)
+Class/batch
+1st year GNM
+2nd year GNM
+1st year BSc
+2nd year BSc
+3rd year BSc
+17 (42.5%)
+6 (15%)
+5 (12.5%)
+5 (12.5%)
+7 (17.5%)
+10 (25%)
+10 (25%)
+7 (17.5%)
+7 (17.5%)
+6 (15%)
+Religion
+Hindu
+Christian
+Muslim
+29 (72.5%)
+9 (22.5%)
+2 (5%)
+26 (65%)
+14 (35%)
+-
+Mother tongue
+Hindi 
+Kannada
+Others
+-
+26 (65%)
+14 (35%)
+1 (2.5%)
+23 (57.5%)
+16 (40%)
+[Table/Fig-3]: Characteristics of the participants.
+For self compassion, within group comparison (ANOVA) did not 
+show significant improvement, F (1,78) = 1.894, p = 0.173. Whereas, 
+interaction between time x group reported significant improvement, 
+F (1,78) = 4.506, p = 0.037. Results of post-hoc analysis with 
+Bonferroni adjustment reported significant improvement within the 
+yoga group (p = 0.016), but there was no significant improvement 
+within the WLC group (p = 0.599).
+Within group comparison (ANOVA) did not show significant increase 
+in satisfaction with life, F (1, 78) = 1.768, p = 0.187. Likewise, in 
+interaction between time x group also there was no significant 
+Psychological
+Variables
+Group
+Pre
+M ± 
+SD
+Post
+M± SD
+% change
+Within group
+Between group
+Group x
+Time
+Diff
+p-value
+pre vs pre
+post vs post
+Self-compassion
+Yoga 
+3.03±
+0.46
+3.19±
+0.28
+5%
+0.16
+0.016*
+0.18
+0.01
+0.037*
+WLC
+3.22±
+0.46
+3.18±
+0.40
+-1%
+-0.04
+0.599
+Satisfaction with life
+Yoga 
+21.60±
+5.02
+22.40±
+5.29
+4%
+0.80
+0.232
+0.75
+0.40
+0.711
+WLC 
+22.35±
+5.07
+22.80±
+4.78
+2%
+0.45
+0.500
+Mindfulness 
+Yoga 
+37.09±
+3.74
+39.46±
+4.97
+6%
+2.37
+0.005*
+1.18
+2.68
+0.001**
+WLC 
+38.28±
+4.92
+36.78±
+5.64
+-4%
+-1.5
+0.073
+Resilience 
+Yoga 
+23.20±
+5.83
+23.68±
+5.92
+2%
+0.48
+0.633
+1.13
+0.73
+0.196
+WLC 
+24.33±
+6.05
+22.95±
+5.47
+-6%
+-1.38
+0.176
+Empathy 
+Yoga 
+97.50±
+13.02
+93.37±
+14.50
+-4%
+-4.13
+0.074
+3.45
+3.87
+0.895
+WLC 
+94.05±
+12.89
+89.50±
+11.60
+-5%
+-4.55
+0.049*
+Stress 
+Yoga 
+20.80±
+4.10
+19.33±
+3.69
+7%
+1.47
+0.059
+0.80
+1.22
+0.066
+WLC 
+20.00±
+4.11
+20.55±
+3.34
+-3%
+-0.55
+0.474
+Table/Fig-4: Results of RM-ANOVA for all the psychological variables in the yoga group (n=40) and the WLC group (n=40).
+*significant at the 0.05 level 
+**significant at the 0.01 level 
+[Table/Fig-4]. Meanwhile, normality test (Shapiro-Wilk) ensured that 
+there is no significant difference between yoga and WLC groups at 
+baseline for all the variables. This is evident from the [Table/Fig-4] 
+that eight week yoga intervention significantly improved mindfulness 
+Monali Devaraj Mathad et al., Effect of Yoga on Psychological Functioning of Nursing Students- A Randomized Wait List Control Trial	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2017 May, Vol-11(5): KC01-KC05
+4
+improvement, F (1, 78) = 0.139, p = 0.711. In post-hoc analysis 
+with Bonferroni correction did not show significant increase within 
+the yoga group (p = 0.232) and the WLC group (p = 0.500).
+Similarly, within group comparison (ANOVA) for mindfulness did not 
+report significant improvement, F (1, 78) =0.547, p = 0.462. But, for 
+interaction between time x group showed significant improvement, 
+F (1, 78) = 10.945, p<0.001. Results of post-hoc analysis with 
+Bonferroni adjustment reported significant increase within the yoga 
+group (p = 0.005), but there was no significant improvement in the 
+WLC group (p = 0.073).
+For resilience, within group comparison (ANOVA), F (1, 78) = 0.393, 
+p = 0.533 and interaction between time x group did not report 
+significant improvement, F (1, 78) = 1.700, p = 0.196. In post-hoc 
+analysis with Bonferroni correction also did not show significant 
+increase within the yoga group (p = 0.633) and the WLC group (p 
+= 0.176).
+Conversely, in within group comparison [ANOVA] significant 
+decrease in empathy was reported, F (1, 78) = 7.265, p = 0.009. 
+However, interaction between time x group did not report significant 
+improvement, F (1, 78) = 0.017, p = 0.895. Post-hoc analysis with 
+Bonferroni adjustment did not find significant increase within yoga 
+group (p = 0.074), but significant decrease in empathy within the 
+WLC group (p = 0.049) was reported.
+Results of within group comparison (ANOVA) did not demonstrate 
+significant decrease in perceived stress, F (1, 78) = 0.720, p 
+= 0.399. Similarly, time x group interaction also did not report 
+significant decrease, F (1, 78) = 3.482, p = 0.066. Findings of post-
+hoc analysis with Bonferroni adjustment did not report significant 
+reduction in stress within the yoga group (p =0.059) and within the 
+WLC group (p = 0.474).
+DISCUSSION
+The results of our study have reported that eight week yoga 
+intervention was significantly effective in improving self compassion 
+and mindfulness among nursing students in yoga group than 
+compared to WLC group. The following studies are in line with 
+our results. Yoga practitioners showed significant improvement 
+in mindfulness [36-38]. Eight week yoga intervention significantly 
+improved mindfulness among healthy population in experimental 
+group than compared to WLC group [39]. Eleven week yoga 
+intervention (one hour per week) among medical students 
+significantly increased self-compassion but, improvement in 
+empathy and perceived stress were not statistically significant 
+[40]. Self compassion is considered as the potential mechanism 
+through which yoga intervention reduces perceived stress [26,41]. 
+Even, in our study there was a decrease in perceived stress among 
+participants of yoga group than WLC group, but results were not 
+statistically significant. Many studies have reported that, yoga is 
+effective in the management of stress [23,38,40,42-49].
+This result was contrary to our expectation, as there was a decrease 
+in empathy in the both groups. But in WLC group, there was a 
+significant decrease in empathy. Previous studies also reported 
+similar findings, that there was decline in empathy among nursing 
+students [50,51]. As our intervention was for eight week, this time 
+duration may be short to witness decline in empathy. Reason for 
+this result remains unclear.
+Subsequently, there was improvement in satisfaction with life in the 
+both groups, but our results could not elicit statistical significance. 
+There is a significant association between satisfaction with life and 
+participation in physical activity [52]. During the phase of intervention 
+students of both the groups were participating in cultural and sports 
+activities. This may the reason for improvement in satisfaction with 
+life in both the groups. Earlier studies were in accord with our result. 
+In a RCT, six week yoga intervention one hour/week improved life 
+satisfaction and resilience to stress among university staff [53]. In 
+our study, also there was improvement in resilience in yoga group 
+but not in WLC group. 
+During the phase of yoga intervention students had to attend 
+their internal assessment tests, complete their annual academic 
+requirements and many students were participating in annual 
+cultural and sports competition. This may be the reason for mixed 
+results in our study.
+LIMITATION
+The scope of this study is limited in terms of assessment tools as 
+self reported questionnaires were used for data collection. However, 
+duration of intervention could have been for longer than eight week 
+with readings taken at multiple timelines and follow up report of the 
+study. This study could have been implemented in the beginning 
+of the academic program, to evaluate the effect of yoga on the 
+psychological functioning of nursing students.
+CONCLUSION
+Results of our study have demonstrated, eight week yoga intervention 
+significantly improved mindfulness and self-compassion among 
+participants in yoga group than compared to WLC group. Both 
+mindfulness and self compassion plays vital role in combating stress. 
+As nursing students are exposed to high levels of stress compared 
+to other students. It is essential to inculcate yoga intervention in the 
+nursing education to meet demands of the profession.
+ACKNOWLEDGEMENTS
+We would like to thank Principal, Kempegowda Institute of Nursing 
+for giving permission to conduct research in their college.
+We thank and appreciate all the nursing students for their sincere 
+participation in our research study. 
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+PARTICULARS OF CONTRIBUTORS:
+1.	 Research Scholar, Department of Division of Yoga and Humanities, S-VYASA University, Bengaluru, Karnataka, India.
+2.	 Assistant Professor, Department of Division of Yoga and Humanities, S-VYASA University, Bengaluru, Karnataka, India.
+3.	 Assistant Professor, Department of Division of Yoga and Humanities, S-VYASA University, Bengaluru, Karnataka, India.
+NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
+Ms. Monali Devaraj Mathad,
+Research Scholar, S-VYASA University, #19, Eknath Bhavan, 
+Gavipuram Circle, Kempe Gowda Nagar, Bengaluru-560019, Karnataka, India.
+E-mail: [email protected]
+Financial OR OTHER COMPETING INTERESTS: None.
+Date of Submission: Jan 03, 2017
+Date of Peer Review: Feb 02, 2017
+Date of Acceptance: Mar 09, 2017
+Date of Publishing: May 01, 2017

subfolder_0/Effect of Yoga on Sleep Quality and Neuroendocrine Immune Response in Metastatic Breast Cancer Patients.txt

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+Indian J Palliat Care. 2017 Jul-Sep; 23(3): 253–260.
+doi: 10.4103/IJPC.IJPC_102_17
+PMCID: PMC5545949
+PMID: 28827927
+Effect of Yoga on Sleep Quality and Neuroendocrine Immune Response
+in Metastatic Breast Cancer Patients
+Raghavendra Mohan Rao, HS Vadiraja,  R Nagaratna,  K S Gopinath,  Shekhar Patil,  Ravi B Diwakar,
+HP Shahsidhara,  BS Ajaikumar,  and HR Nagendra
+Department of Complementary and Alternative Medicine, Healthcare Global, Bengaluru, Karnataka, India
+Department of Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka,
+India
+Department of Surgical Oncology, HCG Bangalore Institute of Oncology Specialty Center, Bengaluru,
+Karnataka, India
+Department of Medical Oncology, HCG Bangalore Institute of Oncology Specialty Center, Bengaluru,
+Karnataka, India
+Department of Radiation Oncology, HCG Bangalore Institute of Oncology Specialty Center, Bengaluru,
+Karnataka, India
+Department of Research and Development, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru,
+Karnataka, India
+Address for correspondence: Dr. Raghavendra Mohan Rao, Head CAM Program, Healthcare Global
+Enterprises Ltd., No. 8, HCG Towers, P Kalinga Rao Road, Sampangiramnagar, Bengaluru - 560 098,
+Karnataka, India. E-mail: [email protected]
+Copyright : © 2017 Indian Journal of Palliative Care
+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:
+Studies have shown that distress and accompanying neuroendocrine stress responses as important
+predictor of survival in advanced breast cancer patients. Some psychotherapeutic intervention studies
+have shown have modulation of neuroendocrine-immune responses in advanced breast cancer patients.
+In this study, we evaluate the effects of yoga on perceived stress, sleep, diurnal cortisol, and natural
+killer (NK) cell counts in patients with metastatic cancer.
+Methods:
+In this study, 91 patients with metastatic breast cancer who satisfied selection criteria and consented to
+participate were recruited and randomized to receive “integrated yoga based stress reduction program”
+(n = 45) or standard “education and supportive therapy sessions” (n = 46) over a 3 month period.
+Psychometric assessments for sleep quality were done before and after intervention. Blood draws for
+1
+1
+2
+3
+3
+3
+4
+5
+1
+2
+3
+4
+5
+NK cell counts were collected before and after the intervention. Saliva samples were collected for three
+consecutive days before and after intervention. Data were analyzed using the analysis of covariance on
+postmeasures using respective baseline measure as a covariate.
+Results:
+There was a significant decrease in scales of symptom distress (P < 0.001), sleep parameters (P =
+0.02), and improvement in quality of sleep (P = 0.001) and Insomnia Rating Scale sleep score (P =
+0.001) following intervention. There was a decrease in morning waking cortisol in yoga group (P =
+0.003) alone following intervention. There was a significant improvement in NK cell percent (P =
+0.03) following intervention in yoga group compared to control group.
+Conclusion:
+The results suggest modulation of neuroendocrine responses and improvement in sleep in patients with
+advanced breast cancer following yoga intervention.
+Keywords: Cortisol, immune, natural killer cell, sleep, yoga
+Iඖගක඗ඌඝඋගඑ඗ඖ
+The advancement and progression of breast cancer impose severe psychologic distress. There follows a
+sequel of dejection, depression anxiety, and fear of dying and thoughts of impending treatments-related
+side effects that are known to cause distress, impair sleep, and normal functioning.[1,2] Metastatic
+breast cancer patients often have to cope with uncertainty about their future which is known to cause
+severe stress.[3] This chronic stress is known to impair sleep and circadian rhythms. Impairment in
+sleep in cancer patients could be due to pain, electrolyte disturbances, infection, or psychologic distress
+and mood states.[4] Sleep is an important buffer of stress response. Both sleep quality and duration are
+important attributes of sleep.[5] While good sleep acts as a buffer of stress response, impaired sleep is
+known to exacerbate symptoms, distress, and fatigue.[6] Alteration in circadian patterns of sleep with
+daytime sleepiness and fatigue is one of the early signs of sleep impairment.[4,6] This impairment in
+sleep is primarily caused due to elevated stress hormones such as cortisol and change in circadian
+rhythms of cortisol due to perceived stress.[7] This triad of stress, sleep impairment, and altered diurnal
+cortisol rhythm is known exacerbate symptom distress, pain, fatigue, and lower antitumor immune
+response in patents.[8]
+This treatment-related distress coupled with daily hassles is intense enough to cause elevated cortisol
+levels and hypothalamopituitary axes dysregulation.[8,9] Most distressed patients have had flat or
+upward cortisol slopes that have shown to be an important predictor for survival.[7,8]
+Moreover, the effects of this intense stressor are known to affect psychoneuroendocrine and
+psychoneuroimmune axes causing maladaptive neuroendocrine responses and immunosuppression.
+[10,11] This is evident in earlier studies wherein advanced breast cancer patients had low natural killer
+(NK) cell counts due to their psychologic distress.[8,11] The study of changes in these pathways has
+intrigued scientists to try psychologic and mind-body interventions that can modulate these pathways
+and help patients cope with this stressor.
+Several studies have shown that psychotherapeutic interventions modulate abnormal rhythms and
+morning salivary cortisol peaks and improve sleep quality and reduce distress. Cognitive behavior
+therapy,[12,13] supportive therapy,[14] and other mind-body therapies such as mindfulness-based
+stress reduction,[15] Yoga, Tai Chi,[16] etc., have shown to reduce morning cortisol levels. In our
+earlier study with stage I–III breast cancer patients undergoing radiotherapy, our integrated yoga
+program showed decrease in cortisol levels following radiotherapy.[17] However, most of these studies
+have shown changes in early cancer patients with exception of few on metastatic breast cancer patients
+using psychotherapeutic interventions.[16]
+Mඍගඐ඗ඌඛ
+In this study, 91 patients with metastatic breast cancer were recruited to participate in a trial comparing
+an integrated yoga program versus education and supportive therapy sessions on stress, sleep, diurnal
+salivary cortisol rhythms, and NK cell counts. The recruitments were carried out from January 2004 to
+June 2007 with referrals from medical and radiation oncology outpatient departments of a
+comprehensive cancer care center. The Institutional Review Board of the participating institution
+approved the study. The subjects were recruited if they satisfied the selection criteria and gave written
+consent to participate in the study.
+Selection criteria
+Patients were included if they met the following criteria:
+Women diagnosed with stage IV breast cancer within 6 months–2 years after diagnosis either
+recurrent disease or progressive disease
+Age between 30 and 70 years
+Zubrod's performance status 0–2 (ambulatory >50% of time)
+Minimum high school education
+Willingness to participate in the study.
+Exclusion criteria were
+Duration of metastasis more than 1 year
+Brain metastasis
+Those undergoing chemotherapy/radiotherapy during the study except for treatment of bone
+metastases with bisphosphonates/zoledronic acid
+Those on hydrocortisone medications
+A concurrent medical condition likely to interfere with yoga intervention or survival
+Any major psychiatric, neurological illness, or autoimmune disorders
+Those who are on hydrocortisone medications or have HIV
+Pregnant and lactating mothers or planning to conceive during the study period
+Those who are recruited for clinical trials involving investigational new drugs
+Prior practice of yoga in the last 6 months
+Prior chemotherapy other than treatment of bone metastases mentioned above in the last 2 weeks
+History of any pathologic fractures.
+In this study, 257 patients with advanced metastatic breast cancer patients were screened over a 3-year
+period. One hundred and fifty-three patients were eligible, and 91 patients consented to participate in
+this study. Patients were recruited to participate in a two-arm prospective randomized controlled trial
+comparing the effects of an “integrated yoga based stress reduction program” (n = 45) versus standard
+“education and supportive therapy sessions” (n = 46).
+Sample size
+Earlier study with Mindfulness-Based Stress Reduction Program (MBSR) had shown a modest effect
+size (ES = 0.38) on EORTC QLC30 global quality of life measure.[18] We used G power to calculate
+the sample size with α = 0.05 and β = 0.2 and an ES of 0.38 for repeated measures ANOVA between
+factor effects. The sample size thus required was (n = 44) in each group. Second, earlier studies were
+only on stage I–III breast cancer patients and not on metastatic breast cancer patients.
+Randomization
+A person who had no part in the trial randomly allocated consenting participants to either yoga or
+supportive therapy groups using random numbers generated by a random number table at a different
+site. Randomization was performed using opaque envelopes with group assignments, which were
+opened sequentially in the order of assignment during recruitment with names and registration numbers
+written on their covers.
+Masking and blinding
+Being a popular intervention, it was not possible to mask the yoga intervention from the subjects.
+However, the investigators (treating oncologists) were blind to the intervention and subjects were asked
+not to disclose the type of intervention (yoga or supportive therapy) to them. Second, the saliva and
+blood samples were blinded from the technicians who analyzed the coded samples at a site different
+from the study center. The samples and data were unblinded only at the conclusion of the study.
+Outcome measures
+Pittsburgh Insomnia Rating Scale is a widely used instrument in clinical and research practice.[19] It is
+a scale with 65-items. It was designed to assess severity of insomnia in clinical settings. It is known to
+assess subjective distress score (46 items) related to sleep, subjective sleep parameters (10 items) and
+sleep-related quality-of-life (9 items). The items have to be scored according to symptoms experienced
+in the previous week. The test-retest reliability and internal consistency for the scale was 0.93 (Veqar
+and Hussain, 2016).[20]
+Diurnal salivary cortisol measures
+Saliva collection and storage: participants were trained to collect their saliva by chewing on a cotton
+swab and dribble the saliva to a plastic holder resting inside a sterile centrifuge tube. Samples were
+collected at 0600 h, 0900 h, and 2100 h for 3 consecutive days. The samples were stored in refrigerator
+and delivered to study personnel after 3 days. Samples were then centrifuged to remove mucous,
+freeze, and stored at −70°C in Eppendorf tubes for analysis.
+Quantifications of salivary cortisol
+Salivary cortisol levels were assessed using enzyme immunoassay method using kits manufactured by
+Salimetrics Inc., USA. The test samples were run in duplicates and readings taken on a microplate
+reader (Bio-Rad, USA). The tests were standardized under controlled laboratory conditions using
+standards, positive, and negative controls provided along with the kit by the manufacturer. The plates
+were read at 450 nm, and a standard curve was plotted on a graph for each run by plotting the log of
+cortisol concentrations on “y” axis and log of optical density (O.D) reading on “x” axes and best fit line
+determined by regression analyses. The values were then extrapolated with the graph using the mean
+O.D readings of the duplicate wells and plotting their corresponding concentration on the graph. The
+detection range with these kits was 0.012–3.0 Hgm/dl. The intra-assay coefficient ranged from 3.35%
+to 3.65% and inter-assay coefficient from 3.75% to 6.41% with these samples. Mean cortisol levels for
+specific time points over a 3-day period were extrapolated.
+Natural killer cells (CD56%) measures
+Blood sample collection: all subjects in metastatic breast cancer study were asked to provide blood
+samples at the study start and at the end of intervention. About 5 ml of heparinized blood sample was
+collected in vacuettes under sterile conditions. All the blood samples were collected between 8 am to
+12 am to reduce diurnal variability.
+Quantification of natural killer cells (CD56%)
+The NK cell assay was done using reagents and antibodies from DAKO Corporation, USA in a Becton
+Dickinson Flow Cytometer. Flow cytometer measures and analyses optical properties of single cells
+passing through a focused laser beam, analysis of hundreds of cells per second provides a statistically
+significant picture, when the cells pass through the laser beam they disrupt and scatter the laser light
+which is detected as forward scatter (FSC) and side scatter (SSC). While FSC is related to cell size, the
+SSC is an indicator of cells internal complexity. Cells are stained with monoclonal antibodies coupled
+with fluorescent dye FITC, and the conjugated samples were acquired using flow cytometer, when
+acquiring, blood cells are segregated into different populations-lymphocytes, monocytes, and
+erythrocytes using cell quest pro software version 3.1. The cytometer processes the electronic signals
+resulting from each cell and creates numeric value for each parameter. Each cell count acquired is taken
+as one event. Before acquiring this is set based on the availability of the cells in the sample (it is set for
+10,000 events). Once acquisition is done, the cells segregated are analyzed by encircling the cell
+population in FSC/SSC plot. Stained cells are separated from the unstained cells by gating. The
+cytometer processes the electronic signals resulting from each cell and creates numeric value for each
+parameter thereby total number of NK cells and percentage NK cells are calculated. Absolute
+lymphocyte count (ALC) was also estimated using this procedure.
+Interventions
+The intervention group received “integrated yoga program” and the control group received “supportive
+counseling sessions” both imparted as individual sessions. The objectives of this yoga intervention as
+described to participants were as follows: (i) to develop an opportunity to understand one's personal
+responses to daily stress and explore ways and means to cope with them, (ii) to learn concepts and
+techniques which bring about stress reduction and change in appraisal, and (iii) to enable the
+participants to take an active part in their self-care and healing.
+The yoga practices consisted of a set of asanas (postures done with awareness) breathing exercises,
+pranayama (voluntarily regulated nostril breathing), meditation, and yogic relaxation techniques with
+imagery. These practices were based on principles of attention diversion, awareness and relaxation to
+cope with stressful experiences.
+The sessions began with didactic lectures and interactive sessions on philosophical concepts of yoga
+and importance of these in managing day-to-day stressful experiences (10 min) beginning every
+session. This was followed by a preparatory practice (20 min) with few easy yoga postures, breathing
+exercises, and pranayama and yogic relaxation. The subjects were then guided through any one of these
+meditation practices for next 30 min which included focusing awareness on sounds and chants from
+Vedic texts,[21] or breath awareness and impulses of touch emanating from palms and fingers while
+practicing yogic mudras, or a dynamic form of meditation (cyclic meditation) which involved practice
+with eyes closed of four yoga postures interspersed with relaxation while supine, thus achieving a
+combination of both “stimulating” and “calming,” practice.[22] In meditation, participants try to
+develop clarity in their thinking, learn to observe their own mind, decrease negative mind states and
+develop positive mind states, and maintain equipoise in their emotions. These sessions were followed
+by informal individual counseling sessions that focused on problems related to impediments in home
+practice, clarification of participant's doubts, motivation, and supportive interaction with spouses. The
+participants were also informed about practical day-to-day application of awareness and relaxation to
+attain a state of equanimity during stressful situations and were given homework in learning to adapt to
+such situations by applying these principles.
+The subjects were given booklets and instructions on these practices and were encouraged to pursue
+relevant themes and gain greater depth through proficiency in practice. Subjects were provided
+audiotapes of these practices for home practice using the instructor's voice so that a familiar voice
+could be heard on the cassette. Subjects were asked to attend yoga intervention at least two times/week
+for 12 weeks. The control groups were imparted supportive counseling during their hospital visits.
+Patients were exposed to at least 24 in person sessions with home practice on the remaining days.
+Patients were asked to maintain a diary noting their daily activity, daily yoga schedule, duration of
+practice, intake of medications, and distressing symptoms if any, etc.
+Their homework was monitored on a day-to-day basis by their instructor who conducted weekly house
+visits, and participants were also encouraged to maintain a daily log listing the yoga practices done, use
+of audiovisual aids, duration of practice, experience of distressful symptoms, and diet history. There
+were two instructors in all one being a physician in naturopathy and yoga and other a trained and
+certified therapist in yoga from the yoga institute. They together supervised and imparted the yoga
+intervention while trained social workers and counselors at the cancer hospital imparted supportive
+therapy intervention.
+Control intervention-supportive counseling sessions
+Supportive counseling sessions as control intervention included two important components “education
+and reinforcing social support.” The reasons why we chose to have education and supportive therapy
+sessions as control intervention are 3-fold.
+This was used as a control intervention to control for the nonspecific effects of the program that may be
+associated with adjustments such as attention, support, and a sense of control. In fact, these didactic
+educational interventions are known to improve quality of life of women with breast cancer[23,24] and
+serve as an effective coping preparation in controlling chemotherapy-related side effects.[25]
+Even though the use of education and supportive therapy is a form of enhanced usual care, if yoga
+program does not provide any benefit over this intervention, then we will know that didactic
+educational programs should be integrated within the standard of care.
+Similar supportive sessions have been used successfully as a control comparison group to evaluate
+psychotherapeutic interventions.[26,27] These sessions aimed at enriching the patient's knowledge of
+their disease and treatment options, thereby reducing any apprehensions and anxiety regarding their
+treatment and involved interaction with the patient's spouses. Subjects and their caretakers were invited
+to participate in an introductory session lasting 60 min before starting any conventional treatment
+wherein they were given information about each conventional treatment and management of its related
+side effects, dietary advice, providing information about a variety of common questions and showing a
+patient coping successfully. This counseling was extended over the course of their intervention during
+their hospital visits (once in 10 days, 15 min sessions), and participants were encouraged to meet their
+counselor whenever they had any concerns or issues to discuss. Subjects in the supportive therapy
+group also completed daily logs or dairies on treatment-related symptoms, medication, and diet while
+the goals of yoga intervention were stress reduction and appraisal change, the goals of supportive
+therapy were education, reinforcing social support, and coping preparation.
+Baseline assessments were done on 91 patients in case of metastatic breast cancer patients. A total of
+66 patients contributed data to the current analyses. The reasons for dropouts were attributed to
+migration to other hospitals, use of other complementary therapies (e.g., homeopathy or ayurveda),
+lack of interest, time constraints, and other concurrent illness [Figure 1]. Among the 66 study
+completers, 46 out of 66 completers gave the saliva samples as per protocol. Fifteen subjects (yoga n =
+5, control, n = 10) in the study were not comfortable in giving saliva samples. Subjects who missed
+collecting saliva sample on consecutive days at the same time were excluded from the analysis (n = 5).
+Open in a separate window
+Figure 1
+Trial profile
+Data analysis
+Statistical procedures were conducted using SPSS version 10 (Sun Micro solutions, Gujarat, India) for
+PC Windows 2000. The data of baseline and follow-up of both the groups were assessed with tests for
+normality and homogeneity using Shapiro–Wilks test and one-way ANOVA. We used the analysis of
+covariance (ANCOVA) to study the effects of intervention on outcome measures at follow-up
+assessments using their respective baseline measure as a covariate. Paired samples’ t-test was done to
+see within-group changes. All analyses were carried out with intention to treat principle to account for
+missing values and dropouts.
+Diurnal salivary cortisol
+Mean cortisol levels for specific time points over a 3-consecutive days were extrapolated at 0600,
+0900, 2100 hrs. The diurnal cortisol response was evaluated by calculating the area under curve for
+time 0600, 0900 and 2100 h. This helps to limit the amount of statistical comparisons between groups
+to minimize the correction of the α-error probability. With the AUC variables, the number of repeated
+measurements is irrelevant and thus, the number of statistical comparisons only depends on the number
+of groups to be compared. With the two AUC formulas, AUCg for baseline diurnal cortisol
+measurements and AUCi increase in the AUC with respect to AUCg for postmeasure using trapezoidal
+method,[28] different aspects of the time course of the repeated measurements could be assessed. The
+slope of diurnal cortisol rhythm was analyzed using random coefficient modeling (i.e., “linear mixed
+models”), which has been advocated by some researchers.[29] Slopes were compared at baseline and at
+postmeasurements in both the groups. Alternatively, nonparametric Mann–Whitney U-test and
+Wilcoxon-signed rank test were also done for variables with skewed distribution.
+Rඍඛඝඔගඛ
+Sociodemographic and medical characteristics of the study sample
+The mean age of participants was 48.9 ± 9.1 years in yoga and 50.2 ± 9.2 years in control groups.
+Twenty-Six subjects underwent surgery, chemotherapy, radiotherapy and chemotherapy, 11 subjects
+received chemotherapy and radiotherapy and eight subjects underwent surgery and radiotherapy as
+primary treatment. Participants in both groups were comparable with respect to sociodemographic and
+medical characteristics. A goodness of fit test run on all these demographic variables did not show any
+significant changes between yoga and supportive therapy groups (P > 0.05) [Table 1].
+Table 1
+Demographic and medical characteristics of the initially randomized sample
+Insomnia Rating Scale
+Insomnia Rating Scale symptom distress
+Insomnia Rating Scale sleep parameters
+Insomnia Rating Scale quality of life
+Insomnia Rating Scale total scores
+Diurnal salivary cortisol levels
+ANCOVA on postmeasures using baseline symptom distress
+scores as a covariate showed a significant difference between groups with better decrease in symptom
+distress scores in yoga compared to control group [F (1,61) = 21.23, P < 0.001, ES-1.2, Percentage
+change (PC) - 91.31%]. Paired-sample t-test done to assess within group change showed a significant
+decrease in symptom distress scores in yoga group only (t = 3.1, P = 0.004) and not in the control
+group (t = −1.32, P = 0.19) [Table 2].
+Table 2
+Comparison of Insomnia Rating Scale scores using analysis of covariance between yoga and
+control groups with the respective baseline measure as a covariate
+ANCOVA on postmeasures using baseline sleep distress
+parameter scores as a covariate showed a significant difference between groups with better decrease in
+sleep distress parameter scores in yoga compared to control group [F (1,61) = 5.75, P = 0.02, ES - 0.6,
+PC - 111.43%]. Paired-sample t-test done to assess within group change showed a significant decrease
+in sleep distress parameter scores in yoga group only (t = 2.5, P = 0.01) and not in the control group (t
+= −1.30, P = 0.20) [Table 2].
+ANCOVA on postmeasures using baseline sleep quality of life
+scores as a covariate showed a significant difference between groups with better decrease in sleep
+quality of life scores in yoga compared to control group [F (1,61) = 13.03, P = 0.001, ES - 0.9, PC -
+20.25%]. Paired-sample t-test done to assess within group change showed a significant decrease in
+sleep quality of life scores in yoga group only (t = 2.9, P = 0.006) and not in the control group (t =
+0.78, P = 0.44) [Table 2].
+ANCOVA on postmeasures using baseline sleep total distress scores
+as a covariate showed a significant difference between groups with better decrease in sleep total
+distress scores in yoga compared to control group [F (1,61) = 22.40, P = 0.001, ES - 1.2, PC - 70.77%].
+Paired-sample t-test done to assess within group change showed a significant decrease in sleep total
+distress scores in yoga group only (t = 3.3, P = 0.002) and not in the control group (t = −1.33, P = 0.19)
+[Table 2].
+ANCOVA was used to assess between-group differences using baseline
+cortisol value (for the corresponding time) as a covariate did not show any significant change. A liner
+mixed effects model using R software showed no difference in precortisol slopes (P = 0.67, t = 0.41)
+and postcortisol slopes (post: P =0.42, t = 0.8) between groups [Table 3]. Paired-samples t-test to assess
+within group change following intervention showed a significant decrease in 0600 h. Cortisol (t = 2.28,
+P = 0.031) in yoga group alone but not in the control group (t = −0.31, P = 0.76) [Table 3].
+Natural killer cell count and percentage
+Absolute lymphocyte count
+Adherence to intervention
+Table 3
+Results of diurnal cortisol levels after intervention using paired t-test and analysis of covariance
+ANCOVA was used to assess between-group differences using
+baseline NK cell % value as a covariate showed significant improvement in NK cell % in yoga group
+compared to control group [F (1, 31) = 5.43, P = 0.03, ES - 0.5, PC - 32.43%]. Other parameters such
+as NK cell count did not show any significant difference between groups. Paired-samples t-test to
+assess within group change following intervention showed a significant increase in NK cell % (t =
+−3.10, P < 0.01) in yoga group alone but not in the control group (t = 1.03, P = 0.32) [Table 4].
+Table 4
+Comparison of mean values of natural killer cell and absolute lymphocyte count levels using
+paired t-test and analysis of covariance
+The baseline values of ALC were different in the two groups. There was no
+significant change within or between groups in ALC [Table 4].
+In this study, the adherence was good with 80% attending 24 supervised
+sessions. There was a significant decrease in 9 am salivary cortisol levels (t = −3.6, P = 0.001) in those
+who attended >20 classes as compared to those attending <20 classes on independent samples t-test [
+Table 5].
+Table 5
+Comparison of change scores on salivary cortisol and natural killer cell counts using
+independent samples t-test between those attending yoga classes (>20/<20 classes) in yoga
+group
+Dඑඛඋඝඛඛඑ඗ඖ
+Sleep on Pittsburg Insomnia Rating Scale
+In this study, there was a significant decrease in symptom distress (91.3%, ES = 1.2), sleep parameters
+(111.4%, ES = 0.6), quality of life (20.3%, ES = 0.9), and overall insomnia score (70.8%, ES = 1.2).
+Our results are consistent with earlier findings with mindfulness-based stress reduction intervention
+that has shown improvement in overall sleep quality by 20.4%.[30] Insomnia has been related to poor
+NK cell function, higher morning cortisol levels and abnormal diurnal rhythms in breast cancer
+patients.[8] This is an important problem as it seems to worsen with age and psychological distress.[5]
+This is also one of the important symptoms in the cancer care continuum expressed often by patients.
+[4] Improving sleep duration, quality, and restoring the normal sleep rhythms are important to preserve
+immune homeostasis and quality of life. The improvements seen with our intervention suggests that
+yoga could be used as an adjunct to manage sleep disorders in cancer patients.
+Diurnal salivary cortisol level
+There was also a significant decrease in early morning salivary cortisol levels in the advanced breast
+cancer study in yoga group only (40.9%, ES = 0.5). The decrease in morning salivary cortisol levels
+suggests possible stress-reducing benefits of yoga intervention. Our results are similar to earlier studies
+that have shown similar decreases in cortisol in early breast cancer study undergoing adjuvant
+radiotherapy.[17] Our results are also similar to changes (16%–45%) in cortisol seen with behavioral
+interventions in cancer populations.[13,31,32] While these earlier studies have measured one time
+plasma cortisol, we chose to assess both morning and evening levels of free salivary cortisol as changes
+in the rate of cortisol secretion over a day (diurnal cortisol rhythm) is considered as a robust measure
+compared to onetime cortisol assessment.[8,33] Earlier studies with similar stress reduction
+interventions such as MBSR have also shown decrements in cortisol in breast cancer patients who had
+initially high cortisol levels suggesting that more distressed patients tend to benefit with stress
+reduction intervention.[18] However, there was no difference in both high and low basal cortisol
+groups in our study.
+One of the major limitations in this study is the inequality in contact duration of interventions.
+Supportive therapy interventions were used with an intention of negating the confounding variables
+such as instructor-patient interaction, education, and attention.[27] However, inequality in contact
+duration of this intervention could have affected its effectiveness as successes of such interventions
+depend mainly on contact duration and content. Similar supportive sessions have been used
+successfully as a control comparison group to evaluate psychotherapeutic interventions[26,27] and
+have been effective in controlling chemotherapy-related side effects.
+C඗ඖඋඔඝඛඑ඗ඖ
+Future studies should unravel the putative mechanisms and aspects of hypothalamic-pituitary-adrenal
+axes dysregulations and assess neuroendocrine responses to artificially induced stressors in the
+laboratory. Future studies should use more sophisticated measurements of immune function such as NK
+cell cytotoxicity, DNA repair mechanism, etc., to understand the psychoneuroimmune mechanisms
+underlying such interventions. Larger randomized controlled studies using more structured psychiatric
+and behavioral intervention as controls are needed.
+Financial support and sponsorship
+This Study was funded with grants from the Central Council for research in Yoga and Naturopathy,
+Ministry of AYUSH, Government of India.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgments
+Central Council for Research in Yoga and Development, Ministry of AYUSH, Government of India.
+Rඍඎඍකඍඖඋඍඛ
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subfolder_0/Effect of Yoga on homocysteine level, symptomatology and quality of life in industrial workers with Chronic Venous Insufficiency_ Study protocol for a randomized controlled trial - ScienceDirect.txt

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+Get rights and content
+Advances in Integrative Medicine
+Volume 9, Issue 2, May 2022, Pages 119-125
+Study Protocol
+Effect of Yoga on homocysteine level, symptomatology and
+quality of life in industrial workers with Chronic Venous
+Insufficiency: Study protocol for a randomized controlled trial
+U. Yamuna, Vijaya Majumdar, Apar Avinash Saoji
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga, Anusandhana Samsthana, # 19, Eknath
+Bhavan, Gavipuram Circle, KG Nagar, Bengaluru 560019, India
+Received 11 November 2021, Accepted 8 February 2022, Available online 11 February 2022, Version of Record 9
+June 2022.
+Show less
+https://doi.org/10.1016/j.aimed.2022.02.002
+Abstract
+Background and objectives
+Chronic Venous Insufficiency (CVI) is often associated with prolonged standing at work. CVI
+could lead to multiple symptoms and vascular inflammation. Yoga as therapy has helped in
+mitigating several occupational hazards. The current study protocol is designed to assess the
+effect of Yoga on CVI.
+Materials and methods
+Share
+Cite
+One hundred industry workers with CVI will be randomly allotted to Yoga and wait-list
+control groups following an equal allocation ratio. Yoga group will receive a specially designed
+Yoga module six days a week for three months. The Control group will continue with the
+routine activities. Serum homocysteine, Venous Clinical Severity Scale (VCSS), Ankle Brachial
+pressure index and psychological status will be assessed at baseline and the end of three
+months of intervention.
+Statistical analyses
+Data will be tested for normality and appropriate tests will be used to assess the differences
+between the groups.
+Expected outcomes
+Specifically designed Yoga module will help to reduce the vascular inflammation, symptoms
+of CVI and enhance psychological functioning.
+Introduction
+Chronic Venous Insufficiency (CVI) is one of the peripheral venous diseases which involve the
+retrograde flow of blood in the lower extremities of the venous system [1]. Pathophysiology of
+CVI involves multiple factors such as valve incompetence, calf muscle dysfunction, and
+venous stasis [2]. Valve incompetence causes blood stasis, increases venous blood pressure, and
+leads to venous dilation, inflammation, and vein wall weakness [3], [4]. The clinical symptoms
+of CVI result from increased venous pressure, venous dilation, and valve incompetence. The
+common symptoms of CVI include itching, pain, heaviness in the legs, ache, skin color
+changes [5]. Symptoms are not much severe at the initial stage of CVI, depending on age,
+gender, body mass index. Manifestation of the disease may reach secondary conditions such as
+leg ulcers and deep vein thrombosis [6]. General risk factors for CVI are age, obesity, strong
+family tendency, gender, and occupations that demand prolonged standing at workplaces [6],
+[7], [8]. However, studies on the gender-wise prevalence of CVI report conflicting outcomes. A
+study conducted in the United Kingdom reported the prevalence of CVI being more in men
+(40%) than women (32%) [9]. Another epidemiological study indicated the prevalence of CVI to
+be higher in women than in men [10]. Though we see a general trend of higher prevalence of
+CVI in men, however, women tend to manifest the disease their pregnancy given the increased
+intrabdominal pressure.
+Prolonged standing at the workplace is one of the main contributors to CVI. Pathogenesis
+originates from the dilation of superficial veins and causes morphologic abnormalities [11].
+An extended period of standing increases pressure in the veins of the legs, thereby affecting
+the pumping function of the calf muscle. Such changes lead to valve incompetence and
+damage [12]. A study conducted on which industrial workers concluded that those who used to
+stand for longer duration (>50% of working hours) had a higher prevalence of CVI compared
+to those who spent less time standing [13].fl
+Vascular inflammation is a key feature in the etiopathogenesis of CVI and the associated
+complications. Hyperhomocysteinemia (HHcy), increased circulating homocysteine level [14],
+[15] is a well-established marker of vascular inflammation. HHcy is also associated with
+peripheral vascular disorders, deep vein thrombosis and coronary artery disorders [14]. In
+CVI, HHcy is commonly manifested [16]. An increased concentration of homocysteine is also
+associated with platelet activation, endothelial injury, and thrombosis. [17], [18]. Its plausible
+role in endothelial dysfunction could underline the etiological link between HHcy with
+vascular diseases and vascular inflammation, accompanied by accelerated vein wall leakage,
+and increased recruitment of leukocytes to endothelium [19].
+Lifestyle modification-related activities like leg elevation exercise, walking, and weight loss are
+recommended in CVI management [20]. Studies indicate a beneficial role of physical exercises
+in reducing reflux blood volume [21] and venous hypertension [22]. However, a reported
+review indicated insufficient evidence for the role of exercise in the management of CVI [23].
+Another Meta-analysis found improvements in calf muscle functions and venous
+hemodynamics with physical exercise and recommended further clinical trials to ascertain the
+role of exercise in CVI management [24].
+Though well recognized, the relevance of preventive measures has been seldomly given
+enough attention. In 1997, Krijnen et al. reported beneficial impact of compression stockings
+in diminishing subjective complaints and reducing diurnal leg swelling. However, we do not
+find much evidence reporting the use of such measures to prevent or manage complications
+of CVI. To this end, Canadian Centre for Health and Safety (CCOHS), (2016) has indicated the
+importance of neutral alignment and minimizing lower extremity fatigue by using the proper
+footwear and floor condition to prevent such injuries. Given the association with prolonged
+standing with reduced blood supply, CCOHS advocates working in a standing position by
+changing working positions frequently, avoiding extreme bending, stretching, twisting, pacing
+work appropriately, and allowing workers reasonable rest periods. CCOHS also suggests using
+right-sized footwear and accessories like stockings, socks, and movements to prevent and
+manage CVI and other musculoskeletal issues due to prolonged standing at the workplace.
+Yoga is an ancient Indian science of holistic living that has gained popularity for its
+therapeutic and health-promoting effects in recent times. Yoga has been used for various
+health issues such as respiratory, cardiovascular, musculoskeletal, metabolic, pain, and cancer
+syndromes [25], [26]. A single case study demonstrated improvement of calf muscle pump
+function, venous return, physical and mental health in CVO [27]. Yogic practices have shown
+positive effects on the symptoms of venous insufficiency, which reduces the progression of the
+disease.
+Research studies reported that Yoga would have therapeutic benefits in reducing
+inflammation, fatigue and joint rigidity. It improves the peripheral muscle strength and
+strengthens the muscles of lower limbs, ankles and enhances hip and ankle strategies in an
+individual [28], [29], [30], [31]. Regular yoga practice substantially minimizes inflammatory
+response to stressful encounters, which has a high impact on an individual's quality of life. Afi
+study reported the beneficial role of yogic postures and breathing exercises in activating
+pump muscles, increasing range of movements: flexion of large muscles, maximum skin
+stretch [32]. Few studies reported the positive effects of Yoga in managing pain and
+lymphedema [33], [34], [35].
+In different occupational settings, Yoga is found to mitigate occupational health hazards.
+Different occupational settings in which Yoga is applied include healthcare professionals [36],
+[37], computer professionals [38], defense personnel [39], athletes [40], etc. These studies
+indicate a possible beneficial role of Yoga in mitigating the possible occupational hazards and
+enhance efficiency.
+CVI is a common issue among workers who need to stand for a prolonged time. Few studies
+with physical therapy have demonstrated the beneficial role of active physical intervention in
+managing/preventing work-related CVI. Yoga, as a mind-body approach, could be a non-
+invasive and cost-effective therapy for CVI management. However, only a single case study has
+implemented Yoga as an intervention for CVI with beneficial effect [27]. A study reported that
+yoga would reduce the homocysteine level and restore endothelial dysfunctions in women
+with primary dysmenorrhea [41]. Like Yoga, regular exercise significantly lowered plasma
+homocysteine in young overweight or obese women with Polycystic ovary syndrome (PCOS), a
+group at increased risk of premature atherosclerosis [15]. Evidence-based research with large
+sample size is necessary to understand the efficacy of Yoga in CVI management. In this study,
+we would try to understand the impact of yoga intervention on CVI symptoms and quality of
+life and elicit changes in the homocysteine level as a biomarker of vascular inflammation in
+CVI.
+Section snippets
+Objectives
+The main objectives of this study is to investigate the efficacy of Yoga on homocysteine level,
+symptomatology, and quality of life in industrial workers with CVI which is associated with
+prolonged standing at industrial workplaces.…
+Trial design
+The design of this trial is a parallel group, randomized controlled trial with two parallel
+groups with a 1:1 allocation ratio testing the effect of Yoga in one group against another. Fig. 1
+illustrates the proposed trial profile.…
+Study setting
+The research study will be conducted at one of the manufacturing Industries located in Jigani,
+Bangalore, from November 2021 to April 2022.…
+Eligibility criteria
+The participants will be selected based on the inclusion and exclusion criteria, depicted in
+Table 1.…
+Intervention
+The specific yoga…
+Research ethics approval
+The trial has been reviewed and approved by the institutional ethics committee (IEC) of
+Swami Vivekananda Yoga Anusandhana Samsthana (Deemed-to-be-university under Section 3
+of the UGC act, 1956) in the committee meeting held on 19th December, 2020. The
+institutional ethics committee clearance certificate reference number is RES/IEC-
+SVYASA/184/2021. The trial has been registered in the Clinical Trials Registry-India (CTRI).
+The registration number for the trial is CTRI/2021/02/030944.…
+Consent
+Written…
+Access to data
+Only the principal investigator and the study coordinator will have access to the final trial
+dataset.…
+Dissemination policy
+The knowledge that researchers get from this research will be shared with participants
+through community meetings. Confidential information will not be shared. Data will be
+published the results in a peer-reviewed scientific journal and presented at national/
+international conferences so that other interested people may learn from our research.…
+Trial status
+Recruitment and intervention is in progress.…
+Fundingfi
+No funding is yet received for the trial. We are trying to find funding sources for the study.…
+CRediT authorship contribution statement
+U. Yamuna: Writing – original draft and revised draft, Writing – review & editing. Vijaya
+Majumdar: Conceptualization, Investigation, Methodology, Project administration,
+Supervision, Writing – original and revised draft, Writing – review & editing. Apar Avinash
+Saoji: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project
+administration, Supervision, Visualization, Writing – original and revised draft, Writing –
+review & editing.…
+Conflict of interest
+The authors report no conflict of interests.…
+References (50)
+A.A.M. Biemans et al.
+Validation of the chronic venous insufficiency quality of life questionnaire in dutch
+patients treated for varicose veins
+Eur. J. Vasc. Endovasc. Surg. (2011)
+S. Melnyk et al.
+A new HPLC method for the simultaneous determination of oxidized and reduced
+plasma aminothiols using coulometric electrochemical detection
+J. Nutr. Biochem. (1999)
+S.D. Ciezar-Andersen et al.
+A systematic review of yoga interventions for helping health professionals and students
+Complement. Ther. Med. (2021)
+J. Park et al.
+Frailty modifies the intervention effect of chair yoga on pain among older adults with
+lower extremity osteoarthritis: secondary analysis of a nonpharmacological
+intervention trial
+Exp. Gerontol. (2020)
+M. Ni et al.
+Controlled pilot study of the effects of power yoga in Parkinson’s disease
+Complement. Ther. Med. (2016)
+T. Field
+Yoga research review, complement
+Ther. Clin. Pract. (2016)
+H. Cramer et al.
+Yoga therapy: efficacy, mechanisms and implementation
+Complement. Ther. Med. (2018)
+R.C. Sam et al.
+The prevalence of hyperhomocysteinemia, methylene tetrahydrofolate reductase
+C677T mutation, and vitamin B12 and folate deficiency in patients with chronic
+venous insufficiency
+J. Vasc. Surg. (2003)
+S. Zhang et al.
+Varicose veins: diagnosis, management, and treatment
+J. Nurse Pract. (2014)
+J.L. Beebe-Dimmer et al.
+The epidemiology of chronic venous insufficiency and varicose veins
+Ann. Epidemiol. (2005)
+View more references
+Cited by (0)
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+CM practitioners has received little empirical attention. In direct response, our study
+examines the perceptions of CM students and faculty related specifically to health and
+learning technologies in clinical CM work and education.
+A cross-sectional online survey was administered to all current students (n = 4851) and
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+clinical training in CM settings (M3.2, SD 1.3) or learning rapport skills (M3.2, SD 1.2). Of
+those academics who were also in clinical practice, only a small number reported conducting
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+ScienceDirect ® is a registered trademark of Elsevier B.V.

subfolder_0/Effect of a Ten-Day Yoga-Based Vacation Program on Short-Term and Working Memory in Schoolchildren..txt

@@ -0,0 +1,310 @@
+See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/301204057
+Effect of a Ten-Day Yoga-Based Vacation Program on Short-Term and Working
+Memory in Schoolchildren
+Article · October 2015
+CITATION
+1
+READS
+183
+1 author:
+Some of the authors of this publication are also working on these related projects:
+Yoga for Mental Health among patients with HTN View project
+Yoga for Addiction View project
+Kashinath Metri
+Central University of Rajasthan
+48 PUBLICATIONS   168 CITATIONS   
+SEE PROFILE
+All content following this page was uploaded by Kashinath Metri on 12 April 2016.
+The user has requested enhancement of the downloaded file.
+Ayurveda Journal of Health
+VOL. XIII, ISSUE 1, WINTER 2015
+37
+Abstract
+Background: Memory is an important component of
+cognition and good memory in schoolchildren helps
+them to perform better in school. Yoga is known to
+improve cognitive function in school children and
+this study examines if yoga can improve memory in
+schoolchildren.
+Aim: To see the effect of a ten-day yoga-based vacation
+program on short-term and working memory in
+schoolchildren.
+Methods: Sixty schoolchildren aged 10-11 years, who
+attended a yoga-based training summer vacation
+program were enrolled in this study. All students
+underwent a 10-day intense yoga program consisting
+of Àsanas (physical postures), prÀõÀyÀma (breathing
+practices), meditation, relaxation techniques, and
+yogic games. Short-term and working memory was
+assessed by the digit forward–backward span test
+before and at the end of the training program.
+Results: A significant improvement in digit span
+score (p < 0.001) was observed at the end of the 10-
+day training program.
+Conclusion: The 10-day yoga program was found to
+significantly improve both short-term and working
+memory in the schoolchildren who participated in
+the program. The improvement in working memory
+(23.24%) is greater than short-term memory (11.67%).
+Keywords: Yoga, memory, children, digit forward,
+backward.
+Introduction
+The term memory implies the capacity to encode,
+store, and retrieve information.1 It is one of our most
+important cognitive functions. It is essential for
+Effect of a Ten-Day Yoga-Based Vacation
+Program on Short-Term and Working
+Memory in Schoolchildren
+B.N. Hema,1 G.M. Kashinath,1 H.R. Nagendra1
+children to have a good memory
+for better school performance and
+an efficient memory is necessary
+to excel in the current educational
+system. Unfortunately there is a
+lack of viable interventions in the
+current education system that can
+enhance memory.2 Hence there is a need for an
+intervention which can help improve memory in
+schoolchildren. This study evaluates the effect of
+yoga on short-term and working memory. Short-
+term memory allows for recall for a period of several
+seconds to a minute without rehearsal. The capacity
+of short-term memory is also very limited, and is
+typically on the order of 4-5 items.3 Working memory
+is a form of short-term memory that allows us to
+hold an idea in our mind long enough to carry out
+an action, such as calling a telephone number we
+just looked up.
+Yoga is an ancient science that was practiced by
+our ancient sages for many higher purposes. A
+modern form of yoga is currently very popular
+around the world. In recent decades, scientific
+research on yoga has revealed its potential role in
+prevention, treatment, and management of many
+health-related issues. It has been also reported that
+yoga has the potential for improving cognitive
+function including attention,4 concentration,5
+memory,6 and planning.7 The current study examines
+the effect of the Personality Development Course
+on memory in schoolchildren. The Personality
+Development Course is a 10-day yoga-based summer
+vacation program for schoolchildren conducted by
+S-VYASA University, Bangalore. Previous studies
+have shown that this program resulted in significant
+improvements in planning8 and attention. This study
+examines the effect of this program on short-term
+and working memory.
+1
+Division of Yoga and Life Sciences, Swami Vivekananda
+Yoga Anusandhana Samsthana (S-VYASA University),
+No. 19, Ekanath Bhavan, Gavipuram Circle, K.G. Nagar,
+Bangalore - 590 019.
+Ayurveda Journal of Health
+VOL. XIII, ISSUE 1, WINTER 2015
+38
+Methods
+SUBJECTS
+Sixty school children (11-12 years old) attending the
+10-day yoga training course during their summer
+vacation were enrolled in this study. Children were
+excluded from the study if they had any history of
+neurological or psychiatric issues, used any
+medication that affected the central nervous system,
+or had any documented learning disabilities.
+Intervention
+The subjects participated in the 10-day yoga training
+program for eight hours each day. The program
+consisted of different sessions on physical postures
+(yogÀsanas, 1½ hr), breathing practices (prÀõÀyÀma,
+1 hr), internal cleansing practices, including eye-
+cleansing techniques (kriyÀs, ½ hour), meditation and
+devotional sessions (1½ hr), and guided relaxation
+(½ hr). In addition to these particular practices, the
+program also involved games (2 hr) and telling of
+meaningful stories (1 hr) to promote a sense of values
+and feelings of responsibility.
+Assessment
+DIGIT SPAN FORWARD AND BACKWARD
+Digit Span (DS) is a sub-test in the Wechsler Adult
+Intelligence Scale, 3rd ed (WAIS-III).9 It includes two
+sub-sections (DS-Forward and DS-Backward), and
+is considered a good tool to evaluate short-term
+memory and working memory. DS-F evaluates short-
+term memory by simply requiring participants to
+repeat numbers. DS-B assesses working memory by
+requiring participants to memorize numbers and to
+repeat the numbers in the opposite order. For DS-F,
+participants repeat numbers in the same order as
+they were read aloud by the assessor. For DS-B,
+participants repeat numbers in the opposite order
+of that presented aloud by the assessor. Thus, In
+both sub-tests, the assessor reads a series of number
+sequences which the participant must repeat in either
+forward or reverse order. DS-F has 16 sequences.
+DS-B has 14 sequences. The primary measures of this
+test are raw scores that reflect the number of
+correctly repeated sequences until the discontinue
+criterion (that is, failure to reproduce two sequences
+of equal length) is met. The maximum raw score of
+DS-F is 16. The maximum raw score of DS-B is 14.
+Data Analysis
+Data was analysed using SPSS software (version 10).
+A paired sample t-test was used to analyze the pre
+and post changes.
+Results
+Normal distribution of the data was confirmed by
+Shapiro-wilk test and the paired sample test was
+applied to see the pre/post-changes which show the
+significant increase in digit span test scores (p < 0.001)
+after 10 days of the yoga-based training. Figure 1
+shows that the mean digit span score significantly
+increased after the children participated in the 10-
+day yoga program.
+Thus, the 10-day yoga program was found to
+significantly improve both short-term and working
+memory in the schoolchildren who participated in
+the program. The improvement in working memory
+(23.24%) is greater than that observed for short-term
+memory (11.67%).
+Discussion
+fig. 1: Changes in digit span score before and after 10 days of
+yoga training. The mean of the digit span score increases from
+18.01 to 20.91 following the 10-day yoga program. *p < 0.001.
+This study was designed to determine the influence
+of a 10-day yoga training program on short-term
+and working memory in 60 schoolchildren. The
+training program resulted in a significant
+improvement in both short-term and working
+memory. Our results confirm previous studies that
+have demonstrated that yoga is effective in
+enhancing memory in schoolchildren. In one study,
+a yoga-based education system was shown to
+improve spatial memory.10 The results of the current
+study are similar to earlier studies that have
+examined the effect of yoga on memory.
+Ayurveda Journal of Health
+VOL. XIII, ISSUE 1, WINTER 2015
+39
+Yoga is well known to reduce anxiety11 and
+provides deep relaxation at both the physical and
+psychological levels.12 The findings that yoga improves
+memory could be due to the reduction of anxiety and
+the enhanced relaxation which is achieved by the
+practice of yoga Àsanas and prÀõÀyÀma, mediation
+and yogic game sessions. Although religious chantings
+like OÛ, GÀytrÁ mantra, and m¦tyuðjaya mantra are
+effective in improving cognitive function in the
+children, these practices cannot be widely adopted in
+the schools, because schools include children with
+different religious backgrounds. Hence it is always
+better to include just Àsanas, prÀõÀyÀma, meditation,
+and yogic games within the conventional education
+system as a yoga session.
+The strength of this study is that it is the first
+study to show that yoga improves short-term and
+working memory in schoolchildren. It should be noted
+that a limitation of this study was the lack of a control
+group. None the less, the current study suggests that
+introducing yoga into the school education curriculum
+is beneficial for improving memory in schoolchildren.
+Future studies will extend these findings to determine
+the effect of intense yoga-based training programs
+on immunological and stress markers.
+Conclusion
+A 10-day yoga program may help to improve short-
+term and working memory in schoolchildren. Hence
+it is important to introduce into the regular school
+curriculum, a yoga session which includes, Àsanas,
+prÀõÀyÀma, meditation, and some yogic games, in
+order to help improve memory in schoolchildren.
+References
+1
+A.W. Robert, C.K. Frank, 2001, MIT Encyclopedia of
+Cognitive Science: A Bradford Book, Massachusetts
+London: The MIT Press Cambridge.
+2
+B. 
+Pradhan, H.R. 
+Nagendra, 
+2009, 
+Effect
+of Yoga Relaxation Techniques on Performance of Digit-
+Table 1: Pre and Post Changes in the Digit Forward–Backward Span Test
+Varibale
+Pre-yoga
+Post-yoga
+p-Value
+% Change
+(Mean ± SD)
+(Mean ± SD)
+Digit forward
+11.13 ± 1.35
+12.43 ± 1.80
+<0.001*a
+11.67
+Digit backward
+  6.88 ± 1.50
+  8.48 ± 1.77
+<0.001*a
+23.24
+Digit forward–backward span
+18.02 ± 2.44
+20.92 ± 3.13
+< 0.001*b
+16.09
+a Wicoxon signed rank test, b paired sample t-test, and *significant change at< 0.001 level.
+Dr. Kashinath G. Metri, BAMS, MD is Assistant
+Professor at S-VYASA University Bengaluru, India.
+He has a Bachelors in Ayurveda Medicine from Rajiv
+Gandhi University Bengaluru, India and Doctor of
+Medicine in Yoga and Rehabilitation from S-VYASA
+University, Bengaluru, India.  He has guided more
+than 10 postgraduates of yoga in their research work
+in yoga therapy and is currently guiding 15 post-
+graduates. Dr. Metri has more than 10 articles
+published in international peer-reviewed  journals
+in the field of Yoga and Ayurveda.
+Email: [email protected]  Mob.: +91 9035257626
+letter Substitution Task by Teenagers, Int J Yoga, 2(1):
+30-34.
+3
+N. Cowan, 2001, The Magical Number 4 in Short-term
+Memory: A Reconsideration of Mental Storage
+Capacity, Behav Brain Sci., February, 24(1): 87-114;
+discussion on pp. 114-85.
+4
+Shirley Telles,  P. Raghuraj, Dhananjay Arankalle, K.V.
+Naveen, 2008, Immediate Effect of High-Frequency
+Yoga Breathing on Attention, Indian Journal of Medical
+Sciences, 62(1): 20-22.
+5
+J.T. Hopkins, L.J. Hopkins, 1979, A Study of Yoga and
+Concentration, Academic Therapy, 14(3): 341-45.
+6
+K.V. Naveen, R. Nagaratna, H.R. Nmagendra, Shelrey
+Telles, 1997, Yoga Breathing Through a Particular Nostril
+Increases Special Memory Score without Latelization,
+Physiological Effects, 81: 555-61.
+7
+N.K. Manjunath, Shirley Telles, 2001, Improved
+Performance in the Tower of London Test Following
+Yoga, Indian J Physiol Pharmacol, 45(3): 351-54.
+8
+A. Kadambini, 2005, Effect of Yoga on Performance in a
+Planning Task in Tower of London Test, MSc thesis: S-
+VYASA University.
+9
+D.A. Wechsler, 1997, Wechsler Adult Intelligence Scale,
+3rd ed, San Antonio: The Psychological Corporation.
+1 0
+R. Rangan, H.R. Nagendra, G. Ramachandra Bhat, 2009,
+Effect of Yogic Education System and Modern Education
+System on Memory, Int J Yoga, 2.
+1 1
+G. Kirkwood, H. Rampes, V. Tuffrey, J. Richardson, K.
+Pilkington, 2005, Yoga for Anxiety: A Systematic Review
+of the Research Evidence, Br J Sports Med, 39: 884-91.
+1 2
+Ibid., J R Soc Med., 86: 5254-58.
+View publication stats
+View publication stats

subfolder_0/Effect of anapanasati meditation on anxiety a randomized control trial.txt

@@ -0,0 +1,465 @@
+ANNALS OF NEUROSCIENCES  VOLUME 26  NUMBER 1  JANUARY 2019
+www.annalsofneurosciences.org
+32
+ANNALS
+RES ARTICLE
+Effect of anapanasati meditation on anxiety: a randomized  
+control trial
+B. Sivaramappaa, Sudheer Deshpandeb, P Venkata Giri Kumara,*, H.R. Nagendraa
+a S-VYASA Yoga University, Bengaluru, Karnataka, India
+b VYASA, Eknath Bhavan, Bangalore, Karnataka, India 
+ABSTRACT
+Background: Meditation has shown positive results in improving the psychological disorders 
+such as anxiety. There is a need to study the therapeutic benefits of Anapanasati meditation, a 
+mindfulness meditation technique. 
+Purpose: The study aims at investigating the effect of Anapanasati meditation on individuals 
+with moderate anxiety. 
+Methods: A total of 112 participants who were willing to participate in the study were recruit-
+ed for the study. Anapanasati meditation was used as an intervention. The participants were 
+divided into two groups experiment and control groups. Experiment group had 56 persons 
+performing Anapanasati meditation and Control group had 56 persons not performing any 
+type of meditation. The experiment group practiced one hour of Anapanasati meditation daily 
+under the supervision of experts for six months and continued their daily routine and control 
+group was not given any intervention, but they continued their daily routine. State Trait Anxiety 
+Inventory (STAI) is used to assess the anxiety level. 
+Results: The STAI score before and after Anapanasati meditation was analysed for both experi-
+ment and control groups using Paired Samples T test. The experiment group has shown signif-
+icant reduction in the STAI (P < 0.05) score after the intervention whereas in the control group 
+the reduction in STAI score was not significant. 
+Conclusion: This study has shown that after six months of intervention, the subjects with 
+ 
+moderate anxiety who practiced Anapanasati meditation had a significant decrease in their STAI 
+score and the control group has not shown significant change in the STAI score. 
+doi : 10.5214/ans.0972.7531.260107
+KEY WORDS 
+Anapanasati meditation
+State Trait Anxiety Inventory
+Mindfulness
+*Corresponding author:
+P Venkata Giri Kumar
+S-VYASA Yoga University, Vivekananda 
+Road
+Kalluballu Post, Jigani, Anekal,  
+Bengaluru – 560105, Karanataka, India
+Contact no +91 9880658950
+E-mail: [email protected]
+Introduction
+Anxiety is an emotional state such as nervousness, tension, 
+worry or apprehension which a person perceives for various 
+reasons [1]. The research indicates that anxiety is closely as-
+sociated to chronic allergy such as asthma, cognitive impair-
+ment and dementia and many other chronic diseases such as 
+rheumatology [2–4]. Preoperative anxiety is commonly ex-
+perienced by the patients waiting for surgery and in a study 
+authors suggested that listening to Tibetan music helps in 
+managing the preoperative levels [5]. The quality of life of the 
+individuals with chronic illness varies with comorbid anxiety 
+which emphasizes the importance of reducing the anxiety 
+levels [6]. Number of scales were developed for measuring 
+anxiety levels and State Trait Anxiety Inventory (STAI), Beck 
+Anxiety Inventory (BAI) and Hospital Anxiety And Depression 
+Scale-Anxiety (HADS-A) are widely used in assessing the anx-
+iety levels in research and clinical studies [4]. 
+Meditation is a set of self-regulatory practices [7] or psy-
+chosomatic practices [8] with a focus on training the attention 
+and awareness such that concentration will be developed. It 
+is well known that meditation, one of the limbs of Patanjali 
+Yoga [9], plays a significant role in improving the psycholog-
+ical disorders and research suggests the use of mindfulness 
+ 
+meditation for reducing depression and anxiety levels 
+ 
+[10–12]. Recently there has been increasing research interest 
+on therapeutic benefits of meditation for psychological disor-
+ders and studies on meditation have shown significant pos-
+itive results in psychological disorders [11,13–16]. Despite 
+the therapeutic benefits of meditation, there are considerable 
+discrepancies on the effect of meditation on brain as studied 
+by Electroencephalogram [17]. 
+The earlier studies have considered different meditation 
+techniques but there were no studies done with Anapanasa-
+ti meditation, a form of Mindfulness meditation. Anpanasati 
+meditation is the name of the meditation practice adopted 
+by Gautam Buddha and it is nothing but mere observation of 
+one’s own breath ie., inhaling and exhaling [18]. In this study 
+we aimed at studying the effect of Anapanasati meditation on 
+the individuals with moderate anxiety assessed with State 
+Trait Anxiety Inventory scale.
+Methods
+Subjects
+The subjects were selected from Pyramid Valley Interna-
+tional Bangalore and Pyramid Spiritual Science Academy, 
+Koramangala, Bangalore. A total of 112 subjects who were 
+www.annalsofneurosciences.org	
+ANNALS OF NEUROSCIENCES  VOLUME 26  NUMBER 1  JANUARY 2019
+33
+ANNALS
+S
+RES ARTICLE
+willing to participate in the study were selected for the 
+study. The age group ranged between 20 and 65 years. 
+Inclusion Criteria
+Males and females within the age group of 20 to 65 years were 
+included in the study. 
+Exclusion Criteria
+Individuals who have been diagnosed with diabetes, cancer, 
+hypertension were excluded from the study. 
+Design 
+This is a prospective random control design. The participants 
+were divided into two groups experiment and control. The 
+subjects selected for study were randomly allotted into two 
+groups by using random number generator program. A total 
+of 56 participants were included in experiment group and 56 
+participants were included in control group. The invigilators 
+coded and saved the answered questionnaires after the study. 
+A person not involved in group formation evaluated the coded 
+answer sheets. A person who was not involved in this study 
+decoded the answer sheets only after noting the scores before 
+and after data was completed.
+State Trait Anxiety Inventory (STAI) [1], a self-report 
+questionnaire is used as the scale to study the effect of in-
+tervention. STAI consists of two parts state anxiety and trait 
+anxiety each consisting of 20 questions which takes values 
+from 1 to 4. We have considered state anxiety part (STAI-S) 
+of the questionnaire for our study which indicates the cur-
+rent state of anxiety in a specific situation when compared 
+to trait anxiety which is a general tendency of the individ-
+ual. The score can range from 20 to 80 and the score in-
+creases with anxiety levels [1]. The score greater than 40 
+is considered to be clinically significant score for STAI scale 
+[4,5]. The subjects were asked to read each statement and 
+select the statement which reflects the true state of the in-
+dividual at that moment. The informed consent was taken 
+from all the participants who were willing to participate in 
+the study. 
+Intervention 
+Anapanasati Meditation is given as intervention to partici-
+pants in the experiment group and participants were asked 
+to practice meditation daily one hour along with their routine 
+duties and there was no intervention to Control Group but 
+they were asked to continue their daily routine. The Medita-
+tion classes were conducted six days a week for six months 
+under the supervision of experts. It was ensured that there 
+was no interaction between the groups during the entire pe-
+riod of six months. The tests were administered on the first 
+and last day of the study. The subjects were accommodated at 
+a quiet environment free from distractions to fill up the ques-
+tionnaires. The subjects were asked to fill up the question-
+naires with experts present for any clarification and without 
+consulting other subject while filling up the questionnaire.
+Statistical Analysis
+The data were analysed using SPSS Statistics Version 10. The 
+data was presented as mean ± standard deviation. The data 
+was assessed for normality using Kolmogorov-Smirnov test 
+and STAI score was found to be normal in both experimental 
+and control groups. P value <0.05 is considered statistically 
+significant for all comparisons and the data were reported to 
+two significant figures. The statistical tests used were Paired 
+Samples t-test for pre-post comparison within the groups. The 
+Cohen’s d effect size for assessing the effect of intervention was 
+computed as the ratio of the difference between means of ex-
+periment and control groups to the pooled standard deviation.
+Results
+The STAI score before and after the Anapanasati intervention 
+was analysed for both Experiment and Control groups using 
+Paired Samples T test as shown in Table 1. The experiment 
+group has shown significant reduction in the STAI (P < 0.05) 
+score after the intervention whereas STAI score has increased 
+in the control group. The pre and post STAI scores across age 
+groups of Experiment and Control groups were tabulated in 
+Table 2. The Cohen’s d effect size was computed and it has 
+taken a value of 1.52.
+Table 1: Paired Samples T Test 
+Group N
+STAI (Pre) 
+STAI (Post)
+P Value
+CI
+Experiment 
+5648.32 ± 6.57
+45.73 ± 3.28
+0.01*
+[0.59, 4.58]
+Control 
+5650.45 ± 4.55
+51.93 ± 4.76
+0.01*
+[–2.61, –0.353]
+Data is represented as mean ± standard deviation 
+STAI: State Trait Anxiety Inventory 
+N: Number of Participants 
+Pre: Pre data taken before intervention 
+Post: Post data taken after intervention 
+*P Value significance at 0.05 level 
+CI: 95% Confidence Interval of the difference between pre and post BDI scores
+ANNALS OF NEUROSCIENCES  VOLUME 26  NUMBER 1  JANUARY 2019
+www.annalsofneurosciences.org
+34
+ANNALS
+RES ARTICLE
+Fig. 1:  Comparing Pre and Post STAI Score across three different 
+ranges of score in experiment group.
+Group 1: Participants in experiment group with STAI score less than 40 
+Group 2: Participants in experiment group with STAI score between 40 
+ 
+and 60 
+Group 3: Participants in experiment group with STAI score greater 
+ 
+than 60
+Table 2: STAI vs Age in Experiment and Control Groups
+Age Group
+Experiment Group 
+Control Group
+STAI Pre 
+STAI Post
+P Value
+STAI Pre
+STAI post
+P Value
+<= 40
+44.0 ± 5.03
+45.14 ± 3.44
+0.625
+50.44 ± 4.22
+52.22 ± 4.43
+0.03*
+> 40
+49.44 ± 6.56
+45.85 ± 2.75
+0.004*
+49.44 ± 5.09
+51.69 ± 6.03
+0.17
+Data is represented as mean ± standard deviation 
+STAI: State Trait Anxiety Inventory Score
+Pre: STAI score before intervention 
+Post: STAI score after intervention 
+*P Value significance at 0.05 level
+results of the previous studies. The role of yoga in improving 
+the quality of life which gets influenced by negative emotions 
+and aggression is well understood [25–27] and meditation 
+being a limb of Yoga [9] has a significant role in improving the 
+quality of life and reducing the anxiety and depression levels. 
+The results of our study highlight the importance of medita-
+tion in reducing the anxiety levels as measured by STAI. 
+We further analysed the data and observed that after 
+practicing Anapanasati meditation for six months the anxi-
+ety has come down in older subjects with age greater than 40 
+whereas the anxiety has increased in younger subjects with age 
+less than 40. The reason for such an increase in STAI score in 
+younger adults may due to lower sample size of younger group 
+which has only 7 subjects and warrants further focussed study 
+to establish the effectiveness across different age groups. The 
+STAI score was lying between 40 to 60 for majority of the par-
+ticipants in both experiment and control groups. In experiment 
+group there were only 5 subjects with less than 40 and only 
+one subject with score greater than 60 (Fig 1). The STAI score 
+has moderately increased in the subjects who were having the 
+score less than 40 after intervention and the reason for such an 
+increase need to be understood from various factors such as 
+physiological, psychological and socio-economic status of the 
+individuals and not considering them in our study is a limita-
+tion. The results of the current study confirm the effectiveness 
+of Anapanasati meditation but warrants further in depth study 
+to understand the effectiveness when anxiety is comorbid with 
+other physiological and psychological disorders. 
+This is the first time the effect of Anapanasati meditation 
+on anxiety was studied and the results were promising and 
+paved the way for in-depth studies to unravel the hidden po-
+tential of the meditation. The study has been done with equal 
+sample size in both the groups and the baseline score of both 
+the groups is nearly same which is the strength of the study. 
+Despite the promising results there are many limitations in the 
+study which need to be addressed in future studies. The study 
+was done with moderately smaller sample size and there is a 
+need to do the study with larger sample size covering all age 
+groups. The STAI score was not covering the low, moderate 
+and high levels as majority of the participants were in moder-
+ate group. There is a need to study the effect of Anapanasati 
+meditation with larger sample size covering the range of STAI 
+score such that the effect of meditation at various levels of 
+anxiety can be studied. The results confirm that Anapanasati 
+ 
+Discussion
+The present study focused on investigating the effect of Anap-
+anasati meditation on the individuals with moderate anxiety 
+and STAI scale was used for assessing the anxiety level. STAI 
+scale is considered to be one of the best measures and litera-
+ture review indicates that the number of citations with STAI 
+are more compared to other measures and originally the scale 
+was designed for normal population which was extended lat-
+er for clinical studies [1]. In the present study at the end of the 
+six month period we have observed that the anxiety levels of 
+the subjects in Experiment group have reduced significantly 
+whereas in Control group the anxiety levels have moderate-
+ly increased. The previous studies on Anapansati meditation 
+have shown that the stress parameter activation coefficient 
+and health parameter integral area as measured by Electro 
+Photonic Imaging (EPI) technique have reduced significant-
+ly with meditation [19] and also Anapanasati meditation was 
+closely associated to attention task performance [20]. The 
+earlier studies on mindfulness meditation established the 
+effectiveness of meditation in reducing the anxiety and de-
+pression levels [13,21–24] and our results with Anapanasati 
+meditation, a form of mindfulness meditation, match with the 
+www.annalsofneurosciences.org	
+ANNALS OF NEUROSCIENCES  VOLUME 26  NUMBER 1  JANUARY 2019
+35
+ANNALS
+S
+RES ARTICLE
+meditation has reduced the STAI scores when compared to 
+control group who were not performing any meditation but 
+due to the lack of physiological, psychological and socio-eco-
+nomic status of the participants it is difficult to understand 
+the reasons why the anxiety levels have increased in the 
+participants of control group. We have not measured gen-
+eral anthropometric and clinical parameters such as height, 
+weight, blood pressure, pulse rate etc. and hence study lacks 
+the strength in assessing the therapeutic benefits of the in-
+tervention.
+Conclusion
+In conclusion, the participants of Anapanasati meditation 
+have shown significant reduction in the anxiety score mea-
+sured with State Trait Anxiety Inventory. There was no such 
+significant change in the STAI score of control group. Anap-
+anasati meditation is a form of mindfulness meditation and 
+the results emphasize the need for its regular practice in 
+ 
+improving the quality of life. 
+Acknowledgement
+I am thankful to all who willingly participated in this study 
+and I sincerely acknowledge their whole-hearted participa-
+tion. I thank all those who helped me to complete this study 
+and arrive at the results.
+Authorship contribution 
+This article complies with International Committee of Medical 
+Journal editor’s uniform requirements for manuscript.
+Ethical statement 
+Signed informed consent was obtained from all the subjects. 
+The institutional ethical committee of the parent institution 
+had cleared the project proposal with ethical approval num-
+ber IEC/Vyasa/24/2014.
+Source of funding
+None
+Conflict of interest
+None 
+Received Date : 06-08-18; Revised Date : 19-10-18;  
+Accepted Date : 19-11-18
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subfolder_0/Effect of short duration integrated classroom yoga module on physical, cognitive, emotional and personality measures of school children.txt

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+100 	
+© 2021 Yoga Mīmāṃsā | Published by Wolters Kluwer - Medknow
+Original Article
+Effect of short duration integrated classroom yoga 
+module on physical, cognitive, emotional and 
+personality measures of school children
+Atul Sinha, Sony Kumari
+Department of Yoga and Humanities, Swami Vivekananda Yoga Anusandhana Samsthana (Deemed to be University), Bengaluru, 
+Karnataka, India
+INTRODUCTION
+UNICEF estimated that an alarming 10%–20% of the world’s 
+2.2 billion child and adolescent population was afflicted by mental 
+health problems (Kieling et al., 2011). The National Mental Health 
+Survey (2016) in India found that 7.3% of adolescents suffered at 
+least one condition of mental morbidity (Gururaj et al, 2016).  In the 
+USA 7.5% of adolescents met the DSM-IV criteria for one or more 
+mental health conditions (Kessler & Wang, 2008). These findings 
+suggested that young people needed social-emotional learning 
+(Butzer, Bury, Telles, & Khalsa, 2016). Further, the Association 
+for Supervision and Curriculum Development’s Commission on 
+the Whole Child (ASCD), felt the need to go beyond cognitive 
+development and educate the whole child defined as intellectually 
+Context: Despite evidence of therapeutic benefits of yoga on school children, many schools do not include yoga 
+in their daily schedule. Reasons cited are lack of time and resources. An efficacious short duration integrated 
+classroom yoga module (ICYM) can overcome such problems.
+Aim: This study aimed to test the effect of such a yoga module on physical fitness, cognitive performance, emotional 
+wellbeing, and personality characteristic of school children.
+Methods: The design was a randomized controlled trial with participants sourced from grades 7–10. The intervention 
+period was 2 months. The primary outcome measures were 4 tests from the EUROFIT physical fitness testing 
+battery, Stroop color-word naming task, Rosenberg self-esteem scale, WHO-5 wellbeing index, and Sushruta Child 
+Personality Inventory. Statistical analysis used a repeated measure analysis of variance. Secondary outcome 
+measure was a qualitative assessment.
+Results: The yoga group showed significant differences compared to the control group in 2 of 4 physical fitness 
+variables, Stroop color-word naming task, and in the WHO-5 wellbeing index.
+Conclusion: ICYM is a validated, feasible, and efficacious school-based short-duration integrated yoga module. 
+It can be considered for incorporation into the daily school schedule.
+Key Words: Classroom yoga, cognitive performance, emotional wellbeing, physical fitness, short-duration yoga, 
+yoga in schools
+Address for correspondence: 
+Mr. Atul Sinha, 103 Regent Place, 28/2 Thubrahalli, Whitefield Road, Bengaluru - 560 066, Karnataka, India.
+E-mail: [email protected]
+Submitted: 04-Jun-2021  Revised: 23-Oct-2021  Accepted: 26-Oct-2021  Published: 22-Dec-2021
+How to cite this article: Sinha A, Kumari S. Effect of short duration 
+integrated classroom yoga module on physical, cognitive, emotional 
+and personality measures of school children. Yoga Mimamsa 
+2021;53:100-8.
+This is an open access journal, and articles are distributed under the terms of the 
+Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which 
+allows others to remix, tweak, and build upon the work non-commercially, as long as 
+appropriate credit is given and the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+Access this article online
+Quick Response Code:
+Website:
+www.ym-kdham.in
+DOI:
+10.4103/ym.ym_55_21
+Abstract
+[Downloaded free from http://www.ym-kdham.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Sinha and Kumari: Effect of ICYM on wellbeing of school children
+Yoga Mīmāṃsā | Volume 53 | Issue 2 | July-December 2021	
+101
+active, physically, verbally, socially, and academically competent; 
+empathetic, kind, caring and fair; creative and curious; disciplined, 
+self-directed and goal-oriented; free, critical thinker, confident and 
+cared for and valued (Hyde, 2012).
+Growing modern research evidence suggests that yoga is 
+efficacious in developing the whole child. Traditional texts of 
+yoga too articulate a vision of education as laying the foundations 
+of character and personality through self-transformation 
+(Niranjanananda, 2009). 
+Many school-based studies have found that yoga was beneficial 
+for children. A meta-analysis by Galantino, Galbavy, & Quinn 
+(2008) found that yoga positively impacted physiological health 
+variables such as reaction time, motor speed, musculoskeletal 
+strength, and cardio-pulmonary measures. Another meta-analysis 
+by Zenner, Herrnleben-Kurz, & Walach (2014) showed that 
+cognitive performance, stress levels, resilience, and emotional 
+balance improved with mindfulness interventions. Serwacki 
+& Cook-Cottone (2012) reviewed 12 studies and reported that 
+yoga positively impacted cognitive efficiency, attentional control, 
+emotional balance, anxiety, reactivity, and negative behavior. A 
+study found that sattva (controlled illuminative energy) increased 
+while rajas (uncontrolled active energy) and tamas (uncontrolled 
+inert energy) reduced with yoga intervention, resulting in a tranquil 
+personality (Patil & Nagendra, 2014).
+Many Indian studies have reported the beneficial effects of yoga 
+on physical, cognitive, and emotional measures of school children. 
+It had a beneficial effect on physical fitness (Purohit, Pradhan, & 
+Nagendra, 2016). It impacted cardiopulmonary health positively 
+(Shivakumar, Suthakar, & Urs, 2016). Yoga was significantly 
+associated with memory, attention, and executive function (Chaya, 
+Nagendra, Selvam, Kurpad, & Srinivasan,  2012; Verma, Shete, 
+& Singh Thakur, 2014). It improved self-esteem, self-adjustment, 
+and self-efficacy (Bhardwaj & Agrawal, 2013; Bhardwaj & 
+Bhardwaj, 2015; Das, Deepeshwar, Subramanya, & Manjunath, 
+2016). Yoga reduced anxiety (Gusain & Dauneria, 2016).
+Despite awareness of the benefits of yoga, most schools either 
+have not incorporated yoga in the curriculum or have done so sub-
+optimally, usually one session a week. The reasons cited are paucity 
+of time and resources such as yoga rooms and yoga instructors. We 
+argue that unless a solution is found to overcome these problems it 
+will be difficult to incorporate yoga into the daily school schedule. 
+We hypothesize that a short-duration integrated classroom yoga 
+module (ICYM) instructed by the class teacher will have a positive 
+impact on physical fitness, cognitive performance, emotional 
+wellbeing, and personality characteristics. Such a module can 
+overcome the cited problems and allow for yoga’s inclusion in the 
+daily school schedule. Traditional texts too support the practice 
+of yoga in the classroom (Satyananda, 1990, p 50-56, 110-132).
+Studies conducted so far on classroom yoga suffer from 
+methodological infirmities, small sample sizes, and non-standard 
+interventions. Studies by Butzer et al. (2015), Chen & Pauwels 
+(2014), and Lawson, Lisa Cox, & Blackwell (2012), used once a 
+week intervention, yoga-based activities, and a modified form of 
+yoga respectively in uncontrolled pilot studies with small sample 
+sizes. These studies found directional improvements in stress 
+reduction, emotional wellbeing, and behavior. A study by Telles, 
+Gupta, Gandharva, Vishwakarma, Kala, & Balkrishna (2019) 
+used an 18-min pranayama intervention for 3 days and reported 
+a positive impact on attention and anxiety. It is evident that the 
+current research on short-duration classroom yoga is clearly 
+inadequate and there is a need for a methodologically sound study.
+The present study aimed to evaluate the effect of a previously 
+validated ICYM (Sinha, Kumari, & Ganguly, 2021), on physical, 
+cognitive, emotional, and personality measures. These measures 
+were chosen since they formed the major components that defined 
+the whole child. Specific tests used were (i) EUROFIT physical 
+fitness testing battery since it was a comprehensive field test, 
+(ii) Stroop color-word naming task since it was a reliable test of 
+neurophysiological function, (iii) Rosenberg self-esteem scale 
+since self-esteem is associated with other mal-adaptations, (iv) 
+WHO-5 wellbeing index since it was a key desired outcome in 
+social-emotional learning, and (v) Sushruta Child Personality 
+Inventory (SCPI) measuring gunas, since it indicated a tranquil 
+personality.
+METHODS
+Participants
+The study sourced participants from two urban campuses of 
+Samsidh Mount Litera Zee School, Bengaluru, INDIA. One 
+campus provided the yoga group and the other the control group. 
+All students from Grades 7–10 who met the inclusion criteria 
+participated in the study.
+The sample size for physical fitness tests was restricted to 98 
+(yoga = 48, control = 50) because the administration of the tests 
+required significant time and resources. Randomization was 
+achieved by setting quotas for each grade and drawing from 
+paper slips. For the cognitive performance test the sample size 
+was 253 (yoga = 143, control = 110). For the emotional wellbeing 
+tests the sample size was 244 (yoga = 137, control = 107). For 
+the personality characteristic test the sample size was 254 (yoga 
+= 148, control = 106). Randomization was achieved since both 
+control and intervention groups were drawn from the same grades 
+of the two campuses. However, drawing the control group from 
+one campus and the experimental group from another campus 
+resulted in unequal randomization. The sample sizes for cognitive 
+performance, emotional wellbeing and personality characteristic 
+tests varied marginally due to nonavailability of students on 
+account of absenteeism or participation in other activities on 
+the days the tests were administered. The detailed participant 
+characteristics are given in Table 1.
+The inclusion criteria were (i) participants from Grades 7–10, 
+(ii) of both genders. The exclusion criteria were (i) major 
+illness or surgery in the last two months, (ii) any mental health 
+[Downloaded free from http://www.ym-kdham.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Sinha and Kumari: Effect of ICYM on wellbeing of school children
+102 	
+Yoga Mīmāṃsā | Volume 53 | Issue 2 | July-December 2021
+issue, (iii) any condition contraindicating physical activity. 
+A signed informed consent was obtained from the school 
+principal (dated July 10, 20 19). The study was approved by the 
+Institutional Ethics Committee of S-VYASA University (RES/
+IEC-SVYASA/145/2019).
+Design
+The design of the study was a randomized controlled trial with 
+pre-post assessments. The intervention period was 2 months with 
+5 days a week of yoga practice. The study was conducted in July-
+September 2019. The design profile is given in Figure 1.
+Yoga intervention
+The intervention used was the 12-min ICYM. The module was 
+systematically developed based on literature review, expert-
+validated and efficacy confirmed in a pilot study (Sinha, Kumari 
+& Ganguly, 2021). Class teachers were given systematic training 
+to conduct the sessions. The detailed module is shown in Table 2.
+Assessment
+The primary outcome measures comprised (i) 4 tests from 
+the EUROFIT physical fitness testing battery (Kemper & Van 
+Mechelen, 1996), (ii) Stroop color-word naming task (Jensen & 
+Rohwer Jr., 1966), (iii) Rosenberg self-esteem scale (Rosenberg, 
+1965), (iv) WHO-5 wellbeing index (Topp, Østergaard, 
+Søndergaard, & Bech, 2015) and (vi) SCPI (Suchitra & Nagendra, 
+2013). The secondary outcome measure was a qualitative 
+assessment of the experience, benefits, and feasibility.
+EUROFIT fitness testing battery
+The EUROFIT fitness testing battery is a field test. Components of 
+fitness were identified by factor analysis ensuring test reliability. 
+Despite noncomparability with isometric tests, the coefficient of 
+correlation nevertheless ranged from 0.43 to 0.82, where a score 
+of .60 is considered good validity. Many Indian studies have 
+used this test (Telles, Singh, Bhardwaj, Kumar, & Balkrishna, 
+2013; Karkera, Swaminathan, Pais, Vishal, & Rai, 2014; Purohit, 
+et al., 2016).
+Flamingo balance test
+Participants balanced on a narrow wooden bar on one leg. The 
+number of falls in 60 s was recorded.
+Sit and reach flexibility test
+Participants sat on the floor with both legs stretched and touching 
+the base of a measuring table. They stretched fully and the 
+distance stretched was recorded from the measuring scale on 
+the tabletop.
+Table 1: Age and gender of participants
+T
+otal
+Yoga group
+Control group
+EUROFIT physical fitness tests
+Sample size
+98
+48
+50
+Age (years)
+13.46 (1.105)
+13.65 (1.021)
+13.28 (1.161)
+Age range
+11-16
+12-16
+11-16
+Gender ratio (B:G)
+49:49
+23:25
+26:24
+Stroop colour‑word task
+Sample size
+253
+143
+110
+Age (years)
+13.15 (1.195)
+13.42 (1.128)
+12.79 (1.189)
+Age range
+11-16
+11-16
+11-15
+Gender ratio (B:G)
+127:126
+70:73
+57:53
+Rosenberg self‑esteem scale and WHO‑5 well‑being index
+Sample size
+244
+137
+107
+Age (years)
+13.06 (1.243)
+13.34 (1.202)
+12.70 (1.207)
+Age range
+11-16
+11-16
+11-15
+Gender ratio (B:G)
+126:118
+75:73
+54:52
+SCPI
+Sample size
+254
+148
+106
+Age (years)
+13.16 (1.215)
+13.45 (1.139)
+12.75 (1.210)
+Age range
+11-16
+11-16
+11-15
+Gender ratio (B:G)
+129:125
+75:73
+54:52
+Age (years), values are group means (SD). SD, Standard deviation; SCPI, Sushruta Child Personality Inventory
+Figure 1: Design profile
+[Downloaded free from http://www.ym-kdham.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Sinha and Kumari: Effect of ICYM on wellbeing of school children
+Yoga Mīmāṃsā | Volume 53 | Issue 2 | July-December 2021	
+103
+Sit-ups trunk strength
+Participants were required to lie on their back with knees bent, 
+hands behind their heads, and perform sit ups. The number of 
+sit-ups in 30 s was recorded.
+10 m × 5 m shuttle run agility test
+Cones were kept at 10 m distance. The participants ran to the cone 
+and back five times. The timing of the run was recorded.
+Stroop color-word naming task
+The Stroop color-word task measures the participant’s control 
+over neuropsychological functions involved in color, word, and 
+an interference naming response. The reliabilities of the basic 
+scores are high ranging from 0.71 to 0.88. The scale has been 
+used extensively in Indian studies (Prakash Dubey, Abhishek, 
+Gupta, Rastogi, & Siddiqui, 2010; Telles et al., 2013; (Purohit & 
+Pradhan, 2017); Vanitha, Suresh, Chandrasekar, & Punita, 2017; 
+Suresh, Jagadisan, Kandasamy, & Senthilkumar, 2018).
+The test consists of three pages. The first page tests how fast the 
+participant can read out words. The second page tests how fast the 
+participant can call out colors. The third page tests the speed with 
+which the participant can name the color of the ink and disregard 
+the word printed in that ink-color. The correct number of words, 
+colors, and ink-colors called in 45 seconds is recorded.
+Rosenberg self-esteem scale
+The Rosenberg self-esteem scale is a self-report scale that 
+measures global self-esteem. The scale demonstrates a coefficient 
+of reproducibility of 0.92 and test-retest reliability of 0.85 which 
+are considered excellent. The scale has been used extensively in 
+Indian studies (Schmitt & Allik, 2005; Sethi, Nagendra, & Ganpat, 
+2013; Jhambh, Arun, & Garg, 2014; Pal, Sharan, & Chadda, 2017; 
+Ramanathan, Bhavanani, & Trakroo, 2017).
+WHO-5 wellbeing index
+The WHO-5 wellbeing index is a self-report scale. It has 5 items 
+measuring emotional wellbeing. Experts have given this scale 
+a high rating on clinimetric validity. Predictive validity too is 
+high. Many Indian studies have used this scale (Chaturvedula & 
+Joseph, 2007; Agger, Raghuvanshi, Shabana, Polatin, & Laursen, 
+2009; Puri, Sapra, & Jain, 2013; Firdaus, 2017; (Sinha, Kumari 
+& Ganguly 2021).
+Sushruta Child Personality Inventory
+The SCPI is a self-report scale measuring personality characteristics. 
+The scale is based on the concept that the mind is always in a 
+dynamic equilibrium between three types of energies called gunas 
+namely sattva (controlled illuminative energy), rajas (uncontrolled 
+active energy) and tamas (uncontrolled inert energy). Wellbeing is 
+disturbed when rajas and tamas dominate (Deshpande, Nagendra 
+& Raghuram, 2008). The scale has a Cronbach alpha score of over 
+0.60 making it reliable. Validity was ensured by selecting items 
+which were supported by factor analysis. Patil & Nagendra (2014) 
+have used this scale in an Indian study.
+Qualitative assessment
+The qualitative assessment aimed to get insights into (i) the 
+Table 2: Integrated classroom yoga module: Set 1 and Set 2 practiced on alternate days
+Set 1
+Set 2
+Yoga practice
+Time 
+(min)
+Description
+Yoga practice
+Time 
+(min)
+Description
+Dhyana (meditative 
+silence)
+1
+Sit straight with eyes closed. 
+Attention on breathing. Watch your 
+thoughts flowing
+Dhyana (meditative 
+silence)
+1
+Sit straight with eyes closed. 
+Attention on breathing. Watch 
+your thoughts flowing
+Asanas
+Asanas
+Katichakrasana
+1
+20 rounds
+Ardhakatichakrasana
+1
+Hold for 7 counts on each side
+Hastauthanasana/
+Padahastasana
+1
+3 rounds backward‑forward 
+bending. On 4th round hold for 7 
+counts on backward bend and then 
+on forward bend
+Ardhachakrasana/
+Padahastasana
+1
+3 rounds of backward‑forward 
+bending. On 4th round hold for 7 
+counts on back bend and then on 
+forward bend
+Tadasana
+1
+3 rounds of up and down followed 
+by 1 round of holding for 10 counts
+Gaumukhasana 
+(standing)
+1
+Hold on each side to the count 
+of 10
+Vrikshasana
+1
+Hold on each side for 10 counts
+Garudasana
+1
+Hold on each side for 10 counts
+Pranayama
+Pranayama
+Yogic breathing 
+(abdominal)
+1
+10 rounds
+Yogic breathing 
+(abdominal)
+1
+10 rounds
+NadiShudhi
+2
+6 rounds
+NadiShudhi
+2
+6 rounds
+Bhramari
+1
+6 rounds
+Bhramari
+1
+6 rounds
+OM chanting
+1
+6 rounds
+OM chanting
+1
+6 rounds
+Dhyana
+1
+Mentally recap the practices. 
+Attention on breathing
+Dhyana
+1
+Mentally recap the practices. 
+Attention on breathing
+Affirmation
+Affirmation
+I am a powerful soul
+0.5
+3 rounds
+I am a loveful soul
+0.5
+3 rounds
+Closing
+0.5
+Rub palms, massage eyes, face, 
+neck. With a few blinks open eyes
+Closing
+0.5
+Rub palms, massage eyes, face, 
+neck. With a few blinks open eyes
+Total timing
+12
+Total timing
+12
+[Downloaded free from http://www.ym-kdham.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Sinha and Kumari: Effect of ICYM on wellbeing of school children
+104 	
+Yoga Mīmāṃsā | Volume 53 | Issue 2 | July-December 2021
+experience, (ii) perceived benefits, (iii) drivers and barriers to 
+continued practice. The methodology used was focus group 
+discussions conducted by a professional qualitative researcher. 
+Two groups of randomly selected (drawing from paper slips) 
+students and one group of class teachers participated in the study.
+Data analysis
+At the first level, pre-intervention and postintervention means of 
+the yoga group and control group were compared independently 
+using paired sample t-test. At the next level repeated measure 
+analysis of variance (RM-ANOVA) was carried out for each 
+variable. The within-subjects factor was time (preintervention and 
+post-intervention). The between-subjects factor was Groups (yoga 
+and control). The alpha level was set at p < 0.05. The assumptions 
+of sphericity measured by Mauchly’s test and homogeneity of 
+variance measured by Levene’s test were satisfied. The raw data 
+were analyzed using Statistical Package for Social Science (SPSS) 
+version 26, IBM, Armonk, NY, USA. 
+RESULTS
+EUROFIT physical fitness testing battery
+In the yoga group, the paired sample t-test was associated with 
+statistically significant pre-post differences in all the four tests 
+(p < 0.001). The effect size for flexibility (d = 0.78) and strength 
+tests (d = 0.91) were large. For balance (d = 0.53) and agility tests 
+(d = 0.53), they were medium. In the control group the difference 
+in means were statistically significant in balance (p < 0.001) and 
+flexibility tests (p < 0.007) only. The effect size for flexibility test 
+was small (d = 0.40) and for balance test medium [d = 0.56; Table 3].
+In the RM-ANOVA test, there was sufficient evidence to reject 
+the intervention effect null hypothesis for sit and reach flexibility 
+test (p < 0.001) and sit ups trunk strength test (p < 0.001). The 
+effect size for flexibility test was nearly large (ƞ2
+p = 0.243) and 
+for strength test medium (ƞ2
+p = 0.185). There was insufficient 
+evidence to reject the intervention effect null hypotheses for 
+Flamingo balance test (p < 0.465) and 10 m × 5 m shuttle run 
+agility test [p < 0.133; Table 4].
+Stroop color-word naming task
+In the yoga group, the paired sample t-test was associated with 
+statistically significant pre-post differences in all three scores 
+(p < 0.001). The effect size for word (d = 0.62) and color scores 
+(d = 0.63) were medium. For color-word score, it was large 
+(d = 0.99). In the control group, the difference in means was 
+statistically significant in all the three scores (p < 0.001). The effect 
+size was small for word (d = 0.35) and color scores (d = 0.47). It 
+was medium for color-word score [d = 0.55; Table 3].
+In the RM-ANOVA test, there was sufficient evidence to reject 
+the intervention effect null hypothesis for Stroop color-word 
+score (p < 0.001). The effect size was small (ƞ2
+p = 0.06). There 
+was insufficient evidence to reject the intervention effect null 
+hypotheses for word (p < 0.07) and color scores [p < 0.074; 
+Table 4].
+Rosenberg self-esteem scale
+In both the yoga and control groups, the paired sample 
+t-test was associated with statistically insignificant pre-post 
+differences [p > 0.05; Table 3].
+In the RM-ANOVA test, there was insufficient evidence to reject 
+the intervention effect null hypothesis [p < 0.057; Table 4].
+WHO-5 well-being index
+In the yoga group, the paired sample t-test was associated with 
+statistically significant pre-post difference (p < 0.001) with small 
+effect size (d = 0.33). In the control group, the difference was 
+statistically insignificant [p < 0.097; Table 3].
+In the RM-ANOVA test, there was sufficient evidence to reject 
+the intervention effect null hypothesis (p < 0.001). The effect size 
+was small [ƞ2
+p = 0.055; Table 4].
+Sushruta Child Personality Inventory
+In the yoga group, the paired sample t-test was associated with 
+statistically significant pre-post differences in rajas (p < 0.011) 
+and tamas (p < 0.004) scores with small effect sizes (d = 0.21; 
+d = 0.24) and insignificant difference in sattva score (p < 0.516). 
+In the control group, the pre-post difference was statistically 
+significant in sattva (p < 0.044) and tamas scores (p < 0.020) 
+with small effect sizes (d = 0.20; d = 0.23). It was statistically 
+insignificant for rajas score [p < 0.647; Table 3].
+In the RM-ANOVA test, there was insufficient evidence to 
+reject the intervention effect null hypotheses for all three scores 
+[p > 0.05; Table 4].
+Qualitative assessment
+The variety in the module due to a mix of postures, breathing, 
+and meditation made the practice enjoyable. Students reported 
+improvements in fitness, stamina, and increased participation 
+in sports. Both students and teachers were most enthusiastic 
+while reporting cognitive benefits. Students reported better 
+concentration, grasp of concepts, and recall of lessons. Teachers 
+felt that the students had developed a more positive attitude 
+towards academics. Students credited the meditative practice 
+with instilling calmness, increased patience, and reduced stress. 
+Teachers felt that discipline had improved. Students reported that 
+they felt friendlier. Teachers noticed a greater social cohesion. 
+Both students and teachers felt that the short duration of the 
+practice, its convenience, and benefits made the ICYM acceptable 
+for continued practice.
+DISCUSSION
+The present study hypothesized that ICYM will impact fitness, 
+cognitive performance, emotional wellbeing, and personality 
+characteristic of school children. In the study, the yoga group 
+showed significant differences compared to the control group in 
+2 out of 4 EUROFIT tests, in the Stroop color-word score and 
+the WHO-5 emotional wellbeing index. The test of significance 
+[Downloaded free from http://www.ym-kdham.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Sinha and Kumari: Effect of ICYM on wellbeing of school children
+Yoga Mīmāṃsā | Volume 53 | Issue 2 | July-December 2021	
+105
+(p-value) tells us that there is a statistical difference between the 
+means of the experimental group compared to the control group. 
+However, it does not tell us the extent of the difference. This is 
+measured by the effect size. It is a measure of how much variation 
+Table 4: Repeated measure analysis of variance table for variables of EUROFIT physical fitness 
+testing battery, STROOP colour‑word naming Task, Rosenberg Self‑Esteem Scale, WHO‑5 emotional 
+well‑being index, Sushruta Child Personality Inventory
+T
+est
+Factor
+Variable
+F
+df
+Huyhn Feldt Ɛ
+P
+Partial eta squared
+EUROFIT
+Within ‑ subjects 
+(time)
+Flamingo balance test
+28.832
+1
+1
+0.001
+0.231
+Sit and reach flexibility test
+1.208
+1
+1
+0.274
+0.012
+Sit ups trunk strength test
+7.44
+1
+1
+0.008
+0.072
+10×5 m shuttle run agility test
+11.36
+1
+1
+0.001
+0.106
+Group × time
+Flamingo balance test
+0.538
+1
+‑
+0.465
+0.006
+Sit and reach flexibility test
+30.777
+1
+‑
+0.001
+0.243
+Sit ups trunk strength test
+21.739
+1
+‑
+0.001
+0.185
+10×5 m shuttle run agility test
+2.301
+1
+‑
+0.133
+0.023
+STROOP
+Within ‑ subjects 
+(time)
+Word score
+57.109
+1
+1
+0.001
+0.185
+Colour score
+73.985
+1
+1
+0.001
+0.228
+Colour‑word score
+149.763
+1
+1
+0.001
+0.060
+Group × time
+Word score
+3.304
+1
+‑
+0.070
+0.013
+Colour score
+3.229
+1
+‑
+0.074
+0.013
+Colour‑word score
+16.079
+1
+‑
+0.001
+0.060
+Rosenberg/
+WHO‑5
+Within ‑ subjects 
+(time)
+Rosenberg self‑esteem scale
+1.801
+1
+1
+0.181
+0.007
+WHO‑5 emotional well‑being 
+index
+1.286
+1
+1
+0.258
+0.005
+Group × time
+Rosenberg self‑esteem scale
+3.203
+1
+‑
+0.057
+0.013
+WHO‑5 emotional well‑being 
+index
+14.166
+1
+‑
+0.001
+0.055
+SCPI
+Within ‑ subjects 
+(time)
+Sattva score
+3.249
+1
+1
+0.073
+0.013
+Rajas score
+4.317
+1
+1
+0.039
+0.017
+Tamas score
+13.300
+1
+1
+0.001
+0.050
+Group × time
+Sattva score
+0.791
+1
+‑
+0.375
+0.003
+Rajas score
+2.053
+1
+‑
+0.153
+0.008
+Tamas score
+0.044
+1
+‑
+0.835
+0.001
+SCPI, Sushruta Child Personality Inventory
+Table 3: Paired sample t-test - Means (Standard Deviation), Effect Size: EUROFIT physical fitness 
+testing battery, Stroop color-word naming task, Rosenberg self-esteem scale, WHO-5 emotional well-
+being index, Sushruta child personality inventory
+T
+est
+n
+Yoga
+Control
+Yoga
+Control
+Pre
+Post
+P
+Cohen’s 
+d
+Pre
+Post
+P
+Cohen’s 
+d
+EUROFIT
+Flamingo 
+balance test
+48
+50
+7.50 (6.36)
+4.75 (4.72)
+0.001
+0.53
+11.98 (7.33)
+8.36 (7.37)
+0.001
+0.56
+Sit and reach 
+flexibility test
+17.98 (6.64)
+20.94 (7.40)
+0.001
+0.78
+16.44 (5.48)
+14.46 (6.49)
+0.007
+0.40
+Sit ups trunk 
+strength test
+19.29 (4.77)
+23.19 (4.93)
+0.001
+0.91
+9.82 (6.72)
+8.80 (6.44)
+0.233
+0.17
+10×5 m shuttle 
+run agility test
+15.77 (1.98)
+15.13 (1.68)
+0.001
+0.53
+17.51 (2.04)
+17.26 (2.16)
+0.218
+0.18
+Stroop
+Word score
+143
+110
+87.87 (16.79) 93.64 (18.04) 0.001
+0.62
+90.64 (14.71) 94.17 (12.99) 0.001
+0.35
+Color score
+59.22 (11.78) 65.43 (11.34) 0.001
+0.63
+59.95 (11.64) 64.04 (10.80) 0.001
+0.47
+Color‑word score
+30.33 (10.04)
+38.62 (8.48)
+0.001
+0.99
+33.07 (8.49)
+37.27 (8.96)
+0.001
+0.55
+Rosenberg 
+Self‑Esteem Scale
+137
+107
+28.55 (3.42)
+28.66 (3.51)
+0.702
+0.03
+28.66 (4.03)
+27.90 (4.45)
+0.068
+0.18
+WHO‑5 emotional 
+well‑being index
+137
+107
+17.21 (4.04)
+18.57 (3.17)
+0.001
+0.33
+16.39 (4.68)
+15.66 (4.85)
+0.097
+0.16
+SCPI
+Sattva score
+148
+106
+13.62 (2.06)
+13.74 (2.17)
+0.516
+0.05
+12.75 (2.17)
+13.10 (2.40)
+0.044
+0.20
+Rajas score
+8.93 (2.22)
+8.42 (2.64)
+0.011
+0.21
+7.57 (2.31)
+7.47 (2.06)
+0.647
+0.04
+Tamas score
+6.95 (2.13)
+6.39 (2.49)
+0.004
+0.24
+6.68 (2.59)
+6.18 (2.05)
+0.020
+0.23
+Pre and post are group means (SD). SD, Standard deviation; SCPI, Sushruta Child Personality Inventory
+[Downloaded free from http://www.ym-kdham.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Sinha and Kumari: Effect of ICYM on wellbeing of school children
+106 	
+Yoga Mīmāṃsā | Volume 53 | Issue 2 | July-December 2021
+in the dependent variable is due to the independent variable. In the 
+present study, the results showed that the effect size in the fitness 
+tests was medium to large while in the cognition and emotional 
+wellbeing tests they were small. We argue that small effect sizes in 
+some tests should not be dismissed since every little improvement 
+in children’s wellbeing is encouraging.
+The qualitative assessment buttressed the benefits shown in 
+the quantitative study. Its findings were in consonance with 
+previous qualitative research that reported the perceived benefits 
+as kinesthetic awareness, improved self-image, stress reduction, 
+self-regulation of emotions, and social cohesion (Conboy, Noggle, 
+Frey, Kudesia, & Khalsa, 2013).
+We now compare the results of the ICYM with studies that used 
+longer-duration yoga modules. A study by Purohit, et al. (2016), 
+found significant differences in the yoga group in 9 out of 11 
+EUROFIT variables. It can be concluded that the impact of the 
+ICYM on physical fitness is somewhat in conformity with a 
+longer duration module. A study using the Stroop test (Purohit 
+& Pradhan, 2016), reported a significant improvement in the 
+yoga group with medium effect size. The ICYM also showed a 
+significant improvement albeit with a small effect size. Studies 
+using longer duration yoga modules have reported improvements 
+in self-esteem, self-efficacy, self-confidence, self-concept, mood 
+disturbance, tension-anxiety, negative affects with medium effect 
+sizes (Benson et al., 1994; Noggle, Steiner, Minami, & Khalsa, 
+2012; Bhardwaj & Bhardwaj, 2015; Bhardwaj & Agarwal, 2013; 
+Das et al., 2016). The ICYM was associated with a significant 
+improvement in emotional well-being with a small effect size.
+Since ICYM is classroom yoga module we have compared the 
+results with other studies that used classroom yoga interventions. 
+An uncontrolled pilot study by Butzer, et al. (2015) reported 
+some behavior improvement and stress reduction. Another 
+uncontrolled study used a15-min yoga activity as intervention and 
+showed directional improvements in mental, social, and physical 
+wellbeing (Chen & Pauwels, 2014). A quasi-experimental study 
+by Lawson et al. (2012) used a 10-min modified yoga intervention 
+and found minimal improvements in fine motor skills and 
+academic measures. A study by Telles et al. (2019) used an 18-min 
+Pranayama intervention for 3 days and reported improvements 
+in attention and anxiety reduction. Though suffering from some 
+methodological infirmities like short periods of intervention, 
+non-standard modules, and teacher-reported assessments, they all 
+point to directional improvements in behavior, stress, emotional 
+wellbeing, cognition, and academic measures. The present study 
+used a validated classroom yoga module, randomized controlled 
+design and longer period of intervention to show improvements 
+that were directionally demonstrated by earlier studies.
+The question arises as to why the ICYM positively impacted 
+physical, cognitive, and emotional measures. One possible reason 
+could be that the module itself had been developed methodically. 
+It was an integrated practice incorporating asana (physical 
+postures), pranayama (breathing practice), dhyana (meditation), 
+and mantra (chanting). The practices were specifically selected 
+for their impact on physical wellbeing, mental calmness, 
+stress reduction, and impact on concentration. They had been 
+sequenced in a manner that the physical postures involved full-
+body movement namely sideways-forward-backward bending, 
+stretching, and balancing. The breathing exercises too included 
+full breathing, balancing breathing, and an inward focusing 
+practice. Chanting and meditation promoted calmness, stress 
+reduction, and concentration. The second possible reason was 
+that the convenience of the module made it possible to practice 
+daily. We speculate that the daily practice may have contributed 
+strongly to its efficacy. The third reason was that we know from 
+modern research that yoga is related with physical, cognitive, and 
+emotional benefits. This module may have worked because it is a 
+shorter version of a proven practice.
+CONCLUSION
+It may be concluded that the short duration ICYM can be 
+considered for inclusion in the daily school schedule when it is 
+not feasible for a longer duration module to be included.
+The study has substantial strengths: (i) ICYM was a systematically 
+developed and validated module, (ii) the research design and 
+sample size were robust, (iii) the variables covered the major 
+domains defined as the whole child, (iv) the quantitative study 
+was supplemented with a qualitative assessment.
+The limitations of the study were: (i) unequal randomization, (ii) 
+lack of follow-up assessments. Future studies could specialize 
+in assessing multiple variables within each benefit category. 
+Longitudinal studies could strengthen the findings of this study. 
+Classroom yoga modules for different age groups could be 
+developed and tested.
+Acknowledgments
+We would like to acknowledge the cooperation of the Samsidh 
+Mount Litera Zee School management, teachers, and especially 
+the enthusiastic young students.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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subfolder_0/Effect of two yoga-based relaxation techniques on memory scores and state anxiety.txt

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+BioMed 
+Central
+Open Access
+Page 1 of 5
+(page number not for citation purposes)
+BioPsychoSocial Medicine
+Short report
+Effect of two yoga-based relaxation techniques on memory scores 
+and state anxiety
+Pailoor Subramanya and Shirley Telles*
+Address: Indian Council of Medical Research Center for Advanced Research in Yoga and Neurophysiology, SVYASA, Bangalore, India
+Email: Pailoor Subramanya - [email protected]; Shirley Telles* - [email protected]
+* Corresponding author    
+Abstract
+Background: A yoga practice involving cycles of yoga postures and supine rest (called cyclic
+meditation) was previously shown to improve performance in attention tasks more than relaxation
+in the corpse posture (shavasana). This was ascribed to reduced anxiety, though this was not
+assessed.
+Methods: In fifty-seven male volunteers (group average age ± S.D., 26.6 ± 4.5 years) the immediate
+effect of two yoga relaxation techniques was studied on memory and state anxiety. All participants
+were assessed before and after (i) Cyclic meditation (CM) practiced for 22:30 minutes on one day
+and (ii) an equal duration of Supine rest (SR) or the corpse posture (shavasana), on another day.
+Sections of the Wechsler memory scale (WMS) were used to assess; (i) attention and
+concentration (digit span forward and backward), and (ii) associate learning. State anxiety was
+assessed using Spielberger's State-Trait Anxiety Inventory (STAI).
+Results: There was a significant improvement in the scores of all sections of the WMS studied after
+both CM and SR, but, the magnitude of change was more after CM compared to after SR. The state
+anxiety scores decreased after both CM and SR, with a greater magnitude of decrease after CM.
+There was no correlation between percentage change in memory scores and state anxiety for
+either session.
+Conclusion: A cyclical combination of yoga postures and supine rest in CM improved memory
+scores immediately after the practice and decreased state anxiety more than rest in a classical yoga
+relaxation posture (shavasana).
+Findings
+Yoga includes practices such as physical postures, regu-
+lated breathing, and meditation, among other techniques
+[1]. Meditation practice reduces stress and increases calm-
+ness [2], but many novices find it difficult to practice med-
+itation initially [3]. In fact, meditation is the seventh of
+eight steps traditionally described [Patanjali, circa 900
+B.C.] [1]. Some people find it easier to begin by practicing
+yoga postures. Based on this a 'moving meditation' called
+cyclic meditation was evolved which has cycles of yoga
+postures alternating with guided relaxation while supine
+[3]. Cyclic meditation practice improved the performance
+in a P300 event related potential task [4] and also
+improved the performance in a letter cancellation task [5].
+Published: 13 August 2009
+BioPsychoSocial Medicine 2009, 3:8
+doi:10.1186/1751-0759-3-8
+Received: 16 June 2009
+Accepted: 13 August 2009
+This article is available from: http://www.bpsmedicine.com/content/3/1/8
+© 2009 Subramanya and Telles; licensee BioMed Central Ltd. 
+This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
+which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
+BioPsychoSocial Medicine 2009, 3:8
+http://www.bpsmedicine.com/content/3/1/8
+Page 2 of 5
+(page number not for citation purposes)
+Both tasks require selective attention and concentration.
+The benefits were ascribed to possible stress reducing
+effects of cyclic meditation, as the practice reduces physi-
+ological [6,7] and cortical [8] arousal. However the effects
+of cyclic meditation on state anxiety have not been
+assessed.
+In the present study cyclic meditation was compared to an
+equal duration of supine rest in the corpse posture (sha-
+vasana), as both are supposed to increase relaxation.
+Hence, the present study was designed to assess the effects
+of cyclic meditation and shavasana on state anxiety and
+the performance in memory tasks, to see whether they
+would change after the practices.
+There were 57 male participants, aged between 18 and 40
+years (group average age ± S.D., 26.6 ± 4.5 years), all with
+normal health and not on medication. They were residing
+at a yoga center. All of them had a minimum of 15 years
+of education and could understand the tasks. Their expe-
+rience of cyclic meditation and of relaxation in the corpse
+posture (shavasana) was between 6 and 48 months (group
+average 20.1 ± 14.9 months). The study had been
+explained to the participants, whose signed informed con-
+sent was taken. The Institutional Ethics committee
+approval was obtained.
+All participants were assessed before and after two practice
+sessions, viz., cyclic meditation (CM) and supine rest (SR)
+in shavasana. At random twenty-nine participants had CM
+on the first day, and SR the next day. The remaining par-
+ticipants had the reverse schedule. The time of day was
+kept constant for both sessions of an individual. Sessions
+were 22:30 minutes in duration.
+Memory tasks were selected from the Wechsler memory
+scale which has been standardized for use in an Indian
+population. The following sections were selected (i) digit
+span forward and backward, and (ii) verbal paired associ-
+ate learning (easy and hard), with 10 items each. The ver-
+bal 
+paired 
+associate 
+learning 
+task 
+involved 
+the
+presentation of ten pairs of unrelated words as three trials.
+After the three trials the examinee was presented with the
+first word in each pair and he or she was asked to provide
+the second word. Out of the ten pairs, six pairs were
+semantically easy to remember (e.g., table-chair). Where
+such associations existed, it was described as associate
+learning, easy. Where there were no such associations the
+task was described as associate learning, hard. There were
+six pairs for the easy task and four pairs for the hard task.
+Each correct answer was scored as '1' (for digit span for-
+ward or backward), while for associate learning, each easy
+answer was scored as '1' and difficult or hard answer as '2'.
+This was based on the conventional scoring for Wechsler
+memory scale [9]. Parallel worksheets were prepared,
+changing the digits and words to eliminate serial testing
+artifacts when retesting [10].
+State anxiety was assessed using the Spielberger's State-
+Trait Anxiety Inventory at the beginning and end of the
+CM and SR sessions, after the memory tasks.
+Test sheets were blind scored by a person who was una-
+ware about the participant's practice session or whether
+the assessments were before or after a practice session.
+During cyclic meditation participants kept their eyes
+closed and followed pre-recorded instructions. The
+emphasis was on carrying out the practice slowly, with
+awareness and relaxation. The practice has been detailed
+in earlier reports [4,6], but is described here in brief. The
+practice begins with isometric contraction of the muscles
+of the body while supine (1:00 min), followed by a stand-
+ing posture (2:20 min), and two side bending postures
+(3:50 min). This is followed once more by a standing pos-
+ture (2:20 min), a forward bending posture (1:30 min)
+and a backward bending posture (1:30 min). These yoga
+postures are followed by 10:00 min of guided relaxation
+while supine, with instructions to relax different parts of
+the body while being aware of them.
+Relaxation in the corpse posture (shavasana) or supine rest
+was for the same duration, i.e., 22:30 min. This is a classic
+yoga posture, intended for relaxation [11]. Here, partici-
+pants lie flat on the ground with their legs apart, arms
+away from the sides of the body, palms facing upwards
+and the eyes closed. During the training, participants had
+been instructed to attempt to remain relaxed while being
+aware of body sensations during shavasana.
+Data were analyzed using SPSS (Version 16.0). There were
+separate repeated measures analyses of variance (ANO-
+VAs) for each of the assessments, with two Within Sub-
+jects factors [i.e., States (before, after) and Sessions (CM,
+SR)]. Post-hoc analysis was with Bonferroni adjustment,
+comparing after with before values. The percentage
+change in each of the memory tasks {(where percentage
+change was [(After-value/Before-value*100)-100]} was
+tested for correlation with state anxiety using the Pearson
+correlation test.
+Digit span forward scores differed significantly between
+Sessions (F = 4.1, p = 0.048), and between States (F =
+286.4, p < 0.001), with a significant interaction between
+them (F = 13.4, p < 0.001). Digit span backward scores
+also differed between Sessions (F = 15.7, p < 0.001), and
+States (F = 124.4, p < 0.001) with a significant interaction
+between them (F = 37.9, p < 0.001). Similarly, associate
+BioPsychoSocial Medicine 2009, 3:8
+http://www.bpsmedicine.com/content/3/1/8
+Page 3 of 5
+(page number not for citation purposes)
+Change in scores (mean ± SD) of (a) Digit-span forward and backward, (b) Associate learning, easy and hard, and (c) State anx-
+iety, before and after CM and SR
+Figure 1
+Change in scores (mean ± SD) of (a) Digit-span forward and backward, (b) Associate learning, easy and hard, 
+and (c) State anxiety, before and after CM and SR. *** p < 0.001, after compared to before (post-hoc analysis).
+   a) 
+0
+1
+2
+3
+4
+5
+6
+7
+8
+9
+10
+CM
+SR
+CM
+SR
+Digit span forw ard
+Digit span backw ard
+Scores (in numbers)
+Before
+After
+***
+***
+***
+***
+b) 
+0
+5
+10
+15
+20
+25
+CM
+SR
+CM
+SR
+Associate learning easy
+Associate learning hard
+Scores (in numbers)
+Before
+After
+***
+***
+***
+***
+c)
+STAI
+0
+5
+10
+15
+20
+25
+30
+35
+40
+45
+50
+CM
+SR
+Sessions
+Scores (in numbers)
+Before
+After
+***
+***
+                          
+Before
+After
+BioPsychoSocial Medicine 2009, 3:8
+http://www.bpsmedicine.com/content/3/1/8
+Page 4 of 5
+(page number not for citation purposes)
+learning, easy scores differed significantly between Ses-
+sions (F = 16.5, p < 0.001), and States (F = 237.9, p <
+0.001), with the interaction between the two being signif-
+icant (F = 37.1, p < 0.001). Also, for associate learning,
+hard, the scores differed significantly between Sessions (F
+= 16.4, p < 0.001) and States (F = 268.5, p < 0.001), with
+a significant interaction between them (F = 94.4, p <
+0.001).
+The state anxiety scores also differed significantly between
+Sessions (F = 54.9, p < 0.001), and States (F = 175.5, p <
+0.001), with a significant interaction between them (F =
+178.8, p < 0.001).
+A significant interaction between factors, suggests that the
+two factors are not independent of each other, or one fac-
+tor may be modified by the other factor.
+Post-hoc analyses showed that following both CM and SR
+there was a significant increase in digit span forward
+scores (p < 0.001 in both cases), digit span backward
+scores (p < 0.001 in both cases), associate learning, easy (p
+< 0.001 in both cases) and associate learning, hard (p <
+0.001 in both cases). State anxiety scores decreased after
+both CM and SR (p < 0.001 in both cases). All values for
+post-hoc analyses were Bonferroni adjusted (Figure 1).
+The increase in scores for the digit span and associate
+learning tasks following CM was greater [digit span for-
+ward (27.7 percent), backward (33.5 percent), associate
+learning, easy (20.7 percent), and associate learning hard
+(37.7 percent)] than the increase following SR [digit span
+forward (16.1 percent), backward (9.2 percent), associate
+learning, easy (9.4 percent), and associate learning, hard
+(10.6 percent)]. Also, there was a greater magnitude of
+decrease in state anxiety after CM (22.4 percent) com-
+pared to after SR (5.6 percent). The digit span tests assess
+attention, concentration and primary working memory
+[12]. Earlier studies have shown that CM practice
+increases selective attention more than an equal duration
+of supine rest [4,5]. The present results suggest that pri-
+mary working memory also improves with CM practice.
+Verbal paired associate learning assesses integration of
+information and episodic memory. The present results
+suggest an improvement in these aspects of memory after
+both CM and SR, with a greater magnitude of increase
+after CM.
+Cyclic meditation involves movement, and such practices
+(another example being Tai-Chi-Qui-Gong) have been
+described as 'moving meditations' [13]. These techniques
+are described as meditations because during these prac-
+tices practitioners ideally assume a meditative state of
+mind. This is characterized by interoception, awareness of
+body sensations, and relaxation [14]. Hence though these
+moving meditations differ from the classic description of
+meditation, in which the practitioners remain seated,
+keeping as still as possible, the mental state in both prac-
+tices is supposed to be comparable.
+The present results suggest that movement as a part of
+cyclic meditation may actually facilitate performance in
+attention and memory tasks more than an equal duration
+of time in a conventional relaxation posture (shavasana).
+A major drawback of the study is that participants were
+residing at the yoga center, and though they were not spe-
+cifically told about the previous studies, they had access to
+them and this could have influenced their performance
+and hence the outcome. An attempt would be made to
+conduct the assessments on participants who are trained
+in CM but have no access to the findings reported earlier.
+Conflict of interests
+PS and ST have no conflicts of interest in relation to this
+article.
+Authors' contributions
+PS carried out the assessments, the data analysis and par-
+ticipated in compiling the manuscript. ST conceived and
+designed the study, and compiled the manuscript. Both
+authors read and approved the final manuscript.
+Acknowledgements
+The authors gratefully acknowledge H.R. Nagendra, Ph.D. who derived the 
+cyclic meditation technique from an ancient yoga text. The funding from the 
+Indian Council of Medical Research (ICMR), Government of India, as part 
+of a grant (Project No. 2001-05010) towards the Centre for Advanced 
+Research in Yoga and Neurophysiology (CAR-Y&N) is also gratefully 
+acknowledged.
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+BioPsychoSocial Medicine 2009, 3:8
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subfolder_0/Effect of yoga on EUROFIT physical fitness parameters on adolescents dwelling in an orphan home A randomized control study.txt

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+Full Terms & Conditions of access and use can be found at
+http://www.tandfonline.com/action/journalInformation?journalCode=rvch20
+Download by: [14.139.155.82]
+Date: 27 July 2016, At: 23:55
+Vulnerable Children and Youth Studies
+An International Interdisciplinary Journal for Research, Policy and Care
+ISSN: 1745-0128 (Print) 1745-0136 (Online) Journal homepage: http://www.tandfonline.com/loi/rvch20
+Effect of yoga on EUROFIT physical fitness
+parameters on adolescents dwelling in an orphan
+home: A randomized control study
+Satya Prakash Purohit, Balaram Pradhan & Hongasandra Ramarao
+Nagendra
+To cite this article: Satya Prakash Purohit, Balaram Pradhan & Hongasandra Ramarao
+Nagendra (2016) Effect of yoga on EUROFIT physical fitness parameters on adolescents
+dwelling in an orphan home: A randomized control study, Vulnerable Children and Youth
+Studies, 11:1, 33-46, DOI: 10.1080/17450128.2016.1139764
+To link to this article:  http://dx.doi.org/10.1080/17450128.2016.1139764
+Published online: 05 Feb 2016.
+Submit your article to this journal 
+Article views: 63
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+Citing articles: 1 View citing articles 
+Effect of yoga on EUROFIT physical fitness parameters on
+adolescents dwelling in an orphan home: A randomized
+control study
+Satya Prakash Purohit
+a, Balaram Pradhana and Hongasandra Ramarao Nagendrab
+aDivision of Yoga and Humanities, S-VYASA Yoga University, Bengaluru, India; bChancellor, S-VYASA Yoga
+University, Bengaluru, India
+ABSTRACT
+Childhood parental loss, parental separation, poverty and rearing
+in orphanages have negative impact on physical, psychological
+and social well-being in orphans. Yoga has a profound knowledge
+base and practical solutions for such traumatic consequences. The
+aim of the study was to evaluate the effect of a Yoga program on
+the physical fitness of adolescents staying in an orphanage. A total
+of 72 apparently healthy adolescents participated from an orpha-
+nage. They were randomized (based on their age and gender) and
+allocated into two groups as Yoga group (n = 40; 14 girls, 26 boys
+and age = 12.69 ± 1.35) and Wait-List Control group (WLC) (n = 32,
+13 girls, 19 boys and age = 12.58 ± 1.52). The Yoga group (YG)
+underwent 3 months of Yoga program in a schedule of 90 mins/
+day and 4 days/week, whereas the WLC group underwent day-to-
+day activities. European physical fitness test battery (EUROFIT) was
+assessed in both groups at the beginning and end of the program.
+The group × time interaction analysis showed significant (p < 0.05)
+positive differences in Flamingo left-leg balance (FLL), Flamingo
+right-leg balance (FLR), left-hand tapping test (PTL), right-hand
+tapping test (PTR), sit and reach (SAR), standing broad jump
+(SBJ), sit-ups (SUP), bent arm hang (BAH) test, shuttle run (SHR)
+in YG compared to WLC group. Further analysis done on group ×
+time interaction along with Bonferroni-corrected p-values showed
+significant positive differences in FLL, FLR, PTL, PTR, SAR, SBJ and
+SUP in YG compared to WLC group. The results suggested that the
+3-month Yoga program was found useful for the young orphan
+adolescents in improving their physical fitness.
+ARTICLE HISTORY
+Received 14 June 2015
+Accepted 31 December 2015
+KEYWORDS
+Yoga; orphans; physical
+fitness; EUROFIT; adolescents
+Children who are under the age of 18 years and have lost one or both parents are
+known as orphans and are categorized as double or single orphans, respectively. Single
+orphans are categorized as maternal orphans, the children who have lost their mothers,
+and paternal orphans, who have lost their fathers (George, 2011; UNICEF, UNAID, &
+USAID, 2004). There is another category called social orphans, the children who live
+without parents because of abandonment, or because their parents gave them up as a
+result of poverty, alcoholism or imprisonment (Dillon, 2009). The total number of
+CONTACT Satya Prakash Purohit
+[email protected]
+Research Scholar, Division of Yoga and Humanities,
+S-VYASA Yoga University, # 19, Eknath Bhavan, Gavipuram Circle, Bengaluru 560019, India
+VULNERABLE CHILDREN AND YOUTH STUDIES, 2016
+VOL. 11, NO. 1, 33–46
+http://dx.doi.org/10.1080/17450128.2016.1139764
+© 2016 Taylor & Francis
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+orphans estimated is 143 million worldwide (UNICEF, UNAID, & USAID, 2004),
+72 million in South Asia and East Asia (UNICEF, 2008) and 20 million in India
+(Rajan & James, 2008).
+Orphan children are considered to be one of the most disadvantaged groups, who live a
+life full of stress, poverty and grief and are easily subjected to be abused, neglected and
+exploited (Nayak, 2014). Poverty in early childhood is one of the major predictor of worse
+developmental outcomes in later life (Heckman, 2006). Early parental loss and permanent
+or long-term separation from parents affect neuroendocrine functions (Luecken &
+Appelhans, 2006; Nicolson, 2004), basal salivary cortisol concentrations (Pfeffer,
+Altemus, Heo, & Jiang, 2007), HPA axis mediation (Chrousos, 2009; Romero, Dickens,
+& Cyr, 2009), which can induce chronic stress and later produce a negative impact on the
+physical and mental health in developing children (Luecken & Roubinov, 2012).
+The orphans are in need of supportive living environment because their biological
+parents are unable to take care of them (UNICEF, 2008). There are many NGOs
+working for orphans at local, national and international level through orphanages to
+support basic needs and education. But there are many limitations associated with
+orphanages. At orphanages, orphans are unable to get individualized nurturing (Ahmad
+et al., 2005), are deprived of emotional fulfillment as they could have got from their
+family and relatives and are away from the social customs, culture, tradition, norms and
+regulation (Naqshbandi, Sehgal, & Hassan, 2012). A study also showed that post-
+institutionalized children had motor system delays compared to the noninstitutiona-
+lized children (Roeber, Tober, Bolt, & Pollak, 2012).
+Whatever the external condition may be, the children have to evolve out from the
+environment and prove themselves as the children of mainstream. For such a positive
+change in them, they need to be physically and mentally fit. Physical fitness is being
+considered as a powerful marker of health in childhood and adolescent and can be defined
+as the ability to perform a given set of physical activity, which later translate into
+cardiorespiratory fitness, muscular fitness, speed and agility (Ortega, Ruiz, Castillo, &
+Sjöström, 2008). Effective intervention programs are found to be helpful for the promotion
+of physical health for school children (Pelegrini, Silva, Petroski, & Glaner, 2011).
+Yoga is also now considered as an important intervention for promoting physical
+health. Regular practice of yoga promotes muscular strength (Bhavanani, Udupa,
+Madanmohan, & Ravindra, 2011; Chen, Mao, Lai, Li, & Kuo, 2009; Dash & Telles,
+2001), endurance (Chen et al., 2009; D’souza & Avadhany, 2014), flexibility (Bal &
+Kaur, 2009; Chen et al., 2009), cardiopulmonary fitness (Bhutkar, Bhutkar, Taware, &
+Surdi, 2011; Chen et al., 2009) and overall physical fitness (Telles, Singh, Bhardwaj,
+Kumar, & Balkrishna, 2013) in children.
+Thus, the present study is intended to evaluate the effect of yoga on physical fitness
+of the young orphan adolescents.
+Method
+Participants
+The study was conducted in an orphanage, a suburban area of Bangalore between the
+months September 2014 and November 2014. A total of 135 resident young adolescent
+34
+S. P. PUROHIT ET AL.
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+orphans were screened in the study, out of which only 80 were enrolled based on the
+inclusion and exclusion criteria. Children were eligible for inclusions if they (a) were
+orphans of any type, (b) aged between 11–16 years, (c) boys and girls, (d) apparently
+healthy children with no chronic illness and (e) physically or mentally handicapped.
+The approvals from the Institutional Review Board and the Institutional Ethics
+Committee of Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) Yoga
+University were obtained as per the guidelines. A signed informed consent from the
+institution head and a signed informed assent was obtained from all participants after
+explaining the study in detail.
+Design
+This was a randomized WLC pre-post study. Participants were randomized by a
+statistician using a computerized random number table from www.randomizer.org
+and assigned into two groups as Yoga group (YG) and WLC. The YG underwent the
+Yoga program for 3 months. Participants in the WLC underwent day-to-day regular
+activity (study).
+Intervention
+The YG was given integrated approach of yoga – 90 minutes, 4 days/week, 3 months.
+Later the same intervention was served to WLC for same duration. The yoga
+intervention was taught and supervised by two certified yoga teachers from S-
+VYASA (one with master’s degree in yoga and the other with postgraduation
+diploma in yoga therapy). The principle and concept of an integrated approach of
+yoga is based on the research works of S-VYASA (Nagarathna & Nagendra, 2006). In
+the beginning of the class there used to be yogic prayer, a small session on under-
+standing of the yogic concepts and their relevance to lead a positive lifestyle. Yoga
+intervention included loosening and breathing exercises, yoga postures, concentra-
+tion and relaxation techniques and yogic games aimed to the multidimensional
+strengthening of the body, mind and social skills. The various components of the
+Yoga program are mentioned in the Table 1.
+Assessments
+The following explained data were collected by the research staffof S-VYASA during
+the pre- and post-adjacent weeks to the intervention period for all the recruited
+participants. The investigators and two physical education teachers were available to
+answer questions and provide unbiased guidance during the assessment. The statis-
+tician who generated the randomization sequence and subsequently analyzed the
+data and the researchers who were carrying out the allocation and assessments were
+blinded.
+Demographic data
+Age, gender, education, parental status, duration of staying in orphanage were collected
+from the office record and through an interview.
+VULNERABLE CHILDREN AND YOUTH STUDIES
+35
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+Table 1. List of practices in the Yoga program.
+Order no.
+Intervention components
+No. of rounds
+Approx. time (total 90 min)
+Schedule
+General justification
+1
+Yogic prayer, session on basic concepts of
+yoga and instructions for the class
+10 min
+4 days /week
+(Wednesday, Thursday,
+Saturday and Sunday)
+Give directions and
+motivation for living a life
+with positivity and
+enthusiasm with acceptance
+and the importance of
+different yoga activities/skills
+2
+Preparatory practices
+(a)
+Warm-up: jogging, jumping, hop-
+ping, forward and backward bend-
+ing, side bends and twisting
+(b)
+Loosening: for toes, ankle, knee,
+hips, fingers, wrist, elbow and neck
+(c)
+Stretching with breathing exercises:
+hands in and out, hands stretch,
+ankle stretch, hip stretch, back-
+stretch, tiger stretch (spinal up-
+downs), supine straight leg raising,
+cycling, lumber stretch, rocking and
+rolling
+1 each
+10 min
+4 days /week
+(Wednesday, Thursday,
+Saturday and Sunday)
+Preparatory practices of
+asana and Pranayama.
+Warm up the body, loosen
+the joints and stretch the
+muscles
+3
+Sun salutation (Suryanamaskar)
+10–12
+10 min
+4 days /week
+(Wednesday, Thursday,
+Saturday and Sunday)
+Gives an all-round benefit by
+balancing physiological
+systems and removing
+mental rigidity (Tamas)
+(Continued)
+36
+S. P. PUROHIT ET AL.
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+Table 1. (Continued).
+Order no.
+Intervention components
+No. of rounds
+Approx. time (total 90 min)
+Schedule
+General justification
+4
+Asana (postures)
+A. Standing postures
+(a) Half waist rotation posture (Ardhakati
+Chakrasana)
+(b) Foot palm posture (Padahastasana)
+(c) Half wheel posture (Ardha Chakrasana)
+(d) Triangle posture (Trikonasana)
+(e) Tree posture (Vrikshasana)
+(f) Eagle posture (Garudasana)
+B. Sitting postures
+(a) Diamond (Vajrasana)
+(b) Rabbit posture (Shashankasana)
+(c) Sleeping diamond posture (Supta
+Vajrasana)
+(d) Camel posture (Ustrasana)
+(e) Posterior stretch (Paschimottanasana)
+(f) Spinal twist posture (Ardha
+Matsyendrāsana)
+(g) Cow face posture (Gomukhasana)
+C. Prone posture
+(a) Cobra posture (Bhujangasana)
+(b) Grasshopper posture (Salabhasana)
+(c) Bow posture (Dhanurasana)
+(d) Shoulder stand (Sarvangasana)
+(e) Plough posture (Halasana)
+D. Supine postures
+(a) Fish posture (Matsyasana)
+(b) Boat posture (Naukasana)
+1 each
+20 min (around 1 min each posture)
+4 days /week
+(Wednesday, Thursday,
+Saturday and Sunday)
+Culturing the body and mind
+by improving strength,
+stamina and flexibility
+5
+Deep relaxation technique (DRT)
+1
+10 min
+4 days /week
+(Wednesday, Thursday,
+Saturday and Sunday)
+Gives total rest to the body
+muscles and mind
+(Continued)
+VULNERABLE CHILDREN AND YOUTH STUDIES
+37
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+Table 1. (Continued).
+Order no.
+Intervention components
+No. of rounds
+Approx. time (total 90 min)
+Schedule
+General justification
+6
+Pranayama (voluntary regulation of breath)
+(a)
+Breathing with forceful exhalation
+with
+passive
+inhalation
+(Kapalabhati-3 types)
+(b)
+Breathing with rapid inhalation and
+exhalation (Bhastrika)
+(c)
+Slow and rhythmic alternate nostril
+breathing (Nadi Sodhana)
+(d)
+Exhalation, with a honeybee sound
+(Bhramari)
+(e)
+Hissing in thought while exhaling
+(Ujjai)
+1 each
+15 min
+4 days (Wednesday, Thursday,
+Saturday and Sunday)
+Improves lung capacity,
+balances vital energy,
+regulates emotions by
+reducing anxiety and stress
+7
+Concentration techniques
+(a)
+Eye exercises (Netra Sakti Vikasana)
+(b)
+Practice to improve collective moti-
+vation (Dhriti Sakti Vikasaka)
+(c)
+Activity to improve intellect (Dhi
+shakti vikasaka)
+(d)
+Trataka
+(e)
+Palming
+1 each
+15 min
+2 days /week
+(Wednesday and Saturday)
+Gives rest and rejuvenates
+the ocular muscle.
+Also improves concentration
+and attention
+8
+Yogic games (games for memory, awareness
+and creativity)
+15 min
+2 days /week
+(Thursday and Sunday)
+Yogic games help in
+reducing stress and the
+feeling of loneliness by
+improving the social skills/
+peer relationship and caring
+attitude
+38
+S. P. PUROHIT ET AL.
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+Anthropometric measures
+(a) Height (in cms) was measured in standing position without footwear, to nearest to
+0.1 cm. (b) The participants were weighed with a standard weighing (Wt) machine, to
+nearest to 0.1 kg. (c) Body mass index (BMI) was calculated for each participant from
+the height and weight of the individual by using formula BMI = Wt in kg/Ht in m2.
+EUROFIT physical tests battery (Adam, Klissouras, Ravazzolo, Renson, & Tuxworth,
+1988)
+EUROFIT physical fitness test is a standardized battery, which was developed by the
+Council of Europe���s Committee to help the teachers to access the physical health-related
+fitness of the children of school age and it has been used in many European schools since
+1988. The tests selected from the battery were (1) Flamingo left-leg balance (FLL), (2)
+Flamingo right-leg balance (FLR), (3) left-hand plate tapping test (PTL), (4) right-hand
+plate taping test (5) sit and reach (SAR), (6) standing broad jump (SBJ), (7) left-hand grip
+strength (LHS), (8) right-hand grip strength, (9) sit-ups (SUP), (10) bent arm hang (BAH)
+test and (11) shuttle run (SHR). Prior to the tests, participants were familiarized with the
+test methods by giving them clear instructions with demonstration in a group and once
+again students were taught individually at the time of taking data.
+Data analysis
+Data were analyzed using the Statistical Package for Social Science (Version 18.0). Gender
+categorical variables were analyzed using χ2 test. The independent sample t-test was used
+to check the difference between groups for demographic measures. Analysis of repeated
+measure followed by Bonferroni post hoc was performed for the EUROFIT.
+Results
+Figure 1 shows the study profile. There were total eight dropouts from WLC. The
+reasons for the dropouts were: two were suspended from all the extracurricular activ-
+ities of the institution during the post-assessment due to their behavioral issues, two
+were sick and other four were not willing to complete the task. The data of 40
+participants in YG and 32 in the control group were available for final analysis. The
+baseline BMI of YG and WLC is 15.54 ± 1.94 and 16.23 ± 2.43, respectively, with
+p = 0.039, independent t-test.
+Table 2 displays the baseline mean age between groups (p = 0.78, independent t-test).
+The distribution of gender (p = 0.624, χ2 test) was not significantly different between the
+two groups.
+Repeated measures of analysis of variance (ANOVA) showed that there were no
+significant differences between the two groups’ mean score of baseline (p > 0.05) for all
+EUROFIT’s measures except FLR and SBJ. Post hoc test with Bonferroni adjustment
+(Table 3) showed significant reduction in the number of falls in FLL in 60 sec and
+improvement in the number of tappings (PTL) in 25 sec, improvement in the explosive
+power in SBJ, improvement in the number of SUP in 30 sec and improvement in LHS
+and RHS in both groups. Whereas significant (p < 0.001) improvements in FLR, PTR,
+VULNERABLE CHILDREN AND YOUTH STUDIES
+39
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+BAH and SHR were found only in YG, significant (p < 0.001) decrement was found in
+SAR in WLC group.
+The group × time interaction (Table 4) showed significant positive differences
+(p < 0.05) in FLL, FLR, PTL, PRT, SAR, SBJ, SUP, BAH and SHR without Bonferroni
+correction. Further analysis done with Bonferroni correction with corrected p-values
+(0.004545455) found significant positive difference in FLL, FLR, PTL, PTR, SAR, SBJ
+and SUP in YG compared to WLC group. This suggested that the performance of YG
+was better than WLC.
+Discussion
+The current randomized two-armed WLC study was aimed to investigate the effect of
+3 months of yoga intervention on EUROFIT outcome measures on orphan adolescents.
+Table 2. Demographic data.
+Variables
+Yoga (n = 40)
+WLC (n = 32)
+p-Value
+Gender
+Male
+14 (35%)
+13 (40.6%)
+0.624 (χ2 test)
+Female
+26 (65%)
+19 (59.4%)
+Orphan status
+Double orphan (n)
+10 (25.0%)
+10 (31.3%)
+0.755 (χ2 test)
+Single orphan (n)
+20 (50.0%)
+16 (50.0%)
+Social orphan (n)
+10 (25.0%)
+6 (18.8%)
+Anthropometric variables
+Age (years)
+12.69 ± 1.35
+12.58 ± 1.52
+0.735 (Independent sample t-test)
+Height (cm)
+142.39 ± 11.10
+149.91 ± 10.92
+0.568 (Independent sample t-test)
+Weight (kg)
+31.72 ± 8.11
+33.82 ± 8.04
+0.281 (Independent sample t-test)
+The baselines were matched between groups’ variables.
+After 3 months
+Participants screened for the study N = 135
+Participants recruited N = 80
+WLC (n = 40)
+Pre Assessment
+WLC (n = 32)
+Post Assessment
+YOGA (n = 40)
+Pre Assessment
+YOGA (n = 40)
+Post Assessment
+Randomization
+Figure 1. The trial profile.
+40
+S. P. PUROHIT ET AL.
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+Table 3. Comparison of EUROFIT physical fitness measures of Yoga group and Wait-List Control group.
+Yoga (n = 40)
+Wait-List Control (n = 32)
+Pre
+Post
+Pre
+Post
+Mean±SD
+95% C.I.
+(LB to UB)
+Mean±SD
+95% C.I. (LB to UB) % Change
+Mean ±SD
+95% C.I. (LB to UB)
+Mean±SD
+95% C.I. (LB to UB) % Change
+FLL (n)
+13.25 ± 3.9
+12–14.5
+8.75 ± 3.45***
+7.65–9.85
+33.96
+11.97 ± 4.8
+10.24–13.7
+11 ± 4.37*
+9.42–12.58
+8.09
+FLR (n)
+13 ± 4.11
+11.69–14.31
+8.93 ± 3.92***
+7.67–10.18
+31.35
+10.78 ± 5.19
+8.91–12.65
+10.25 ± 5.21
+8.37–12.13
+4.93
+PTL (s)
+16.18 ± 2.88
+15.26–17.1
+13.21 ± 2.84***
+12.3–14.12
+18.35
+15.61 ± 2.21
+14.81–16.41
+14.87 ± 2.37*
+14.02–15.73
+4.75
+PTR (s)
+14.61 ± 2.37
+13.85–15.37
+12.46 ± 2.25***
+11.74–13.18
+14.69
+14.24 ± 2.45
+13.36–15.12
+13.68 ± 2.25
+12.87–14.49
+3.94
+SAR (cm)
+36.15 ± 6.4
+34.1–38.2
+39.84 ± 6.57***
+37.74–41.94
+10.20
+37.45 ± 5.61
+35.43–39.47
+35.73 ± 6.85*
+33.27–38.2
+4.59
+SBJ (cm)
+121.03 ± 24.58
+113.16–
+128.89
+143.9 ± 27.68***
+135.05–152.75
+18.90
+132.88 ± 20.17
+125.6–140.15
+138.88 ± 24.13*
+130.18–147.57
+4.52
+LHS (kg)
+14 ± 5.15
+12.35–15.65
+18.6 ± 7.47***
+16.21–20.99
+32.86
+15.34 ± 6.19
+13.11–17.57
+18.81 ± 6.55***
+16.45–21.17
+22.61
+RHS (kg)
+15.78 ± 6.41
+13.73–17.82
+18.5 ± 7.12***
+16.22–20.78
+17.27
+17.84 ± 6.8
+15.39–20.3
+19.81 ± 7.6***
+17.07–22.55
+11.03
+SUP (n)
+8.18 ± 7.01
+5.93–10.42
+14.55 ± 5.67***
+12.74–16.36
+77.98
+9.03 ± 7.21
+6.43–11.63
+10.94 ± 6.78**
+8.49–13.38
+21.11
+BAH (s)
+15.28 ± 15.7
+10.26–20.3
+20.8 ± 20.81***
+14.14–27.45
+36.10
+14.64 ± 11.48
+10.5–18.78
+16.59 ± 12.25
+12.17–21
+13.28
+SHR (s)
+16.37 ± 1.66
+15.83–16.9
+15.68 ± 1.38**
+15.24–16.12
+4.21
+15.95 ± 1.53
+15.39–16.5
+16.12 ± 1.38
+15.63–16.62
+1.11
+Flamingo left-leg balance (FLL), Flamingo right-leg balance (FLR), left-hand plate tapping test (PTL), right-hand plate tapping test (PTR), sit and reach (SAR), standing broad jump (SBJ), left-
+hand grip strength (LHS), right-hand grip strength (RHS), sit-ups (SUP), bent arm hang (BAH) test and shuttle run (SHR); *p < 0.05, **p < 0.01 and ***p < 0.001; pre compared with post.
+VULNERABLE CHILDREN AND YOUTH STUDIES
+41
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+The result showed that the difference in percentage change between the YG and WLC
+in FLL (25.87%), FLR (26.42%), PTL (13.6%), PTR (10.75%), SAR (14.79%), SBJ
+(14.38%), LHS (10.25%), RHS (6.24%), SUP (56.87%), BAH (22.82%) and SHR
+(5.32%), which indicates that the magnitude of change in these variables is higher in
+YG compared to WLC group.
+Our analysis using repeated measures ANOVA following post hoc analysis found
+significant positive improvement in all 11 measures in YG, whereas in WLC group, 6
+measures improved positively and 1 improved negatively as displayed in Table 3. These
+significant changes were appropriately confirmed by using the sign test and the bino-
+mial test.
+In the YG, changes in all 11 variables were in positive direction, in accordance with
+the experimental hypothesis. Applying a sign test gives p = (½)11 = 0.000488, meaning
+that, taking all physical fitness test together, yoga produced overall significant improve-
+ments. In contrast, the control group only improved in 6 out of 11 outcome variables
+for which the sign test gives p = 0.500, which is not significant.
+The group × time interaction found 9 significant positive outcome variables, which
+indicates that yoga intervention had better impact than WLC group. The null hypoth-
+esis that Yoga is entirely equivalent to WLC can be tested overall on significant
+outcome variables (9 out of 11) using binomial test, once again yielding p = 0.0327.
+Hence, overall for all 11 variables considered as a group, the null hypothesis fails; Yoga
+outperformed WLC, that is, the yoga intervention had definite benefits.
+The Flamingo leg balance test (FLL and FLR) is a single leg balance test which
+measures the static balance, the ability to maintain the center of gravity within a base of
+support in a quiet upright position during standing or sitting (Yim-Chiplis & Talbot,
+2000). The improvements in balance might be due to balancing postures such as
+Vriksasana, Garudasana and Virabhadrasana, which are single-leg stance (Flamingo
+balance) along with visual focus on a single point. Visual focus/concentration also plays
+a role in the balance (Hart & Tracy, 2008) which was taken care up by Trataka practice.
+In contrast, the balance is not improved in YG (Telles et al., 2013). This might be due to
+the variation in the yoga training session duration.
+Table 4. Group × time interaction analysis (Yoga group compared to Wait-List Control group).
+Yoga
+Control
+F-
+values
+Exact p-values without Bonferroni-
+corrected significance
+p-Values after Bonferroni-
+corrected p-value
+FLL
+−4.50 ± 2.15
+−0.97 ± 2.69
+38.319
+3.60 × 10−8***
+3.97 × 10−7***
+FLR
+−4.08 ± 2.13
+−0.53 ± 1.61
+60.870
+4.23 × 10−11***
+4.65 × 10−10***
+PTL
+−2.97 ± 2.36
+−0.74 ± 1.22
+23.409
+7.53 × 10−6***
+8.28 × 10−5***
+PTR
+−2.15 ± 1.94
+−0.56 ± 1.38
+15.202
+2.19 × 10−4***
+0.00241*
+SAR
+3.69 ± 3.95
+−1.72 ± 4.41
+30.027
+6.32 × 10−7***
+6.95 × 10−6***
+SBJ
+22.88 ± 16.79
+6.00 ± 10.08 25.040
+4.01 × 10−6***
+4.42 × 10−5***
+LHS
+4.60 ± 4.09
+3.47 ± 3.53
+1.530
+2.20 × 10−1
+1.000
+RHS
+2.73 ± 3.62
+1.97 ± 2.90
+0.921
+3.41 × 10−1
+1.000
+SUP
+6.38 ± 4.06
+1.91 ± 3.92
+22.187
+1.22 × 10−5***
+0.00013***
+BAH
+5.52 ± 9.22
+1.94 ± 4.73
+3.958
+5.06 × 10−2*
+0.557
+SHR
+−0.69 ± 1.09
+0.18 ± 1.65
+7.105
+9.54 × 10−3**
+0.105
+Flamingo left-leg balance (FLL), Flamingo right-leg balance (FLR), left-hand plate tapping test (PTL), right-hand plate
+tapping test (PTR), sit and reach (SAR), standing broad jump (SBJ), left-hand grip strength (LHS), right-hand grip
+strength (RHS), sit-ups (SUP), bent arm hang (BAH) test and shuttle run (SHR); *p < 0.05, **p < 0.01 and ***p < 0.001.
+42
+S. P. PUROHIT ET AL.
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+The plate-tapping task (PTL and PTR) measures the motor speed and motor speed is
+determined by muscle strength, endurance and coordination (Hutson, 2014). The result
+in this study showed alignment with the studies where Yoga practices healthy volun-
+teers by a repetitive tapping performance (Dash & Telles, 1999; Telles, Sharma, Yadav,
+Singh, & Balkrishna, 2014) and eye–hand coordination in computer users (Telles, Dash,
+& Naveen, 2009)
+SAR, which measures the trunk flexibility, improved in YG compared to WLC; the
+results aligned with the study done among children (Chen et al., 2009) and young adults
+(Bal & Kaur, 2009) following yoga. This improvement might be due to forward, back-
+ward and side bending, tiger stretching and postures such as Padahastasana,
+Paschimottanasana, Bhujangasana, Ustrasana, Vakrasana and Ardhamatsyandrasana
+included in this study.
+There was also a significant improvement in SBJ in YG compared to WLC and also
+from baseline. This might be due to the improvement in calf muscle strength, which is
+again due to stretching and strengthening of the muscle by applying body weight on the
+legs by Vrikshasana, Trikonasana and Garudasana (D’souza & Avadhany, 2014). It was
+also observed that stretching of the thigh muscles was due to Padahastasana and
+Parvatasana and contraction of the thigh muscles was due to Ardha Chakrasana and
+Bhujangasana (Cobra Pose). Inverted postures such as Halasana and Sarvangasana
+might have helped by reversing the effect of gravity and promoting the blood circula-
+tion and reducing the venous pressure in the leg.
+There was also a higher magnitude of percent change in hand grip strength in LHS
+and RHS in YG compared to WLC. This supports the findings of the Yoga study (Dash
+& Telles, 2001; Madanmohan, Udupa, & Bhavanani, 2003). This might be again due to
+more utilization of upper body muscles for weight-bearing postures in Suryanamaskar
+(Bhutkar et al., 2011) and improved cardiorespiratory fitness of Suryanamaskar. It
+might be due to reduced oxygen need in Pranayama.
+The improvement in duration of time in the BAH in YG might be because of more
+utilization of upper body muscles for weight bearing during the steps of Chaturanga
+Dandasana, Bhujangasana and Parvatasana of Suryanamaskar (Bhutkar et al., 2011).
+This might also be due to the aerobic effects of Suryanamaskar as it involves the static
+stretching and slow dynamic components with an optimal stress on cardiorespiratory
+system (Sinha, Ray, Pathak, & Selvamurthy, 2004).
+The numbers of SUPs in 30 sec were improved in the Yoga compared to WLC
+group, which was aligned with earlier studies (Dwyer, Sallis, Blizzard, Lazzarus, & Dean,
+2001; Telles et al., 2013). Yogic activities such as straight leg raising, cycling,
+Pavanamuktasana, Navasana and Suryanamaskar might strengthen the abdominal
+muscles. This could also be due to the cardiorespiratory benefit of Suryanamaskar
+(Bhutkar et al., 2011) and improvement of whole-body endurance and resting cardio-
+pulmonary parameters (Bhavanani et al., 2011).
+There was a significant decrease in time in SHR, which showed improvement in
+speed and agility of the individuals in YG compared to WLC, which might be due to the
+improvement in cardiopulmonary fitness (Bhutkar et al., 2011; Chen et al., 2009), speed
+and agility (Bal & Kaur, 2009) in earlier studies in Yoga and also due the dynamic
+practice of Suryanamaskar and Yogic games.
+VULNERABLE CHILDREN AND YOUTH STUDIES
+43
+Downloaded by [14.139.155.82] at 23:55 27 July 2016 
+The strength of the study was that it adopted a randomized control design and the
+sample size was as per the effect size form the study of same setting. The main
+limitation of the study was it was conducted on the adolescents belonging to one
+orphanage and the results were not able to rule out the effect of diet and other school
+activities.
+The study might be improvised in design by further conducting a multicentric
+trial and developing a yoga module especially for orphans. In summary, intervention
+of yoga over a 3-month period suggested the improvements in all EUROFIT mea-
+sures and was useful for the young orphans, to be practiced for physical health on a
+day-to-day basis.
+Acknowledgments
+We are thankful to the Department of Psychology, S-VYASA Yoga University, Bengaluru, for
+providing the necessary support needed for the research.
+Disclosure statement
+No potential conflict of interest was reported by the authors.
+ORCID
+Satya Prakash Purohit
+http://orcid.org/0000-0002-1944-1194
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subfolder_0/Effect of yoga on Human Aggression and Violent Behaviour A Review of the Indian Yoga Scriptures and Scientific Studies.txt

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+ 
+ 
+Instructions for authors, subscriptions and further details:  
+http://hse.hipatiapress.com 
+Effect of Yoga on Human Aggression and Violent Behaviour-  
+A Review of the Indian Yoga Scriptures and Scientific Studies 
+ 
+A.G. Govindaraja Setty1, Pailoor Subramanya1 & B. Mahadevan2 
+ 
+1) Swami Vivekananda Yoga University (SVYASA), India 
+2) Indian Institute of Management, Bangalore, India 
+ 
+ 
+Date of publication: February 23rd, 2016 
+Edition period: February 2016-June 2016 
+ 
+ 
+To cite this article: Govindaraja Setty, A.G., Subramanya, P., & 
+Mahadevan, B. (2016). Effect of Yoga on Human Aggression and Violent 
+Behaviour- A Review of the Indian Yoga Scriptures and Scientific Studies. 
+Social and Education History 5(1), 83-104. doi:10.17583/hse.2016.1859  
+ 
+To link this article: http://dx.doi.org/10.17583/hse.2016.1859 
+ 
+ 
+PLEASE SCROLL DOWN FOR ARTICLE  
+ 
+The terms and conditions of use are related to the Open Journal System and 
+to Creative Commons Attribution License (CC-BY). 
+HSE – Social and Education History Vol. 5 No. 1 February 2016 pp. 
+83-104 
+ 
+ 
+ 
+2016 Hipatia Press 
+ISSN: 2014-3567 
+DOI: 10.17583/hse.2016.1859 
+ 
+Effect of Yoga on Human Aggression and 
+Violent Behaviour – A Review of the Indian 
+Yoga Scriptures and Scientific Studies 
+ 
+A.G. Govindaraja Setty 
+Swami Vivekananda Yoga 
+University (India)  
+ 
+Pailoor Subramanya 
+Swami Vivekananda Yoga 
+University (India)  
+B. Mahadevan  
+ 
+ 
+ 
+ 
+ 
+Indian Institute of Management, Bangalore (India)  
+ 
+Abstract 
+______________________________________________________________ 
+Among the deviant human behaviors, aggression appears to be the most prevalent and 
+disturbing one, affecting one and all. Uncontrolled aggression/violent behavior could 
+cause a significant toll, equally affecting both involved and the non-involved. This 
+delinquent human behavior has been well addressed in Indian yogic scriptures. It 
+provides a theoretical framework to understand the causes, ill-effects, need for peace, 
+harmony, and ways to correct the aggression behavior.  It is also claimed that yoga is a 
+way for inner bliss and external coherence; and with this time-tested technique, it is 
+possible to bring about a sense of inner peace and emotional stability, thus having 
+potential to correct aggressive behaviors. This review paper also brings out the studies 
+made to find out effect of yoga on human aggression/violent behavior. 
+_______________________________________________________________ 
+Keywords: Yoga, aggression, violence, violent behaviour 
+HSE – Social and Education History Vol. 5 No. 1 February 2016 pp. 
+83-104 
+ 
+ 
+ 
+2016 Hipatia Press 
+ISSN: 2014-3567 
+DOI: 10.17583/hse.2016.1859 
+ 
+El Efecto del Yoga en la Agresividad 
+Humana y en el Comportamiento Violento 
+– Una Revisiónde las Escrituras Indias de 
+Yoga y Estudios Científicos 
+ 
+A.G. Govindaraja Setty 
+Swami Vivekananda Yoga 
+University, Bangalore (India)  
+ 
+Pailoor Subramanya 
+Swami Vivekananda Yoga 
+University, Bangalore (India)  
+B. Mahadevan  
+ 
+ 
+ 
+ 
+ 
+Indian Institute of Management, Bangalore (India)  
+ 
+Resumen 
+_____________________________________________________________ 
+Entre las conductas humanas desviadas, la agresión aparece como una de las más 
+frecuentes y alarmantes, afectando a todas las personas sin excepción. La conducta 
+agresiva/violenta incontrolada puede causar graves consecuencias, afectando tanto a las 
+personas directamente implicadas como a las no implicadas. Este comportamiento 
+humano delictivo ha sido abordado con profundidad en las escrituras indias yóguicas. 
+Ello aporta un marco teórico para entender las causas, efectos nocivos, la necesidad de 
+paz, harmonía y las formas para corregir las conductas violentas. También se afirma que 
+el yoga es una forma de alcanzar la paz interior y la coherencia exterior; y con esta 
+técnica probada  en el tiempo es posible lograr un sentimiento de paz interna y de 
+estabilidad emocional, por lo que tiene potencial para corregir conductas agresivas. Esta 
+revisión bibliográfica pone de relieve los estudios llevados a cabo para identificar los 
+efectos del yoga en las conductas humanas agresivas/violentas.  
+_______________________________________________________________ 
+Keywords: Yoga, agresión, violencia, comportamiento violento 
+HSE – Social and Education History, 4(3) 85 
+ 
+ 
+ 
+Among the deviant human behaviors, aggression and violence 
+appear to be the most prevalent and highly disturbing, affecting one 
+and all in the society, hence considered a serious global health 
+problem (WHO, 2014). Some of the studies say that this aberrant 
+behavior normally surfacing in childhood becomes habitual and continues at 
+all age points of an individual and that in childhood it might lead to rejection 
+from family as well from fellow children, relational tribulations leading to 
+isolation during adolescence and criminal, illegal or unlawful behavior in 
+adulthood (Huesmann & Guerra, 1997) and the whole society looks down at 
+such an individual. Further, it could affect both the involved and the non-
+involved; and unchecked aggression and violence exact a significant toll on 
+human societies.   
+Though normally men score slightly higher on aggression, this deviant 
+attitude is not gender-sensitive. Significant correlates of interpersonal 
+violence were found in younger age. Intensity of aggression is directly 
+attributable to one’s amount of frustration. Though aggressive behaviors 
+evolved as adaptations to deal with competition, they can have destructive 
+consequences. Family members have been the object of violence in more 
+than 50% of cases (Kumar, Akhtar, Roy & Baruah, 1999). Worldwide, mass 
+media reports, a number of violent acts affecting one and all, that are neither 
+country specific (Miron, 2001) nor religion specific (Cobban, 2005) and 
+world over findings regarding violence-related behaviors are remarkably 
+similar. The economic cost associated with violence-related injuries, 
+disabilities, and premature deaths is estimated to be in billions of dollars.  
+The gravity of the problem could be understood from the fact that 49 World 
+Health Assembly Geneva, declared violence as leading global public health 
+problem and urged members to assess the problem of violence in their 
+territories; and convey details to WHA, besides clearly defining their 
+approach to deal with it. Further, WHA requested the Director-General for 
+public health to address the problem of violence, promote research on 
+violence on priority and document them for the benefit of member nations.  
+“Aggression” and “violence” are generic terms. Oxford dictionary 
+defines “aggression” as “feelings of anger or antipathy, readiness to attack or 
+confront, resulting in hostile or violent behavior”. WHO defines “Violence” 
+as “intentional use of physical force or power, threatened or actual, against 
+A 
+86   Govindaraja et al – Effect of Yoga on Human Aggression 
+ 
+ 
+oneself, another person, or against a group or community or section of 
+people, which either results or has a high likelihood of resulting in injury, 
+death, psychological harm, mal-development or deprivation”.  “Violent 
+behaviors” are latent perception variables towards violence, which are 
+guided by one’s own value systems. 
+ 
+Aggression and Violence: Indian Scriptural Perspective 
+ 
+Aggression and violence have been well addressed in Indian scriptures 
+(Vedas, Upanishads, Bhagavad Gītā, Brahma Sutras, Yoga Sutras, and 
+Bhakti (Devotion) Sutras), which are also considered as conventional yoga 
+texts. This traditional literature provides a theoretical framework to 
+understand the aggression and violence in conventional background. In 
+every Indian scripture, there is invariably a mention on aggression and 
+violence, ill effects, ways to avoid, and need for harmony and coherence. 
+These include teachings under ‘The doctrine of ahimsa’ (Rajapakse, 1988; 
+Phillips, 2010). ‘Ahimsa’ means and includes avoiding any harm (physical, 
+mental or emotional), to remain passive in any situation, without the desire 
+to harm anyone (Muktibodhananda, 2004). Himsa is brought out by three 
+ways namely, ‘violence done’, ‘violence got done’ and ‘violence sanctioned’ 
+(Adidevananda, 1998), wherein all the three bring endless agony. But when 
+a person is firmly established in ahimsa, in his/her presence, even cruel 
+persons renounce violence (Adidevananda, 1998). Indian yogic scriptures 
+recommend that personality of an individual gets nourished by a mix of both 
+‘relaxing’ and ‘stimulating’ practices by attaining a state of mental equipoise 
+(Telles & Reddy, 2000). 
+Prevalence of Aggression and Violent Behavior: Indian Scriptural 
+Perspective 
+ 
+Indian scriptures answer the question, ‘does aggressive and violent behavior 
+indeed exist in us? If yes, in whom and in what ways?’‘Pretentiousness, 
+arrogance, overweening pride, wrath, rudeness, aggression, scant regard for 
+pain of others, insensitiveness to spiritual values are prevalent in those born 
+to demoniac (Asuri) heritage’; whereas, non-violence, truthfulness, freedom 
+HSE – Social and Education History, 4(3) 87 
+ 
+ 
+from anger renunciation, tranquility, aversion to slander, compassion to 
+living beings, sensitivity to the pain of others, empathy, freedom from 
+sensuality, gentleness, modesty, steadfastness, are the qualities present in 
+those born to divine (Daivi) inheritance’ (Bhagavad Gītā 16.2,4) 
+(Tapasyānanda, 2003).  
+ 
+Causes for Aggression and Violence, and Need to Address: Indian 
+Scriptural Perspective  
+ 
+Indian scriptures clearly establish the causes for aggressive and violent 
+behavior and assert that we have propensity to be violent. Causes could 
+range from ‘sense objectivity, greed and illusion. Bhagavad Gītā (2.62) says, 
+if one dwells longingly on sense objects, inclination towards them is 
+generated; inclination develops into desire; desire begets anger, and finally 
+culminates in aggression. Bhāgavatam (4.8.3) says, hypocrisy and illusion 
+beget greed and deceitfulness, they, in turn, beget aggression and violence.  
+Insatiable lust, uncontrolled anger, born out of ‘rajas’ prompt men to engage 
+in violence (Bhagavad Gītā 3.37). ‘Rajas’ is passion-based leading to 
+craving for objective pleasures; and clinging to objects already possessed by 
+an individual. Tamas is ignorance-born and produces delusion leading to 
+negligence, indolence, scant regard for pain of others (Bhagavad Gītā 14.7-
+8). The children (derivatives) of aggression and violence are ‘hostility’ and 
+‘harsh abusive words’ (verbal aggression) (Velanakar, 2013).      
+The gradual degradation of aggressive and violent personalities is also 
+brought out by Indian yoga scriptures. Aggression generates delusion, 
+delusion results in loss of memory, loss of memory brings about destruction 
+of discriminative intelligence, and loss of discriminataive intelligence spells 
+ruin to a man (Bhagavad Gītā 2.63).  
+Bhagavad Gītā (16.21) establishes in a pristine way that lust, aggression, 
+and greed lead to destruction of man’s spiritual nature. They form the 
+gateway to hell; hence surely be abandoned (Tapasyānanda, 2003).  
+Patañjali 
+Yoga 
+sūtra 
+(2.30) 
+says, 
+ahiṁsā 
+(non-violence), 
+satya 
+(truthfulness), asteya (non-stealing), brahmacharya (sexual self-restraint), 
+aparigraha (non-obsessively possessive) are five yamas (moral universal 
+commandments for self-control) (Prabhavananda, 2004). Patañjali Yoga 
+88   Govindaraja et al – Effect of Yoga on Human Aggression 
+ 
+ 
+Sūtra (2.35) says, when a yogi is resolutely committed to non-violence, there 
+is no hostility, wherever he is present (Prabhavananda, 2004).  Manusmṛti 
+(5.43) says a Brahmin of virtuous disposition, whether dwells in (own) 
+house, with a teacher or in the forest, must never, in times of distress, cause 
+injury to any creature, which is not sanctioned by Vedas.  Bhāgavatam 
+(4.18.14) says, you will get the divine feet of Bhagavān Nṛsiṁha (one of the 
+ten incarnations of Lord Vishnu), only on your abandonment of desire, 
+melancholy, aggression, pride, apprehension, and grief which are the causes 
+for vicious cycle of birth and death (Velanakar, 2013). 
+ 
+Addressing Aggression and Violent Behavior: Yoga Way 
+ 
+Practical lessons of Indian yogic scriptures could provide broad framework 
+and specific ways to fight against this delinquent behavior and answer the 
+question, can we as human beings, bring about a paradigm shift in our 
+personality by avoiding all these aggression and violent behavior. One of the 
+eighteen Indian mythologies, Bhāgavatam (1.18.22) says one who is in 
+divine love with the Supreme Lord can make non-violence and peace one’s 
+dharma and strive for the ultimate realization through dhyāna (Velanakar, 
+2013). The word ‘yoga’ implies non-duality, oneness with the Supreme 
+Soul; and the very notional duality causes fear, anger, lust and therefore 
+reaching oneness can address this delinquent behavior (Adidevananda, 
+1998). Violence is attributable to ignorance caused by pretentiousness, 
+impatience, lack of straight-forwardness, abhorrence, lack of self-control, 
+lack of devotion and scant regard for cleanliness (Bhagavad Gītā 13.7-11). 
+Bhāgavatam (6.4.14) further says, a person can transcend ‘Triguṇas’ 
+(personality traits) by appeasing and controlling the teeming aggression by 
+steady, indrawn, discriminating mind (Velanakar, 2013). Withdrawal of 
+mind is nothing but ‘prathyāhāra’ mentioned in ashtanga yoga texts. 
+According to yogic scriptures, early seers (spiritual masters or yogis or 
+prophets) of India devised and used yoga as a means to explore the external 
+and internal realms; and to attain ultimate knowledge described in sacred 
+Indian texts. These great masters or yogis prescribed yoga as a way of life to 
+be in tune with the highest reality; and the importance is on individualized or 
+one’s own confirmation and not merely on religious dogmas or doctrines. 
+HSE – Social and Education History, 4(3) 89 
+ 
+ 
+They preached that yoga is both a way for internal bliss and external 
+coherence. "Yoga" is derived from a Sanskrit root word ‘Yuj’ (join), hence 
+"yoga" means and includes, joining of the body, mind and the ‘Self’(soul) 
+(Nagendra, 2000).  
+Addressing violent and aggressive behavior through yoga has been 
+suggested by many researchers on the ground that it is very effective and be 
+documented to promote research on violence on the lines suggested by 
+World Health Assembly, Geneva for the benefit of member States. Yoga is 
+an ancient science, originating in India, which includes diverse practices like 
+physical postures (asana), regulated breathing (pranayama), meditation and 
+lectures on philosophical aspects of yoga. The ultimate aim of yoga is to 
+remain unperturbed in success or failure and perfection of the personality of 
+its practitioner to remain equipoise in all conditions (Bhagavad Gītā 2.48). 
+The yoga texts suggest that the solution lies in developing health and 
+personality of the individuals brought out by a mix of both ‘relaxing’ and 
+‘stimulating’ practices which help in reaching a state of mental equipoise 
+(Telles, Reddy, & Nagendra, 2000) and supports the view that combination 
+of yoga postures interspersed with relaxation reduces arousal more than 
+mere relaxation (Sarang & Telles, 2006).  
+Asanas, which are physical movements, may give exercises to various 
+organs and systems and provide them an avenue to deal with character, 
+attitudes and tensions; can bring about healthy changes in several 
+psychopathological conditions (Krishna Rao, 2000).  When yoga induced 
+non-violence in speech, thought and action is established, one’s aggressive 
+nature is relinquished; others abandon hostility in such a yogi’s presence 
+(Iyengar, 1993). Swami Vivekananda says, ‘the test of ahimsa is absence of 
+jealousy’ (Prabhavananda, 2004). Generosity, acceptance, patience, freedom 
+from self-importance, unpretending, ahimsa (non-violence), self-control and 
+straight-forwardness are the divine qualities one can nourish through yoga 
+(Bhagavad Gītā 13.7-11).        
+Yoga is an ancient science and an art and a way of life, aimed at 
+harmonious system of developing the body, mind and spirit. The Indian 
+scriptures claim that yoga, with its powerful, time-tested techniques, can 
+bring about a sense of inner peace, which can culminate in emotional 
+stability, harmony and clarity of mind (Nagendra, 2000). Bhagavad Gītā 
+90   Govindaraja et al – Effect of Yoga on Human Aggression 
+ 
+ 
+defines yoga as ‘samatvam yoga ucyate’, - ‘always being in a state of 
+unperturbed evenness’. Patañjali, who is quoted widely in yoga researches, 
+defines yoga as ‘Yogahcittavrittinirodah’, i.e., ‘Yoga is the cessation of 
+movements in consciousness’ which can lead to complete mastery over 
+mind. Sage Vasistha, (‘Yoga Vasistha’) defines yoga as a technique to slow 
+down or calm down the mind through deep internal awareness (Nagarathna  
+& Nagendra, 2003).  
+Thus, in its attempts to achieve these results, yoga offers varied 
+techniques like asanas (bodily postures), pranayama (regulated breathing), 
+and dhyāna (meditation) coupled with swadhyāya (sermons of philosophical 
+aspects of yoga). Violent/aggressive individuals normally do not respond or 
+react to oral methods only; instead, they are to be addressed through 
+psychodynamic psychotherapies like yoga, martial arts, out-door games 
+(Twemlow, Sacco, & Fonagy, 2008).  
+The way yoga leads to reduction of aggression is understandable: anger, 
+aggression and violence are said to be unrestrained speed in one’s mind 
+(Nagarathna  & Nagendra, 2003) whereas, yoga is the art of slowing down 
+the mind, so that one has time to think and act. This modification is owing to 
+increased clarity of thoughts, calmness, serenity, and control over emotions, 
+carving out a happy living. The norms prescribed by Indian scriptures for 
+yogic life are characterized by peace, tranquility, harmony, love, happiness, 
+and efficiency, driven by discrimination, right thinking, right understanding, 
+and calculated actions.   
+ 
+Causes as per Research Studies; Aggression Theories 
+ 
+Research says there is no single cause for human aggression and violence. It 
+ranges from factors like racism (Rogers & Prentice-Dunn, 1981), religious 
+intolerance (Corrigan & Neal, 2010), sex-induced (Gurvinder & Dinesh, 
+2013), media influence (Gentile, Coyne, & Walsh, 2011), violent video 
+games (Adachi & Willoughby, 2011), prolonged television viewing 
+(Mitrofan, Paul, & Spencer, 2009), low self-esteem (Bushman & 
+Baumeister, 1998), food insecurity (Brinkman & Hendrix, 2011).  
+Aggression theories offer broader framework for these causes. Among 
+conventional theories, instinct theory (Sigmund Freud) says, aggression is 
+HSE – Social and Education History, 4(3) 91 
+ 
+ 
+because of release of dammed up energy. For instance, hunting and fighting 
+instincts are found in frustrated ones. When aroused, they over-ride other 
+instincts like sympathy, paternal instinct and become expressive through 
+aggression and violence. Sigmund Freud calls these instinctive drives as 
+‘libido’, which are nothing but energy derived from Eros (life instinct) (Eron 
+& Huesmann, 1994). 
+Dollard and his associates (Yale University), offered ‘frustration and 
+aggression’ theory. When a person is frustrated, when his/her desires or 
+wishes are let down, he/she responds aggressively. Thus, frustration always 
+presupposes aggression (Dollard & Miller, 1939). 
+Theory of hormones and chromosomes got popularity from 1920’s. 
+Discovery of human chromosomes led to research linking excessive male 
+aggression with the presence of extra Y chromosome. Some researchers 
+suggest that Y chromosome is the cause for aggression; and doubling Y 
+chromosome doubles one’s aggression and violent behavior (Jarvik, Klodin, 
+& Matsuyama, 1973). 
+Among the recent theories, cognitive neoassociation theory suggests that 
+incidents involving aversion lead to negative affect (Berkowitz, 2012). 
+These in turn stimulate expressions, thought process, memories, and 
+response patterns like fight and flight. These fight and flight patterns give 
+way to reactions like anger and fear respectively.  
+Social learning theory proposes that aggressive responses are acquired in 
+similar ways, the people learn other intricate forms of social behaviors by 
+way of direct experience or by learning from others (Bandura, 1978).   
+‘Script theory’ says that ‘scripts’ are situation-guided ‘stored-up 
+behaviors’ (Huesmann, 1998).  These stored up scripts could be retrieved 
+later and may guide the behavior of an individual. This explanation of script 
+theory is comparable to what yoga scriptures pronounce: consciousness has 
+four faculties. First is the mind (manas - receiving faculty). Being non-
+judgmental, it keeps receiving the knowledge through senses, good or bad. 
+Such knowledge is passed on to next faculty - buddhi (intellect - 
+discriminating faculty). It qualifies the knowledge as good or bad, negative 
+or positive. Such qualified knowledge is passed on to third faculty namely 
+‘ahankara’ (ego). This faculty may choose to retain either the positive or 
+negative knowledge and reject the other. Having retained one of these two, it 
+92   Govindaraja et al – Effect of Yoga on Human Aggression 
+ 
+ 
+becomes part of the knowledge retained. Further, this retained knowledge is 
+passed on to the next faculty namely ‘chitta’ which ‘stores’ the knowledge 
+for future retrieval.  
+Excitation transfer theory proposes ‘transfer of arousal’. When two 
+disturbing events are disconnected by a short time period, arousal from first 
+event is erroneously attributed to second and the person wrongly behaves 
+aggressively to the second event (Bryant & Miron, 2003).  
+Social interaction theory advocates aggression as a function of social 
+influence (Felson & Tedeschi, 1993). For example, coercion is employed to 
+get something valuable, or to cause an intended change or outcome.  
+ 
+Studies on Effect of Yoga on Aggression and Violent Behavior 
+  
+Earlier research studies on effect of yoga on human aggression and violent 
+behavior have considered varied sample sizes, intervention periods, diverse 
+age groups of both sexes, varied ethnic groups, nationality, on different 
+forms of aggression and violence (physical, verbal, covert), on normal as 
+well as high-risk individuals. With all this diversity, the outcomes appear to 
+be remarkably similar and encouraging. Even the Indian yoga scriptures do 
+not limit or prohibit the application of yoga to any particular age category, 
+gender or personality type and hence the scope is very wide as for as the 
+application is considered.   
+ 
+ 
+Studies on Effect of Yoga on Aggression and Violent Behavior of At-
+Risk-Youth 
+ 
+Aggression that manifests in childhood could lead to rejection from fellow 
+children in childhood, relational problems during adolescence and criminal 
+behavior in adulthood (Guerra, Rowell Huesmann, & Spindler, 2003). 
+Hence, it is desirable for the parents, elders and teachers to identify this 
+delinquent behavior at the earliest. In a pre and post quasi-experimental 
+control group design, 49 students (females 54.4%) in 9th to 12th grades of 
+school for at-risk youth, California, participated. The participants were 
+academically heterogeneous, 33.3% black, 33.3% Hispanic, 4.3% Native 
+HSE – Social and Education History, 4(3) 93 
+ 
+ 
+American, 6.2% Asian, 2.1% white and 20.8% mixed races. The youth were 
+characterized by risk factors like aggression, academic failure, poor grades, 
+high truancy, repeated suspension and expulsion. Transformative life skills 
+(TLS – which includes asanas, pranayama and meditation) were taught by 
+certified yoga teachers for 3-4 days a week in the first semester for 30 
+minutes per day. Yoga practitioners demonstrated significant decrease in 
+nervousness, depression, psychological anguish, intrusive views, physical 
+provocation, emotional stimulation; and significantly less likely to approve 
+revenge and overall less aggression, suggesting possibility for yoga-based 
+wellness program and TLS to favorably influence emotions among high-risk 
+youth (Frank, Bose, & Schrobenhauser-Clonan, 2014).  
+As a part of countrywide violence prevention effort, Niroga Institute 
+conducted transformative life skills (TLS) program (yogasanas, pranayama, 
+and meditation), daily 60 minutes for 18 weeks involving 472 students from 
+Alameda County Juvenile Justice Center. In another group 85 students 
+participated in control group, which did not get the TLS. Additionally, a 
+condensed 15 minutes TLS program was done in a large urban public high 
+school. The yoga intervention was by certified yoga teachers.  The scales 
+used were perceived stress scale (PSS-10) and Tangney’s self-control scale-
+13. At the end of the study period ‘at-risk-imprisoned adolescents’ reported 
+lessened perceived stress and escalated self-control and self-awareness. They 
+showed statistically significant improvement in stress resilience, self-control, 
+and self-awareness. PSS reduced by a mean change of 1.31; self-control 
+improved by a mean change of 1.68 (Ramadoss & Bose, 2010). Thus, these 
+two studies are suggestive of feasibility of yoga intervention to youth with 
+known background of risk factors like aggression, academic poor 
+performance. 
+ 
+Studies on Effect of Yoga on Verbal Aggression 
+ 
+Being one of the aggression expressions, ‘verbal aggression’ is use of 
+abusive words to insult/hurt another person. In one of the studies, effect of 
+yoga on verbal aggressiveness in 173 normal healthy adults was studied (age 
+17 - 62 years). Yoga group practiced integrated yoga module and control 
+group practiced moderate physical exercises for one hour a day, six days a 
+94   Govindaraja et al – Effect of Yoga on Human Aggression 
+ 
+ 
+week, for eight weeks. Self-administered verbal aggressive scale was used.  
+Significant reduction in verbal aggression in yoga group (P = 0.0) and non-
+significant upsurge in control group was reported (Deshpande, Nagendra, & 
+Raghuram, 2008b). The aggression or violent behavior could manifest in any 
+of the three kinds namely, verbal, physical or covert. Irrespective of the kind 
+of aggression that manifests in an individual, yoga could offer a positive and 
+a constructive change.  
+ 
+Studies of Effect of Yoga on Perceived Well-Being 
+ 
+Yoga could be a preventive intervention and a way for improving children's 
+perceived well-being, which Berger studied as outcome measures. Pilot 
+study compared fourth and fifth-grade students. One program was offered 
+yoga for one hour a week for 12 weeks; other program was not offered yoga.  
+Outcome measures were emotional well-being assessed by Harter’s global 
+self-worth and physical appearance subscales; physical well-being was 
+assessed by flexibility and balance. Yoga group showed less negative 
+conduct scores and heightened comfort (Berger, Silver, & Stein, 2009). Thus 
+the outcomes suggest that yoga, besides being a way for refining 
+adolescents’ perceived well-being, can also be a preventive intervention. 
+ 
+ 
+Studies on Effect of Yoga on Correlates of Aggression and Violent 
+Behavior 
+ 
+Some of the reports suggests that high levels of nervousness and aggression 
+do affect parameters like grip strength, dexterity scores and optical illusion. 
+In order to study these correlates a study was done, wherein, in the age range 
+12 to 16 years, equal number of subjects were there in each of the three 
+groups namely, community home girls trained in yoga for a period of six 
+months, community home girls who practiced physical exercises and girls 
+who attended their regular schools. Degree of optical illusion was 
+significantly higher in physical exercises group when compared to yoga 
+group and regular school group.  Hand grip was significantly less in physical 
+exercises group compared to yoga group (Raghuraj & Telles, 1997). The 
+HSE – Social and Education History, 4(3) 95 
+ 
+ 
+improved performance of the yoga group compared to physical activity 
+group suggests that yoga practice has a beneficial effect on these parameters, 
+which are considered to be the derivatives of aggression and violent 
+behaviors. 
+ 
+Studies on Effect of Yoga on Personality Traits (Gunas as per Bhagavad 
+Gītā) 
+ 
+A person with calmness, purity, without pride and self-importance, having 
+concern for others’ pain, is ‘sattvik’. A person with passions, cruelty, impure 
+at heart and is subject to elation and depression in success and failure, is 
+‘rajasic’. A person with unsteadiness, offensive, ego, deceitful, malevolent, 
+procrastination, and indolence is ‘tamasic’ (Bhagavad Gītā 18.26-28). In one 
+of the studies self-administered "Bhagavad Gītā Personality Inventory” was 
+used to measure these Gunas. In the age group of 18 to 71, 226 subjects of 
+both sexes participated. The yoga group practiced integrated yoga module 
+and control group practiced physical exercises daily one hour, six days a 
+week, for eight weeks. The outcomes demonstrated that the baseline scores 
+for all areas for both groups did not differ considerably. There were 
+noteworthy improvements in all domains in both groups. However, the 
+number of persons who showed progress in Sattva and decline in Tamas was 
+substantial in yoga group (Deshpande, Nagendra, & Nagarathna, 2009; 
+Deshpande, Nagendra, & Raghuram, 2008a). Thus, evidencing that yoga 
+could be a helpful tool in bringing out positive changes in personality traits, 
+irrespective of the age and gender. 
+ 
+Studies on Effect of Yoga on Predictors of Aggression 
+ 
+Variables like empathy, emotional quotient, general well being, and beliefs 
+about aggression are found to be good predictors of aggression levels. When 
+these variables are addressed through yoga, effect could be found in 
+aggression level as a correlate. A pre-post yoga intervention study measured 
+persistent attention, emotive intelligence (EQ), general wellbeing through 
+general health questionnaire, and Guna personality –sattva (purity), rajas 
+(craving) and tamas (brutality). Control group was not there. In the age 
+96   Govindaraja et al – Effect of Yoga on Human Aggression 
+ 
+ 
+group of 17 to 63 years 108 subjects participated.  Yoga practitioners 
+demonstrated substantial changes in all variables (P < 0.001) excepting 
+‘sattva’. EQ and overall health variables compare considerably with each 
+other and negatively with tamas. EQ and tamas form positive and negative 
+forecasters of health. Sattva correlates positively with EQ signifying that a 
+sattvic personality demonstrates improved self-control. This recommends 
+that yoga practice may improve guna personality (traits) and can stabilize 
+EQ (Khemka, Hankey, & Ramarao, 2011).  
+ 
+Studies on Effect of Yoga on Cognitive Functions 
+ 
+When a person longingly dwells on sense objects, gradually preference 
+towards them develops. This preference develops desire; desire produces 
+anger and aggression. Aggression brings about delusion, and delusion leads 
+to loss of memory. Loss of memory culminates in destruction of 
+discriminative intelligence, which in turn, brings about complete devastation 
+to the person (Bhagavad Gītā 2.62-63). Thus, aggression and violent 
+behavior affect the cognitive functions like thinking, memory, analyzing, 
+perception and judgment. In one of the studies, effect of yoga on cognitive 
+functions and attitude towards violence (ATV) in 100 rural school children, 
+aged 13-15 years, of both sexes, in 8th and 9th grades was studied. The 
+subjects were divided into yoga and control groups. The yoga group 
+practiced yoga for one hour a day for 10 days and control group practiced 
+physical exercises. Digit letter substitution test was used to measure 
+cognitive function, whereas ATV scale was used to measure attitude towards 
+violence. The outcomes showed significant change in cognitive functions, 
+42% and 24% mean change in yoga and control groups respectively. But 
+there were no noteworthy results in ATV, 3% and 12.8% mean change in 
+yoga and control group respectively. However, yoga group experienced 
+other benefits like increased flexibility, improved digestion, good sleep, 
+relaxation and were cooperative with teachers/parents (Reddy, 2015). 
+Adolescence is the age when the aggression is at its peak and if 
+uncorrected, it could manifest at all age points of an individual, say research 
+studies. A study was done to find out the effect of yogic practices like 
+Suryanamaskara and pranayama on 30 adolescents’ logical memory, 
+HSE – Social and Education History, 4(3) 97 
+ 
+ 
+aggression and anxiety levels. The yoga intervention was given for a period 
+of 25 days and the outcomes measured were logical memory, anxiety and 
+aggression levels by aggression scale. The Result showed statistically 
+significant decrease in post anxiety and aggression levels and improved 
+logical memory of participants (Singh, 2015).  
+In another study, yoga practitioners outdid physical exercise practitioners 
+on variables like trait anxiety, somatic anxiety, cognitive anxiety, aggression 
+and achievement impetus (Vengatesh, 2014). 
+ 
+Studies on Effect of Yoga on Somatic Grievances of Women and Girls 
+ 
+A study on physiological and psychological effects of hatha-yoga in healthy 
+women showed no considerable changes between the clusters regarding 
+endocrine parameters and BP. The yoga group had substantial reduction of 
+heart rate all through the yoga practice. The study accounted for substantial 
+variances between groups in psychological parameters. Yoga group 
+displayed distinctly higher scores in life fulfillment, morale, extravertedness, 
+lower scores in nervousness and aggression, frankness, emotionality and 
+somatic grievances. Substantial dissimilarities could be witnessed 
+concerning handling of stress and temperament (Schell, Allolio, & 
+Schonecke, 1994). The study suggests that the derivatives of high levels of 
+aggression and violent behavior like hypertension and high heart rate do get 
+improved with the intervention of yoga.   
+ 
+Conclusion 
+ 
+It is evident from various research studies that yoga intervention on subjects 
+of varied age, ethnicity, and nationality have shown remarkably similar 
+results and findings are quite encouraging to deal with the problem of 
+aggression through yoga. Researches on aggression and violence have 
+progressed to a stage where a unifying construction is needed in the sense 
+that different kinds of interventions (yoga, Transformative life skills, 
+counseling, addressing predictors of aggression and violent behavior) can be 
+blended to be more effective in addressing this delinquent human behavior. 
+Further, there is a need for standardizing the yogic intervention module and 
+98   Govindaraja et al – Effect of Yoga on Human Aggression 
+ 
+ 
+period of intervention, so that this delinquent human behavior is addressed 
+effectively and the results could be more evident. It also helps to 
+scientifically establish the basis for transformation claimed by Indian yoga 
+scriptures. Man is a social being. Sociability, that is one’s ability to cordially 
+blend with the fellow beings in the societal structure, is one of the important 
+facets of health according to World Health Organization. Indian yoga 
+scriptures deal extensively with this subject. There is a need to use this 
+ancient wisdom, claimed by Indian scriptures. This would provide a new and 
+effective framework to deal with the problem of human aggression and 
+violent behavior. Research is scarce particularly concerning the effects of 
+yoga on domains like human beliefs and attitude towards aggression and 
+violence, normative beliefs supporting aggression, perception towards 
+alternatives for violent methods normally adopted by aggressors, and 
+perceptions towards social norms for aggression and alternatives.  
+The yoga scriptures (including scientific researches) claim that 
+irrespective of the age, this ancient science of yoga can be taught. The 
+detailed yoga protocol intervention to suit different age groups can be well 
+defined and standardized and the results can be documented for the benefit 
+of all, which helps in understanding the methods researched to be effective 
+in correcting aggressive and violent behavior, and understanding the nature, 
+causes, 
+contributive 
+factors, 
+neuro-psychological 
+changes, 
+gender 
+differences, forms of aggression (latent and manifest), relationship between 
+select behavioral-characteristics as predictors of aggression. This could be 
+one of the valuable, cost effective, alternative (or complementary) methods 
+that involve no drugs and no invasive treatments to correct this delinquent 
+human behavior. 
+Excepting the theory of hormones and chromosomes, most of the 
+aggression theories deal only with the mind as the root instrumental cause 
+for aggression and violent behavior. Yoga deals comprehensively with this 
+subject. Hence there is a need for the researchers to look at this ancient, time 
+tested method advocated by Indian yogic scriptures.  
+ 
+ 
+ 
+ 
+HSE – Social and Education History, 4(3) 99 
+ 
+ 
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+University, India. Orcid: http://orcid.org/0000-0002-3621-8699 
+Pailoor Subramanya, Assistant Director - Research & Head-PhD. Swami 
+Vivekanda Yoga University, India. 
+B. Mahadevan, Professor, Indian Institute of Management, Bangalore, 
+India 
+Contact Address: Swami Vivekananda Yoga University (SVYASA) 
+#19, Eknath Bhavan, Gavipuram Circle, K.G.Nagar 
+Bangalore – 560019, Karnataka, India.  
+E-Mail: [email protected] 
+ 
+ 

subfolder_0/Effect of yoga on cognitive functions in climacteric.txt

@@ -0,0 +1,1098 @@
+Effect of yoga on cognitive functions in climacteric
+syndrome: a randomised control study
+R Chattha,a R Nagarathna,b V Padmalatha,c HR Nagendrad
+a Division of Yoga and Life Sciences Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), Bangalore, India b Division of Yoga
+and Life Sciences, SVYASA, Bangalore, India c Maiya Multispeciality Hospital, Bangalore, India d SVYASA, Bangalore, India
+Correspondence: Dr V Padmalatha, FRCOG (Lon), MRCP (Ire), Consultant Obstetrician and Gynecologist, Maiya Multispeciality Hospital,
+Bangalore, India. Email [email protected]
+Accepted 13 March 2008. Published OnlineEarly 23 May 2008.
+Objective To assess the efficacy of an integrated approach of yoga
+therapy (IAYT) on cognitive abilities in climacteric syndrome.
+Design A randomised control study wherein the participants were
+divided into experimental and control groups.
+Settings Fourteen centres of Swami Vivekananda Yoga Research
+Foundation, Bangalore, India.
+Sample One hundred and eight perimenopausal women between
+40 and 55 years with follicle-stimulating hormone level equal to or
+greater than 15 miu/ml. One hundred and twenty perimenopausal
+women were randomly allotted into the yoga and the control
+groups.
+Methods The yoga group practised a module comprising
+breathing practices, sun salutation and cyclic meditation, whereas
+the control group practised a set of simple physical exercises,
+under supervision (1 hour/day, 5 days/week for 8 weeks).
+Main outcome measures Assessments were made by vasomotor
+symptom checklist, six-letter cancellation test (SLCT) for attention
+and concentration and Punit Govil Intelligence Memory Scale
+(PGIMS) with ten subtests.
+Results The Wilcoxon test showed significant (P < 0.001)
+reduction in hot flushes, night sweats and sleep disturbance in
+yoga group, with a trend of significant difference between groups
+at P = 0.06 on Mann–Whitney test in night sweats. There was no
+change within or between groups in the control group. The SLCT
+score and the PGIMS showed significant improvement in eight of
+ten subtests in the yoga group and six of ten subtests in the control
+group. The yoga group performed significantly better (P < 0.001)
+with higher effect sizes in SLCT and seven tests of PGIMS
+compared with the control group.
+Conclusions Integrated approach of yoga therapy can improve hot
+flushes and night sweats. It also can improve cognitive functions
+such as remote memory, mental balance, attention and
+concentration, delayed and immediate recall, verbal retention and
+recognition tests.
+Keywords Climacteric, cognitive abilities, yoga.
+Please cite this paper as: Chattha R, Nagarathna R, Padmalatha V, Nagendra H. Effect of yoga on cognitive functions in climacteric syndrome: a randomised
+control study. BJOG 2008;115:991–1000.
+Introduction
+Climacteric is a physiologic transition characterised by deple-
+tion of the ovarian follicles, decreasing estradiol and inhibin
+production, leading to an increase in follicle-stimulating hor-
+mone (FSH), loss of menstrual cycle, accompanied by men-
+opausal symptoms.1 Because the average life span of women
+in India has touched 62 years, the problems of menopause
+have attained a greater attention.2 Altered levels of neurotro-
+phic ovarian steroid (17beta-estradiol) have been recognised
+as one of the factors influencing degenerative processes that
+lead to ageing.3 Senescence is characterised neurologically by
+a decline in cognitive function.4 Cognitive decline during
+ageing is seen in memory abilities,5 focusing, attention6,7
+and information processing.8 Numerous studies indicate that
+estrogen is essential for optimal brain function. Estrogens
+have been reported to influence verbal fluency, verbal mem-
+ory tests and performance on spatial tasks and fine motor
+skills.9–12 This decline is the result of degenerative processes
+initiated by dysregulation of the hypothalamic–pituitary–
+gonadal (HPG) axis with menopause and andropause that
+leads to alterations in the concentration of all serum HPG
+hormones. Estrogen is known to enhance the activity at neu-
+ronal synapses, thus exerting its direct neuroprotective and
+neurotrophic effects on brain tissue, by maintaining the integ-
+rity of the nigral-dopamine system.13 These dopamine-
+producing neurons that are involved in cognitive functions
+start dying when estrogen levels are low.14 The protective effect
+ª 2008 Swami Vivekananda Yoga Anusandhana Samsthana Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
+991
+DOI: 10.1111/j.1471-0528.2008.01749.x
+www.blackwellpublishing.com/bjog
+Menopause
+of estrogens on neuronal cells may also be due to their ability
+to alter free radical production and/or free radical action on
+cells.15 It has been shown that estrogen deprivation is likely to
+initiate or enhance degenerative changes caused by oxidative
+stress and to reduce the brain’s ability to maintain synaptic
+connectivity and cholinergic integrity leading to the cognitive
+decline seen in aged individuals.16
+The hippocampus has long been presumed the primary site
+of action of estrogens on cognition; and explicit memory is
+considered the cognitive function most vulnerable to meno-
+pausal loss of estrogen. Keenan et al. hypothesised that the
+prefrontal cortex and its neural circuitry are prime mediators
+of estrogen’s role in cognition. The prefrontal cortex is critical
+for intact working memory, and estrogen enhances perfor-
+mance on working memory tasks.17 Neuroimaging techniques
+like positron emission tomography and magnetic resonance
+imaging proved that estrogen-induced increase in cerebral
+blood flow were particularly noticed in the hippocampus,
+para hippocampus, gyrus and temporal regions, which are
+a part of memory circuit.18 Murphy et al.19 reported that
+age-related loss of brain tissue in hippocampus and parietal
+lobes was significantly greater in women than in men. Thus,
+estrogen strongly influences mood and cognition, and the
+decline of this hormone at menopause can produce signifi-
+cant emotional and cognitive problems in women.9
+No doubt hormone replacement therapy (HRT) reverts the
+cognitive, vasomotor and psychological impairments and is
+cardio-protective, but holds a risk of cancer of endometrium
+and breast, as well as three-fold risk of venous thromboem-
+bolism.20 Due to these serious adverse effects of HRT, there
+has been a gap in the management of menopausal symptoms
+emphasising the need to develop and explore the efficacy
+of alternative therapeutic avenues that have demonstrated
+promise in alleviating menopausal symptoms since 2006.21
+Cognitive-behavioural intervention was shown to be effective
+in treating anxiety, depression, hot flushes and cardiac com-
+plaints, improving partnership relations and overall score of
+sexuality in a pilot study on 30 women with climacteric syn-
+drome.22 There are very few studies on yoga treating used for
+climacteric syndrome. There are several studies (two pilot
+studies and one three-armed study) that shows that yoga im-
+proves the menopausal symptoms,23–25 but there are no stud-
+ies on the effect of yoga on cognitive functions in climacteric.
+Yoga is an ancient Indian science and way of life that
+includes the practice of specific postures, regulated breathing
+and meditation.26 Yogasanas and pranayamas are today rec-
+ognised as techniques that can improve muscle strength,
+flexibility, blood circulation and oxygen uptake as well as
+hormone functions27 at the gross level. Meditation (intrinsic
+yoga techniques called Dharana, Dhyana and Samadhi) has
+been described as training in awareness, produces definite
+changes in perception, attention and cognition.28 It has been
+shown that processing of sensory information at the thalamic
+level is facilitated during the practice of pranayama (breathing
+exercises)29 and meditation.30 Integrated approach of yoga
+that combines physical postures, pranayama and meditation
+together with the notional correction based on philosophy of
+yoga was found to improve both cognitive (visual perception)
+and motor functions (hand steadiness)31 in college students
+following 10 days of yoga practice. This improvement was
+believed to be due to improved eye hand coordination, atten-
+tion, concentration and relaxation. With these promising
+benefits of yoga, we could hypothesise that yoga may decrease
+the cognitive dysfunction and the clinical symptoms of
+climacteric.
+Thus, the aim of the study was to assess the efficacy of the
+integrated approach of yoga therapy (IAYT) on cognitive
+functions in perimenopausal women.
+Methods
+Participants
+The sample size was calculated from an earlier study that
+compared the effect of two different drugs in menopausal
+women (as there are no studies on yoga). Using the pre-post
+mean and SD values from the vasomotor outcome variables
+from that study, an effect size of 0.52 was calculated.32 Using
+this value of effect size and the values for ‘alpha’ and power at
+0.05 and 0.8, respectively, a sample size of 108 was derived.
+Of a total of 201 women experiencing menopausal symp-
+toms screened, 120 women (married or single) who satisfied
+the inclusion criteria of (a) age between 40 and 55 years and
+(b) serum FSH level equal to or higher than 15 miu/ml on
+the sixth day of the menstrual cycle if she was menstruating
+regularly or at the time of recruitment if she had stopped
+menstruating or had irregular cycles were selected for the
+study. Women who had undergone hysterectomy with retained
+ovaries were also included. Exclusion criteria were (a) women
+who were practising yoga for a month or more, (b) women
+with no knowledge of English, (c) women with less than high
+school education, (d) women taking HRT, (e) women who
+underwent any surgery in past 3 months, (f) those with gynae-
+cological problems like endometriosis, fibroids, ovarian cysts,
+prolapsed uterus etc., (g) women with other medical disor-
+ders (like hypertension, diabetes mellitus, hypo/hyperthyr-
+oidism) and (h) those on psychiatric medication.
+Source of participants
+The study was conducted at the Yoga University, Swami
+Vivekananda Yoga Research Foundation (SVYASA) in Bangalore
+city. The subjects were recruited through advertisements and
+giving talks about the benefit of these practices in women’s
+organisations, clubs and organisations such as lioness clubs.
+They were also contacted through banners, newspaper adver-
+tisements and circulation of pamphlets apart from references
+through word of mouth. Some women were recruited through
+Chattha et al.
+992
+ª 2008 Swami Vivekananda Yoga Anusandhana Samsthana Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
+gynaecological clinics as they consulted the doctor for their
+menopausal symptoms. In all, they were recruited from 14
+different areas of Bangalore and classes were conducted at 14
+nodal centres of SVYASA in different parts of the city.
+Ethical clearance and consent
+The institutional review board and ethical committee of the
+University Swami Vivekananda Yoga Research Foundation,
+Bangalore, sanctioned formal approval. The research staff
+answered queries and the participants then made an informed
+independent decision about participating in the study.
+Design
+This was a prospective, randomised controlled trial (RCT)
+wherein 120 participants were randomly divided into two
+groups: one group practised integrated approach of yoga ther-
+apy (IAYT) and the other practised a set of physical exercises.
+The women who satisfied the inclusion criteria were regis-
+tered in different nodal centres by using pre-labelled enve-
+lopes to avoid selection bias; roll numbers were allotted and
+these numbers were randomly divided into two groups using
+a computer-generated random number table (http://www.
+randomizer.org) prepared for the specific number of partic-
+ipants available in the centre. Participants were assessed for
+the cognitive tests before and after 8 weeks of intervention.
+Both the yoga and control groups were given their respective
+set of practices for 1 hour of intervention per day, 5 days per
+week for 8 weeks, by specially trained instructors for both
+yoga and non-yogic physical exercise groups.
+Blinding
+As this is an interventional study, this could not be a double-
+blind study, but attempts were made to blind and mask wher-
+ever feasible to reduce the bias. The statistician who did the
+randomisation of the serial numbers of participants and the
+final analysis was blind to the source of the data. The answer
+sheets for the six-letter cancellation test (SLCT) and Punit
+Govil Intelligence Memory Scale (PGIMS) were coded and kept
+away for final analysis and were decoded only after complete
+analysis. The memory tests were administered by a psychologist
+(who was not involved in interacting with the participants) to
+the whole group before randomisation. Care was taken to
+arrange the timings and venue of the classes for the two groups
+suitably to avoid interaction and exchange of information and
+techniques among the participants of the two groups.
+Assessments
+Biochemical assessment
+Serum FSH was used for initial screening of the subjects to
+satisfy one of the inclusion criteria. Blood samples were
+Figure 1. Trial profile.
+Yoga in climacteric syndrome
+ª 2008 Swami Vivekananda Yoga Anusandhana Samsthana Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
+993
+collected in ‘Anand Diagnostic Laboratory’, Bangalore, on the
+sixth day of menstruation if the woman was menstruating
+regularly or at the time of recruitment itself if the woman
+had stopped menstruating or had irregular cycles. Estimation
+of FSH was carried out by electrochemiluminescence method
+using Roche Elecsys 2010 FSH kit. As per the standardisation,
+the normal range for the FSH values during follicular phase
+for regularly menstruating Indian women was 3.5–12.5 miu/
+ml. For the present study, a value of >15 miu/ml was consid-
+ered the inclusion criterion.33
+Vasomotor symptoms checklist
+A checklist of three of the major symptoms of climacteric
+(vasomotor symptoms checklist [VCL] 1, hot flushes; VCL
+2, night sweats and VCL 3, sleep disturbances), with severity
+scoring ranging from 0 to 3 (0 being absence of that symptom
+and 3 being severely suffering from that symptom), was used
+to assess the vasomotor symptoms for all participants.
+Six-letter cancellation test
+Six-letter cancellation test (SLCT) for adults is a paper-and-
+pencil test that uses a letter cancellation task that measures
+cognitive functions such as selective and focused attention,
+visual scanning as well as activation and inhibition of rapid
+responses. It consists of a test worksheet that specifies six
+target letters to be cancelled and has a ‘working section’,
+which consists of letters of the alphabet, arranged randomly
+in 22 rows and 14 columns. The participants are asked to
+cancel as many of the six target letters as possible in a specified
+time of 90 seconds.34 The total number of cancellations and
+wrong cancellations are scored, and the net scores are cal-
+culated by deducting wrong cancellations from the total at-
+tempt. This test has been evaluated for its reliability and
+validity based on standard criteria. Reliability has been ascer-
+tained based on (a) temporal stability and (b) internal con-
+sistency.35 The content validity of this test is adequate for the
+purpose for which it is intended.36 The normal value for
+healthy Indian adults for SLCT is 38 ± 6.34
+Tests of memory
+PGIMS is a battery of ten memory tests, which measures the
+remote memory, recent memory, mental balance, two tests for
+attention and concentration (for digit memory and reverse
+digit memory), delayed recall, immediate recall, retention
+for similar pairs, retention for dissimilar pairs, visual retention
+and recognition test. The participant is supposed to write the
+responses to the questions asked by the administrator. Of the
+ten tests, eight tests are verbal, one test pertains to geometrical
+drawing and one on recognising objects. The reliability of this
+scale has been tested, and the norms for adults (>20 years)
+with no psychiatric/neurological illnesses are available. PGIMS
+is incorporated as one of the important tests to evaluate cog-
+nitive functions and organic brain dysfunctions. Administra-
+tion takes 15–20 minutes per participant. The test retest
+reliability on 40 subjects ranged between 0.70 and 0.84 for
+organic psychotic groups, 0.48 and 0.84 for neurotic group.
+On the whole, however, an increase of four points was
+observed on repeated testing. For these two groups, split-half
+reliability was found to be 0.91 and 0.83, respectively.37
+Yoga intervention
+The yoga module used for the experimental intervention called
+integrated approach of yoga therapy (IAYT) for perimeno-
+pausal women was developed specifically for the purpose culled
+out from original scriptures (Patanjali yoga sutras and Mandu-
+kya karika) that highlight the concepts of a holistic approach to
+health management at physical, mental, emotional and intel-
+lectual levels with techniques to improve mental equilibrium
+and cognitive abilities. All these practices are aimed at one
+common effect, i.e. ‘to develop mastery over modifications of
+the mind’ (chitta vritti nirodhah—Sage Patanjali) through
+‘slowing down the rate of flow of thoughts in the mind’
+(manah prashamana upayah yogah—Sage Vasishta).
+1 Sun salutation that includes a flow of 12 postures combined
+with breathing and chanting.38
+2 Yogic breathing practices combined with simple body
+movements aimed to bring about a slow rhythmic breath-
+ing pattern that is the safest way to get mastery over the
+mind.39 The principles involved in the technique of breath-
+ing were (a) slow down the rate of breathing while synchro-
+nising the body movements with breathing, (b) ensure that
+exhalation was longer than inhalation and (c) practice with
+full awareness of the touch of the flow of air through the
+nostril down the air passages.
+3 Cyclic meditation (CM): Meditation is considered to be
+a part of yoga that works directly at the mind level (Antar-
+anga yoga), which is a valuable tool to reach a state of alertful
+rest (calming down or silencing the internal dialogue). CM
+is a 35-minute practice that includes a combination of acti-
+vating and pacifying practices to reach deeper quietitude and
+equilibrium than meditating in a single posture.40
+4 The study group got lectures on physiology of menopause,
+healthy lifestyle including diet, exercise and yogic stress
+management techniques. Also, they were given yogic con-
+cepts to achieve a notional correction to help the partici-
+pant (a) recognise her ability to tap the inner energy, which
+is made of immense bliss that could keep up her youthful
+feeling and allay the fears, (b) to restore her inbuilt freedom
+to change the responses to situations and (c) learn to touch
+the bed of silence, which is the source of all creativity that is
+essential for promotion of any cognitive function.41
+Control intervention
+The control group practised a set of exercise programme
+comprising easy (nonsweating) body movements supervised
+by physical trainers for the same duration of 1 hour daily, 5
+Chattha et al.
+994
+ª 2008 Swami Vivekananda Yoga Anusandhana Samsthana Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
+days a week for 8 weeks. The exercise involved the stretching
+of the arms, legs and spinal twists, strengthening the muscles
+around knee joints, shoulder joints, neck and wrist joints.
+Lectures and individual counselling was given on conven-
+tional modern medical concepts about healthy lifestyle
+including diet, exercise and physiology of menopause and
+stress management techniques. Details are given in Table 1.
+Data extraction
+Data of 108 (leaving the 12 dropouts of 120) participants were
+scored as per the instructions in the manual by a psychologist
+and were analysed by the statistician using SPSS version
+10.0 (SPSS Inc., Chicago, IL, USA). The test of normality
+was carried out using Kolmogorov–Smirnov test as the sam-
+ple size was above 50. Because the data were not normally
+distributed, nonparametric tests were used: Mann–Whitney
+test for between group comparison and Wilcoxon signed-
+ranks test for within group comparison. The baseline values
+for all the variables in both the groups were compared using
+Mann–Whitney test. Effect sizes were calculated to measure
+the magnitude of difference of parameters between the two
+groups.42 Correlations were checked by Spearman’s correla-
+tion coefficient, as the data were non-normal. For the design
+of this study (one within-subjects and one between-subjects
+factor), there were no ancillary analyses.
+Results
+The flowchart describes the trial profile (Figure 1). Of the 120
+participants, there were 12 dropouts, 5 in the yoga and 7 in
+the control group due to (a) husband’s ill health, (b) transfer
+to other cities and (c) unexpected events in the family.
+Table 2 shows demographic data. At baseline, the data
+were not significantly different between the two groups for
+FSH and body mass index (P = 0.11 and 0.07, respectively,
+Mann–Whitney test), for SLCT (P = 0.528) and all subtests
+of PGIMS (P value for test I, 0.39; II, 0.49; III, 0.24; IV (i),
+0.43; IV (ii), 0.01; V, 0.625; VI, 0.59; VII, 0.72; VIII, 0.98; IX,
+0.92 and X, 0.06).
+Table 3 shows the results of VCL. The scores on all three
+symptoms in VCL reduced significantly in yoga group with
+a nonsignificant change in control group (except night
+sweats). Mann–Whitney test showed a trend of significant
+(P = 0.06) difference between groups in night sweats only.
+Table 4 shows the results of the SLCT and PGIMS. The
+values of SLCT improved in both groups. Mann–Whitney test
+showed significantly greater improvement (P < 0.001) in yoga
+group (effect size 1.16) than the control group (effect size 0.6).
+The results for the different cognitive functions of the
+PGIMS tests are as follows:
+• PGIMS-I (remote memory): Both groups showed signifi-
+cant increase (P = 0.001, Wilcoxon test). There was greater
+improvement (P < 0.001, Mann–Whitney test) in the yoga
+(effect size 0.84) than in the control group (effect size 0.58).
+• PGIMS-II (recent memory): There was no change observed
+in this test because the effect sizes were very low (0.01,
+Mann–Whitney test) in both groups.
+• PGIMS-III (mental balance): Yoga group showed significant
+increase (P < 0.001, Wilcoxon test), whereas the control
+group showed no change (P = 0.39). There was greater im-
+provement (P < 0.001, Mann–Whitney test) in the yoga
+group (effect size 1.66) than in the control group (effect size
+0.17).
+• PGIMS-IV (i) (attention and concentration): Both groups
+showed significant increase with greater improvement (P <
+0.001, Mann–Whitney test) in the yoga (effect size 0.74)
+than in the control group (effect size 0.34).
+• PGIMS-IV (ii) (attention and concentration): Both groups
+showed significant increase (P = 0.001, Wilcoxon test).
+There was significant difference between (P < 0.001, Mann–
+Whitney test) yoga (effect size 0.61) and control groups
+(effect size 0.63).
+Table 1. Practices used for the two intervention groups
+Experimental group
+Control group
+1
+Lectures on IAYT, diet, emotion culture,
+concepts and management of stress
+according to yogic practices (15 minutes)
+Lectures on importance of exercise, role of diet in
+menopause, stress, stress physiology (15 minutes)
+2
+Breathing exercises: (10 minutes)
+Loosening practices: (10 minutes)
+Hasta 

+ay

+ama s
+´vasanam (hands in and out breathing)
+Twisting
+Hasta vist

+ara s
+´vasanam (hands stretch breathing)
+Forward and backward bending
+Gulpha vist

+ara s
+´vasanam (ankle stretch breathing)
+Side bending
+Vy

+aghra s
+´vasanam (tiger breathing)
+Spinal twist
+Setu bandha s
+´vasanam (bridge posture breathing)
+Toe walking
+3
+Suryanamaskara (sun salutation) (10 minutes)
+Brisk walk (10 minutes)
+4
+Avartan dhyanam (CM) (25 minutes)
+Supine rest (25 minutes)
+Yoga in climacteric syndrome
+ª 2008 Swami Vivekananda Yoga Anusandhana Samsthana Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
+995
+• PGIMS-V (delayed recall): The yoga group showed signifi-
+cant increase (P < 0.001, Wilcoxon test), whereas the control
+group showed no improvement (P = 0.36). There was greater
+improvement (P < 0.001, Mann–Whitney test) in the yoga
+(effect size 1.47) than in the control group (effect size 0.18).
+• PGIMS-VI (immediate recall): The yoga group showed sig-
+nificant increase (P < 0.001, Wilcoxon test), but the control
+group showed significant change (P = 0.015). There was
+greater improvement (P < 0.001, Mann–Whitney test) in
+the yoga (effect size 1.51) than in the control group (effect
+size 0.42).
+• PGIMS-VII (verbal retention of similar pairs): There was no
+change in both the groups (P = 0.18 in yoga group, P = 0.25
+in control group in Wilcoxon test). There was no difference
+between the groups (P = 0.56, Mann–Whitney test).
+• PGIMS-VIII (verbal retention of dissimilar pairs): Both
+groups showed significant increase (P < 0.001 in yoga group,
+P = 0.009 in control group in Wilcoxon test). The magnitude
+of change within group was more in the control group (effect
+size 1.23) than that in the yoga group (effect size 0.90).
+• PGIMS-IX
+(visual
+retention):
+There
+was
+significant
+increase in the yoga group (P < 0.001, Wilcoxon test),
+whereas no change in the control group (P = 0.39). There
+was greater improvement (P = 0.01, Mann–Whitney test)
+in the yoga (effect size 0.70) than in the control group
+(effect size 0.14).
+• PGIMS-X (recognition): Both groups showed significant
+increase (P = 0.001, Wilcoxon test). There was greater
+improvement (P = 0.001, Mann–Whitney test) in the yoga
+(effect size 0.58) than in the control group (effect size 0.28).
+Table 2. Demographic data
+Serial number
+Variables
+Yoga
+Control
+1
+Age (mean 
 SD)
+49 
 3.6
+48 
 4
+Number between 40–45 (years)
+13
+14
+Number between 46–50 (years)
+22
+23
+Number between 51–55 (years)
+19
+17
+2
+W/H
+14/40
+9/45
+3
+Body mass index (mean 
 SD)
+28 
 3.4
+29 
 4
+4
+V/NV
+43/11
+45/9
+n
+FSH (mean 
 SD) miu/ml
+n
+FSH (mean 
 SD) miu/ml
+5
+A: premenopausal
+14
+43.88 
 21.64
+16
+37.94 
 17.52
+B: irregular menstruation
+17
+47.16 
 23.45
+20
+38.72 
 14.94
+C: menopausal
+9
+83.65 
 43.59
+7
+56.9 
 20.77
+D: postmenopausal
+14
+59.5 
 18.67
+11
+66.81 
 21.14
+6
+FSH (miu/ml) mean 
 SD
+56 
 29.9
+47 
 21.5
+V/NV, vegetarian/non-vegetarian; W/H, working/housewives.A, women having regular menstruation; B, irregular menstrual cycles, C, menopause
+attained between 1 year and 3 years ago; D, menopause attained more than 3 years ago. There is no significant difference between groups in
+all the variables at baseline.
+Table 3. Results of vasomotor symptom checklist (VCL)
+Variables
+Y
+C
+Y
+C
+Y
+C
+Significant
+Y and C P**
+Effect size
+Y and C
+Pre mean
+
 SD
+Post mean
+
 SD
+Pre mean
+
 SD
+Post mean
+
 SD
+Significant P*
+Effect size
+pre-post
+VCL 1
+1.02 
 1.02
+0.50 
 0.77
+0.78 
 0.84
+0.70 
 0.74
+,0.001
+0.39
+0.65
+0.10
+0.08
+0.26
+VCL 2
+0.83 
 1.06
+0.43 
 0.69
+0.85 
 0.90
+0.65 
 0.73
+,0.001
+0.04
+0.62
+0.27
+0.06
+0.31
+VCL 3
+0.74 
 0.99
+0.44 
 0.72
+0.85 
 0.98
+0.74 
 0.91
+001
+0.18
+0.49
+0.14
+0.08
+0.36
+C, control group; VCL 1, hot flushes; VCL 2, night sweats; VCL 3, disturbed sleep; Y, yoga group.Mean 
 SD and P values for within and between
+groups and effect sizes are calculated for vasomotor symptoms before and after 8 weeks of intervention. VCL: There is significant improvement
+in yoga group and nonsignificant improvement in control group except night sweats.
+*Wilcoxon P value.
+**Mann–Whitney P value.
+Chattha et al.
+996
+ª 2008 Swami Vivekananda Yoga Anusandhana Samsthana Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
+Discussion
+Cognitive functions and vasomotor symptoms were assessed
+in this randomised control prospective two-arm interven-
+tional study on 108 perimenopausal women (age 40–55
+years). Mann–Whitney test to compare the two groups
+showed that there was significantly better improvement in
+the yoga group compared with the control group in hot
+flushes and attention task in SLCT. In PGIMS, there was
+significant improvement within both groups with significant
+difference between groups, the effect sizes being better in the
+yoga group than in the control group in PGIMS-I (remote
+memory), III (mental balance), IV (i and ii) (attention and
+concentration [i and ii]), VI (immediate recall) and X tests
+(recognition test). There was significant improvement only
+in yoga group and not in control group with significant dif-
+ference between groups in PGIMS-V (delayed recall) and
+PGIMS-IX (visual retention). In PGIMS-VIII (verbal retention-
+ii), both groups improved with higher effect size in control
+group and significant difference between groups. The PGIMS-
+II (recent memory) and PGIMS-VII (verbal retention-i) tests
+showed no change in both the groups.
+Comparison with other studies
+The preferred option for complementary and alternative
+medicine (CAM) by women43 has triggered interest into
+research on these therapies. Of the four studies (two on
+cognitive behavioural therapy (CBT) and two on relaxation
+response), only one was a well-designed RCT on 33 women
+taking relaxation response training compared with a reading
+group, demonstrated a significant reduction in hot flush
+intensity, tension-anxiety and depression in perimenopausal
+women after 10 weeks of intervention.44 Our recent rando-
+mised control study in the Indian population has shown the
+Table 4. Results of SLCT and PGIMS
+Variable
+Groups
+Pre
+mean 
 SD
+Post
+mean 
 SD
+Within
+group, P*
+Effect size
+pre-post
+Between
+Y and C, P**
+Effect size
+Y and C
+Normative
+data
+SLCT
+Y
+27.43 
 6.91
+35.31 
 6.72
+,0.001
+1.16
+,0.001
+0.8
+30 
 6
+C
+26.48 
 6.37
+30.19 
 6.63
+,0.001
+0.6
+PGIMS-I
+Y
+5.43 
 0.66
+5.87 
 0.34
+,0.001
+0.84
+,0.001
+1.55
+5.78 
 0.52
+C
+5.52 
 0.67
+5.17 
 0.54
+0.001
+0.58
+PGIMS-II
+Y
+4.94 
 0.23
+4.94 
 0.23
+0.83
+0.00
+0.080
+0.01
+4.91 
 0.29
+C
+5 
 0.51
+4.93 
 1.15
+0.439
+0.08
+PGIMS-III
+Y
+4.93 
 1.15
+6.52 
 0.72
+,0.001
+1.66
+,0.001
+1.36
+5.69 
 2.64
+C
+5.19 
 0.93
+5.33 
 0.7
+0.394
+0.17
+PGIMS-IV (i)
+Y
+5.39 
 1.04
+6.2 
 1.14
+,0.001
+0.74
+,0.001
+0.94
+8.46 
 1.91***
+C
+5.24 
 1.11
+4.83 
 1.3
+0.014
+0.34
+PGIMS-IV (ii)
+Y
+3.57 
 1.09
+4.19 
 0.95
+,0.001
+0.61
+,0.001
+0.58
+C
+4.17 
 1.15
+3.56 
 0.74
+0.001
+0.63
+PGIMS-V
+Y
+8.11 
 0.88
+9.33 
 0.78
+,0.001
+1.47
+,0.001
+1.20
+6.99 
 1.53
+C
+8.02 
 0.9
+8.17 
 0.8
+0.363
+0.18
+PGIMS-VI
+Y
+9.26 
 1.51
+11.13 
 0.89
+,0.001
+1.51
+,0.001
+0.93
+7.41 
 1.98
+C
+9.41 
 1.5
+9.98 
 1.21
+0.015
+0.42
+PGIMS-VII
+Y
+4.93 
 0.26
+4.98 
 0.14
+0.18
+0.24
+0.56
+0.10
+4.36 
 0.78
+C
+4.91 
 0.29
+4.96 
 0.19
+0.257
+0.20
+PGIMS-VIII
+Y
+11.48 
 2.67
+13.46 
 1.59
+,0.001
+0.90
+,0.001
+0.73
+11 
 3.59
+C
+9.28 
 2
+11.85 
 2.18
+0.009
+1.23
+PGIMS-IX
+Y
+10.85 
 2.46
+12.35 
 1.76
+,0.001
+0.70
+0.01
+0.26
+8.2 
 3.28
+C
+11.43 
 2.46
+11.76 
 2.1
+0.39
+0.14
+PGIMS-X
+Y
+8.13 
 2.37
+9.37 
 1.89
+,0.001
+0.58
+0.001
+0.37
+8.36 
 1.61
+C
+7.57 
 1.53
+8.59 
 1.4
+,0.001
+0.28
+C, control group; Y, yoga group.Mean 
 SD and P values are calculated for PGIMS (ten subtests) using Wilcoxon P value and Mann–Whitney
+P value. Variables: PGMIS-I, remote memory; PGIMS-II, recent memory; PGIMS-III, mental balance; PGIMS-IV (i), attention and concentration (i);
+PGIMS-IV (ii), attention and concentration (ii); PGIMS-V, delayed recall; PGIMS-VI, immediate recall; PGIMS-VII, verbal retention (i); PGIMS-VIII,
+verbal retention (ii); PGIMS-IX, visual retention; PGIMS-X, recognition test. There was greater improvement in the yoga group than the control
+group in SLCT: improvement in yoga is better than control group and in all subtests of memory except II and VII and the control showed better
+effect size than yoga group in VIII test.
+*Wilcoxon P value.
+**Mann–Whitney P value.
+***This score is given in the PGIMS manual combining both attention and concentration (i) and (ii).37
+Yoga in climacteric syndrome
+ª 2008 Swami Vivekananda Yoga Anusandhana Samsthana Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
+997
+reduction in vasomotor and other menopausal symptoms 8
+weeks after the supervised practice of the integrated approach
+of yoga therapy as measured by Greene climacteric scale (GCS)
+with a significant difference between groups with higher effect
+sizes in the yoga group than the control group in all factors of
+GCS.45
+There are no studies on changes in cognitive functions with
+nonpharmacological therapies. In comparison, the present
+study on IAYT that combined both body and mind level
+practices of self-management (lifestyle change) has shown
+significant improvement in both frontal lobe and memory
+functions for the first time through a nonpharmacological
+intervention. A study on the interaction of HRT and physical
+activity (PA) showed a beneficial relationship between PA and
+cognitive performance in postmenopausal women irrespective
+of HRT use.46 These studies tend to point out that the self-
+corrective techniques that the person puts in by applying her
+mind, be it a PA or IAYT, influences the cognitive functions.
+Mechanism
+SLCT measures the attention capacity, a frontal lobe function.
+A self-control study on the effect of CM (that has been incor-
+porated in the IAYT for the experimental group in the present
+study) has shown significant increase in SLCT scores imme-
+diately after CM, suggesting enhanced efficiency and shorter
+time in cortical neural processing.47
+Electrophysiological studies during cognitive functions of
+the brain have reported that P300 (a specific positive wave
+that occurs at the 300th millisecond in the tracing of evoked
+potential) is generated from hippocampus and other associ-
+ated areas.48 Estrogen receptors have been detected in the
+pyramidal cells nuclei of the ventral hippocampus and other
+specific brain areas that are involved in learning, memory and
+cognition. Cyclic changes in synaptic genesis and spine den-
+sity of the hippocampus have been shown to be induced by
+estrogen,18 which gets depleted in this age; hence, memory
+functions may undergo a declining change. However, con-
+trary to our expectation, estrogen replacement therapy
+(ERT) per se may not improve the cognitive functions.46 A
+study on the effect of CM observed that there was reduction in
+the peak latencies of P300 after CM compared with the prev-
+alues that suggest enhanced efficiency and shorter time in
+processing. Also, the P300 peak amplitudes after CM were
+higher compared with the prevalues, suggesting an increased
+in attentional resources.49 Thus, it may be hypothesised that
+the improvement in the cognitive functions observed in this
+study is due to the effect of yoga in bringing about better
+information processing in the subtle layers of the frontal lobe.
+This in turn could be due to the alertful rest that CM may
+offer and may not be related to estrogen-mediated response.
+CM developed on a subtle principle suggested by a rarely used
+authentic scripture (Mandukya karika) that includes stimula-
+tion–relaxation combination for achieving deeper degree of
+rest. This principle is made practical by knitting yoga postures
+interspersed with periods of supine relaxation and has been
+shown to provide deeper degree of rest than simple supine
+rest or the commonly used meditative techniques.50
+Novelty, limitations and suggestions for
+future work
+This is the first RCT that has looked at cognitive functions
+after yoga practice in climacteric. An objective measure, serum
+FSH level, was used as the inclusion criterion rather than only
+the subjective symptoms of menopausal rating scale. Control
+group also had the supervised practices for the same duration
+as the experimental group.
+One limitation of the study with regard to external validity
+was that because the tests were in English, the sample was
+restricted to women with knowledge of the English language.
+Thus, our sample should be taken to be fairly representative of
+women in urban India.
+Other limitations were that the estradiol levels were not
+measured. Although we have used FSH levels as the only objec-
+tive inclusion criterion,51 it will be interesting to see the effect of
+long-term practice of IAYT on FSH and estradiol levels.
+Suggestions for future work
+Functional studies to look at the changes in neurohormonal
+changes in the brain during IAYT in climacteric would throw
+light on the mechanism.
+Conclusions
+Thus, the present study has shown that the practice of IAYT
+for 8 weeks improves the cognitive functions like attention,
+concentration, mental balance, verbal retention and recogni-
+tion abilities in menopausal women compared with physical
+exercises.
+The control group practices that comprised of physical
+exercises also showed improvement in many of the memory
+functions similar to earlier studies on the efficacy of PA in
+perimenopausal women.46 Thus, the present study shows the
+superiority of yoga over PA in improving the cognitive func-
+tions that could be attributed to emphasis on correctness in
+breathing, synchronising breathing with body movements,
+relaxation and mindful rest.
+Funding
+This study was funded by the parent institution: Swami
+Vivekananda Yoga Research Foundation, Bangalore, India.
+Contribution to authorship
+R.C.: Involved in designing, conducting and writing the man-
+uscript. R.N.: Regular supervision of the study in all phases
+Chattha et al.
+998
+ª 2008 Swami Vivekananda Yoga Anusandhana Samsthana Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
+including the manuscript writing. V.P.: Gynaecologist who
+assessed the clients for recruitment, contributed in all phases
+of the study by regular supervision and guidance. Inputs for
+the manuscript writing. H.R.N.: Guidance and advice on the
+yoga component of the design, training the therapists and
+writing the manuscript.
+Details of ethics approval
+Formal approval was sanctioned in their letter SVYASA/
+PHD/ETHICS/04-3011 dated 30 November 2004 by the insti-
+tutional review board and ethical committee of the University
+Swami Vivekananda Yoga Research Foundation, Bangalore.
+Acknowledgements
+We extend our gratitude to Dr Ravi Kulkarni, Biostatistician,
+for helping in the statistical analysis of this study. We are
+thankful to all the yoga teachers and physical trainers who
+took the classes for this project. We are grateful to the Anand
+Diagnostic Laboratory. We are thankful to the subjects for
+their cooperation during the study. j
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subfolder_0/Effect of yoga program on executive functions of adolescents dwelling in an orphan home_ A randomized controlled study.txt

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+Original article
+Effect of yoga program on executive functions of adolescents dwelling
+in an orphan home: A randomized controlled study
+Satya Prakash Purohit*, Balaram Pradhan a
+Division of Yoga and Humanities, SVYASA Yoga University, #19, Eknath Bhavan, Gavipuram Circle, 560 019, Bengaluru, India
+a r t i c l e i n f o
+Article history:
+Received 21 August 2015
+Received in revised form
+15 February 2016
+Accepted 21 March 2016
+Available online 20 April 2016
+Keywords:
+Yoga
+Orphans
+Adolescents
+Cognitive function
+Executive function
+a b s t r a c t
+Executive function (EF) is important for physical and mental health of children. Studies have shown that
+children with poverty and early life stress have reduced EF. The aim of the study was to evaluate the
+effect of Yoga program on the EF of orphan adolescents. Seventy two apparently healthy orphan ado-
+lescents
+randomized
+and
+allocated
+into
+two
+groups
+as
+Yoga
+group
+(n
+¼
+40;
+14
+girls,
+age ¼ 12.69 ± 1.35 yrs) and Wait List Control (WLC) group (n ¼ 32, 13 girls, age ¼ 12.58 ± 1.52 yrs). Yoga
+group underwent three months of Yoga program in a schedule of 90 min per day, four days per week
+whereas the WLC group followed the routine activities. They were assessed by Stroop Color-Word Task,
+Digit Symbol Substitution Test (DSST), Digits Span Test and Trial Making Test (TMT) at the beginning and
+end of the program.
+The repeated measures ANOVA showed significant difference in time and group interactions (p < 0.05)
+for all subtests of Stroop Color-Word Task and Digit Span Test and part-A of TMT whereas there were no
+significant difference found in DSST and TMT (part-B).
+The post-hoc test with Bonferroni adjustment also showed significant improvements (p < 0.001)
+within the Yoga group in all test scores while in wrong score of DSST did not exhibit significant reduction.
+Whereas the WLC group, showed significant improvement (p < 0.05) in Stroop Color, Color-Word score,
+net score of DSST, Digit Span forward and Digit Span Total.
+Three months Yoga program was found useful for the young orphan adolescents in improving their
+executive functions.
+Copyright © 2016, Center for Food and Biomolecules, National Taiwan University. Production and hosting
+by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
+creativecommons.org/licenses/by-nc-nd/4.0/).
+1. Introduction
+Globally two hundred million children failed to reach their po-
+tential in cognitive development because of interrelated factors like
+poverty, inadequate care and poor health.1 Orphans are among such
+disadvantaged children living in the community with poverty, se-
+vere grief and easily subjected to abuse, negligence and exploita-
+tion.2 Prevalence of orphans was 143 million worldwide,3 72
+million in South and East Asia,4 and 20 million in India.5
+Adverse childhood events have a negative effect on latter life
+cognitive performance.6 Socio-economic conditions of one's early
+life or childhood are positively correlated with intelligence, aca-
+demic achievement and other developmental outcomes in later
+life.7,8 Previous studies with older Post Institutionalization (PI)
+children have shown reduced performance on cognitive flexibility,9
+working memory performance,9e11 and inhibitory control.11e13 It is
+also reported that PI children have attention deficits and hyperac-
+tivity symptoms, which persist into adolescence.14,15
+The higher order of cognitive processes, such as cognitive flex-
+ibility, working memory, and inhibition control which allow in-
+dividuals to engage in planning, to be conscious and goal-directed
+problem solving are called Executive Function (EF).16,17 In children,
+EF is related to emotion regulation,18 conscience and moral devel-
+opment,19 also math and literacy ability.20 EF is very important
+factor for physical and mental health,21 making friendship,22 and
+for success in school.23,24 Furthermore EF predicts school readi-
+ness,20 later academic performance.25 Developments in such
+cognitive functions are important in early life because deficiency in
+these functions caused at childhood predict similar problems in the
+* Corresponding author. Tel.: þ91 080 2263 9961, þ91 7676745174 (mobile).
+E-mail addresses: [email protected] (S.P. Purohit), balaramp13@gmail.
+com (B. Pradhan).
+Peer review under responsibility of The Center for Food and Biomolecules,
+National Taiwan University.
+a Tel.: þ91 080 2263 9961, þ91 9483711185(mobile).
+Contents lists available at ScienceDirect
+Journal of Traditional and Complementary Medicine
+journal homepage: http://www.elsevier.com/locate/jtcme
+http://dx.doi.org/10.1016/j.jtcme.2016.03.001
+2225-4110/Copyright © 2016, Center for Food and Biomolecules, National Taiwan University. Production and hosting by Elsevier Taiwan LLC. This is an open access article
+under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
+Journal of Traditional and Complementary Medicine 7 (2017) 99e105
+later years.21,26 It is believed that the higher order cognitive func-
+tions may play an important role in balancing emotional arousal,
+cognitive
+processing,27
+and reducing the impact of adverse
+circumstances.28
+Various activities are suggested to improve children's EF. The
+best evidences exist are computer based training programs for
+enhancing memory and reasoning,29,30 task-switching computer-
+based training,31 traditional martial arts,32 aerobics,33 and Yoga.34
+Yoga is an ancient Indian science and the way of life which in-
+cludes practice of specific postures, breathing regulation, and
+meditation.35 Earlier studies on Yoga including physical postures,
+Yogic breathing, meditation and guided relaxation technique have
+been shown its efficacy in improving delayed recall of spatial in-
+formation and verbal memory,36 in reducing planning and execu-
+tion time,34 and cognitive processes37 in adults. It is also proved
+that there was an improvement in cognitive performance of 7e9
+year-old school children from a socioeconomically disadvantaged
+background in South India after three months of Yoga.38 Yogic life
+style has also a positive impact in planning ability.39 There is also
+evidence of the positive impact of Yoga on cognitive functions in
+children with attention deficit and hyperactive disorder.40e43 In
+addition, Yoga is an effective method to improve various cognitive
+functions of remote memory, mental balance, attention, concen-
+tration, attention span, processing speed, attention alternation
+ability, delayed and immediate recall, executive functions, verbal
+retention, and recognition tests in healthy young subjects.44,45
+However, recent reviews stated that most of the Yoga studies on
+children were open, unblinded, small sample sizes, short in-
+terventions. Also many of the randomized studies have not
+mentioned the process of randomization or have used inappro-
+priate statistical analysis.46,47 Thus, understanding the effect of
+Yoga on cognitive functions of orphans may be necessary in
+providing avenues for promoting the mental strength to overcome
+various tragedies in their upcoming life. In sum, the present study
+was intended to evaluate the effect of Yoga on cognitive perfor-
+mances of young orphan adolescents.
+2. Material and methods
+2.1. Participants
+Out of 135 registrants, 80 were chosen for the study based on
+the inclusion and exclusion criteria. Children were eligible for in-
+clusion by following criteria: a) orphan(s) of any type, b) aged be-
+tween 11 and 16 years, c) boys and girls, d) apparently healthy
+without any chronic illness, physical, or mentally handicap. The
+study was conducted between September 2014 and November
+2014 in an orphanage, within a suburban area of Bangalore.
+2.2. Ethical clearance
+The study was approved (RES/IEC-SVYASA/32/204) by the
+Institutional Ethics Committee of SVYASA (Swami Vivekananda
+Yoga Anusandhana Samsthana) University. Both signed informed
+consent from the institution head and signed informed assent from
+all participants were obtained, upon explaining the study details.
+2.3. Design
+It was a randomized wait-list controlled pre-post study. After
+the initial process of screening, participants were randomized by a
+statistician using a random number table from www.randomizer.
+org and assigned into two groups: Yoga group and Wait List Con-
+trol (WLC) group. The Yoga group underwent the Yoga program for
+3-months whereas the WLC group underwent routine activity.
+2.4. Blinding
+The statistician (who did the randomization and analyzed the
+data) and the researchers (who carried out the allocation & as-
+sessments) were blinded.
+2.5. Intervention
+The Yoga group received a combined approach of Yoga activities
+of 90 min, 4 days per week, for 3-months. Later the same inter-
+vention was served to WLC for the same duration. The Yoga pro-
+gram was conducted by two certified Yoga teachers from SVYASA
+(one with a master's degree in Yoga and other with a post-
+graduation diploma in Yoga therapy). The principle and concept
+of an integrated approach of the Yoga program was based on the
+research works of SVYASA.48 The details of the intervention (Yoga
+program) are given in Table 1.
+2.6. Assessments
+The socio-demographic data was collected from the office of the
+orphan home as it was collected as a routine documentation by
+them. The final demographic data after post assessment in Yoga
+group was taken on 40 participants where the males were 14(35%),
+female were 26(65%), whereas in WLC male were 13 (40.6%), female
+were 19 (59.4%) out of 32 participants. The cognitive functions tests
+(Table 2) were collected by the research staffs of SVYASA during the
+prior and following weeks adjacent to the intervention period for
+all recruited participants. The investigators were available to clear
+all possible doubts and provide unbiased guidance during the
+assessment. There were four executive function tests, included in
+the study, as detailed below.
+2.6.1. Stroop color and word test49
+The children's version Stroop test measures the EF, which
+involves in both word and color naming responses. The test was
+in the form of a booklet containing three pages of word and
+color conditions. The first page tests how fast the participant can
+read words; name the colors in the second page; name which
+color the words were printed in, ignoring the name of the word
+in the third page. The test extracts three basic scores, namely
+Stroop Word (STROOP_W) score, Stroop Color (STROOP_C) score
+and
+Stroop Color-Word (STROOP_CW) score.
+The task was
+administered individually and test instructions were explained
+before starting the test. Errors of the participants were indicated
+and asked to be corrected by the examiner before continuing.
+The participants were given 45 s for each page and the
+time taken to complete the task was recorded by using a stop
+watch.
+2.6.2. Trial making test (TMT)50
+This test was used to access the visual search, scanning, pro-
+cessing speed, mental flexibility, and EF. It has two parts, part-A
+(TMT_A) and part-B (TMT_B). In TMT_A, participants have to
+draw lines sequentially connecting 25 encircled numbers distrib-
+uted on a sheet of paper; And in TMT_B the task is similar except
+the participant must alternate the sequence between numbers and
+letters (e.g.1, A, 2, B, 3, C, etc.). The score on each part represents the
+amount of time required to complete the task. Participants were
+administered part A and B of the TMT and Total time in seconds for
+both part A and B was recorded.
+2.6.3. Wechsler intelligence scale for children51
+It was used in order to assess working memory and mental
+tracking processes. Both forward and backward spans were
+S.P. Purohit, B. Pradhan / Journal of Traditional and Complementary Medicine 7 (2017) 99e105
+100
+calculated. For Digits Span Forward (DS_F), the participant was
+supposed to repeat digits of the strings exactly as read by the
+examiner. Two trials were administered of each string length. In
+Digits Span Backward (DS_B), the procedures are identical to DS_F
+except that the participant was required to repeat the string of
+digits in a reverse order. Scoring for each correctly reproduce digit
+span was scored as “one” and otherwise as “zero”. The total score
+(DS_T) was calculated in addition of the DS_F and DS_B scores.
+2.6.4. Digit Symbol Substitution Test (DSST)51
+DSST was used in order to access various cognitive components
+as scanning, matching, switching, and writing operations which are
+reflective of several higher cognitive functions such as perception,
+encoding and retrieval processes, transformation of information
+stored in active memory and decision making.52 It has a worksheet
+with a specified row of six different symbols matched with six
+different digits with pairs, which were to be canceled and had a
+working section consisting of different pairs arrange randomly in
+22 rows and 14 columns. Participants were asked to cancel the
+correct pairs as much as possible in 90 s with any possible strategy.
+The total number of canceled pairs in the test (DSST_T), wrong
+targets (DSST_W) and net scores (DSST_N) (total attempted-
+wrongly attempted) was calculated for the analysis.
+2.7. Data analysis
+Data were analyzed using the Statistical Package for Social Sci-
+ence (Version 18.0). Gender categorical variables were analyzed
+Table 1
+List of practices in the yoga program.
+Order no.
+Intervention components
+No. of rounds
+Approx. time
+(Total 90 min)
+Schedule
+1
+Yogic prayer, Session on basic concepts of yoga and
+instructions for the class
+10 min
+4 days/week (Wednesday, Thursday,
+Saturday and Sunday)
+2
+Preparatory practices:
+a) Warm up: jogging, jumping, hopping, forward &
+backward bending, side bending, twisting
+b) Loosening: for toes, ankle, knee, hips, fingers,
+wrist, elbow and neck
+c) Stretching with breathing exercises: hands in and out,
+hands stretch, ankle stretch, hip stretch, backstretch, tiger
+stretch (spinal ups- down), supine straight leg raising, cycling,
+lumber stretch, rocking and rolling
+One each
+10 min
+4 days/week (Wednesday, Thursday,
+Saturday and Sunday)
+3
+Sun salutation (Suryanamaskar)
+10e12
+10 min
+4 days/week (Wednesday, Thursday,
+Saturday and Sunday)
+4
+Asana (Postures):
+A. Standing postures
+a) Half waist rotation posture (Ardhakati Chakrasana)
+b) Foot palm posture (Padahastasan)
+c) Half wheel posture (Ardha chakrasana)
+d) Triangle posture (Trikonasana)
+e) Tree posture (Vrikshana)
+f) Eagle posture (Gasudasana)
+B. Sitting postures
+a) Diamond (Vajrasana)
+b) Rabbit posture (Shasahankasana)
+c) Sleeping diamond posture (Suptavajrasana)
+d) Camel posture (Ustrasana)
+e) Posterior stretch (Paschimotasana)
+f) Spinal twist posture (Ardhamatsyendrasana)
+g) Cow face posture (Gomukhasana)
+C. Prone posture:
+a) Cobra posture (Bhujangasana)
+b) Grasshopper posture (Salabhasana)
+c) Bow posture (Dhanurasana)
+d) Shoulder stand (Sarvangasana)
+e) Plow posture (Halasana)
+D. Supine postures
+a) Fish posture (Matsyasana)
+b) Boat posture (Naukasana)
+1 each
+20 min (around 1 min
+each posture)
+4 days/week (Wednesday, Thursday,
+Saturday and Sunday)
+5
+Deep relaxation technique (DRT)
+1
+10 min
+4 days/week (Wednesday, Thursday,
+Saturday and Sunday)
+6
+Pranayama (voluntary regulation of breath):
+a) Breathing with forceful exhalation with
+passive inhalation (Kapalabhati-3 types)
+b) Breathing with rapid inhalation & exhalation (Bhastrika)
+c) Slow & rhythmic alternate nostril breathing (Nadisodhana)
+d) Exhalation, with a honey bee sound (Bharamari)
+e) Ujjayi (Hissing in thought while exhaling)
+1 each
+15 min
+4 days (Wednesday, Thursday,
+Saturday and Sunday)
+7
+Concentration Techniques:
+a) Eye exercises (Netra shakti vikasana)
+b) Practice to improve collective motivation (Dhruti shakti vikashaka)
+c) Activity to improve intellect (Dhi shakti vikasaka)
+d) Trataka
+e) Palming
+1 each
+15 min
+2 days/week (Wednesday and Saturday)
+8
+Yogic games (games for memory, awareness and creativity)
+15 min
+2 days/week (Thursday and Sunday)
+S.P. Purohit, B. Pradhan / Journal of Traditional and Complementary Medicine 7 (2017) 99e105
+101
+using Chi squared test. The Independent Sample ‘t’ test was used to
+check the difference between groups for demographic measures.
+Analysis of repeated measure followed by Bonferroni post-hoc was
+performed for all the cognitive functions and Anthropometric
+outcome measures.
+3. Results
+The trial profile of the study is shown in Fig. 1. There were no
+dropouts from Yoga group but eight from WLC. Among eight, two
+were sick, two were suspended during the post assessment due to
+their behavioral issues and other four were not willing to complete
+the task. There were 40 data from Yoga group and 32 from the WLC
+were available for the final analysis. The baseline mean age be-
+tween groups was matched (p ¼ 0.78, Independent ‘t’ test). The
+distribution of gender (p ¼ 0.624, Chi2 test) was not significantly
+different between the two groups.
+Repeated measures of ANOVA showed that there were no sig-
+nificant differences between the groups mean score of baseline
+(p > 0.05) for all the cognitive functions tests except Stroop_CW,
+DS_F and DS_T.
+There were significant difference (p < 0.001) found in times
+(pre-post) score for STROOP_C [F (1,70) ¼ 39.165, p < 0.001],
+STROOP_W [F (1,70) ¼ 32.540, p < 0.001], STROOP_CW [F
+(1,70) ¼ 16.880, p < 0.001]; DSST_T [F (1,70) ¼ 17.968, p < 0.001],
+DSST_N F (1,70) ¼ 19.366, p < 0.001]; DS_F [F (1,70) ¼ 44.796,
+p < 0.001], DS_B [F (1,70) ¼ 29.228, p < 0.001], DS_T [F
+(1,70) ¼ 64.221, p < 0.001]; TMT_A [F (1,70) ¼ 5.113, p < 0.001] and
+TMT_B [F (1,70) ¼ 15.100, p < 0.001].
+The group by time interaction showed (Table 2) significant dif-
+ferences (p < 0.05) in STROOP_C, STROOP_W, STROOP_CW; DS_F,
+DS_B, DS_T; TMT_A. This suggests performance of the Yoga group is
+better than WLC, whereas there were no significant differences
+found in, DSST_T, DSST_W, DSST_N, and TMT_B.
+Within the Yoga group, post-hoc test with Bonferroni adjust-
+ment showed (Table 2) significant improvements (p < 0.001) in
+score for STROOP_C (12.95%), STROOP_W (17.69%), STROOP_CW
+(19.98), DSST_T (15.02%), DSST_N, (16.89%), DS_F (33.81%), DS_B
+(43.51 %), DS_T (37.86 %), TMT_A, (19.52%) and TMT_B (19.43%).
+There was no significant improvement in DSST_W (12.94 %).
+Within WLC group, post-hoc test with Bonferroni adjustment
+showed (Table 2) significant improvement in STROOP_C (p < 0.05,
+5.14%), STROOP_CW (p < 0.01, 5.24%); DSST_N (p < 0.05, 10.91%),
+DS_F (p < 0.05, 9.92 %), DS_T (p < 0.01, 11.50 %), whereas there were
+no significant improvement in STROOP_W (3.78 %), DSST_T (8.18 %),
+DSST_W (23.64 %), DS_B (14.04 %), TMT_A (5.98 %), TMT_B (9.73 %).
+4. Discussion
+The present study was intended to study the effect of three
+months of Yoga as compared to a WLC group on the CF of orphan
+adolescents. The effect of the Yoga program provides evidence on
+improving cognitive functions in orphan adolescents. The result
+showed that the EF of the yoga group improved significantly
+(p < 0.05) in the following domains; STROOP_W, STROOP_C,
+STROOP_CW, DS_F, DS_B, DS_T, TMT_A, and TMT_B whereas WLC
+group exhibited improvement STROOP_C, DSST_N, DS_F, DS_T as
+compared to their baseline. The group by time interaction analysis
+showed significant differences (p < 0.05) in STROOP_C, STROOP_W,
+STROOP_CW; DS_F, DS_B, DS_T; TMT_A. This suggests performance
+of the Yoga group is better than WLC.
+Present study demonstrated that yoga has moderate effect
+(g ¼ 0.29) on overall cognition, executive functions (g ¼ 0. 27),
+attention and processing speed measures (g ¼ 0.34). These effect
+sizes are comparable with a recent meta-analysis study of ran-
+domized controlled trials on Yoga,53 where the overall observed
+effect size of Yoga on cognition was (g ¼ 0.33), executive function
+(g ¼ 0.27), attention and processing speed (g ¼ 0.29).
+Earlier findings of studies on Yoga were aligned with the present
+study in Stroop,54 DSST,55 DSF and DSB,56e59 TMT.45,58 Two recent
+studies have demonstrated 12 weeks of yoga sessions were posi-
+tively associated with acute increase in thalamic GABA levels,
+improvement in mood and anxiety scales,60 and reduction in
+depressive symptoms.61 When yoga postures performed with a gap
+in between, provides relaxation to body, then ultimately enhances
+cognition. Previous studies on yoga techniques which consisted of
+sequence of yoga postures interspersed with relaxation techniques,
+found improvement in selective attention,62 and inhibition of the
+cortical region.63 Suryanamakara, an important part of intervention
+given,
+performed
+with
+rhythmic
+breathing
+develop
+internal
+awareness which might have influenced the cognitive outcome
+measures in the present study.
+Yoga breathing techniques have influence on brain cortex area.
+For example, high frequency yoga breathing practice (Kapalabhati)
+enhances blood flow to pre frontal cortex,64 and cortical electrical
+activity measured through electroencephalogram.65 Pre-frontal
+Table 2
+Comparison of the tests executive functions of yoga and wait-list control group.
+Yoga (n ¼ 40)
+WLC (n ¼ 32)
+Group*time
+interaction
+Pre
+Post
+Pre
+Post
+Mean ± SD
+95% C.I.
+(LB to UB)
+Mean ± SD
+95% C.I.
+(LB to UB)
+Mean ± SD
+95% C.I.
+(LB to UB)
+Mean ± SD
+95% C.I. (LB to UB)
+STROOP_W
+62.18 ± 22.36
+54.95 to 69.40
+73.18 ± 21.67***
+65.84 to 80.51
+69.44 ± 23.59
+61.36 to 77.52
+72.06 ± 25.13
+63.86 to 80.27
+.001
+STROOP_C
+48.65 ± 10.57
+45.20 to 52.10
+54.95 ± 11.86***
+51.13 to 58.77
+53.47 ± 11.38
+49.61 to 57.33
+56.22 ± 12.44*
+51.95 to 60.49
+.017
+STROOP_CW
+27.90 ± 7.12
+25.67 to 30.13
+33.43 ± 8.71***
+30.75 to 36.10
+32.78 ± 6.99
+30.29 to 35.27
+34.50 ± 8.20**
+31.51 to 37.49
+.034
+DSST_T
+33.95 ± 8.40
+31.31 to 36.59
+39.05 ± 8.42***
+36.20 to 41.90
+33.22 ± 8.37
+30.26 to 36.18
+35.94 ± 9.77
+32.75 to 39.13
+.201
+DSST_W
+2.13 ± 2.03
+1.53 to 2.72
+1.85 ± 2.62
+1.17 to 2.53
+1.72 ± 1.69
+1.05 to 2.38
+1.31 ± 1.42
+0.55 to 2.08
+.843
+DSST_N
+31.83 ± 8.52
+29.16 to 34.49
+37.20 ± 8.94***
+34.20 to 40.20
+31.22 ± 8.38
+28.24 to 34.20
+34.63 ± 10.22*
+31.27 to 37.98
+.327
+DS_F
+7.03 ± 1.51
+6.58 to 7.47
+9.40 ± 2.05***
+8.82 to 9.98
+8.19 ± 1.31
+7.69 to 8.69
+9.00 ± 1.50*
+8.36 to 9.64
+.002
+DS_B
+3.28 ± 1.18
+2.86 to 3.69
+4.70 ± 1.57***
+4.24 to 5.16
+3.56 ± 1.46
+3.10 to 4.02
+4.06 ± 1.32
+3.55 to 4.58
+.011
+DS_T
+10.30 ± 2.20
+9.60 to 11.00
+14.20 ± 3.05***
+13.34 to 15.06
+11.69 ± 2.28
+10.90 to 12.48
+13.03 ± 2.25**
+12.07 to 13.99
+.000
+TMT_A
+46.28 ± 15.27
+41.81 to 50.75
+37.25 ± 10.40***
+33.23 to 41.26
+41.45 ± 12.69
+36.44 to 46.45
+43.92 ± 15.18
+39.43 to 48.42
+.000
+TMT_B
+89.98 ± 32.80
+78.66 to 101.30
+72.50 ± 21.10***
+63.99 to 81.00
+95.99 ± 39.45
+83.33 to 108.65
+86.65 ± 32.90
+77.14 to 96.16
+.242
+STROOP_W ¼ Stroop Word, STROOP_C ¼ Stroop Color, STROOP_CW ¼ Stroop Color Word, DSST_T ¼ Digit Symbol Substitution Total Score, DSST_W ¼ Digit Symbol Sub-
+stitution Wrong Score, DSST_N ¼ Digit Symbol Substitution Net Score, DS_F ¼ Digit Span Forward, DS_B ¼ Digit Span Backward, DS_T ¼ Digit Span Total, TMT_A ¼ Trial Making
+Test A, TMT_B ¼ Trial Making Test B, YG ¼ Yoga Group, WLC ¼ Wait-List Control Group.
+*p < 0.05, **p < 0.01, ***p < 0.001; pre compared with post.
+S.P. Purohit, B. Pradhan / Journal of Traditional and Complementary Medicine 7 (2017) 99e105
+102
+cortex is associated with memory, attention, and EF.66,67 Yoga
+breathing (Pranayama) regulated the autonomic functions by
+dominating sympathetic68e70 or parasympathetic tone71,72 based
+on the types of techniques. Different yoga breathing techniques
+were found to be important contributors for significant improve-
+ment in various cognitive domains.57,73,74 Kapalabhati and Bhastrika
+Pranayama had influence on auditory working memory, and central
+neural processing and sensory-motor performance.75 Bhramari
+Pranayama may enhance inhibition response and cognitive control
+in healthy participants.76
+Trataka is a yogic technique in which a person practices focusing
+and defocusing on a chosen object.48 This improves the concen-
+tration of mental thought process which channelizes action toward
+given task/test. A recent study on Trataka for one month showed
+there were beneficial effects by enhancing cognitive functions tests
+and TMT_B in elderly participants.58 The mechanisms in Trataka
+practice involve Dharana (focusing) and Dhyana (defocusing) which
+also contributes in enhancing cognitive measures.
+Strengths of the study arise from randomized design with use of
+well-validated measures of EF while the raters and statistician were
+blinded and the main limitation of the study includes, it was con-
+ducted on adolescents belonging to one orphanage and the results
+were not able to rule out the effect of diet and other school
+activities. Improvement observed in WLC group may be due to test-
+retest effect, uncontrolled physical activities in schools, time and
+growth effect.
+The study can be improvised in design by further reducing the
+age range of participants, developing a Yoga Module especially for
+orphans and also comparing the Yoga intervention with other kinds
+of complementary alternative therapies such as Ayurveda, Natu-
+ropathy for promotion of positive health for orphans.
+5. Conclusion
+Evidence for the effectiveness of three months yoga on EF was
+demonstrated in this study, which may be a useful tool for the
+young orphans, to be practiced for cognitive health on a daily basis.
+The sustained effect of Yoga on EF seen in the present study may
+have potential implications on learning, classroom behavior and in
+handling the adverse circumstances and stand as a preventive
+measure for mental health problems.
+Conflict of interest
+None declared.
+3 months day to 
+day activities 
+Participants enrolled for the 
+study (n=135)
+Excluded (n=55) 
+Based on the inclusion 
+and exclusion criteria 
+Participants recruited (n= 80) 
+Allocation
+Randomization
+Yoga group (n=40) 
+Wait–list controlled 
+group (n=40) 
+Retained (n=40) 
+No dropouts 
+Retained (n=32) 
+Dropout due to various reasons 
+(n=8)
+3 months Yoga 
+Program
+Retained (n=40) 
+Retained (n=32) 
+Analysis 
+Fig. 1. Trial profile.
+S.P. Purohit, B. Pradhan / Journal of Traditional and Complementary Medicine 7 (2017) 99e105
+103
+Sources of support
+Not funded.
+Acknowledgment
+We are thankful to the department of Psychology, SVYASA Yoga
+University, Bangalore for providing the necessary support needed
+for the research. We also thank Dr. Rajashree and Ms. Soubhagya
+Laxmi and Ms. Jinsook, who helped me during various phases of the
+work. We also would like to thank all the participants involved in
+this project.
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+105

subfolder_0/Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia.txt

@@ -0,0 +1,766 @@
+Effect of yoga therapy on facial emotion
+recognition deficits, symptoms and
+functioning in patients with schizophrenia
+Behere RV, Arasappa R, Jagannathan A, Varambally S,
+Venkatasubramanian G, Thirthalli J, Subbakrishna DK, Nagendra HR,
+Gangadhar BN. Effect of yoga therapy on facial emotion recognition
+deficits, symptoms and functioning in patients with schizophrenia.
+Objective: Facial emotion recognition deficits have been consistently
+demonstrated in schizophrenia and can impair socio-occupational
+functioning in these patients. Treatments to improve these deficits in
+antipsychotic-stabilized patients have not been well studied. Yoga
+therapy has been described to improve functioning in various domains
+in schizophrenia; however, its effect on FERD is not known.
+Method: Antipsychotic-stabilized patients randomized to receive Yoga
+(n = 27), Exercise (n = 17) or Waitlist group (n = 22) were assessed
+at baseline, 2nd month, and 4th month of follow-up by raters blind to
+group status. Assessments included Positive and Negative Syndrome
+Scale (PANSS), Socio-Occupational Functioning Scale (SOFS), and
+Tool for Recognition of Emotions in Neuropsychiatric DisorderS
+(TRENDS).
+Results: There was a significant positive correlation between baseline
+FERD and socio-occupational functioning (r = 0.3, P = 0.01).
+Paired samples t test showed significant improvement in positive and
+negative symptoms, socio-occupational functioning and performance
+on TRENDS (P < 0.05) in the Yoga group, but not in the other two
+groups. Maximum improvement occurred at the end of 2 months, and
+improvement in positive and negative symptoms persisted at the end of
+4 months.
+Conclusion: Yoga therapy can be a useful add-on treatment to improve
+psychopathology, FERD, and socio-occupational functioning in
+antipsychotic-stabilized patients with schizophrenia.
+R. V. Behere1, R. Arasappa1,
+A. Jagannathan2, S. Varambally1,
+G. Venkatasubramanian1, J.
+Thirthalli1, D. K. Subbakrishna3,
+H. R. Nagendra4, B. N. Gangadhar1
+Departments of 1Psychiatry, 2Psychiatric Social Work,
+3Biostatistics, National Institute of Mental Health and
+Neurosciences, Bangalore and 4Swami Vivekananda
+Yoga Anusandhana Samsthana (SVYASA) University,
+Bangalore, India
+Key words: schizophrenia; treatment; outcome
+B. N. Gangadhar, Professor, Department of Psychiatry,
+National Institute of Mental Health and Neurosciences,
+Bangalore-560029, India.
+E-mail: [email protected]
+Accepted for publication August 20, 2010
+Significant outcomes
+• Yoga as an add-on therapy improved psychopathology, emotion recognition deficits, and socio-
+occupational functioning in antipsychotic-stabilized patients with schizophrenia in comparison with
+Physical Exercise and Waitlist groups.
+• The maximum change in variables occurred at the end of 2nd month of follow-up in the Yoga group
+and the benefits obtained persisted at the end of 4th month of follow-up.
+• Facial emotion recognition deficits were associated with poorer socio-occupational functioning at
+baseline.
+Acta Psychiatr Scand 2011: 123: 147–153
+All rights reserved
+DOI: 10.1111/j.1600-0447.2010.01605.x
+ 2010 John Wiley & Sons A/S
+ACTA PSYCHIATRICA
+SCANDINAVICA
+147
+Introduction
+Schizophrenia is a clinical syndrome characterized
+by abnormalities in cognition, perception and
+behaviour. Recently, deficits in the sphere of
+social cognition are being increasingly recognized
+in schizophrenia (1). Facial emotion recognition
+deficits (FERD) are an important component of
+impairment in social cognition (2). FERD have
+been consistently demonstrated in patients with
+schizophrenia (3, 4). These deficits have been
+demonstrated for negative emotions of fear and
+anger (5, 6).
+Facial emotion recognition deficits can lead to
+impairment in interpersonal communication and
+may underlie difficulties in social adjustment (7).
+These deficits are also associated with poor work
+and global functioning, suggesting that affect
+recognition is an important aspect of psychosocial
+and occupational functioning in stable out-patients
+(8). Hence, interventions to improve FERD can
+enhance the socio-occupational functioning in
+schizophrenia.
+Studies
+have
+shown
+that
+FERD
+could
+be
+improved by behavioural interventions like cogni-
+tive
+enhancement
+training
+(9).
+Recently,
+we
+reported that risperidone treatment can improve
+FERD in drug-naı¨ve subjects
+(10). However,
+FERD have been described as a residual deficit in
+schizophrenia and have been documented in anti-
+psychotic-stabilized patients (11). The scope of the
+current conventional treatments for residual defi-
+cits is limited. Yoga is a traditional Indian system
+used in alternative and complementary medicine.
+In a randomized controlled trial, it has been found
+to improve negative symptoms and functioning in
+antipsychotic-stabilized patients with schizophre-
+nia (12).
+To date, there have been no studies on the effect
+of yoga as an add-on treatment for FERD.
+Aims of the study
+To study the effect of yoga as an add-on treatment
+on emotion recognition deficits, psychopathology,
+and socio-occupational functioning in antipsy-
+chotic-stabilized patients with schizophrenia.
+Material and methods
+Sample
+Patients with a diagnosis of schizophrenia (DSM
+IV), who were on regular follow-up and willing to
+give consent for the study, were recruited from the
+Outpatient services of the Department of Psychi-
+atry, NIMHANS. A qualified psychiatrist con-
+firmed
+the
+diagnosis
+independently
+based
+on
+clinical interview, information obtained from care-
+givers, and supportive information from case
+records. A total of 91 patients were included in
+the study with their age ranging from 18 to
+60 years and Clinical Global Impression (CGI)
+score £3 (as assessed by the treating psychiatrist).
+These patients were on stabilized antipsychotic
+medications for 6 weeks or longer, as decided by
+the treating psychiatrist, before being recruited
+into the study and continued the same medication
+until the completion of the study. Patients with
+comorbid psychiatric disorders, medical or neuro-
+logical illness
+were excluded. The study was
+approved by the ethics committee of the institute.
+Procedure
+Using computer-generated random numbers, 91
+patients were allocated to three treatment groups:
+Yoga (n = 34), Exercise (n = 31), and Waitlist
+(n = 26). The numbers were not necessarily equal.
+The variations in these numbers were not signifi-
+cantly different from chance. The randomization
+was performed by one of the authors in the study
+(Dr JT). The raters were blind to the status, and
+the raters were not involved in imparting yoga
+therapy or exercise.
+Yoga and Exercise groups received the yoga and
+exercise training respectively from a trained yoga
+instructor for a period of a month. For the next
+2 months, they practiced yoga or exercise at home.
+The patients caregivers were instructed to monitor
+the yoga therapy at home and keep a log of the
+yoga sessions practiced. Patients in the Waitlist
+group did not receive any add-on intervention.
+Patients in all the three groups continued to receive
+stable dose of antipsychotic medications until the
+end of the study. As per study protocol, only those
+Limitations
+• Baseline matching of Waitlist and Yoga groups on parameters such as negative symptoms and Tool
+for Recognition of Emotions in Neuropsychiatric DisorderS Accuracy Score may have improved the
+methodology of the study.
+• A longer duration of supervised yoga therapy by the trained yoga therapist may have produced more
+robust results.
+• The findings need to be replicated in a larger sample of patients.
+Behere et al.
+148
+patients who completed all assessments at the end
+of the study duration were included in the final
+data analysis. Those patients who dropped out or
+those who required a change in dosage of antipsy-
+chotics
+during
+the
+study
+duration
+were
+not
+included. During follow-up assessments, number
+of drop-outs was 7 in Yoga group, 14 in Exercise
+group, and 4 in Waitlist group. Hence, the number
+of patients who completed the study and included
+in the final analysis was 27 in Yoga group, 17 in
+Exercise group, and 22 in Waitlist group. The
+drop-outs were not significantly different from the
+final study sample in their baseline clinical and
+demographic characteristics. The patients who
+dropped out either had not practiced yoga at
+home or did not come for follow-up assessments
+because of logistical reasons. It is interesting to
+note that none of the patients were excluded from
+the initial sample for reason of change in dosage of
+antipsychotic medication.
+The yoga module developed by Swami Viveka-
+nanda Yoga Anusandhana Samsthana (SVYASA)
+was used. The techniques have been reported in an
+earlier study (12); briefly, it consisted of loosening
+exercises, breathing practices,
+suryanamaskara,
+sitting, supine, and prone posture asanas along
+with pranayama and relaxation techniques. Med-
+itation was not included in the module. The
+exercises were adapted from the National Fitness
+Corps – Handbook for Middle High and Higher
+Secondary Schools. It consisted of brisk walking,
+jogging, and exercises in standing and sitting
+postures and relaxation. For further details regard-
+ing the yoga and exercise techniques, please see
+Appendix 1.
+Patients socio-demographic data were collected
+using semistructured data sheet. Their psychopa-
+thology was assessed by Positive and Negative
+Syndrome Scale (PANSS) (13). Socio-occupational
+functioning was assessed by Socio-Occupational
+Functioning Scale (SOFS) (14). Their emotion
+recognition abilities were assessed using Tool for
+Recognition
+of
+Emotions
+in
+Neuropsychiatric
+DisorderS (TRENDS) (15). This is a culturally
+sensitive, ecologically valid tool, consisting of 52
+static (still) and 28 dynamic (video clip) images (i.e.
+totally 80 images) of six basic emotions – happy,
+sad, fear, anger, surprise, disgust, and a neutral
+expression emoted by four experienced actors (one
+young man, one young woman, one older man,
+and one older woman). The performance on
+TRENDS was assessed by calculating the total
+number of images that were correctly indentified
+out of a maximum of 80 and termed the TRENDS
+Accuracy Score (TRACS). Patients were assessed
+at the baseline, 2nd and 4th month of follow-up.
+All assessments were made by raters who were
+blind to the group status.
+Statistical analysis
+One-way anova was used to assess differences in
+baseline clinical and demographic variables among
+the three groups. The paired-samples t test was
+used to assess the change in variables after the
+study period in the individual groups. Pearsons
+correlation analysis was performed to look at the
+association between the clinical variables.
+Results
+On one-way anova, the subjects in all three groups
+were comparable on age, sex, and duration of
+illness. The three groups differed significantly on
+baseline negative symptoms (F = 4.8, P = 0.01)
+and baseline TRACS (F = 3.2, P = 0.05) with the
+Yoga group having greater negative symptom
+score and lower TRACS (Table 1).
+Change in variables between baseline and 2nd
+month follow-up and baseline and 4th month
+follow-up in the individual groups was examined
+using paired-samples t test (Table 2). In the Yoga
+group, there was significant change in positive and
+negative symptoms and TRACS. The improvement
+continued to remain significant even after the 4th
+month assessments. The improvement in positive
+and negative symptoms and SOFS score remained
+significant after applying Bonferroni correction for
+multiple comparisons. There were no significant
+changes in variables in either the Exercise or the
+Waitlist groups. The maximum change in variables
+occurred at the 2nd month of follow-up. On
+correlation analysis, it was observed that lower
+baseline scores on TRACS correlated with poorer
+Table 1. One-way anova ⁄ chi-square analysis of baseline clinical and demographic variables in patient groups
+Variable
+Yoga (Mean € SD)
+Exercise (Mean € SD)
+Waitlist (Mean € SD)
+F ⁄ (v2)
+P
+Age (years)
+31.3 € 9.3
+30.2 € 8.0
+33.6 € 9.9
+0.74
+0.5
+Duration of illness (months)
+126.2 € 101.6
+86.6 € 93.1
+121.6 € 108.6
+0.82
+0.4
+Sex (M : F)
+18 : 9
+14 : 3
+15 : 7
+1.4
+0.5
+Mean dosage of antipsychotic and
+[range] (CPZ equivalents in mg ⁄ day)
+335.0 € 205.3 [400]
+297.9 € 150.9 [300]
+340.0 € 172.4 [675]
+0.21
+0.8
+Effect of yoga therapy on patients with schizophrenia
+149
+socio-occupational functioning as measured by
+SOFS (r = 0.3, P = 0.01). There was no signifi-
+cant correlation between TRACS and positive or
+negative symptoms. There was no significant cor-
+relation between change in negative symptoms and
+change in TRACS.
+Discussion
+This is the first study to explore the effect of yoga
+therapy on FERD. The results of this study show
+that yoga therapy as an add-on to antipsychotic
+treatment can be beneficial in improving positive
+symptoms, negative symptoms, FERD, and socio-
+occupational functioning. The results of this study
+support the findings of an earlier study that
+demonstrated yoga as an add-on therapy to benefit
+several dimensions of outcome in schizophrenia (12).
+Although there was a significant difference in
+negative symptoms and TRACS between groups at
+baseline,
+there
+was
+no
+significant
+correlation
+between
+change
+in
+negative
+symptoms
+and
+change in TRACS, suggesting that change in
+negative symptoms alone might not have resulted
+in improvement in emotion recognition scores. In
+the Exercise and Waitlist groups, the negative
+symptoms and FERD did not improve, supporting
+the current understanding that these are residual
+deficits in schizophrenia. The possibility of anti-
+psychotic medication confounding the results was
+minimized by ensuring stable antipsychotic dos-
+ages for 6–8 weeks prior to study and throughout
+the study duration. Hence, the finding of signifi-
+cant improvement in these parameters in antipsy-
+chotic-stabilized patients is of important clinical
+relevance.
+The correlation between FERD and socio-occu-
+pational functioning supports findings of earlier
+studies (7). Impairment in facial emotion recogni-
+tion abilities can impair the ability to interact in
+social
+situations and
+hence
+can
+affect
+socio-
+occupational functioning (16). However, interven-
+tions to improve these deficits are limited. We
+recently reported risperidone to improve FERD in
+antipsychotic-naı¨ve schizophrenia (10). Structured
+interventions such as cognitive enhancement ther-
+apy have also been described to improve these
+deficits (9). However, these interventions can be
+time-intensive, requiring trained mental health
+professionals. Yoga therapy is a popular alterna-
+tive system of medicine, and resources to obtain
+this training are widely available in a developing
+country like India, where mental health resources
+are sparse. After an initial training period, patients
+can continue practice at home, which can reduce
+dependence on mental health resources. Interest-
+ingly, benefits of yoga therapy that occurred at the
+2nd month of follow-up continued to persist even
+at the 4th month. One genuine concern is the
+monitoring of yoga practice at home. Although
+patients and caregivers were instructed to maintain
+a logbook of yoga practice, many of the patients
+did not maintain the logbook as per our expecta-
+tion. A longer duration of supervised yoga therapy
+by the trained yoga therapist may have produced
+more robust results.
+Integration of conventional psychiatric treat-
+ments with mind body practices is an emerging
+field. An example of this is the recent study that
+integrated yoga breath intervention with exposure
+therapy in post-traumatic stress disorder and
+depression in survivors of Tsunami (17). Hence, it
+is important that yoga therapists should receive
+training in mental health disorders to sensitize
+them to the needs of the psychiatric population.
+The mental health professionals should work in
+close association with the yoga therapists, so that
+they are readily available to handle the needs of the
+patients, if they may arise. In this context, it is
+interesting to note that in our study, none of the
+Table 2. Paired–samples t test comparing change in variables from baseline to 2nd month$ and 4th month# of follow-up in individual patient groups
+Group
+Variables
+Baseline
+2nd month
+4th month
+t$ value
+P$ value
+t# value
+P# value
+Yoga
+Positive symptoms
+15.1 € 11.7
+11.9 € 4.7
+12.1 € 5.4
+3.5
+0.002*
+2.8
+0.008*
+Negative symptoms
+17.8 € 4.9
+14.7 € 3.9
+14.7 € 3.8
+5.1
+<0.001*
+3.5
+0.002*
+TRACS
+49.4 € 11.4
+54.1 € 11.7
+54.6 € 14.4
+2.3
+0.03*
+1.8
+0.09
+SOFS score
+30.8 € 7.4
+25.1 € 6.4
+25.7 € 7.9
+4.4
+<0.001*
+0.38
+0.7
+Exercise group
+Positive symptoms
+14.9 € 4.3
+13.5 € 4.7
+14.1 € 5.4
+1.5
+0.2
+0.6
+0.6
+Negative symptoms
+14.8 € 3.9
+13.9 € 3.3
+13.5 € 4.4
+0.94
+0.4
+1.5
+0.2
+TRACS
+51.3 € 10.7
+51.2 € 10.7
+52.8 € 10.4
+0.03
+0.9
+0.65
+0.5
+SOFS score
+26.2 € 5.1
+23.9 € 4.7
+22.0 € 6.8
+1.9
+0.07
+1.3
+0.2
+Waitlist group
+Positive symptoms
+14.7 € 6.3
+12.9 € 5.2
+11.8 € 5.6
+1.7
+0.1
+2.02
+0.06
+Negative symptoms
+14.3 € 3.7
+13.7 € 3.7
+13.7 € 3.6
+0.61
+0.6
+0.65
+0.52
+TRACS
+56.9 € 9.4
+58.4 € 8.9
+53.4 € 16.4
+0.74
+0.5
+0.99
+0.3
+SOFS score
+27.1 € 6.6
+24.9 € 6.1
+25.2 € 5.4
+2.1
+0.05*
+0.27
+0.8
+SOFS, Socio-Occupational Functioning Scale; TRACS, TRENDS Accuracy Score; TRENDS, Tool for Recognition of Emotions in Neuropsychiatric Disorders.
+*Significance at P < 0.05.
+Behere et al.
+150
+patients had worsening of positive symptoms
+during the duration of yoga therapy. Further,
+none of the patients required increase in dose of
+antipsychotics. This probably suggests that yogas-
+anas and breathing techniques can be practiced by
+patients with schizophrenia without worsening of
+psychotic experiences.
+In conclusion, yoga as an add-on treatment
+improves positive and negative symptoms, and
+emotion
+recognition
+abilities
+in
+antipsychotic-
+stabilized patients with schizophrenia, which in
+turn might improve their socio-occupational func-
+tioning. Further systematic studies are needed to
+study the beneficial effects of yoga in patients with
+schizophrenia and their potential neurobiological
+mechanisms.
+Acknowledgement
+This study was supported by AYUSH grant awarded to Dr BN
+Gangadhar vide letter no. Z.31018/1/2006-Y&N/R&P(Ay)/
+EMR. The authors thank the anonymous reviewers for the
+thorough review of the manuscript that has helped immensely
+in improving the quality of the manuscript.
+Declaration of interest
+There is no conflict of interest to declare by any of the authors
+in relation to this manuscript. None of the authors are
+associated with any pharmaceutical companies by way of
+being on speakers list of pharmaceutical companies, receiving
+grants from industry or being members of pharmaceutical
+advisory boards.
+References
+1. Brune M. Emotion recognition, theory of mind, and social
+behavior in schizophrenia. Psychiatry Res 2005;133:135–
+147.
+2. Grady CL, Keightley ML. Studies of altered social cogni-
+tion in neuropsychiatric disorders using functional neu-
+roimaging. Can J Psychiatry 2002;47:327–336.
+3. Mandal MK, Pandey R, Prasad AB. Facial expressions of
+emotions and schizophrenia: a review. Schizophr Bull
+1998;24:399–412.
+4. Bediou B, Krolak-Salmon P, Saoud M et al. Facial expres-
+sion and sex recognition in schizophrenia and depression.
+Can J Psychiatry 2005;50:525–533.
+5. Kohler CG, Turner TH, Bilker WB et al. Facial emotion
+recognition in schizophrenia: intensity effects and error
+pattern. Am J Psychiatry 2003;160:1768–1774.
+6. Mandal MK, Jain A, Haque-Nizamie S, Weiss U, Schneider F.
+Generality and specificity of emotion-recognition deficit in
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+toms. Psychiatry Res 1999;87:39–46.
+7. Kee KS, Green MF, Mintz J, Brekke JS. Is emotion pro-
+cessing a predictor of functional outcome in schizophrenia?
+Schizophr Bull 2003;29:487–497.
+8. Hofer A, Benecke C, Edlinger M et al. Facial emotion
+recognition and its relationship to symptomatic, subjective,
+and functional outcomes in outpatients with chronic
+schizophrenia. Eur Psychiatry 2009;24:27–32.
+9. Hogarty GE, Flesher S. Practice principles of cognitive
+enhancement therapy for schizophrenia. Schizophr Bull
+1999;25:693–708.
+10. Behere RV, Venkatasubramanian G, Arasappa R, Reddy N,
+Gangadhar BN. Effect of risperidone on emotion recog-
+nition deficits in antipsychotic-naive schizophrenia: a
+short-term follow-up study. Schizophr Res 2009;113:72–
+76.
+11. Kucharska-Pietura K, David AS, Masiak M, Phillips ML.
+Perception of facial and vocal affect by people with
+schizophrenia in early and late stages of illness. Br J Psy-
+chiatry 2005;187:523–528.
+12. 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;116:226–232.
+13. Kay SR, Opler LA, Lindenmayer JP. The Positive and
+Negative Syndrome Scale (PANSS): rationale and stan-
+dardisation. Br J Psychiatry Suppl 1989;7:59–67.
+14. Saraswat N, Rao K, Subbakrishna DK, Gangadhar BN. The
+Social Occupational Functioning Scale (SOFS): a brief
+measure of functional status in persons with schizophrenia.
+Schizophr Res 2006;81:301–309.
+15. Behere RV, Raghunandan VN, Venkatasubramanian G,
+Subbakrishna
+DK,
+Jayakumar
+PN,
+Gangadhar
+BN.
+TRENDS: a Tool for Recogniton of Emotions in Neuro-
+psychiatric DisorderS. Indian J Psychol Med 2008;30:
+32–38.
+16. Hooker C, Park S. Emotion processing and its relationship
+to social functioning in schizophrenia patients. Psychiatry
+Res 2002;112:41–50.
+17. Descilo T, Vedamurtachar A, Gerbarg PL et al. Effects of a
+yoga breath intervention alone and in combination with an
+exposure therapy for post-traumatic stress disorder and
+depression in survivors of the 2004 South-East Asia tsu-
+nami. Acta Psychiatr Scand 2010;121:289–300.
+Appendix: Yoga therapy and physical exercise modules
+Appendix A: The integrated yoga therapy module; duration: 1 h
+I. Shithileekarana vyayama (loosening exercises)
+(1) Jogging-2 min
+(2) Mukha dhouti (cleansing through a single blast breath)
+30 s
+(3) Twisting – 1 min
+(4) Hand stretch breathing – 2 min
+(5) Forward and backward bending – 1 min
+(6) Tiger Breathing: nine rounds 1 min
+(7) Cycling – 1 min
+(8) Sashankasana (moon posture) breathing – 1 min
+(9) Dandasana (staffposture) – 30 s
+II Asanas:
+II A. Suryanamaskar (sun salutation) (12 rounds) – 6 min
+Effect of yoga therapy on patients with schizophrenia
+151
+II B. Instant relaxation technique (IRT) 1 min
+Shavasana (corpse posture) – this involves progressively
+tensing all the muscles of the body in 15 s, relaxing all of
+them instantaneously and staying relaxed for 45 s
+II C. Sitting posture asanas:
+II C.1. Vakrasana (twist posture) – 30 s
+II C.2. Prasarita pada paschimatanasana (stretching of back
+with stretched legs) – 1 min
+II C.3. Ustrasana (camel posture) – 1 min
+II D. Prone posture asanas:
+II D.1. Bhujangasana (cobra posture) – 1 min
+II D.2. Shalabhasana (locust posture) – 1 min
+II D.3. Dhanurasana (bow posture) – 1 min
+II E. Supine posture asanas:
+II E.1. Sarvangasana (shoulder stand) – 3 min
+II E.2. Matsyasana (fish posture) – 1 min
+III Breathing exercises:
+III A. Kapalabhati (cleansing breath exercise): 60–80 rounds –
+2 min
+III B. Sectional (abdominal, thoracic, clavicular, and full
+yogic) breathing: each five rounds – 4 min
+III C.
+Nadi-shuddi
+pranayama
+(balancing
+breath):
+nine
+rounds – 2 min
+III D. Nadanusandhana (feeling of inner sound while chanting
+A, U, M) each nine rounds – 10 min
+IV Quick relaxation technique (QRT) – 3 min. This involves
+adopting
+Shavasana
+and
+three
+phases
+of
+observing
+abdominal movements, synchronizing them with deep
+breathing, and feeling of energy and collapsing all the
+muscles
+Appendix B: Physical exercises: adopted from the National
+Fitness Corps – Handbook for Middle High and Higher Secondary
+Schools (29); duration: 1 h*
+I Brisk walking – 10 min
+II Jogging – 5 min
+III Exercise in standing posture – 20 min
+III A. Position: attention
+(1) Raising the arms forward to the shoulder level palms facing
+each other, fingers together
+(2) Bending arms, bringing fists in the armpits with elbows
+pushed backward
+(3) Returning to position one
+(4) Returning to position of attention
+Yoga therapy for the management of patients with schizo-
+phrenia
+III B. Position: attention
+(1) Raising the arms forward to the shoulder level, fingers
+together
+(2) Flinging arms sideward to the shoulder level, palms facing
+the ground heel raise
+(3) Returning to position one
+(4) Returning to position of attention
+III C. Position: attention
+(1) Stepping the left leg forward and raising the arms forward,
+palms are kept facing each other and fingers are kept
+together
+(2) Flinging arms sideward at the shoulder level, palms facing
+the ground and lounging left leg forward
+(3) Returning to position one
+(4) Returning to position of attention
+III D. Position: attention
+(1) Raising arms forward to the shoulder level palms facing
+each other with the fingers together
+(2) Raising the arms upward, palms facing each other and with
+fingers together heels are raised
+(3) Returning to position one
+(4) Returning to position of attention
+III E. Position: attention
+(1) Raising arms sideward, shoulder level, palms facing the
+ground, fingers together
+(2) Squatting on toes, flinging arms upwards, palms facing
+each other
+(3) Returning to position one
+(4) Returning to position of attention
+III F. Position: attention
+(1) Jumping feet astride, raising arms sideward, palms facing
+the ground
+(2) Flinging arms upward above head with a clap and jumping
+feet together
+Behere et al.
+152
+(3) Returning to position one
+(4) Returning to position of attention
+III G. Position: attention
+(1) Hands forward upward rise to shoulder level, palms facing
+each other, heels raise
+(2) Half squat, chest firm (hands bent at elbows) palm
+downward, middle fingers1 ⁄ 2¢¢ distance from each other
+(3) Hands sideward raise, knees straight
+III H. Position: attention
+(1) Hands forward raised, half-knee bent (no gap between
+knees)
+(2) Back to position
+(3) Hands sideward raised, half-knee bent
+(4) Back to position.
+IV. Sitting posture exercises – 20 min
+IV A. Position: cross-legged sitting, hands slanting
+(1) Hands rise over had slowly without bending at elbows,
+palms touching each other, fingers extended upward
+(2) Elbows bend, palms touching head
+(3) Same as 1
+(4) Back to position
+IV B. Position: cross-legged sitting, hands slanting
+(1) Hands sideward, upward, elbows bend, palms touch the
+head
+(2) Trunk bend, head downward
+(3) Same as 1
+(4) Back to position
+IV C. Position: cross-legged sitting, hands slanting
+Chest firm (i.e. elbow bent palms downward and in front of
+the chest)
+(1) Elbows backward press (chest expanding action)
+(2) Hands forward sideward backward press
+IV D. Position: cross-legged sitting, hands sideward slanting.
+1–3: hands upward, downward swing, clap over head
+*The therapist would give 2 min time in between the different
+exercises with a non-specific instruction, just relax now.
+Effect of yoga therapy on patients with schizophrenia
+153

subfolder_0/Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes_ An Exploratory Study.txt

@@ -0,0 +1,256 @@
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+1/11
+Int J Yoga. 2017 Sep-Dec; 10(3): 167–170.
+doi: 10.4103/0973-6131.213471: 10.4103/0973-6131.213471
+PMCID: PMC5793012
+PMID: 29422748
+Effectiveness of Music Therapy on Focused Attention, Working
+Memory and Stress in Type 2 Diabetes: An Exploratory Study
+Indira Tumuluri, Shantala Hegde,  and HR Nagendra
+Division of Humanities, Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru, Karnataka,
+India
+Department of Clinical Psychology, Neuropsychology Unit, NIMHANS, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Shantala Hegde, Department of Clinical Psychology, National Institute of
+Mental Health and Neurosciences-Deemed University, Bengaluru - 560 029, Karnataka, India. E-mail:
+[email protected]
+Received 2016 Jul; Accepted 2016 Nov.
+Copyright : © 2017 International Journal of Yoga
+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
+Cognitive deficits are reported in diabetes mellitus type 2 (DM2). Previous research has shown that music-
+based intervention can not only reduce hyperglycemia but also target cognitive functions as well as stress.
+The aim of this exploratory study was to understand the effect of active participation in music therapy
+(MT) on the cognitive deficits of DM2 patients. MT of twenty sessions was carried out with three
+participants with DM2. Serum cortisol, perceived stress, Color Trail Test (1 and 2), and verbal n-back (1
+and 2) tests were used to measure the outcomes. Feedback was taken for the subjective ratings and
+satisfaction of the participants. Stress and cortisol reduced and focused attention and working memory
+improved in varying degrees. Subjectively, participants reported having benefitted from the intervention.
+This is the first attempt to investigate the effect of music-based intervention on cognitive function in DM2
+patients using case study approach.
+Keywords: Cortisol, focused attention, music therapy, perceived stress, working memory
+Introduction
+Type 2 diabetes (T2D) is a complex metabolic disorder leading to cognitive deficits and increased risk for
+multiple clinical conditions such as dementia and stroke and several other micro- and macro-vascular
+diseases.[1] High levels of psychological stress are also considered as one of the causal and maintaining
+factors of this condition.[2] There is growing evidence of the effectiveness of music not only to improve
+cognitive functions in conditions such as traumatic brain injuries,[3] stroke,[4] and dementia[5] but also in
+the reduction of stress,[6,7] anxiety,[8] and cortisol production,[9] and increase in dopamine levels.[10]
+With lifelong dependency on medication and likely physical side effects, there is a need to explore
+intervention methods that can facilitate not only reduction of stress but also target cognitive dysfunction in
+1
+1
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+2/11
+T2D. Research on the effects of music therapy (MT) on stress has been reported. MT has reduced stress in
+the students caused by a stressor[7] and anxiety and stress of T2D patients.[8] It is in the recent times with
+evidence from neuro-musicology and music cognition that active as well as passive engagement in music
+has shown to have positive effects on cognitive functions. There is no study hitherto examining the effects
+of MT on not only stress but also cognitive functions. The aim of the present study was to examine the
+effect of active participation in MT on the cognitive functioning of diabetes mellitus type 2 (DM2)
+patients. In the first place, we sought to understand the influence of active participation in MT on memory
+and focused attention, second, on cortisol and perceived stress, and finally on the subjective rating and
+satisfaction. It is found that active music therapy (AMT) is more beneficial than passive listening.[11]
+Singing improved the executive function of the children.[12] AMT is actively participating in MT by
+singing or chanting or reciting. The objective of this exploratory study was to examine the effect of using
+case series study design with pre-post evaluation.
+Methods
+The present study included three participants diagnosed with DM2 confirmed with the HbA1c levels.
+Sociodemographic details of the participants are provided in Table 1. Written informed consent was taken
+from the participants after the study was approved by the Institutional Ethics Committee, Swami
+Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India. MT was administered in
+addition to their treatment as usual, i.e., regular medication for DM2. Levels of stress were measured
+objectively by measuring serum cortisol, and the subjective evaluation of stress was measured using
+Cohen's perceived stress scale (PSS). Each item was rated on a 5-point scale ranging from never (0) to
+almost always (4). Positively worded items were reverse scored, and the ratings were summed, with higher
+scores indicating more perceived stress. PSS-10 scores were obtained by reversing the scores on the four
+positive items: For example, 0 = 4, 1 = 3, and 2 = 2, and then summing across all 10 items. Items 4, 5, 7,
+and 8 are the positively stated items. Rensis's 10-point Likert scale was used to understand the rate of
+satisfaction. Verbal working memory and focused attention were measured using verbal n-back 1 and 2
+tasks (Rao et al., 2004) and Color Trail Tests (CTT) 1 and 2 (D’Elia and Satz). In n-back 1, the participant
+responds to the repeated (9) consonants from thirty randomly ordered consonants common to multiple
+Indian languages. In n-back 2, the participant responds whenever a consonant is repeated after an
+intervening consonant. In CTT-1, the participant points out the randomly spread numbers from 1 to 25, odd
+numbers in pink circles and even numbers in yellow ones in ascending order. In CTT-2, the participant
+points out in ascending order the randomly arranged numbers from 1 to 25, leaving number 1, others
+repeated once in pink and once in yellow circles. The main measure in this test is the time necessary to
+complete the task. A semi-structured interview was carried out to know the participants’ experience with
+the intervention. The interviews were video recorded. The serum tests were done by the National
+Accreditation Board for Testing and Calibration Laboratories-accredited laboratory, Metropolis Health
+Care Ltd. All measurements were administered pre- and post-intervention. Serum cortisol was measured
+both the times (pre and post) in between 4.30 and 5 p.m. The experiment was carried out daily (excluding
+Saturdays and Sundays) for 45 min. The protocol of MT is given in Table 2.
+Detailed protocol of music therapy
+The devotional songs were set for each day of the week. Every week, the same devotional songs were
+repeated for familiarity. The participants’ individual songs were not repeated. The same piece of flute
+music was played for all the sessions. There were total 20 sessions.
+Results
+The number of sessions attended by the participants were 16, 14, and 10 by cases 1, 2, and 3, respectively.
+The period between the pre- and post-test is 1 month, weekly five sessions.
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+3/11
+In all the three cases, the cortisol level reduced after the therapy. PSS showed improvement in two cases
+and no improvement in other case [Table 3]. Focused attention as assessed using the Color Trails Test 1
+nominally improved in one case and deteriorated in two cases at postintervention. The performance
+improved in two cases and showed no improvement in the other case in CTT2. In verbal n-back test 1, the
+performance improved in two cases and did not improve in the other case. Performance on the verbal n-
+back 2 did not improve in any case [Refer to Table 4a and b]. All the three patients enjoyed the
+intervention and rated it as 9.5 satisfactory on 10-point Likert scale [Table 3]. Video interviews provided
+the report of the benefits of active participation of the participants in MT.
+Discussion
+The present study aimed at exploring the effects of AMT on cognitive functions and perceived levels of
+stress. In this study, all the three participants showed significant cognitive impairments in the domains of
+focused attention and verbal working memory compared to age, education, and gender-matched Indian
+norms[13] The 15  percentile score (1 standard deviation below the mean) was taken as the cutoff score.
+[14] In the critical review study of, “Is Type II Diabetes Associated with an Increased Risk of Cognitive
+Dysfunction?,” it was observed that patients with T2D had moderate degrees of cognitive impairment in
+verbal memory. It was reported that a study which evaluated 28 T2D patients aged <55 years showed
+poorer performance on the measures of memory and attention.[15] These deficits are due to neural slowing
+and increased cortical atrophy,[16] with higher levels of HbA1c in the present study. As a result, the
+cognitive task completion required greater time and had difficulty for the participants compared to the
+normative performance expected for the Indian males in this group. The participants differed in the way
+they responded to active music participation. Not all the three participants had consistent improvement on
+all cognitive tasks. The group singing in lead and follow manner may have improved the verbal working
+memory as group singing enhanced the mood of patients with chronic pain[17] and improved the mental
+health and well-being of the participants of singing.[18] The inconsistent improvement in this study may
+be due to the subjective emotional state at the time of measurement, or the cognitive functions perhaps
+require much more focused intervention, or the intensity and duration of the present intervention was not
+sufficient to bring about significant changes in the cognitive functions. However, the reduction in the
+cortisol level shows that AMT is feasible to relieve stress as listening to music reduced cortisol
+production[9] and relieved stress.[6,7] The interviews also provided the following subjective positive
+responses to the AMT.
+The video interviews were taken after 12 sessions
+Interviews were transcribed
+The gist of the interviews are provided below.
+Case 1
+It is a very good experience. I am feeling relaxed. The sessions are enjoyable. The therapy is very useful.
+My singing improved. I love relaxation with flute music. I like the interactive sessions most. This therapy
+should be spread. I feel the difference after the therapy.
+Case 2
+I am very happy to participate. The sessions are very interesting. I like the sequence of the songs. I enjoy
+group singing. I feel calm after the session. It helps me to sleep. The songs are well coordinated. Nirvana
+Shatakam singing is the most liked part for me. It makes me deeply relaxed and calm.
+Case 3
+th
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+4/11
+I feel much more relaxed. Blood sugar (fasting) reduced from 400 to 270. I like the singing and interaction
+part.
+The satisfaction of the participants and their willingness to attend AMT in future give support to the
+administration of MT to other DM2 patients. The subjective reports and the PSS scores show that active
+participation in music is a mood-elevating strategy which can enhance positive feelings. To substantiate its
+role in cognitive functions, there is a need for long-term follow-up of cases with more focused intervention
+with selected chants and musical content.
+Conclusion
+This is an exploratory study dealing with three cases
+The results are inconsistent
+In spite of poor cognitive performance, the positive subjective response and reduced PSS scores
+provide a support to continue MT further
+The lower level of cognitive functions may be due to higher levels of HbA1c
+A randomized controlled trial study with larger cohort will be required to establish the findings
+further.
+Financial support and sponsorship
+Liability release.
+Conflicts of interest
+There are no conflicts of interest.
+References
+1. McCrimmon RJ, Ryan CM, Frier BM. Diabetes and cognitive dysfunction. Lancet. 2012;379:2291–9.
+[PubMed: 22683129]
+2. Mooy JM, de Vries H, Grootenhuis PA, Bouter LM, Heine RJ. Major stressful life events in relation to
+prevalence of undetected type 2 diabetes: The Hoorn study. Diabetes Care. 2000;23:197–201. [PubMed:
+10868831]
+3. Thaut MH, Gardiner JC, Holmberg D, Horwitz J, Kent L, Andrews G, et al. Neurologic music therapy
+improves executive function and emotional adjustment in traumatic brain injury rehabilitation. Ann N Y
+Acad Sci. 2009;1169:406–16. [PubMed: 19673815]
+4. Särkämö T, Tervaniemi M, Laitinen S, Forsblom A, Soinila S, Mikkonen M, et al. Music listening
+enhances cognitive recovery and mood after middle cerebral artery stroke. Brain. 2008;131(Pt 3):866–76.
+[PubMed: 18287122]
+5. Sakamoto M, Ando H, Tsutou A. Comparing the effects of different individualized music interventions
+for elderly individuals with severe dementia. Int Psychogeriatr. 2013;25:775–84. [PMCID: PMC3605862]
+[PubMed: 23298693]
+6. Thoma MV, La Marca R, Brönnimann R, Finkel L, Ehlert U, Nater UM. The effect of music on the
+human stress response. PLoS One. 2013;8:e70156. [PMCID: PMC3734071] [PubMed: 23940541]
+7. Labbé E, Schmidt N, Babin J, Pharr M. Coping with stress: The effectiveness of different types of
+music. Appl Psychophysiol Biofeedback. 2007;32:163–8. [PubMed: 17965934]
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+5/11
+8. Mandel SE, Davis BA, Secic M. Effects of music therapy and music-assisted relaxation and imagery on
+health-related outcomes in diabetes education: A feasibility study. Diabetes Educ. 2013;39:568–81.
+[PubMed: 23771840]
+9. Khalfa S, Bella SD, Roy M, Peretz I, Lupien SJ. Effects of relaxing music on salivary cortisol level after
+psychological stress. Ann N Y Acad Sci. 2003;999:374–6. [PubMed: 14681158]
+10. Ashby FG, Isen AM, Turken AU. A neuropsychological theory of positive affect and its influence on
+cognition. Psychol Rev. 1999;106:529–50. [PubMed: 10467897]
+11. Rao TI, Nagendra HR. The effect of active and silent music interventions on patients with type 2
+diabetes measured with electron photonic imaging technique. Int J Humanit Soc Sci. 2014;3:7–14.
+12. Moreno S, Bialystok E, Barac R, Schellenberg EG, Cepeda NJ, Chau T. Short-term music training
+enhances verbal intelligence and executive function. Psychol Sci. 2011;22:1425–33.
+[PMCID: PMC3449320] [PubMed: 21969312]
+13. Rao SL, Subbakrishna DK, Gopukumar K. NIMHANS Neuropsychology Battery-2004. Bangalore:
+NIMHANS; 2004.
+14. Heaton RK, Grant I, Butters N, White DA, Kirson D, Atkinson JH, et al. The HNRC 500 –
+Neuropsychology of HIV infection at different disease stages. HIV Neurobehavioral Research Center. J Int
+Neuropsychol Soc. 1995;1:231–51. [PubMed: 9375218]
+15. Strachan MW, Deary IJ, Ewing FM, Frier BM. Is type II diabetes associated with an increased risk of
+cognitive dysfunction? A critical review of published studies. Diabetes Care. 1997;20:438–45. [PubMed:
+9051402]
+16. McEwen BS. Stress and hippocampal plasticity. Annu Rev Neurosci. 1999;22:105–22. [PubMed:
+10202533]
+17. Kenny DT, Faunce G. The impact of group singing on mood, coping, and perceived pain in chronic
+pain patients attending a multidisciplinary pain clinic. J Music Ther. 2004;41:241–58. [PubMed:
+15327342]
+18. Clift S, Nicol J, Raisbeck M, Whitmore C, Morrison I. Group singing, wellbeing and health: A
+systematic mapping of research evidence. [Last cited on 2010 Oct 01];Univ Melb Refereed E J. 2010 2:1–
+15. Available from: http://www.education.unimelb.edu.au/__data/assets/pdf_file/0007/1105927/clift-
+paper.pdf .
+Figures and Tables
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+6/11
+Table 1
+Details of the participants
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+7/11
+Table 2
+Daily practice
+Open in a separate window
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+8/11
+Table 3
+Pre-and post-scores on the perceived stress scale, cortisol, and visual analog scale
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+9/11
+Table 4
+Raw scores of verbal n-back 1 and 2 tests
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+10/11
+Table 4a
+Raw scores of Color Trails Tests
+1/27/2021
+Effectiveness of Music Therapy on Focused Attention, Working Memory and Stress in Type 2 Diabetes: An Exploratory Study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793012/?report=printable
+11/11
+Table 4b
+Pre-and post-intervention percentile scores on the cognitive tests
+Articles from International Journal of Yoga are provided here courtesy of Wolters Kluwer -- Medknow
+Publications

subfolder_0/Effects of a Holistic Yoga Program on Endocrine Parameters in Adolescents with Polycystic.txt

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+International Journal of Yoga  Vol. 5  Jul-Dec-2012
+112
+depression and anxiety. Indeed, it has a significant effect 
+on adult women, resulting in diminished quality of life, 
+altered feminine identity, and dysfunction in the family 
+and work environment.[4‑6] Further, the risk of adolescents 
+with PCOS, who are at the height of identity development 
+and awareness of body image, having a more significant 
+disturbance in quality of life, cannot be overlooked.
+Studies prove that PCOS women show high prevalence of 
+anxiety.[7] Kerchner et al.,[8] documented a prevalence of 
+11.6% of anxiety syndromes in PCOS women. Also, there 
+is evidence to support the concept that anxiety is a risk 
+factor for the development of depressive disorders[9,10] and 
+suicide attempts[10,11] which have an increased prevalence 
+in PCOS patients.[12] Therefore, it is necessary to include 
+assessment of anxiety symptoms while diagnosing 
+adolescents with PCOS.
+Lifestyle interventions are the first‑line effective treatment 
+for PCOS. Small changes in lifestyle are known to improve 
+INTRODUCTION
+Polycystic ovarian syndrome (PCOS) is the most prevalent 
+female endocrine disorder with estimates ranging from 
+2.2% to as high as 26%.[1,2] In a recent survey, we have 
+found a 9.13% prevalence of PCOS in south Indian 
+adolescent girls.[3]
+Patients with PCOS face challenges to their feminine 
+identity including irregular menstrual cycles, hirsutism, 
+acne, acanthosis nigricans, obesity, and infertility all likely 
+to impact quality of life and mood and potentially precipitate 
+Context: Yoga techniques practiced for varying durations have been shown to reduce state anxiety. This was never assessed 
+in adolescents with polycystic ovarian syndrome (PCOS).
+Aims: To compare the effect of a holistic yoga program with the conventional exercise program on anxiety level in adolescents 
+with PCOS.
+Settings and Design: Ninety adolescent (15‑18 years) girls from a residential college in Andhra Pradesh, who satisfied the 
+Rotterdam criteria, were randomized into two groups.
+Materials and Methods: Anxiety levels were assessed at inclusion and after 12 weeks of intervention wherein yoga group 
+practiced a holistic yoga module while the control group practiced a matching set of physical exercises (1 h/day, for 12 weeks).
+Statistical Analysis Used: Mann‑Whitney U test was used to compare difference scores (delta change) between the two groups
+Results: Changes in state anxiety after the intervention were nonsignificantly different between the two groups (P=0.243), 
+while changes after the intervention were significantly different between the two groups (P=0.002) for trait anxiety.
+Conclusions: Twelve weeks of a holistic yoga program in adolescents with PCOS is significantly better than physical exercise 
+program in reducing anxiety symptoms.
+Key words: Anxiety; polycystic ovarian syndrome; yoga.
+Abstract
+Effect of holistic yoga program on anxiety symptoms in 
+adolescent girls with polycystic ovarian syndrome: 
+A randomized control trial
+Ram Nidhi, Venkatram Padmalatha1, Raghuram Nagarathna, Ram Amritanshu
+Divison of Yoga and Life science, SVYASA University, 1Consultant Obstetrician and Gynecologist, Rangadore Memorial Hospital, Bengaluru, India
+Addrses for correpondence: Ms. Nidhi Ram, 
+#19, Eknath Bhavan, Gavipuram Circle, Kempegowda Nagar, Bangalore ‑ 560 019, India. 
+E‑mail: [email protected]
+Original Article
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.98223
+113
+International Journal of Yoga  Vol. 5  Jul-Dec-2012
+Nidhi, et al.: Effect of yoga on anxiety in adolescents with PCOS: RCT
+symptoms and psychological well being. Two studies 
+have investigated the effect of exercise on psychological 
+outcomes in PCOS. A small, non‑randomized study in 
+overweight and obese women with PCOS reported that a 
+six‑month, self‑directed brisk walking program improved 
+body image distress scores.[13] Recently, Thomson et al.,[14] 
+observed improvements in quality of life and depression 
+in overweight women with PCOS after 20  weeks 
+following an energy‑restricted diet with and without 
+exercise  (aerobic  only or combined aerobic‑resistance 
+exercise).
+Yogic life style, a form of holistic mind‑body medicine, 
+developed thousands of years ago, is simple and 
+can be practiced by all. There is mounting evidence 
+that Yoga reduces anxiety symptoms. A study on 
+cyclic meditation on healthy male volunteers shows 
+reduction in state anxiety as assessed by Spielberger’s 
+inventory.[15] Also, a two‑month (90 min twice a week) 
+yoga intervention showed a significant decrease in 
+state and trait anxiety in women suffering from anxiety 
+disorders.[16] However, till date, the effects of a yoga 
+practice have not been assessed in adolescents with 
+PCOS. The present study was planned to assess the 
+effect of yoga on anxiety level in adolescent girls with 
+PCOS.
+MATERIALS AND METHODS
+Participants
+The study was carried out on adolescent girls aged 15 to 
+18 years from a residential college in Anantapur, Andhra 
+Pradesh, India. Those who satisfied the Rotterdam 
+criterion (2/3 of the features) for PCOS were included in 
+the study. The following were the definitions of the three 
+features.
+Oligo/amenorrhea: Absence of menstruation for 45 days or 
+more and/or less than eight menses per year.[17]
+Clinical hyperandrogenism: Modified Ferriman and 
+Gallway (mFG) score of 6 or higher.[1] Biochemical 
+hyperandrogenism: Serum testosterone level of >82 ng/dl 
+in the absence of other causes of hyperandrogenism.
+Poly cystic ovaries: Presence of >10 cysts, 2‑8 mm in 
+diameter, usually combined with increased ovarian 
+volume of >10 cm3, and an echo‑dense stroma in pelvic 
+ultrasound scan.[18]
+Exclusion criteria were use of oral contraceptives/hormone 
+treatment/insulin‑sensitizing agents within previous 
+six weeks, smoking, hyperprolactinemia, thyroid 
+abnormalities, non‑classic adrenal hyperplasia, prior 
+experience of yoga and those who did not consent for the 
+study.
+The study was approved by the Institutional Ethical 
+Committee of Swami Vivekananda Yoga Anusandhana 
+Samsthana (SVYASA) University. Signed informed consent 
+was obtained from the college authorities, the students and 
+one of the parents.
+Power calculation
+Effect size of 0.61 was obtained by using the post 
+intervention mean difference between the two groups 
+from the study by Tang et  al. on obese PCOS women 
+that compared six months of metformin and lifestyle 
+modification with a placebo, as there were studies on yoga 
+for PCOS.[19] A sample size of 86 with 43 subjects in each 
+arm was calculated keeping this effect size of 0.61, with 
+Type 1 error at 0.05 powered at 0.8.
+Design
+This was a prospective, randomized, active interventional 
+controlled trial in which 90 participants were randomly 
+divided into two study arms: One arm practiced yoga and 
+the other arm practiced conventional physical exercises 
+for the same duration.
+Methods
+All women students of standard 11 and 12 attended an 
+interactive introductory lecture where the purpose and 
+design of the study were elucidated. They were asked to 
+report one week later after obtaining the signed consent 
+from their parents. After obtaining the written consent, 
+a clinical examination was performed. All girls with 
+oligomenorrhea and/or hirsutism (as per the above said 
+definitions) were asked to come for the ultrasound scan 
+and blood tests. Those who satisfied the Rotterdam’s 
+criteria for PCOS were then randomly assigned to two 
+groups using a computer‑generated random number table 
+by the pre labeled sealed envelope method. Based on 
+random number table, participants were assigned to two 
+interventions. Anthropometric measurements (BMI, waist 
+and hip circumference), details of menstrual frequency 
+and anxiety levels were documented.
+Two different halls in the college premises were allotted 
+for yoga and control group practices. Both groups practiced 
+their respective set of practices, 1 h daily, 7 days a week 
+for 12 weeks (total 90 sessions), under the supervision of 
+trained instructors. The daily routine in the class consisted 
+of lecture (5 min) followed by physical practices (40 min), 
+pranayama (5 min) and relaxation (10 min). The instructors 
+maintained the register of daily attendance and the reason 
+for absence if any.
+International Journal of Yoga  Vol. 5  Jul-Dec-2012
+114
+Nidhi, et al.: Effect of yoga on anxiety in adolescents with PCOS: RCT
+Blinding and masking
+Double blinding was not possible as this was an 
+interventional study. The medical officer, ultrasonologist 
+and the laboratory staff were blind to the groups. Also 
+the statistician who did the randomization and the final 
+analysis was blind to the source of the data.
+Assessments
+Abdominal ultrasound scanning of the pelvis with 
+special attention on ovaries was carried out by a certified 
+postgraduate medical ultrasonologist using Philips HD 
+11XE ultrasound system. Vaginal ultrasound scanning was 
+not acceptable to the girls or the parents.
+Fasting sample of venous blood (10 ml) was analyzed at 
+certified laboratories.
+Hormone estimates including total testosterone (TT) 
+and prolactin (PRL) were done by fully automated 
+bidirectionally interfaced chemiluminescent immunoassay. 
+Thyroid stimulating hormone (TSH) was measured by ultra 
+sensitive sandwich chemiluminescent immunoassay. The 
+intra‑ and inter‑assay coefficients of variation were 4.0 and 
+5.6% for testosterone.
+The state‑trait anxiety inventory (STAI) is the most widely 
+used, cross‑cultural anxiety measure. It was originally 
+developed as a research instrument to investigate anxiety 
+in normal adults and has also been successfully used to 
+measure anxiety in junior and senior high school students. 
+The STAI is comprised of separate self‑report scales for 
+measuring two distinct anxiety concepts: It consists 
+of 2  forms (Y1 and Y2) each comprising of 20  items 
+rated on a 4 point scale.[20]
+Form Y1 assesses state anxiety, 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 the respondents 
+feel right now at this moment. Form Y2 evaluates 
+trait anxiety, which is ‘a relatively stable individual 
+predisposition  to  respond to situations perceived as 
+threatening’.
+The overall median alpha co‑efficient is 0.92 and the 
+tool has adequate concurrent, convergent, divergent and 
+construct validity.[20]
+Intervention
+The specific modules of intervention were developed by a 
+team of experts that included a physiatrist, a gynecologist 
+and yoga therapy physician. Care was taken to match 
+the lectures, practical classes and the type of relaxation 
+technique used in the two modules.
+Yoga intervention
+The concepts for the intervention were taken from 
+traditional yoga scriptures (Patanjali yoga sutras, 
+Upanishads and Yoga Vasishtha) that highlight a holistic 
+approach to health management.[21] The practices 
+consisted of asanas (yoga postures), pranayama, relaxation 
+techniques, meditation, and lectures on yogic lifestyle 
+and stress management through yogic counseling. All 
+girls received at least one session (about 1 h each) of 
+individualized counseling that was aimed at cognitive 
+restructuring based on yoga philosophy.
+Control intervention
+Table  1 shows the hour‑long module of practices for 
+the control group that consisted of a set of physical 
+movements, non‑yogic safe breathing exercises followed 
+by supine rest (without instructions) that were matched 
+with the yoga module. One session of counseling was 
+ensured for the students in the control group also. Care 
+was taken by the counselors not to introduce any of the 
+yogic concepts during these sessions [Table 1].
+Data analysis
+All statistical analyses were performed using SPSS 
+version 17.0. Kolmogorov–Smirnov test was used to check 
+for normal distribution. As our objective was to compare 
+the changes after yoga with that of exercise and the data 
+was not normally distributed, non‑parametric analysis was 
+done by using Mann‑Whitney U test to compare difference 
+scores (delta change) between the two groups wherein 
+difference score was calculated by subtracting pre from 
+post values for each variable.
+RESULTS
+Figure 1 describes the trial profile. The recruitment was 
+carried out between December 2009 and January 2011. Of 
+986 girls who agreed for clinical examination, 154 girls 
+with oligomenorrhea and/or hirsutism (as per the above 
+said definitions) were asked to come for ultrasound and 
+hormonal investigations. After the laboratory evaluations, 
+90 girls who satisfied Rotterdam criteria of PCOS were 
+randomized into two groups. Of these, there were total 
+18 dropouts, 8 in the yoga group and 10 in the control 
+group because of less than 75% attendance. The reasons 
+(not confirmed) given for withdrawal were (a) sick leave 
+and (b) unexpected events in the family. The final analysis 
+was done on 72 participants, 37 in the yoga group and 35 
+in the control group.
+115
+International Journal of Yoga  Vol. 5  Jul-Dec-2012
+Nidhi, et al.: Effect of yoga on anxiety in adolescents with PCOS: RCT
+Table  2 shows the demographic data. Of the 90  girls 
+recruited, 82.2% (74/90) were of normal weight (BMI=18.5 
+to 23) and only 17.78% (16/90) were overweight (BMI> 
+23) and 31.11% (28/90) had mFG score ≥6. Maximum 
+66.67% (60/90) numbers of the girls had their menstrual 
+cycle length between 60 and 90 days.
+Mann‑Whitney U test on difference score showed that 
+the changes in state anxiety after the intervention were 
+non‑significantly different between the two groups 
+(P=0.243), although yoga group (‑12.27) observed a greater 
+reduction than the exercise group (‑8.55) [Table 3, Figure 2].
+
+
+
+
+
+
+
+
+
+([HUFLVH
+<RJD
+3UH
+3RVW
+Figure 2: State anxiety
+Table  1: Matched practices between yoga and control 
+groups
+Yoga group
+Time
+Control group
+Time
+Group lecture
+Lectures, in the form of 
+cognitive restructuring 
+based on the spiritual 
+philosophy underlying 
+yogic concepts
+8 min
+Group lecture
+Lectures on 
+conventional modern 
+medical concepts 
+about a healthy 
+lifestyle including 
+diet, exercise
+15 min
+Surya namaskara (sun 
+salutation)
+10 min Brisk walk
+15 min
+Prone asanas
+Prone exercises
+Cobra pose 
+(bhujangasana)
+1 min
+Prone head lift
+1 min
+Locust pose (salabhasana)
+1 min
+Prone leg rising
+1 min
+Bow pose (dhanurasana)
+1 min
+Tiger leg stretch
+1 min
+Standing asanas
+Standing exercises
+Triangle pose 
+(trikonasana)
+1 min
+Spread leg side 
+bending
+1 min
+Twisted angle pose 
+(parsva ‑konasana)
+1 min
+Spread leg twisted 
+bending
+1 min
+Spread leg intense stretch 
+(prasarita padottanasana)
+1 min
+Spread leg forward 
+bend
+1 min
+Supine asanas
+Supine exercises
+Inverted pose (viparita 
+karni)
+1 min
+Straight leg raising
+1 min
+Shoulder stand 
+(sarvangasana)
+1 min
+Straight leg supine 
+twist
+1 min
+Plough pose (halasana)
+1 min
+Cycling ‑ bended 
+knee crunches
+1 min
+Sitting asanas
+Sitting exercises
+Sitting forward stretch 
+(paschimottanasana)
+1 min
+Spread leg forward 
+bend
+1 min
+Fixed angle pose 
+(baddha‑ konasana)
+1 min
+Spread leg alternate 
+toe touching
+1 min
+Garland pose (malasana)
+1 min
+Squat pose
+1 min
+Guided relaxation 
+(savasana)
+10 min Supine rest
+10 min
+Breathing techniques 
+(pranayama)
+Normal breathing
+8 min
+Sectional breathing 
+(vibhagiya‑ pranayama)
+4 min
+Forceful exhalation 
+(kapala bhati)
+2 min
+Right nostril breathing 
+(suryanuloma viloma)
+2 min
+Alternate nostril breathing 
+(nadi suddhi)
+2 min
+OM meditation (OM 
+dhyana)
+10 min
+Figure 1: Trial profile
+6FUHHQHGQ 
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+/DERUDWRU\(YDOXDWLRQ
+
+Table  2: Demography
+Variables
+Yoga (n=42)
+Control (n=43)
+Age, years (mean±S.D.) 
+16.22 ± 1.13
+16.22 ± 0.93
+Height, m (mean±S.D.) 
+1.54 ± 0.06
+1.56 ± 0.05
+Weight, kg (mean±S.D.)
+47.92 ± 6.20
+51.14 ± 7.39
+BMI, kg/m² (mean±S.D.)
+20.30 ± 1.92
+21.22 ± 2.99
+No. of girls with BMI≤23
+No. of girls with BMI>23
+37
+5
+34
+9
+mFG score
+No. of girls with mFG score <6
+No. of girls with mFG score ≥6
+4.60 ± 2.02
+30
+15
+4.20 ± 2.13
+32
+13
+Menstrual frequency in months 
+(mean±S.D)
+1.41 ± 0.8
+1.47 ± 0.87
+No. of girls with cycle length of 
+45 to <60 days
+No. of girls with cycle length of 
+60 to <90 days
+No. of girls with cycle length of 
+≥90 days
+9 
+14 
+19
+9 
+16 
+18
+Mann‑Whitney U test on difference scores of trait 
+anxiety showed that changes after the intervention were 
+significantly different between the two groups (P=0.002; 
+Figure 3) with yoga group (‑14.97) observing a higher 
+reduction than the exercise group (‑7.42).
+DISCUSSION
+This is the first randomized controlled trial comparing 
+the effect of a holistic yoga program with physical 
+exercise on state and trait anxiety in adolescents with 
+PCOS.
+International Journal of Yoga  Vol. 5  Jul-Dec-2012
+116
+Nidhi, et al.: Effect of yoga on anxiety in adolescents with PCOS: RCT
+Present study observed higher values for state and trait 
+anxiety as compared to Spielberger‘s[20] normative data on 
+377 high school juniors (190 males, 187 females) at Long 
+Beach, New York, Senior High School. These normal female 
+students had a mean±SD of 37.57±11.76 with an α of 
+0.92 for A‑state while in the present study mean±SD was 
+55.67±10.85. The mean±SD for A‑trait was 41.61±11.29 
+with an α 0.92 while in the present study mean±SD was 
+58.00±8.09.
+The baseline scores in our study were higher than healthy 
+Indian girls who had A‑trait score of 22.5±5.6 (our PCOS 
+girls=41.61±11.29) as reported by Deb et al.,[22] in their 
+study on 240 healthy adolescent girls from Kolkata city, 
+West Bengal, India.
+The values reported by Spielberg et al. and Deb et al. are 
+from normal high school girls, whereas the data presented 
+by this study are girls from the same age group with PCOS 
+and hence have higher anxiety levels.
+The changes in trait anxiety were significantly different 
+between the two groups after 12 weeks of intervention and 
+5 days of detraining, wherein yoga group (−14.97) observed 
+a higher reduction than the exercise group (−7.42).
+The results observed in this study may have occurred 
+because of the calmness of mind achieved after the yoga 
+practice. There are evidences proving efficacy of yoga 
+in reducing stress arousal by modulating sympathetic 
+nerve activity[23] and reducing anxiety levels.[24] Also, the 
+mental silence facilitates greater awareness by altering 
+the individual’s cognitive appraisal and perceived 
+self‑efficacy with regard to stressors and thus reduces 
+anxiety symptoms.[25] The cognitive‑behavioral effects are 
+thought to result from the yogic practitioner’s increased 
+awareness of how thoughts and emotions arise in response 
+to various environmental events, thereby allowing them to 
+achieve more clear perception, reduced negative emotions, 
+and improved vitality and coping.[26]
+Yoga not only reduces trait anxiety in adolescents with 
+PCOS but also may prevent the long‑term sequelae such as 
+CVD, diabetes etc. Further, yoga as a self corrective therapy 
+is potentially more cost‑effective and enduring. Hence we 
+recommend yoga as both a primary intervention and/or as 
+adjunct to standard medical care.
+This study was performed on a captive adolescent 
+population with a highly selective age group, which raises 
+the question of generalizability of the conclusions of this 
+study. However, the fact that this was a randomized control 
+trial with a large sample participating in each arm provides 
+evidence for this intervention being effective.
+CONCLUSION
+Twelve weeks of a holistic yoga program in adolescents 
+with PCOS is significantly better than physical exercise 
+program in reducing anxiety symptoms. Thus, we 
+recommend yoga to be incorporated as complimentary in 
+management of adolescents with PCOS as this may help 
+in reducing the progression of the disease.
+ACKNOWLEDGMENTS
+We are thankful to the Central Council for Research in Yoga and 
+Naturopathy (C.C.R.Y.N.), Ministry of Health, Government of 
+India, New Delhi for funding this project.
+We would like to place on record our gratitude for the support 
+provided by the Vice Chancellor, SVYASA University. We gratefully 
+acknowledge the co‑operation of the staff and administration of Sri 
+Sai College in recruiting the students and carrying out the study.
+Ethical approval
+The study was approved by the Institutional Ethical Committee 
+of Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA) 
+University (vide project # SVYASA0012/08).
+REFERENCES
+1.	
+Chen X, Yang D, Mo Y, Li L, Chen Y, Huang Y. Prevalence of polycystic 
+ovary syndrome in unselected women from southern China. Eur J Obstet 
+Table 3: Changes in state and trait anxiety post intervention
+Variable
+Yoga (n=37)
+Exercise (n=35)
+Mann-Whitney 
+on diff score 
+(sig.)
+Pre 
+(mean±SD)
+Post 
+(mean±SD)
+Diff score 
+(mean±SD)
+Pre 
+(mean±SD)
+Post 
+(mean±SD)
+Diff score 
+(mean±SD)
+State
+57.79±10.46
+45.52±7.82
+12.27±14.33
+53.55±10.98
+45.00±7.19
+8.55±12.56
+0.243
+Trait
+61.36±7.02
+46.39±7.28
+14.97±9.87
+54.64±7.77
+47.21±6.99
+7.42±7.57
+0.002
+Figure 3: Trait anxiety
+117
+International Journal of Yoga  Vol. 5  Jul-Dec-2012
+Nidhi, et al.: Effect of yoga on anxiety in adolescents with PCOS: RCT
+Gynecol Reprod Biol 2008;139:59‑64.
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+Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Prevalence of Polycystic 
+Ovarian Syndrome in Indian Adolescents. J Pediatr Adolesc Gynecol 
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+Paulson J. An investigation of the relationship between emotional 
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+J 1993;69:189‑96.
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+Development of a health‑related quality‑of‑life questionnaire (PCOSQ) for 
+women with polycystic ovary syndrome (PCOS). J Clin Endocrinol Metab 
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+mental health disorders in women with polycystic ovary syndrome: 
+A longitudinal study. Fertil Steril 2009;91:207‑12.
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+Belzer K, Schneier FR. Comorbidity of anxiety and depressive disorders: 
+Issues in conceptualization, assessment, and treatment. J Psychiatr Pract 
+2004;10:296‑306.
+10.	 Culpepper L. Social anxiety disorder in the primary care setting. J Clin 
+Psychiatry 2006;67:31‑7.
+11.	
+Stein MB. An epidemiologic perspective on social anxiety disorder. J Clin 
+Psychiatry 2006;67:3‑8.
+12. Mansson M, Holte J, Landin‑Wilhelmsen K, Dahlgren E, Johansson A, 
+Landon M. Women with polycystic ovary syndrome are often depressed or 
+anxious‑a case control study. Psychoneuroendocrinology 2008;33:1132‑8.
+13. Liao LM, Nesic J, Chadwick PM, Brooke‑Wavell K, Prelevic GM. Exercise 
+and body image distress in overweight and obese women with polycystic 
+ovary syndrome: A pilot investigation. Gynecol Endocrinol 2008;24:555‑61.
+14.	 Thomson RL, Buckley JD, Lim SS, Noakes M, Clifton PM, Norman RJ, 
+et al. Lifestyle management improves quality of life and depression in 
+overweight and obese women with polycystic ovary syndrome. Fertil Steril 
+2010;94:1812‑6.
+15.	 Subramanya P, Telles S. Effect of two yoga‑based relaxation techniques 
+on memory scores and state anxiety. Biopsychosoc Med 2009;3:8.
+16. Javnbakht M, Hejazi Kenari R, Ghasemi M. Effects of yoga on depression 
+and anxiety of women. Complement Ther Clin Pract 2009;15:102‑4.
+17. Kumarapeli V, Seneviratne RD, Wijeyaratne CN, Yapa R, Dodampahala SH. 
+A simple screening approach for assessing community prevalence and 
+phenotype of polycystic ovary syndrome in a semiurban population in 
+Sri Lanka. Am J Epidemiol 2008;168:321‑8.
+18. Franks S, Gharani N, Waterworth D, Batty S, White D, Williamson R, 
+et  al. The genetic basis of polycystic ovary syndrome. Human 
+Reproduction. 1997;12:2641‑8.
+19. Tang T, Glanville J, Hayden CJ, White D, Barth JH, Balen AH. Combined 
+lifestyle modification and metformin in obese patients with polycystic ovary 
+syndrome. A randomized, placebo‑controlled, double‑blind multicentre study. 
+Hum Reprod 2006;21:80‑9.
+20.	 Spielberger CD, Gorsuch RL, Lushene RD. STAI: Manual for the State‑Trait 
+Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1970.
+21.	 Nagendra HR, Nagarathna R. Breath‑the bridge‑Breathing Practices. In: R N, 
+editor. Bangalore, India: Swami Vivekananda Yoga Prakashan; 2004.
+22. Deb S, Chatterjee P, Walsh K. Anxiety among high school students in India: 
+Comparisons across gender, school type, social strata and perceptions of 
+quality time with parents. Aust J Educ Dev Psychol 2010;10:18-31.
+23.	 Vempati RP, Telles S. Yoga‑based guided relaxation reduces sympathetic 
+activity judged from baseline levels. Psychol Rep 2002;90:487‑94.
+24.	  Telles S, Gaur V, Balkrishna A. Effect of a yoga practice session and a yoga 
+theory session on state anxiety.Percept Mot Skill. 2009;109:924-30.
+25.	 Smith JC. Meditation, biofeedback, and the relaxation controversy. 
+A cognitive‑behavioral perspective. Am Psychol 1986;41:1007‑9.
+26. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness‑based 
+stress reduction and health benefits: A meta‑analysis. J Psychosom Res 
+2004;57:35‑43.
+How to cite this article: Ram N, Padmalatha V, Nagarathna R, 
+Amritanshu R. Effect of holistic yoga program on anxiety symptoms 
+in adolescent girls with polycystic ovarian syndrome: A randomized 
+control trial. Int J Yoga 2012;5:112-7.
+Source of Support: Central Council for Research in Yoga and 
+Naturopathy (C.C.R.Y.N.), Ministry of health, Government of India, New 
+Delhi for funding this project, Conflict of Interest: It is declared that none 
+of the authors involved in this study have any conflict of interest and that 
+all authors of this article have contributed to their fullest capacities
+Staying in touch with the journal
+1)	
+Table of Contents (TOC) email alert 
+	
+Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to 
+www.ijoy.org.in/signup.asp.
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subfolder_0/Efficacy of a validated yoga protocol on dyslipidemia in diabetes patients NMB-2017 India trial.txt

@@ -0,0 +1,756 @@
+medicines
+Article
+Efficacy of a Validated Yoga Protocol on Dyslipidemia
+in Diabetes Patients: NMB-2017 India Trial
+Raghuram Nagarathna 1,*,†, Rahul Tyagi 2,†, Gurkeerat Kaur 2, Vetri Vendan 1,
+Ishwara N. Acharya 3, Akshay Anand 2,*, Amit Singh 1 and Hongasandra R. Nagendra 1
+1
+Swami Vivekananda Yoga Research Foundation, Bengaluru 560105, India; [email protected] (V.V.);
+[email protected] (A.S.); [email protected] (H.R.N.)
+2
+Neuroscience Research Lab, Department of Neurology, Postgraduate Institute of Medical Education and
+Research, Chandigarh 160012, India; [email protected] (R.T.); [email protected] (G.K.)
+3
+Central Council for Research in Yoga & Naturopathy (CCRYN), Delhi 110058, India;
+[email protected]
+*
+Correspondence: [email protected] (R.N.); akshay1anand@rediffmail.com (A.A.)
+†
+These authors contribute equally to the article.
+Received: 15 August 2019; Accepted: 8 October 2019; Published: 11 October 2019
+



+

+Abstract: Background: Dyslipidemia is considered a risk factor in Type 2 diabetes mellitus (T2DM)
+resulting in cardio-vascular complications. Yoga practices have shown promising results in alleviating
+Type 2 Diabetes pathology. Method: In this stratified trial on a Yoga based lifestyle program in
+cases with Type 2 diabetes, in the rural and urban population from all zones of India, a total of
+17,012 adults (>20 years) of both genders were screened for lipid profile and sugar levels. Those who
+satisfied the selection criteria were taught the Diabetes Yoga Protocol (DYP) for three months and
+the data were analyzed. Results: Among those with Diabetes, 29.1% had elevated total cholesterol
+(TC > 200 mg/dL) levels that were higher in urban (69%) than rural (31%) Diabetes patients. There was
+a positive correlation (p = 0.048) between HbA1c and total cholesterol levels. DYP intervention
+helped in reducing TC from 232.34 ± 31.48 mg/dL to 189.38 ± 40.23 mg/dL with significant pre post
+difference (p < 0.001). Conversion rate from high TC (>200 mg/dL) to normal TC (<200 mg/dL) was
+observed in 60.3% of cases with Type 2 Diabetes Mellitus (T2DM); from high LDL (>130 mg/dL) to
+normal LDL (<130 mg/dL) in 73.7%; from high triglyceride (>200 mg/dL) to normal triglyceride level
+(<200 mg/dL) in 63%; from low HDL (<45 mg/dL) to normal HDL (>45 mg/dL) in 43.7% of T2DM
+patients after three months of DYP. Conclusions: A Yoga lifestyle program designed specifically to
+manage Diabetes helps in reducing the co-morbidity of dyslipidemia in cases of patients with T2DM.
+Keywords: diabetic yoga protocol; DYP; dyslipidemia; T2DM; diabetes mellitus
+1. Introduction
+1.1. Prevalence, Burden of Type 2 Diabetes Mellitus and Dyslipidemia
+Type 2 diabetes mellitus (T2DM) is a chronic hyperglycemic metabolic disorder that occurs due
+to a complex interaction of several prevailing lifestyle factors including diet, obesity, and physical
+inactivity against a background of genetic and epigenetic factors [1]. These contribute to insulin
+resistance and relative insulin deficiency over time [2], resulting in complications such as cataracts,
+retinopathy, neuropathy, and nephropathy [3].
+Recent worldwide findings show that the prevalence of Diabetes in adults in developing countries
+when compared to developed countries has increased from 4.3% to 9.0% in men and 5.0% to 7.9% in
+women in the last 35 years [4]. In India, it has been estimated that around 66.8 million people have
+diabetes [5]. As expected, not until very recently was the prevalence in the rural population known.
+Medicines 2019, 6, 100; doi:10.3390/medicines6040100
+www.mdpi.com/journal/medicines
+Medicines 2019, 6, 100
+2 of 11
+A recent study of rural dwelling reported that 8.03% of the recruited population from western Uttar
+Pradesh was suffering from Diabetes and amongst them 9.91% were females and 6.79% were males [6].
+Interestingly, a study assessed the mean expenditure in the management of T2DM and revealed the
+Indian rupee 853.47 to be the estimated average monthly expenses per individual. This expenditure
+increases with the duration of the disease and is concomitant with an increase in the complications
+associated with it [7]. In light of the increased expenditure on screening, diagnosis, monitoring,
+and management of T2DM, the combined health budget of developing countries is affected [5].
+Diabetes and pre-diabetes together affects almost one fourth of the Indian population, which is clearly
+traceable to the rapidly changing lifestyle [8,9].
+Hypertension and hyperlipidemia are the most common co-morbidities associated with T2DM.
+Both these co-morbidities hasten the occurrence of renal and cardiovascular complications at an alarming
+rate [10]. Myocardial infarction remains the most common cause of death in T2DM patients [11,12] as
+well as the prime cause of deaths worldwide [10,13]. Briefly, the factors responsible for an increase
+in cardio-vascular diseases (CVD) are diabetes, hypertension, abnormal cholesterol and triglyceride
+levels, high levels of low density lipoprotein (LDL), low levels of high density lipoprotein (HDL),
+and obesity [14]. Murray and Lopez predicted that between 1990–2020, CVD will cause devastating
+effects on human health and as expected, the diabetes population with dyslipidemia will be severely
+affected [15]. A cross sectional study conducted on 297 Indian subjects reported a direct correlation
+between the blood levels of glycated hemoglobin (HbA1c) and total cholesterol, LDL, and triglycerides
+besides an inverse relation with HDL levels [16,17]. Furthermore, it was shown that T2DM associated
+with decreased HDL and increased production of triglycerides, LDL, and very low lipoproteins (VLDL)
+levels is presumably due to impaired catabolism [18].
+1.2. Lifestyle Interventions
+Studies continue to reveal that even though T2DM is widely prevalent in India, there is a lack
+of access to healthcare, awareness, counseling, and treatments.
+Studies have recommended an
+improvement in lifestyle for managing all modifiable risk factors for the secondary prevention of
+complications in patients with T2DM [19].
+1.3. Why This Yoga Study
+In pursuit of better and cost-effective intervention of T2DM, Yoga has emerged as a natural and
+widely therapeutic option. Supporting evidence has shown that Yoga can positively impact T2DM
+patients by reducing fasting blood glucose (FBG) and HbA1c levels, and helps in improving the
+lipid profile and hypertension of T2DM patients [20]. It has been shown that Yoga has re-emerged
+as an integrated approach and found to be effective in the prevention and treatment of T2DM and
+dyslipidemia to the extent that it reduces overall healthcare costs by reducing future medications
+and hospitalizations [21,22]. However, a standardized protocol based on a Yoga lifestyle research is
+needed for effective community health translation [23,24]. Therefore, we examined the effect of the
+Diabetes Yoga lifestyle protocol on the lipid profile of a large sample population of patients with T2DM
+across India.
+2. Materials and Methods
+2.1. Study Design
+This was a stratified translational research study in randomly selected cluster populations from
+all zones of rural and urban India. Study was approved by the Institutional Ethics Committee of the
+Indian Yoga Association (IYA) vide Res/IEC-IYA/001 dated 16 December 2016. The current study was
+registered in the Clinical Trial Registry of India (CTRI) vide CTRI/2018/03/012804.
+Medicines 2019, 6, 100
+3 of 11
+2.2. Screening and Recruitment of Participants
+The study participants were recruited after obtaining signed informed consent as per the guidelines
+outlined by the Institutional Ethical Committee of Indian IYA. Detailed methodology adopted has been
+previously reported [25,26]. In brief, baseline assessment was carried out by a nationwide door to door
+screening in urban and rural districts under the flagship of the Niyantrita Madhumeha Bh¯
+arat (NMB)
+Abhiy¯
+an (Diabetes Control Program), funded by the Ministry of Health and Family Welfare, the ministry
+of AYUSH, Government of India, New Delhi, and conducted by IYA. The Diabetes Yoga Protocol (DYP)
+was validated by the Quality Council of India. Subjects were recruited based on the Indian Diabetic
+Risk Score (IDRS). T2DM individuals and those with a high risk on the Indian diabetes risk score,
+detected during screening at the randomly selected clusters of villages (rural) and census enumeration
+blocks (urban), were recruited and enrolled. They adopted a three months Yoga lifestyle protocol under
+the supervision of a trained Yoga teacher. Subjects adhered to five days a month for three months and
+attendance was recorded. Compliance was also ensured by WhatsApp reminders for the Yoga sessions.
+2.3. Selection Criteria
+All subjects who satisfied the selection criteria and signed the informed consent were included
+in the study. Medication to T2DM was not considered to be exclusion criteria. However, detailed
+medication records were not available. Known/self-reported/newly detected Diabetics or high risk
+subjects of all genders between age ranges of 20–70 were selected for analysis. For newly detected
+T2DM, the HbA1c level (6.5%) in high risk (>60 on IDRS) population was considered. Subjects with
+other co-morbidities including cancer, serious cardiac illness, chronic liver, pulmonary, neurological,
+renal diseases, lower back pain, and surgical interventions were excluded. Willingness to register in
+the trial was mandatory for inclusion.
+2.4. Assessments
+All assessments were carried out at the baseline and after three months of DYP intervention.
+2.5. Anthropometric Assessments
+Anthropometric assessments included height, weight, waist circumference, and hip circumference
+carried out at the time of screening of the subjects and at follow up.
+2.6. Biochemical Assessments
+Biochemical assessments included fasting blood glucose, glycated hemoglobin (HbA1c),
+total cholesterol, triglycerides, LDL, VLDL, and HDL. Assessments were carried out by accredidated
+diagnostics lab using standard diagnostic tools and procedures acceptable for public utility.
+2.7. Intervention
+DYP was designed by the Delphi method and focused group discussion by experts from Yoga
+traditions of the Indian Yoga Association and researchers on Diabetes [26]. The practices were taught
+by a certified Yoga instructor volunteers in nine day camps (2 h daily) in their respective villages or
+wards. Subsequently, they were asked to continue the practices daily (one hour) at home, through
+the use of DVDs. Weekly follow up classes were conducted at the same venues for three months.
+The detailed methodology is provided in Supplementary Table S1.
+2.8. Statistical Analysis
+The statistical analysis was carried out using SPSS 21.0 software (IBM Corp., Armonk, NY, USA).
+The normality was tested by using the Kolmogorov–Smirnov test. The comparisons were made by
+using paired samples t-test for normally distributed data. Significance level of various proportions
+Medicines 2019, 6, 100
+4 of 11
+were analyzed by the Chi square test. McNemar’s test was performed to assess the conversion. p value
+< 0.05 was considered to test the level of significance.
+3. Results
+In this nationwide study, a total of 17,012 participants with high risk on the IDRS (>60) and
+known Diabetes were recruited. Out of the total, 5150 had HbA1c > 6.5%. Data was collected at
+two time points (i.e., before and after the Yoga intervention). Out of the 5150 T2DM patients with
+HbA1c >6.5%, 1745 individuals were found to have serum total cholesterol (TC) level > 200 mg/dL
+(borderline and hypercholesterolemia range). Post data on cholesterol values were available for
+analysis in 694 individuals after three months of a Yoga lifestyle regime. In the absence of medication
+details, the comparisons were carried between ≥200 and <200 cases with T2DM. Detailed study profile
+has been provided in Figure 1.
+Medicines 2019, 6, x FOR PEER REVIEW 
+4 of 11 
+ 
+3. Results 
+In this nationwide study, a total of 17,012 participants with high risk on the IDRS (>60) and 
+known Diabetes were recruited. Out of the total, 5150 had HbA1c > 6.5%. Data was collected at two 
+time points (i.e., before and after the Yoga intervention). Out of the 5150 T2DM patients with HbA1c 
+>6.5%, 1745 individuals were found to have serum total cholesterol (TC) level > 200 mg/dL (borderline 
+and hypercholesterolemia range). Post data on cholesterol values were available for analysis in 694 
+individuals after three months of a Yoga lifestyle regime. In the absence of medication details, the 
+comparisons were carried between ≥200 and <200 cases with T2DM. Detailed study profile has been 
+provided in Figure 1. 
+ 
+  
+Figure 1. Study profile. 
+3.1. Effect of Diabetes Yoga Protocol on Diabetes Population with Dyslipidemia 
+The DYP reduced the TC levels in 4% of T2DM patients with TC > 200 mg/dL; TC reduced 
+significantly (p ≤ 0.001; t = 22.93) from 232.34 ± 31.48 (pre yoga intervention) to 189.38 ± 40.23 (post 
+yoga intervention). Other variables of lipid profile including triglycerides (Tg), LDL, and VLDL were 
+also found to be significantly reduced after Yoga intervention. Interestingly, the HDL increased 
+significantly in those with low (<45 mg/dL) baseline values and decreased significantly in those with 
+high (>45 mg/dL) baseline values (Table 1). Total cholesterol reduced significantly in all age groups. 
+Figure 1. Study profile.
+3.1. Effect of Diabetes Yoga Protocol on Diabetes Population with Dyslipidemia
+The DYP reduced the TC levels in 4% of T2DM patients with TC > 200 mg/dL; TC reduced
+significantly (p ≤0.001; t = 22.93) from 232.34 ± 31.48 (pre yoga intervention) to 189.38 ± 40.23 (post
+yoga intervention). Other variables of lipid profile including triglycerides (Tg), LDL, and VLDL
+were also found to be significantly reduced after Yoga intervention. Interestingly, the HDL increased
+significantly in those with low (<45 mg/dL) baseline values and decreased significantly in those with
+high (>45 mg/dL) baseline values (Table 1). Total cholesterol reduced significantly in all age groups.
+Medicines 2019, 6, 100
+5 of 11
+Table 1. Pre post changes in lipids in those with high Total Cholesterol in type 2 diabetes patients in different age groups.
+MBG
+TC
+Tg
+LDL
+VLDL
+HDL
+<45 mg/dL
+HDL
+>45 mg/dL
+Cho:HDL
+Ratio
+LDL:HDL
+Ratio
+Mean (SD)
+Mean (SD)
+Mean (SD)
+Mean (SD)
+Mean (SD)
+Mean (SD)
+Mean (SD)
+Mean (SD)
+Mean (SD)
+Overall
+pre
+152.3 (64.3)
+239.4 (31.6)
+201.0 (117.5)
+142.0 (31.3)
+35.7 (15.0)
+34.9 (4.92)
+55.1 (13.5)
+4.66 (1.35)
+2.91 (1.21)
+post
+142.8 (52.7)
+189.8 (40.5)
+173.6 (98.8)
+108.4 (34.9)
+30.9 (14.9)
+44.2 (12.0)
+49.1 (11.8)
+4.03 (1.24)
+2.26 (0.94)
+20–30 years
+pre
+143.87
+(51.05)
+230.35
+(27.04)
+204.90
+(109.25)
+140.03
+(28.33)
+35.95 (15.37)
+42.7 (10.7)
+61.0 (17.3)
+4.55 (1.44)
+2.80 (1.07)
+post
+137.02
+(50.06)
+175.57
+(48.42)
+161.68
+(74.36)
+98.44 (40.75)
+31.65 (15.02)
+49.1 (15.5)
+50.3 (10.1)
+3.73 (1.23)
+2.03 (0.93)
+31–40 years
+pre
+147.41
+(58.54)
+229.66
+(29.48)
+189.97
+(98.71)
+141.61
+(31.29)
+36.37 (15.56)
+38.6 (4.48)
+58.7 (14.1)
+4.60 (1.31)
+2.89 (1.01)
+post
+139.68
+(53.35)
+189.60
+(40.64)
+176.40
+(94.97)
+107.72
+(36.06)
+33.07 (15.60)
+46.1 (10.4)
+47.9 (10.8)
+4.18 (1.36)
+2.36 (1.00)
+41–50 years
+pre
+150.18
+(62.72)
+232.28
+(29.28)
+207.05
+(124.08)
+139.40
+(29.82)
+36.54 (16.17)
+39.9 (4.44)
+57.4 (11.6)
+4.67 (1.28)
+2.87 (1.03)
+post
+140.64
+(50.94)
+185.62
+(40.46)
+163.86
+(89.86)
+105.81
+(34.39)
+30.77 (13.70)
+45.3 (11.1)
+51.4 (12.5)
+3.98 (1.24)
+2.22 (0.90)
+51–60 years
+pre
+151.55
+(57.77)
+231.95
+(28.19)
+204.57
+(120.29)
+140.07
+(27.82)
+36.38 (15.53)
+38.1 (5.64)
+61.2 (18.5)
+4.66 (1.48)
+2.92 (1.39)
+post
+139.17
+(52.35)
+189.24
+(38.78)
+168.79
+(96.36)
+106.40
+(32.93)
+30.59 (13.13)
+45.9 (11.3)
+50.7 (12.0)
+3.99 (1.15)
+2.24 (0.94)
+>60 years
+pre
+145.31
+(59.76)
+230.49
+(26.58)
+199.30
+(113.65)
+140.39
+(29.50)
+35.40 (15.03)
+37.6 (6.3)
+59.0 (13.8)
+4.77 (1.26)
+3.03 (1.45)
+post
+138.32
+(46.60)
+182.81
+(37.36)
+169.85
+(96.50)
+103.92
+(33.32)
+32.01 (15.88)
+47.5 (14.4)
+46.9 (11.3)
+4.11 (1.23)
+2.33 (0.93)
+Medicines 2019, 6, 100
+6 of 11
+3.2. DYP Is Beneficial for TC in Diabetes of All HbA1c Categories in Both Genders of Urban and Rural
+Population
+3.2.1. Dyslipidemia Higher in Rural Population
+Total cholesterol values were >200 mg dL in 29.1%; of these TC was significantly higher in the rural
+diabetes population (31%) than their urban counterparts (28%) (Supplementary Table S1). However,
+after DYP intervention, the reduction in hyperlipidemia was significantly better (p < 0.001.) in the
+rural diabetes population than in urban areas (5% vs. 3%, respectively).
+3.2.2. DYP Reduces Dyslipidemia Equally in Both Genders
+The percentage of T2DM subjects with TC level >200 mg/dL was less when compared to those
+with cholesterol levels <200 mg/dL in both genders. Mean TC level was found to be similar in both the
+genders with T2DM (Supplementary Table S1).
+3.2.3. Hyperlipidemia Increases with Increasing HbA1c
+The data showed that the levels of HbA1c and mean blood glucose levels were found to be
+positively correlated (p = 0.048) with the TC levels. This reveals that, with the increase in HbA1c levels,
+the percentage of T2DM subjects with cholesterol level > 200 mg/dl increased gradually (Figure 2).
+Moreover, after yoga intervention, the cholesterol levels were significantly reduced in all HbA1c
+categories (Supplementary Table S1).
+Medicines 2019, 6, x FOR PEER REVIEW 
+6 of 11 
+ 
+3.2. DYP Is Beneficial for TC in Diabetes of All HbA1c Categories in Both Genders of Urban and Rural 
+Population  
+3.2.1. Dyslipidemia Higher in Rural Population  
+Total cholesterol values were >200 mg dL in 29.1%; of these TC was significantly higher in the 
+rural diabetes population (31%) than their urban counterparts (28%) (Supplementary Table S1). 
+However, after DYP intervention, the reduction in hyperlipidemia was significantly better (p < 0.001.) 
+in the rural diabetes population than in urban areas (5% vs. 3%, respectively). 
+3.2.2. DYP Reduces Dyslipidemia equally in Both Genders  
+The percentage of T2DM subjects with TC level > 200 mg/dL was less when compared to those 
+with cholesterol levels < 200 mg/dL in both genders. Mean TC level was found to be similar in both 
+the genders with T2DM (Supplementary Table S1). 
+3.2.3. Hyperlipidemia Increases with Increasing HbA1c  
+The data showed that the levels of HbA1c and mean blood glucose levels were found to be 
+positively correlated (p = 0.048) with the TC levels. This reveals that, with the increase in HbA1c 
+levels, the percentage of T2DM subjects with cholesterol level > 200 mg/dl increased gradually (Figure 
+2). Moreover, after yoga intervention, the cholesterol levels were significantly reduced in all HbA1c 
+categories (Supplementary Table S1). 
+ 
+Figure 2. Relationship of HbA1c and hyperlipidemia. 
+3.2.4. Effect of DYP on the Conversion of Hyperlipidemia in Diabetes Patients (Table 2)  
+A highly significant percentage of patients with Diabetes who had abnormal lipid levels were 
+converted to normal levels after three months of yoga practice: 60.3% in total cholesterol, 73.7% in 
+LDL, 63% in triglycerides, and 43% in those with low HDL (45 mg/dL).  
+Figure 2. Relationship of HbA1c and hyperlipidemia.
+3.2.4. Effect of DYP on the Conversion of Hyperlipidemia in Diabetes Patients
+A highly significant percentage of patients with Diabetes who had abnormal lipid levels were
+converted to normal levels after three months of yoga practice: 60.3% in total cholesterol, 73.7% in
+LDL, 63% in triglycerides, and 43% in those with low HDL (45 mg/dL) (Table 2).
+Medicines 2019, 6, 100
+7 of 11
+Table 2. Shift in those with high lipid levels after yoga in diabetes patients.
+Pre
+Post
+Sig *
+DM (A1c > 6.5%)
+Above Normal Range
+Below Normal Range
+Variable
+N
+n
+%
+n
+%
+p
+TC > 200 mg/dL
+642
+242
+37.7
+400
+60.3
+<0.001
+LDL >130 mg/dL
+392
+103
+26.3
+289
+73.7
+<0.001
+Tg > 200 mg/dL
+433
+160
+37.0
+273
+63.0
+<0.001
+HDL < 45 mg/dL
+835
+470
+56.3
+365
+43.7
+<0.001
+* McNemar’s test: p ≤0.001.
+4. Discussion
+4.1. Summary
+We assessed the effect of a validated yoga lifestyle protocol on the lipid profile of 5150 patients with
+T2DM. There was a positive correlation between cholesterol with HbA1c values. A higher proportion
+of rural subjects, diabetic females with high A1c, and urban patients with high A1c were found to have
+higher cholesterol levels at the baseline, indicating vulnerability to serious complications.
+Exposure to DYP resulted in a significant reduction in total cholesterol, LDL, VLDL, and triglyceride
+levels. However, HDL was the least affected in the rural region. DYP reduced the cholesterol levels,
+better in males than females; and DYP was equally beneficial in all age groups in both the urban and
+rural population in different ranges of HbA1c levels.
+4.2. Comparisons
+Prior to the current study, Shantakumari et al. evaluated the impact of three months Yoga
+intervention on the dyslipidemic profile in 100 T2DM subjects and found similar findings [27].
+However, the sample size (n-100) was smaller and represented only a south Indian population whereas
+the current pan-India study had a large sample size (5150) using a validated common yoga protocol.
+The outcomes of this DYP study showed an improvement in overall lipid profile (i.e., decrease in
+total cholesterol, triglycerides and LDL levels) among the T2DM subjects. Similarly, Mohammed
+et al. reported reduced total cholesterol, triglycerides, and LDL cholesterol in 158 Yoga practicing
+Type 2 Diabetes and dyslipidemia patients in comparison to the sulphonyl urea treatment group;
+the mean TC of 240.36 mg/dL (High) was reduced to 214.11 mg/dL (borderline) after four months
+of yoga intervention with a 10% reduction [28]. However, in our study, DYP intervention helped
+hyperlipidemia subjects to attain normal levels (189.38 mg/dl) of cholesterol from the baseline levels
+of 232.34 mg/dL with an 18% reduction. A recent systemic review of controlled Yoga trials on adult
+Diabetics recommended additional high quality studies due to methodological limitations in previous
+studies [29]. A recent meta-analysis reporting significant improvements in the lipid profile remained
+limited to non DYP protocols [30], highlighting the importance of validated protocols to further our
+deeper mechanistic understanding while retaining the reproducibility. Therefore, a specific Diabetes
+Yoga Protocol was employed in this nationwide study focused on T2DM patients of all age groups
+across India. We found a positive correlation (p < 0.05) between increasing levels of HbA1c and TC
+(Figure 2). Earlier studies have also shown similar results with high HbA1c as an important predictor
+of high serum lipid levels in T2DM subjects [17,31,32], warranting glycemic control as an important
+factor needed to control dyslipidemia and prevent major cardiovascular events [33].
+4.3. Mechanism of action of Yoga
+Yoga mediated reduction in the dyslipidemia has yet not been explored to the current scale in the
+Diabetic subjects. We describe the underlying mechanism based on existing studies. Mechanistically,
+Medicines 2019, 6, 100
+8 of 11
+insulin resistant cells inhibit lipase activity, the enzyme that catabolizes the lipids resulting in increased
+triglycerides, LDL, and cholesterol levels in the body [32]. In addition, the accumulation of lipids
+increases the risk of other co-morbidities like atherosclerosis, cardiovascular, and coronary artery
+diseases. Dyslipidemia also causes endothelial damage, which results in the loss of physiological
+vasomotor activity [34]. Furthermore, factors like dyslipidemia also contribute to increased blood
+pressure [35], which leads to the activation of the RAAS pathway where the aldosterone hormone is
+secreted due to over activation of the HPA axis in T2DM subjects [36]. Available evidence shows that
+Diabetes neuropathy affects the longest fiber of the parasympathetic system, leading to sympathetic
+imbalance, thus leading to hypertension [37]. However, the existing evidence also indicates that there
+is a persistent increase in the HPA (hypothalamus pituitary adrenal) axis activity in Diabetic patients
+with Diabetes neuropathy [38]. A number of studies depict that there is mitochondrial dysfunction and
+decreased activity of mitochondrial enzymes in T2DM subjects due to insulin resistance. Measurement
+of oxidative phosphorylation in vivo by P-NMR has also shown impaired ATP synthesis in insulin
+resistant subjects [39]. Furthermore, PPARδ (peroxisome proliferate activator receptor) is a lipid
+activated nuclear factor that has an important role in the regulation of glucose, lipid, and lipoprotein
+metabolism. Pre-clinical evidence has shown that PPAR can reduce or prevent obesity induced insulin
+resistance and T2DM [40]. Moreover, PPAR agonists are believed to be potent activators of lipid
+metabolism, thus explaining its beneficial actions on insulin sensitivity and adiposity [41]. Regardless
+of this pharmacological context, it has also been described that Yoga improves the lipid profile in
+T2DM subjects by increasing hepatic lipase and pancreatic lipase activity [27,42]. It has also been
+described that Yoga helps to maintain a balance between sympathetic and parasympathetic balance [43].
+Specifically, the Pranayama practices (as part of most of Yoga protocols), also included in the DYP,
+are believed to decrease the blood sugar level by increasing the utilization and mechanism of glucose
+in liver adipose tissue and peripheral organs [44]. Blood supply to muscles is also improved with
+Pranayama, which enhances the insulin receptor expression in muscles and increases the glucose uptake
+by cells, thus reducing the blood sugar levels [45]. We argue that asanas included in the DYP may
+improve the accessibility of various enzymes to target and stimulate their substrates. This might
+contribute toward the reduction of LDL and TG.
+4.4. Limitations
+The study duration was one of the limitations as the analysis could not extend beyond three
+months. Yet, the drop offrate in the study could be ascribed to challenges in adopting a Yoga lifestyle,
+general laziness, inability to perform Yoga due to health limitations, and relative interest in other forms
+of physical exercises. In certain places, climatic and political conditions also led to drop outs.
+4.5. Strengths
+One of the strengths of this study was the inclusion of a large sample size and the use of a validated
+Diabetes Yoga Protocol. Longitudinal studies may examine the long term effects of DYP.
+5. Conclusions
+DYP significantly attenuated the hyperlipidemic state of T2DM patients. The potential of DYP
+to halt the conversion of hyperlipidemic into CVD among Diabetics can be probed by a longitudinal
+intervention study. There is not only a need to understand the mechanism governing the effects of DYP,
+but also in scaling it into a public intervention national program. Although the available evidence
+proves the significance of the beneficial impact of Yoga on the cholesterol levels, Tg, LDL, and VLDL,
+a standardized approach may further alleviate the fatal consequences of Diabetes. This may reduce
+vulnerability to heart diseases.
+Supplementary Materials: The following are available online at http://www.mdpi.com/2305-6320/6/4/100/s1,
+Table S1: Effect of Yoga intervention on the lipid profile in different ranges of HbA1c in urban and rural subjects.
+Medicines 2019, 6, 100
+9 of 11
+Author Contributions: R.N. and H.R.N. Conceptualization, R.N., V.V. and I.N.A. Data Curation and acquisition,
+Funding Acquisition, Supervision R.N. and A.S. Formal Analysis, Investigation, Methodology, Validation and
+Writing—review and editing. R.T. and G.K. Formal Analysis, Writing—Original draft, Writing-review and editing.
+A.A. Writing- concept of manuscript and editing.
+Funding: This research was funded by Central Council for Research in Yoga and Naturopathy (CCRYN) (Ref F.No.
+16-63/2016-17/CCRYN/RES/Y&D/MCT/ Dated: 15.12.2016).
+Acknowledgments: We acknowledge the support of the Ministry of Health and Family Welfare and Ministry of
+Ayurveda, Yoga & Naturopathy, Unani, Siddha, Sowa Rigpa and Homoeopathy (AYUSH), Government of India,
+New Delhi, and CCRYN for funding this project. We thank the advisory research committee, senior research
+fellows Subzar, Sanjay, Radhika, Sunanda Rathi, Yoga volunteers, and the President of Indian Yoga Association for
+their contribution to this project. We also thank Kanupriya for her contributions in this manuscript.
+Conflicts of Interest: The authors declare no conflict of interest.
+Abbreviations
+CCRYN
+Central Council for Research in Yoga and Naturopathy
+CTRI
+Clinical Trial Registry of India
+CVD
+Cardio-vascular diseases
+DYP
+Diabetes yoga protocol
+FBG
+Fasting blood glucose
+HbA1c
+Glycated hemoglobin
+HDL
+High density lipoprotein
+IDRS
+Indian Diabetic Risk Score
+LDL
+Low density lipoprotein
+NMB
+Niyantrita Madhumeha Bh¯
+arat
+T2DM
+Type 2 diabetes mellitus
+TC
+Total Cholesterol
+Tg
+Triglycerides
+VLDL
+Very Low Lipoproteins
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+article distributed under the terms and conditions of the Creative Commons Attribution
+(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

subfolder_0/Examining Mediators and Moderators of Yoga for Women With Breast Cancer Undergoing Radiotherapy.txt

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+Integrative Cancer Therapies
+January-March 2016: 1­
+–13
+© The Author(s) 2016 
+Reprints and permissions: 
+sagepub.com/journalsPermissions.nav
+DOI: 10.1177/1534735415624141
+ict.sagepub.com
+Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 
+3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) 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).
+Research Articles
+Introduction
+Moderators of Mind-Body Interventions
+Despite the large number of behavioral intervention studies 
+for individuals diagnosed with cancer, the overall efficacy of 
+these treatments in addressing patient symptom burden has 
+been heavily debated.1-5 Though an estimated 20%-40% of 
+cancer patients experience depression, the typical cancer 
+patient enrolled in psychosocial trials tends to be not 
+depressed.4,6 Thus, the frequently used “all-comers” approach 
+to patient recruitment may result in negligible treatment gains 
+for quality of life (QOL) indicators such as depression. In fact, 
+a recent meta-analysis of 61 trials demonstrated that 
+624141 ICTXXX10.1177/1534735415624141Ratcliff et alIntegrative Cancer Therapies
+research-article2016
+1Center for Innovations in Quality, Effectiveness and Safety, Michael E. 
+DeBakey VA Medical Center, Houston, TX, USA
+2Baylor College of Medicine, Houston, TX, USA
+3VA South Central Mental Illness Research, Education, and Clinical 
+Center, Houston, TX, USA
+4The University of Texas MD Anderson Cancer Center, Houston, TX, 
+USA
+5University of Rochester Medical School, Rochester, NY, USA
+6Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India
+Corresponding Author:
+Lorenzo Cohen, Integrative Medicine Program, The University of Texas 
+MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 460, Houston, 
+TX 77030, USA. 
+Email: [email protected].
+Examining Mediators and  
+Moderators of Yoga for  
+Women With Breast  
+Cancer Undergoing Radiotherapy
+Chelsea G. Ratcliff, PhD1,2,3, Kathrin Milbury, PhD4, Kavita D. Chandwani, 
+MD, MPH, DrPH5, Alejandro Chaoul, PhD4, George Perkins, MD4, Raghuram 
+Nagarathna, PhD6, Robin Haddad, MPH4, Hongasandra Ramarao Nagendra, PhD6, 
+N. V. Raghuram, BS6, Amy Spelman, PhD4, Banu Arun, MD4, Qi Wei, MS4, and 
+Lorenzo Cohen, PhD4
+Abstract
+Hypothesis. This study examines moderators and mediators of a yoga intervention targeting quality-of-life (QOL) outcomes in 
+women with breast cancer receiving radiotherapy.Methods. Women undergoing 6 weeks of radiotherapy were randomized 
+to a yoga (YG; n = 53) or stretching (ST; n = 56) intervention or a waitlist control group (WL; n = 54). Depressive symptoms 
+and sleep disturbances were measured at baseline. Mediator (posttraumatic stress symptoms, benefit finding, and cortisol 
+slope) and outcome (36-item Short Form [SF]-36 mental and physical component scales [MCS and PCS]) variables were 
+assessed at baseline, end-of-treatment, and 1-, 3-, and 6-months posttreatment. Results. Baseline depressive symptoms 
+ 
+(P = .03) and sleep disturbances (P < .01) moderated the Group × Time effect on MCS, but not PCS. Women with high 
+baseline depressive symptoms in YG reported marginally higher 3-month MCS than their counterparts in WL (P = .11). 
+Women with high baseline sleep disturbances in YG reported higher 3-months MCS than their counterparts in WL (P < .01) 
+and higher 6-month MCS than their counterparts in ST (P = .01). YG led to greater benefit finding than ST and WL across 
+the follow-up (P = .01). Three-month benefit finding partially mediated the effect of YG on 6-month PCS. Posttraumatic 
+stress symptoms and cortisol slope did not mediate treatment effect on QOL. Conclusion. Yoga may provide the greatest 
+mental-health–related QOL benefits for those experiencing pre-radiotherapy sleep disturbance and depressive symptoms. 
+Yoga may improve physical-health–related QOL by increasing ability to find benefit in the cancer experience.
+Keywords
+breast cancer, QOL, yoga, moderation, mediation
+Submitted Date: 8 September 2015; Revised Date: 19 November 2015; Acceptance Date: 20 November 2015
+ at UNIV OF TX MD ANDERSON on April 11, 2016
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+Integrative Cancer Therapies 
+psychological distress moderated the efficacy of psychosocial 
+treatments regarding mood management for cancer patients.7 
+Furthermore, a meta-analysis of trials targeting depressed 
+cancer patients indicated that psychotherapeutic and pharma-
+cological interventions are effective in reducing depressive 
+symptoms with sustained effects.8
+Although these meta-analyses have been instrumental in 
+identifying the importance of examining moderators of treat-
+ment efficacy, they have rarely included trials of complemen-
+tary medicine interventions such as yoga and meditation. 
+Such exclusion is surprising in light of the rapid proliferation 
+of Eastern-influenced behavioral interventions in oncology 
+research and practice.9-17 Yoga in particular has gained popu-
+larity in the cancer setting, and several systematic reviews 
+and meta-analyses have examined the QOL benefits associ-
+ated with cancer patients’ and survivors’ yoga practice.14-17 
+For instance, a meta-analysis of 13 randomized controlled 
+trials (RCTs) of yoga in cancer patients and survivors revealed 
+large effects for psychological health; medium effects for 
+fatigue, general QOL, and psychosocial well-being; and 
+small effects for sleep disturbances and physical function.17 It 
+is important to note that the reviewed trials did not select for 
+elevated symptom burden (ie, used an “all-comer” approach). 
+Thus, yoga may lead to even greater grains in at-risk partici-
+pants. However, with the exception of some limited evi-
+dence,18 it is largely unknown if patients with elevated 
+distress derive greater QOL benefit from a yoga intervention 
+compared with their less-distressed counterparts.
+The benefits of yoga are multifaceted, targeting not only 
+psychological but also physical and spiritual dimensions of 
+QOL.17 Thus, participant characteristics beyond psycho-
+logical distress may moderate the efficacy of a yoga inter-
+vention. Sleep disturbances, potentially caused by the 
+cancer process itself or cancer treatments, are commonly 
+experienced among women with breast cancer19-21 and are 
+associated with impaired QOL in cancer patients even when 
+controlling for depression and fatigue.20,22,23 Because yoga 
+is an effective treatment to improve sleep in cancer patients 
+and survivors,9,24,25 it may be particularly efficacious for 
+patients reporting high levels of sleep disturbances. In fact, 
+a multicenter RCT involving 410 survivors with moderate 
+to high sleep disturbances demonstrated that an 8-session 
+yoga intervention improved self-reported and actigraphy-
+assessed sleep relative to standard care.9 However, to the 
+best of our knowledge, sleep disturbances have not yet been 
+examined as a yoga intervention moderator.
+Mediators of Mind-Body Interventions
+In addition to lacking a clear understanding of for whom 
+mind-body interventions are most helpful, no cohesive the-
+oretical framework has been proposed to explain how and 
+why yoga interventions produce change.26,27 A recent sys-
+tematic review reports that few potential mechanisms of 
+yoga have been explored to date, and no mechanisms of 
+yoga have been tested in cancer populations.28,29 The excep-
+tion is one study on mindfulness-based stress reduction for 
+cancer patients, which includes some yoga. This study 
+found that increasing mindfulness partially mediated the 
+intervention’s beneficial effects on stress and posttraumatic 
+avoidance.30 However, in light of the growing RCTs exam-
+ining yoga in cancer and the limited exploration of media-
+tors of this intervention, further examination of yoga 
+mediators guided by a conceptual model is needed.
+We propose a stress response model as a way to under-
+stand how yoga produces change in cancer patients. A diag-
+nosis of cancer and its treatment are typically experienced 
+as stressful, or even traumatic, events, and yoga interven-
+tions are generally conceptualized within the framework of 
+a stress reduction program. Thus, practicing yoga may 
+improve health outcomes in cancer patients via modulating 
+the stress response.28 Put another way, yoga may affect 
+posttraumatic stress symptoms, such as cognitive interfer-
+ence and avoidance, while also increasing posttraumatic 
+growth or benefit finding. Importantly, both constructs of 
+trauma response (ie, posttraumatic stress symptoms and 
+benefit finding) have been consistently and prospectively 
+associated with psychological and physical QOL outcomes 
+in various cancer samples.31-39
+With this model in mind, we previously examined the 
+effects of yoga versus usual care on intrusive thoughts/
+avoidance behaviors and benefit finding in a small pilot trial 
+in women with breast cancer undergoing radiotherapy.10 
+Differences between groups in benefit finding did not 
+emerge until the last 3-month assessment time point, pre-
+cluding the examination of benefit finding as an interven-
+tion mediator. Surprisingly, the yoga group reported 
+increased intrusive thoughts 1 month after the end of radio-
+therapy compared with the women in the usual care group, 
+with subsequent reduction at the 3-month time point, and 
+nonsignificant 
+reductions 
+in 
+avoidance 
+behaviors. 
+Interestingly, intrusive thoughts at 1 month were positively 
+associated with benefit finding at 3 months. There is some 
+evidence to suggest that heightened levels of intrusive 
+thoughts experienced during the aftermath of a traumatic 
+event may help individuals more effectively adjust to the 
+stressor and ultimately to find benefit in the traumatic expe-
+rience.40 Thus, the increase in intrusive thoughts associated 
+with yoga may have led to better, more mindful processing 
+of the cancer experience, ultimately fostering finding mean-
+ing in the cancer experience.
+Moreover, within a trauma response model, cortisol 
+rhythmicity may represent one biological pathway by which 
+mind-body interventions improve health and well-being. 
+Both types of trauma response (posttraumatic stress symp-
+toms and benefit finding) are associated with hypothalamic-
+pituitary-adrenal axis function in cancer patients, which in 
+turn is associated with behavioral symptoms (eg, fatigue, 
+ at UNIV OF TX MD ANDERSON on April 11, 2016
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+sleep disturbance, and depression), making changes to cor-
+tisol rhythmicity a potential mechanism of yoga.41-44 
+Although previous studies have shown group main effects 
+of a yoga intervention on diurnal cortisol and speculated a 
+mediating effect, no empirical evidence exists to date.28
+The Present Study
+The goal of the current study was to examine moderators 
+and mediators of a previously reported 3-arm yoga RCT for 
+women diagnosed with breast cancer undergoing radiother-
+apy.45 We focused only on mediators and moderators of the 
+primary outcome variable: health-related QOL. First, we 
+hypothesized that, compared with active and waitlist con-
+trol groups, the yoga program would be especially benefi-
+cial at improving posttreatment QOL for women with 
+elevated pretreatment depressive symptoms and sleep dis-
+turbance. Second, we hypothesized that the beneficial QOL 
+effects of the intervention would be mediated by improved 
+trauma responses (ie, short-term increases in intrusive 
+thoughts and reduction in avoidance behaviors and increased 
+benefit finding) as well as better stress hormone regulation 
+(ie, a steeper cortisol slope).
+Method
+Participants
+Women were recruited prior to radiotherapy treatment 
+(XRT), with inclusion criteria being the following: ≥18 
+years old; ability to read, write, and speak English; diag-
+nosed with stage 0 to III breast cancer; and scheduled to 
+undergo daily adjuvant XRT for 6 weeks at MD Anderson 
+Cancer Center. Patients with lymphedema, metastatic bone 
+disease, deep-vein thrombosis, documented diagnosis of a 
+formal thought disorder, and extreme mobility problems or 
+those who had practiced yoga in the year before diagnosis 
+were excluded. The protocol was approved by the institu-
+tional review board.
+Procedures
+Details of the study procedures have been reported else-
+where.45 Briefly, after receiving written informed consent, 
+self-report and saliva samples (for cortisol data) were col-
+lected from participants at baseline before randomization, 
+during the last week of XRT, and 1, 3, and 6 months later.
+Participants were randomly assigned to 1 of 3 groups: 
+(1) yoga (YG); (2) stretching control (ST); or waitlist con-
+trol (WL) using a form of adaptive randomization,46 accord-
+ing to age, stage of disease, time since diagnosis, type of 
+surgery, and chemotherapy (neoadjuvant or adjuvant). 
+Participants in the WL group received usual care, completed 
+all assessments on the same timeline as the active groups, 
+and were offered yoga classes at the end of their study par-
+ticipation. All participants were asked to refrain from par-
+ticipating in any other yoga classes while on study. 
+Participants in the YG and ST groups attended up to three 
+60-minute classes per week during their 6 weeks of XRT. 
+Each participant received an audio CD and a written manual 
+of the program to encourage at-home practice.
+The integrated yoga program, described previously,10 
+included the following: (1) preparatory warm-up synchro-
+nized with breathing; (2) selected postures, or asanas (for-
+ward-, backward-, and side-bending asanas in sitting and 
+standing positions, cobra posture, crocodile, and half-
+shoulder-stand with support); (3) deep relaxation (supine 
+posture); (4) alternate-nostril breathing or pranayama; and 
+(5) meditation. The program was taught by Vivekananda 
+Yoga Anusandhana Samsthana–trained teachers with spe-
+cific oncology training.
+The stretching program included exercises recom-
+mended specifically for women undergoing or recovering 
+from breast cancer treatment.47,48 The exercises approxi-
+mated the gross movements of the yoga exercises and were 
+taught by cancer center physiotherapists.
+Measures
+Primary Intervention Outcome: Health-Related QOL.  Overall 
+QOL was assessed by the Medical Outcomes Study 36-item 
+Short Form survey (SF-36) and was the primary outcome of 
+the clinical trial published previously.45 The SF-36 assesses 
+physical functioning, physical impediments to role func-
+tioning, bodily pain, general health perceptions, vitality, 
+social functioning, emotional impediments to role function-
+ing, and mental health and includes an overall physical and 
+mental component scale (PCS and MCS).49,50 To reduce the 
+number of analyses, only the component scales are included 
+in outcome analyses. Higher scores reflect better QOL.
+Proposed Moderators.  Depressive symptoms were assessed 
+using the Centers for Epidemiological Studies–Depression 
+measures (CES-D),51 a well-validated measure focusing on 
+affective components of depression. Lower scores reflect 
+fewer depressive symptoms. In this study sample, the inter-
+nal reliability was high (Cronbach’s α = .89).
+Sleep disturbances were assessed using the Pittsburgh 
+Sleep Quality Index (PSQI),52 a questionnaire that assesses 
+sleep disturbances over a 1-month period. We report on the 
+total score, with lower scores reflecting fewer sleep distur-
+bances. Acceptable internal reliability was found in this 
+study sample (Cronbach’s α = .70).
+Proposed Mediators: Posttraumatic Responses.  Posttraumatic 
+stress symptoms were measured by the Impact of Event 
+Scale (IES), a scale that assesses the 2 most common catego-
+ries of responses to traumatic events: intrusion (intrusively 
+ at UNIV OF TX MD ANDERSON on April 11, 2016
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+Integrative Cancer Therapies 
+experienced ideas, images, feelings, or bad dreams) and 
+avoidance behaviors (conscious efforts to avoid certain 
+ideas, feelings, or situations).53 We report on the intrusive 
+thoughts and avoidance behaviors subscales and the total 
+score. Lower scores reflect fewer symptoms. Adequate 
+internal reliability was found for the total scale (Cronbach’s 
+α = .85) as well as intrusive (Cronbach’s α = .85) and avoid-
+ance (Cronbach’s α = .79) subscales.
+Participants’ ability to find benefit was measured by the 
+Benefit Finding Scale (BFS),54,55 a scale assessing accep-
+tance of life’s imperfections, change in priorities, and devel-
+opment of a sense of purpose in life as a result of having 
+been diagnosed with cancer. Higher scores reflect greater 
+benefit finding. In this study sample, the internal reliability 
+was high (Cronbach’s α = .94).
+Cortisol Rhythmicity.  Cortisol was obtained via 5 saliva sam-
+ples (waking, 45 minutes later, approximately 8 and 12 
+hours after waking, and at bedtime) for 3 consecutive days 
+at each assessment. Participants chewed on a cotton swab 
+(Salivette) and placed it in a plastic tube (Sarstedt), which 
+was then frozen at −80°C for later time-resolved immuno-
+assay with fluorescence detection performed at the Univer-
+sity of Dresden. Values <0.0001 and >70 nmol/L were 
+classified as missing. If patients missed a collection point, 
+they were told to leave the tube empty. Reliability for each 
+collection time point within a day across the 3 days and the 
+5 assessment time points ranged from 0.20 to 0.87, with 
+only 6 out of 25 α values (5 samples a day at 5 time points) 
+dropping below 0.50. Reliability was directly related to the 
+sample size, which dropped off by the 6-month follow-up. 
+A steeper, more-negative cortisol slope indicates better cor-
+tisol regulation.
+Covariates.  Patients also completed basic demographic 
+information (eg, age, marital status, education). Medical 
+information was obtained from electronic medical records.
+Data Analyses
+Hypothesis 1: To evaluate whether the intervention was 
+more effective in regard to health-related QOL (SF-36 
+MCS and PCS) for participants with high depressive symp-
+toms (Hypothesis 1A) or greater sleep disturbance 
+(Hypothesis 1B) at baseline, we used an ANCOVA frame-
+work to first examine the Group × Baseline moderator 
+effect using PROC MIXED in SAS v9.2. This was fol-
+lowed by a Group × Time × Baseline moderator ANCOVA 
+to see if the moderator effect varied by time. We controlled 
+for the respective baseline outcome as well as randomiza-
+tion factors (age, stage of disease, time since diagnosis, 
+type of surgery, and chemotherapy type). We also con-
+trolled for baseline SF-36 general health scores in all anal-
+yses as a result of imbalances across groups. We treated 
+time as a categorical variable and the intercept as a random 
+effect. We specified an unstructured covariance structure. 
+For significant 3-way interactions, we decomposed the 
+interaction according to high and low (mean ± ½SD) base-
+line depressive symptoms or sleep disturbance and com-
+pared the least-squared means (LSM) for each group at 
+each time point using a general linear model analysis, con-
+trolling for baseline levels of the outcome variable and 
+illustrating the interaction by plotting the LSM.
+Hypothesis 2: We were interested in determining media-
+tors of significant group effects on health-related QOL. The 
+original trial45 demonstrated group differences in SF-36 
+PCS at 1 and 3 months, and a subscale of the SF-36 PCS 
+(physical functioning) at those time points and 6 months. 
+We chose to examine mediators of SF-36 PCS at 1, 3, and 6 
+months, rather than the physical functioning subscale 
+because the SF-36 PCS is a more comprehensive index of 
+physical health–related QOL.
+To determine the mediator variables, we regressed each 
+proposed mediator (ie, IES, BFS, and cortisol slope) on 
+group, time, and the Group × Time interaction using the 
+model and covariates described above. Where there was a 
+group or Group × Time effect on the proposed mediator 
+variable, we chose the time point associated with the largest 
+group or Group × Time effect as the mediator. If a proposed 
+mediator variable did not significantly differ by group, it 
+was not further examined. Only primary outcome variables 
+assessed after our chosen mediators were included as 
+dependent variables in the mediation models to enable a 
+predictive relationship between the mediator and the depen-
+dent variable to be established.56
+To test for mediation, we calculated indirect effects using 
+Hayes and Preacher’s bias-corrected bootstrap procedure 
+via the MEDIATE macro for SPSS, which is designed to 
+estimate indirect effects of multicategorical independent 
+variables.57 Indicator coding of the grouping variable was 
+used, with WL functioning as the reference group. D1 codes 
+the effect of YG compared with WL controlling for ST, and 
+D2 codes the effect of ST compared with WL controlling 
+for YG. Indirect effects were determined significant when 
+the mean of the indirect effect across all 5000 bootstrap 
+samples was associated with a bias-corrected confidence 
+interval that did not include 0.57
+Results
+Attrition and Adherence
+Out of 294 eligible women approached, 191 consented to 
+participate; 13 dropped out before, and 15 after, randomiza-
+tion, for a baseline sample size of 163 (YG = 53; ST = 56; 
+WL = 54). Measurements were obtained for 80% of the sam-
+ple at 6 months (n = 131; YG = 43, ST = 42, WL =46; see 
+original clinical trial45 for CONSORT). Out of a maximum 
+ at UNIV OF TX MD ANDERSON on April 11, 2016
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+5
+possible 18 classes, 87% of YG and 85% of ST participants 
+attended ≥12 classes (YG = 13.8; ST = 14.7). Only 3 patients 
+in each group attended fewer than half the classes. There 
+were no significant differences in demographic, medical, or 
+baseline self-report scores between those who attended 
+≥75% of classes compared with those who did not. For the 
+YG group, self-reported practice outside of class was high 
+(≥twice per week) at 1 month posttreatment and then 
+declined at 3 and 6 months (71%, 55%, and 45%, respec-
+tively). For the ST group, self-reported practice outside of 
+class (≥twice per week) was lower at 1 month and then 
+increased somewhat at 3 and 6 months (53%, 69%, and 60%, 
+respectively). WL participants were offered the YG program 
+after data collection was complete, but no data were col-
+lected from the WL during or after yoga.
+There were also no group, demographic, or baseline self-
+report differences between those who completed the 
+6-month follow-up assessment and those who did not (Ps > 
+.14), with the exception that older adults were more likely 
+to complete the 6-month assessment.
+Baseline Sample Characteristics
+The 3 groups were similar on all medical and demographic 
+variables (Table 1). There were no statistically significant 
+differences among the groups on any of the self-reported 
+variables at baseline, apart from the SF-36 general health 
+subscale. Women in YG reported lower baseline general 
+health compared with those in ST (P = .01). Depending on 
+the time point, 21% to 34% of participants did not provide 
+saliva samples. There were no differences between patients 
+providing samples and those who did not based on group 
+assignment, medical, demographic, or outcome measures. 
+We present the baseline and follow-up means of self-
+reported variables in Table 2.
+Hypothesis 1: Baseline Depressive Symptoms 
+and Sleep Disturbance as Moderators of 
+Intervention Outcomes
+There were no significant Group × Baseline Depressive 
+Symptom (CES-D) interaction effects on mental health–
+related QOL (SF-36 MCS). However, there was a signifi-
+cant Group × Time × Baseline CES-D interaction effect on 
+SF-36 MCS (F(6, 324) = 2.40; P < .03), suggesting that the 
+effect varied by time. We decomposed the interaction 
+according to high and low (mean ± ½SD) baseline CES-D 
+scores. There were no statistically significant differences in 
+SF-36 MCS scores between groups for those with low or 
+high baseline depressive symptoms at any assessment point 
+(Figure 1A). However, women with high baseline depres-
+sive symptoms in YG had a trend toward higher SF-36 
+MCS scores at 3 months compared with WL (P = .107), and 
+their 1-, 3-, and 6-month SF-36 MCS scores were no differ-
+ent from those of women scoring low on baseline depres-
+sive symptoms. There were no significant Group × Baseline 
+CES-D or Group × Time × Baseline CES-D interaction 
+effects on physical health–related QOL (SF-36 PCS).
+There was no significant Group × Baseline sleep distur-
+bance (PSQI) interaction effects on mental health–related 
+QOL (SF-36 MCS). However, there was a significant Group 
+× Time × Baseline PSQI interaction effect on SF-36 MCS 
+(F(6, 318) = 3.40, P < .01). We decomposed the interaction 
+according to high and low (mean ± ½SD) baseline PSQI 
+scores. There were no significant differences in SF-36 MCS 
+scores between groups for those with low baseline sleep 
+disturbances at any assessment point (Figure 1B). However, 
+among the women with high baseline sleep disturbances, 
+there was a significant Group × Time effect (F(6, 83) = 3.52; 
+P = .003). Specifically, women with high sleep disturbances 
+in YG reported higher 3-month SF-36 MCS scores than 
+their counterparts in WL (t(83) = 3.15; P = .002) and higher 
+6-month SF-36 MCS scores than their counterparts in ST 
+(t(83) = 2.56; P = .012), and their SF-36 MCS scores at each 
+time point were no different from that of women reporting 
+low sleep disturbance at baseline. There were no significant 
+Group × Baseline sleep disturbance (PSQI) or Group × 
+Time × Sleep disturbance (PSQI) interaction effects on 
+physical health–related QOL (SF-36 PCS).
+Hypothesis 2: Mediators of Intervention Effect 
+on QOL
+Posttraumatic Stress Symptoms.  Results revealed no signifi-
+cant Group × Time interaction effect on IES total scale, 
+intrusive thoughts, or avoidance behaviors subscales scores 
+(Ps > .5). Additionally, there were no main effects of group 
+or time on the IES total scale or intrusive thoughts subscale 
+(Ps > .2). There was a main effect of group (F(2,132) = 3.17; 
+P = .05), but not time (P = .6), for the IES avoidance sub-
+scale. Specifically, YG was associated with greater IES 
+avoidance scores (LSM = 11.31; SE = 0.82) compared with 
+WL (LSM = 8.52; SE = 0.76; P = .01). IES avoidance scores 
+did not differ between ST (LSM = 10.16; SE = 0.79) and 
+YG or WL (Ps > .1). Figure 2A presents LSMs of IES 
+avoidance for groups across time.
+The time point at which groups differed most on IES 
+avoidance was at 6 months (F(2, 112) = 3.23; P = .04; Cohen’s 
+ 
+d = 0.40), with women in YG (LSM = 11.29; SE = 1.18; 
+ 
+P = .02) and ST (LSM = 10.14; SE = 1.19; P = .09) reporting 
+greater IES avoidance scores compared with women in WL 
+(LSM = 7.34; SE = 1.69). Using the 6-month time point for 
+the mediator does not enable examining a temporal relation-
+ship between the mediator and outcome, and there were no 
+significant group differences at earlier time points, precluding 
+examination of IES avoidance as an intervention mediator.
+ at UNIV OF TX MD ANDERSON on April 11, 2016
+ict.sagepub.com
+Downloaded from 
+6	
+Integrative Cancer Therapies 
+Benefit Finding.  Results revealed no significant Group × 
+Time interaction effect on BFS scores (P = .9). However, 
+there was a main effect of group (F(2,132) = 4.60; P = .01) and 
+a main effect of time (F(3,335) = 3.12; P = .03) on benefit 
+finding. Specifically, YG was associated with greater bene-
+fit finding (LSM = 46.21; SE = 1.28) compared with ST 
+(LSM = 42.24; SE = 1.23; P = .03) and WL (LSM = 41.05; 
+SE = 1.19; P < .01). Benefit finding did not differ between 
+ST and WL (P = .5). Figure 2B presents LSMs of benefit 
+finding for groups across time.
+Women in YG reported higher levels on benefit finding 
+relative to WL at 1, 3, and 6 months and relative to ST at 3 
+and 6 months (Ps < .05), with no differences between ST 
+and WL. Groups differed most on benefit finding at 3 
+months (F(2, 103) = 3.12; P = .05; Cohen’s d = 0.38), with 
+women in YG reporting greater benefit finding scores (LSM 
+= 46.32; SE = 1.85) compared with ST (LSM = 40.90; SE = 
+1.78; P = .04) and WL (LSM = 40.57; SE = 1.69; P = .02). 
+Therefore, 3-month benefit finding was examined as a 
+mediator of group’s effects on physical health–related QOL 
+Table 1.  Baseline Characteristics of Study Participants, by Group.
+Yoga
+Stretch
+Waitlist
+ 
+n = 53 (33%)
+n = 56 (34%)
+n = 54 (33%)
+Disease stage, n (%)
+  0
+5
+10
+6
+11
+7
+13
+  I
+16
+30
+18
+32
+17
+31
+  II
+15
+28
+14
+25
+15
+28
+  III
+17
+32
+18
+32
+15
+28
+ER/PR status (n = 156), n (%)
+  ER+/PR+
+32
+62
+33
+62
+31
+61
+  ER+/PR−
+7
+13
+7
+13
+6
+12
+  ER−/PR+
+1
+2
+0
+0
+3
+6
+  ER−/PR−
+12
+23
+13
+25
+11
+21
+Surgery, n (%)
+  Mastectomy (without reconstruction)
+12
+23
+17
+31
+12
+22
+  Mastectomy (with reconstruction)
+6
+11
+3
+5
+5
+9
+  Breast conserving
+35
+66
+36
+64
+37
+69
+Chemotherapy, n (%)
+  Yes
+36
+68
+34
+61
+34
+63
+Hormone treatment (n = 156), n (%)
+  Yes
+33
+62
+38
+70
+34
+67
+Marital status (n = 151), n (%)
+  Married and living together
+31
+67
+37
+71
+34
+64
+  Not cohabiting
+15
+33
+15
+29
+19
+36
+Ethnicity (n = 150), n (%)
+  Black/African American
+9
+19
+9
+17
+7
+13
+  White/Caucasian
+32
+68
+28
+55
+37
+71
+  Latino/Hispanic/Mexican
+4
+9
+8
+16
+5
+10
+  Asian/Oriental/Pacific Islander
+2
+4
+4
+8
+1
+2
+  Other
+0
+0
+2
+4
+2
+4
+Employment status (n = 140), n (%)
+  Employed part-/full-time
+15
+33
+21
+43
+18
+39
+  Employed, taken time off
+11
+25
+10
+20
+5
+11
+  Not employed
+19
+42
+18
+37
+23
+50
+Education (n = 152), n (%)
+  Some college or lower
+27
+57
+26
+50
+32
+60
+  College and higher education
+20
+43
+26
+50
+21
+40
+Income (n = 149), n (%)
+  >$75 000
+31
+67
+26
+51
+26
+50
+  <$75 000
+15
+33
+25
+49
+26
+50
+Age (mean, SE)
+52.38
+1.35
+51.14
+1.32
+52.11
+1.34
+Abbreviations: ER = Estrogen receptor; PR = Progesterone receptor
+ at UNIV OF TX MD ANDERSON on April 11, 2016
+ict.sagepub.com
+Downloaded from 
+Ratcliff et al	
+7
+Table 2.  Raw Means and SDs of Measures at Baseline and Follow-up.a
+Yoga
+Stretch
+Waitlist
+ 
+Mean
+SD
+Mean
+SD
+Mean
+SD
+Primary outcome 
+variables
+SF-36 PCS
+  Baseline
+41.9
+9.6
+43.4
+8.6
+44.5
+9.4
+  Post-XRT
+42.3
+9.2
+44.5
+8.1
+44.1
+8.4
+  1 Month
+47.0*
+8.1
+46.9
+9.1
+45.4**
+7.6
+  3 Months
+48.2*
+7.3
+47.6
+8.8
+45.8**
+7.8
+  6 Months
+46.9b
+9.3
+47.5
+8.6
+46.6
+7.5
+SF-36 MCS
+  Baseline
+42.1
+12.4
+45.6
+10.3
+42.2
+12.9
+  Post-XRT
+47.2
+13.5
+49.7
+8.9
+46.8
+11.5
+  1 Month
+46.2
+13.1
+47.1
+11.2
+49.0
+10.1
+  3 Months
+46.5
+12.6
+49.8
+10.2
+46.9
+12.2
+  6 Months
+46.8
+12.7
+50.8
+9.5
+48.8
+9.9
+Moderator variables
+CES-D
+  Baseline
+15.5
+10.5
+11.9
+5.9
+14.9
+10.2
+  Post-XRT
+12.2
+9.7
+10.3
+7.5
+12.4
+9.6
+  1 Month
+13.1
+10.7
+11.6
+9.6
+12.3
+8.3
+  3 Months
+13.9
+10.8
+9.6
+8.8
+12.9
+10.5
+  6 Months
+13.9
+11.8
+10.4
+9.3
+11.5
+9.0
+PSQI
+  Baseline
+8.3
+3.9
+8.5
+4.0
+8.2
+3.7
+  Post-XRT
+6.7
+3.1
+8.3
+4.0
+7.3
+3.7
+  1 Month
+7
+3.8
+7.5
+4.2
+5.9
+3.6
+  3 Months
+6.5
+3.1
+7.2
+3.3
+6.5
+3.8
+  6 Months
+7
+3.5
+7.2
+3.9
+6.4
+4.1
+Mediator variables
+IES total
+  Baseline
+22
+15.2
+20.1
+13.3
+20.4
+13.3
+  Post-XRT
+17.3
+13.9
+17.8
+15
+15.8
+12.1
+  1 Month
+17.1
+13.5
+16.9
+13
+14.4
+12.1
+  3 Months
+18.2
+13
+17.1
+15.7
+15.7
+13.7
+  6 Months
+18.7
+16.6
+16.4
+12.8
+11.9
+10.6
+IES intrusive thoughts
+  Baseline
+10.4
+8.5
+8.9
+7.3
+8.7
+7.6
+  Post-XRT
+6.5
+6.3
+7.5
+7.2
+6.8
+6.4
+  1 Month
+5.8
+6.5
+6.9
+6.4
+5.8
+6.5
+  3 Months
+6.9
+6.3
+7.4
+8.7
+5.8
+5.9
+  6 Months
+7.2
+8.0
+6.8
+6.3
+4.6
+4.9
+IES avoidance
+  Baseline
+11.6
+8.7
+11.2
+7.9
+11.8
+8.8
+  Post-XRT
+11.1
+8.9
+10.4
+9
+9
+7.6
+  1 Month
+11.3
+8.2
+10
+7.9
+8.6
+7.8
+  3 Months
+11.3
+8.4
+9.7
+8.7
+9.9
+9.5
+  6 Months
+11.6*
+10.4
+9.7
+8.4
+7.3**
+7.0
+BFS
+  Baseline
+42.5
+13.4
+44.1
+16
+44.3
+13.8
+  Post-XRT
+46.3
+14.1
+45.9
+16.7
+42.9
+15.1
+  1 Month
+44.4*
+16.1
+43.8
+17.2
+41.6**
+13.7
+  3 Months
+43.9*
+17.7
+42.7**
+18.1
+40.8**
+16.3
+  6 Months
+41.8*
+16.9
+42.1**
+17.4
+38**
+16.4
+Cortisol slope
+  Baseline
+−0.104
+0.04
+−0.118
+0.04
+−0.113
+0.04
+  Post-XRT
+−0.104*
+0.04
+−0.084**
+0.05
+−0.084**
+0.05
+  1 Month
+−0.098*
+0.04
+−0.090
+0.05
+−0.065**
+0.05
+  3 Months
+−0.086
+0.06
+−0.091
+0.04
+−0.078
+0.05
+  6 Months
+−0.090
+0.06
+−0.095
+0.04
+−0.099
+0.04
+Abbreviations: SF-36, 36-item Short Form; PCS, physical component scale; MCS, mental component scale; XRT, radiotherapy treatment; CES-D, Centers for Epidemiological 
+Studies–Depression; PSQI, Pittsburgh Sleep Quality Index; IES, Impact of Event Scale; BFS, Benefit Finding Scale.
+aMeans with asterisk and double asterisk differ at P < .05 based on multilevel modeling analyses.
+bThough groups did not differ significantly on physical health–related quality of life (SF-36 PCS) at 6 months, the original trial found that women in the yoga group reported 
+significantly higher scores on the physical functioning subscale of the SF-36 PCS at 6 months compared with the waitlist control group.
+ at UNIV OF TX MD ANDERSON on April 11, 2016
+ict.sagepub.com
+Downloaded from 
+8	
+Integrative Cancer Therapies 
+Figure 2.  Group differences on posttraumatic response 
+across time: these figures represent the least-squared means 
+(adjusted for the baseline level of the outcome variable, baseline 
+SF-36 general health subscale, and randomization factors) of a 
+multilevel modeling analysis for each of the mediators over time.
+Abbreviations: SF-36, 36-item Short Form; IES, Impact of Event 
+Scale; XRT, radiotherapy treatment.
+(SF-36 PCS) at 6 months because the physical health sub-
+scale of the SF-36 PCS was the only outcome associated 
+with group differences assessed after 3 months.
+Hayes and Preacher’s bias-corrected bootstrap test of 
+indirect effect57 revealed that group did indirectly affect 
+physical health–related QOL (SF-36 PCS) at 6 months via 
+benefit finding at 3 months (Figure 3). First, YG resulted in 
+higher 3-month benefit finding compared with WL (the a1 
+pathway; P = .04), whereas ST and WL did not differ in 
+3-month benefit finding (the a2 pathway; P = .84). Second, 
+holding group constant, those who reported higher benefit 
+finding at 3 months reported higher 6-month physical 
+health–related QOL (the b pathway, P = .04). Third, relative 
+to WL, women in YG reported higher 6-month physical 
+health–related QOL in part because of the positive effect of 
+YG on 3-month benefit finding. Indeed, a bootstrap esti-
+mate of the indirect effect of YG compared with WL on 
+6-month physical health–related QOL via 3-month benefit 
+finding revealed a 95% bias-corrected and accelerated 
+(BCa) confidence interval that did not cross zero (B = 0.77; 
+SE = 0.58; CI = 0.01 and 2.58). Thus, 3-month benefit find-
+ing partially mediated the effect of YG on 6-month physical 
+health–related QOL. Conversely, the BCa confidence inter-
+val for the indirect effect of ST compared with WL did cross 
+zero and was, therefore, not significant (B = 0.07; 
+ 
+SE = 0.43; CI = −0.84 and 0.88). Thus, the effect of ST on 
+6-month physical health–related QOL was not mediated by 
+3-month benefit finding.
+Cortisol.  Results revealed no significant group or time effect 
+on cortisol slope (P > .3). There was a trend for a Group × 
+Time interaction effect (F(6,189) = 1.83; P = .096). Specifi-
+cally, YG was associated with a steeper cortisol slope 
+Figure 1.  The least-squared means of mental health–related 
+QOL (SF-36 MCS) are from a multilevel modeling analyses 
+controlling for baseline MCS score, baseline SF-36 general 
+health subscale, and randomization factors. Figures illustrate 
+a Group × Time interaction for those with (A) high and low 
+baseline depressive symptoms (mean ± ½SD) on the Center 
+for Epidemiologic Studies (CES-D) and (B) high and low baseline 
+sleep disturbances (mean ± ½SD) on the Pittsburgh Sleep 
+Quality Index (PSQI). Higher SF-36 MCS scores represent 
+greater QOL.
+Abbreviations: CES-D, Centers for Epidemiological Studies–
+Depression; QOL, quality of life; SF-36, 36-item Short Form; 
+MCS, mental component scale; YG, yoga group; ST, stretching 
+control group; WL, or waitlist control group; XRT, radiotherapy 
+treatment; PSQI, Pittsburgh Sleep Quality Index.
+ at UNIV OF TX MD ANDERSON on April 11, 2016
+ict.sagepub.com
+Downloaded from 
+Ratcliff et al	
+9
+compared with ST and WL (Ps < .03) immediately after 
+radiotherapy (post-XRT), and YG was associated with a 
+steeper cortisol slope compared with WL at 1 month (P = 
+.02). Figure 2C represents LSMs of cortisol slope for groups 
+at each time point. Because the effects of group and Group 
+× Time on cortisol slope did not reach significance, it was 
+not examined as a mediator.
+Exploratory Analyses: Changes in IES and 
+Outcomes
+Because women in WL reported unexpectedly lower IES 
+avoidance scores over time compared with women in YG, 
+we explored the association between changes in IES avoid-
+ance and QOL outcomes by regressing group, change in 
+IES avoidance at 6 months (the time point associated with 
+significant group differences), and the interaction on QOL 
+outcome variables (physical and mental health–related 
+QOL (SF-36 PCS and MCS), depressive symptoms (CES-
+D), and sleep disturbance (PSQI)) at the final follow-up 
+time point (ie, 6 months). There were significant interaction 
+effects for mental health–related QOL (P = .05) and depres-
+sive symptoms (P = .04). Pearson correlations within each 
+group revealed no association between change in IES avoid-
+ance scores and 6-month mental health–related QOL or 
+depressive symptoms for YG or ST, whereas a greater 
+increase in IES avoidance scores was associated with worse 
+6-month mental health–related QOL (r = −0.31; P = .03) 
+and higher depressive symptoms (r = 0.42; P < .01) for the 
+WL group.
+Discussion
+The present study hypothesized that participating in a yoga 
+intervention during radiotherapy would be particularly ben-
+eficial for women with high baseline depressive symptoms 
+and sleep disturbances on posttreatment QOL compared 
+with their counterparts participating in stretching or waitlist 
+control groups. We also hypothesized that trauma responses 
+(ie, change in posttraumatic stress symptoms and increased 
+benefit finding) and better stress hormone regulation (ie, 
+steeper cortisol slope) would mediate the effect of yoga on 
+primary outcomes. Results partially supported each of the 
+hypotheses.
+Consistent with previous research suggesting that cancer 
+patients with higher distress derive greater benefit from 
+psychosocial interventions,18,58-61 the yoga intervention pro-
+vided the greatest mental health–related benefits for women 
+with elevated sleep disturbance and, to a lesser extent, 
+depressive symptoms prior to the start of radiotherapy. This 
+effect varied by time, with differences emerging especially 
+3 and 6 months after radiotherapy. Thus, yoga was espe-
+cially helpful for those women with disturbed sleep and 
+depressive symptoms at the start of radiotherapy. In fact, the 
+women in the yoga group who had sleep disturbances at 
+study entry had mental health scores at 3 and 6 months after 
+Figure 3.  Yoga indirectly affects physical health–related QOL (SF-36 PCS) at the 6-month follow-up via increased benefit finding 
+(BFS) at 3 months. Values on each path are unstandardized path coefficients taken from bootstrapping analyses controlling for age, 
+stage of disease, time since diagnosis, type of surgery, chemotherapy type, and baseline benefit finding (BFS), physical health–related 
+QOL (SF-36 PCS), and the SF-36 general health subscale. The a1 and a2 paths correspond to the mean differences in 3-month BFS 
+between YG relative to WL and ST relative to WL, respectively. Thus, YG resulted in 3-month BFS scores that were a1 = 5.55 units 
+higher than WL (P = .04), and ST resulted in BFS that were a2 = 0.54 points higher than WL (P = .84). The b pathway corresponds to 
+the relation between 3-month BFS and 6-month SF-36 PCS when group is held constant. Thus, for every 1 point increase in 3-month 
+BFS, individuals reported an average b = 0.14-point increase in 6-month SF-36 PCS (P = .04). The relative indirect effects of group can 
+be determined by multiplying the a and b paths. Thus, relative to WL, YG resulted in SF-36 PCS scores that were a1b = 0.77 units 
+higher as a result of the positive effect of YG on BFS, which corresponds to a significant indirect effect of YG versus WL on 6-month 
+SF-36 PCS via 3-month BFS (B = 0.77; SE = 0.58; 95% bias-corrected and accelerated [BCa] CI = 0.01 and 2.58). Conversely, there was 
+no significant indirect effect of ST versus WL on 6-month SF-36 PCS via 3-month BFS (B = 0.07; SE = 0.43; BCa CI = −0.84 and 0.88).
+Abbreviations: QOL, quality of life; SF-36, 36-item Short Form; PCS, physical component scale; BFS, Benefit Finding Scale; YG, yoga 
+group; ST, stretching control group; WL, or waitlist control group.
+*P < .05.
+ at UNIV OF TX MD ANDERSON on April 11, 2016
+ict.sagepub.com
+Downloaded from 
+10	
+Integrative Cancer Therapies 
+radiotherapy equivalent to those of women who did not 
+have sleep disturbances at study entry. A similar pattern was 
+seen for the benefits of yoga for those with high depressive 
+symptoms at baseline.
+Regarding our mediation hypotheses, yoga led to 
+increased benefit finding across the follow-up period rela-
+tive to the stretching and waitlist control groups, where 
+there was consistent decrease over time. Importantly, we 
+found that yoga indirectly affected physical health–related 
+QOL assessed 6 months after radiotherapy via increased 
+benefit finding reported 3 months after radiotherapy. In 
+other words, part of the effect of yoga on physical health–
+related QOL at the long-term follow-up can be attributed to 
+the increased benefit finding experienced by yoga partici-
+pants midway through the follow-up period. Of note, the 
+longitudinal nature of the data enabled the time-lagged 
+mediation analyses, which are critical for determining 
+mechanisms of effect. This is a particular strength of the 
+present article because such mediation analyses are often 
+lacking in intervention study designs.
+Surprisingly, women in the waitlist group reported less 
+avoidance behaviors (eg, “I tried not to think about it;” “I 
+stayed away from reminders about it”) 6 months following 
+radiotherapy compared with women in the yoga group, who 
+reported little change in avoidance behaviors from baseline, 
+and there was no evidence of a decrease in intrusive thoughts 
+over time for any group. This finding was counter to our 
+hypotheses and that of other studies, which have found 
+mind-body practices in general, and yoga in particular, to be 
+associated with reductions in avoidance-related coping.62,63 
+However, exploratory analyses suggested that the typical 
+deleterious effect of avoidance behaviors on QOL64,65 was 
+not found for those in either of the active groups (yoga or 
+stretching) but remained for those in the waitlist group. This 
+finding was somewhat consistent with our previous pilot 
+trial, in which the yoga group reported short-term increases 
+in intrusive thoughts relative to the waitlist control group.10 
+Furthermore, a meta-analysis by Helgeson et al66 found that 
+increased intrusive or avoidant thoughts about a stressor 
+were associated with increase in benefit finding, which was 
+in turn associated with greater well-being. Thus, it could be 
+that yoga may not reduce posttraumatic stress symptoms (ie, 
+cognitive interference or avoidance) in the acute phase, but 
+this in turn may facilitate improved long-term adjustment.
+There are several limitations to recognize in this study. 
+The majority of participants were white, non-Hispanic, 
+married, and highly educated. Thus, future research is 
+needed to test the generalizability of these findings to more 
+diverse populations. Participants also were not blinded to 
+study condition, and no measure of treatment expectation 
+was collected, which could have biased the findings because 
+of the subjective nature of the outcomes. In addition, 
+although these data suggest that women with elevated lev-
+els of depressive symptoms and sleep disturbances show a 
+greater treatment response, these findings need to be inter-
+preted with caution because the patients were not selected 
+based on pretreatment symptomatology. The study may 
+have also been underpowered for the mediation analyses. In 
+a study of empirical power simulations, Fritz and 
+MacKinnon67 indicated that very large sample sizes are 
+required for tests of mediation to be conducted with at least 
+80% power. Thus, the sample size of the present study 
+likely limits our ability to determine mediators with full 
+power, and the same limitation may be true for moderation 
+analyses. Additionally, the reduced reliability of cortisol 
+slopes assessed at later follow-up points (because of a 
+smaller sample size) may have limited our power to detect 
+the effects of cortisol slopes as a mediator in particular. 
+Finally, we followed participants for only a 6-month period, 
+so the long-term effectiveness of yoga in patients with 
+breast cancer remains to be determined. To address these 
+limitations, we are conducting an ongoing yoga trial using a 
+quasi-double-blinded design, with patients not knowing the 
+details of the intervention groups at baseline and then only 
+knowing the specifics of their assigned group. Additionally, 
+assessors are blind to group assignment. Treatment expecta-
+tions are also being measured, and patients complete a 
+1-year follow-up assessment.
+In conclusion, the current study provides a greater under-
+standing of who will benefit most from a yoga intervention 
+and how a yoga intervention produces change. These results 
+suggest that future studies of the effect of yoga on cancer 
+patients may benefit from screening for participants who 
+report poor sleep or depressive symptoms because yoga may 
+buffer the negative effect of poor sleep or low mood on men-
+tal health–related QOL indices in the months following 
+treatment for cancer. Additionally, these findings imply that 
+yoga may improve physical health–related QOL by increas-
+ing one’s ability to find benefit in the cancer experience. 
+Finally, yoga appears to increase women’s endorsement of 
+symptoms typically associated with posttraumatic stress (ie, 
+intrusive thoughts and/or avoidance behaviors) but disasso-
+ciates the typically harmful link between these symptoms 
+and QOL. Based on these results, we recommend that future 
+research continues to identify pretreatment psychosocial 
+factors that predict intervention response, seeks mechanisms 
+by which interventions work, and begins implementing tar-
+geted, tailored, evidence-based mind-body interventions to 
+optimize recovery and QOL in patients affected by cancer.
+Authors’ Note
+Chelsea G. Ratcliff and Kathrin Milbury contributed equally to the 
+article and are both considered first authors.
+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.
+ at UNIV OF TX MD ANDERSON on April 11, 2016
+ict.sagepub.com
+Downloaded from 
+Ratcliff et al	
+11
+Funding
+The author(s) disclosed receipt of the following financial support 
+for the research, authorship, and/or publication of this article: This 
+work was supported by the National Cancer Institute (Grant 
+Numbers R21CA102385, R01CA138800, R25CA10618), the 
+National Cancer Institute Cancer Center Support (Grant Number 
+A016672), the National Center for Complementary and Integrative 
+Health (Grant Number 5 K01 AT007559-02), a National Cancer 
+Institute cancer prevention fellowship for Chelsea G. Ratcliff 
+(Grant Number R25T CA057730), the South Central Mental 
+Illness, Research, Education, and Clinical Center, and philan-
+thropic support.
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subfolder_0/Gas Discharge Visualization Characteristics of an Indian Diabetes Population.txt

@@ -0,0 +1,24 @@
+GAS DISCHARGE VISUALIZATION CHARACTERISTICS OF AN INDIAN DIABETES 
+POPULATION 
+Bhawna Sharma, Alex Hankey, and Hongasandra Ramarao Nagendra 
+ 
+Abstract 
+Instruments measuring subtle energy levels in human subjects are becoming increasingly 
+popular in complementary medicine. Gas Discharge Visualization is an instrument measuring 
+fingertip electron emission, variations in which correspond to changing health levels in 
+different organs and organ systems. Its characteristics in diabetes have not previously been 
+determined. The purpose of this study is to compare Gas Discharge Visualization parameters 
+of diabetes patients those of healthy individuals. ds: Data taken from 138 diabetes patients, 
+divided into three groups according to duration of patholgy, was compared with data from 84 
+healthy subjects. Three GDV subscales were analysed: GDV Screening, Diagram, and Right Left 
+Symmetry. Significant differences were observed between the two groups in the 
+cardiovascular, endocrine, immune and urogenital systems. Dividing the diabetes group 
+according pathology duration revealed systematic increases in values in all organs and organ 
+systems. Also, our Bangalore based subjects seemed to have different norms from those 
+originally used to calibrate the instrument. Differences between diabetic and healthy groups 
+increase with increasing duration of the disease. Population norms require further 
+investigation. 
+Keywords: gas discharge, visualization, characteristics of diabetes, population 
+ 
+ 
+ 

subfolder_0/Health Perceptions and Adopted Lifestyle Behaviors During the COVID-19 Pandemic Cross-National Survey..txt

@@ -0,0 +1,1550 @@
+Original Paper
+Health Perceptions and Adopted Lifestyle Behaviors During the
+COVID-19 Pandemic: Cross-National Survey
+Nandi Krishnamurthy Manjunath1, PhD; Vijaya Majumdar1, PhD; Antonietta Rozzi2, MA; Wang Huiru3, PhD; Avinash
+Mishra4, PhD; Keishin Kimura5; Raghuram Nagarathna1, MD; Hongasandra Ramarao Nagendra1, PhD
+1Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru, India
+2Sarva Yoga International, Sarzana SP, Italy
+3Shanghai Jiao Tong University, Shanghai, China
+4Vivekananda Yoga China, Shanghai, China
+5Japan Yoga Therapy Society, Yonago City, Japan
+Corresponding Author:
+Vijaya Majumdar, PhD
+Swami Vivekananda Yoga Anusandhana Samsthana University
+#19, Eknath Bhavan, Gavipuram Circle
+KG Naga
+Bengaluru, 560019
+India
+Phone: 91 08026995163
+Email: [email protected]
+Abstract
+Background: Social isolation measures are requisites to control viral spread during the COVID-19 pandemic. However, if these
+measures are implemented for a long period of time, they can result in adverse modification of people’s health perceptions and
+lifestyle behaviors.
+Objective: The aim of this cross-national survey was to address the lack of adequate real-time data on the public response to
+changes in lifestyle behavior during the crisis of the COVID-19 pandemic.
+Methods: A cross-national web-based survey was administered using Google Forms during the month of April 2020. The
+settings were China, Japan, Italy, and India. There were two primary outcomes: (1) response to the health scale, defined as
+perceived health status, a combined score of health-related survey items; and (2) adoption of healthy lifestyle choices, defined
+as the engagement of the respondent in any two of three healthy lifestyle choices (healthy eating habits, engagement in physical
+activity or exercise, and reduced substance use). Statistical associations were assessed with linear and logistic regression analyses.
+Results: We received 3371 responses; 1342 were from India (39.8%), 983 from China (29.2%), 669 from Italy (19.8%), and
+377 (11.2%) from Japan. A differential countrywise response was observed toward perceived health status; the highest scores
+were obtained for Indian respondents (9.43, SD 2.43), and the lowest were obtained for Japanese respondents (6.81, SD 3.44).
+Similarly, countrywise differences in the magnitude of the influence of perceptions on health status were observed; perception
+of interpersonal relationships was most pronounced in the comparatively old Italian and Japanese respondents (β=.68 and .60,
+respectively), and the fear response was most pronounced in Chinese respondents (β=.71). Overall, 78.4% of the respondents
+adopted at least two healthy lifestyle choices amid the COVID-19 pandemic. Unlike health status, the influence of perception of
+interpersonal relationships on the adoption of lifestyle choices was not unanimous, and it was absent in the Italian respondents
+(odds ratio 1.93, 95% CI 0.65-5.79). The influence of perceived health status was a significant predictor of lifestyle change across
+all the countries, most prominently by approximately 6-fold in China and Italy.
+Conclusions: The overall consistent positive influence of increased interpersonal relationships on health perceptions and adopted
+lifestyle behaviors during the pandemic is the key real-time finding of the survey. Favorable behavioral changes should be bolstered
+through regular virtual interpersonal interactions, particularly in countries with an overall middle-aged or older population. Further,
+controlling the fear response of the public through counseling could also help improve health perceptions and lifestyle behavior.
+However, the observed human behavior needs to be viewed within the purview of cultural disparities, self-perceptions, demographic
+variances, and the influence of countrywise phase variations of the pandemic. The observations derived from a short lockdown
+period are preliminary, and real insight could only be obtained from a longer follow-up.
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 1
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+(JMIR Form Res 2021;5(6):e23630) doi: 10.2196/23630
+KEYWORDS
+health behavior; self-report; cross-national survey; COVID-19; behavior; perception; lifestyle; nutrition; real-time
+Introduction
+The World Health Organization (WHO) declared the outbreak
+of COVID-19 a pandemic on March 11, 2020 [1]. As of March
+24, 2020, the most affected regions in the world were the
+Western Pacific region (China, the Republic of Korea, Japan,
+etc), with a total of 96,580 reported confirmed cases, and the
+European region (Italy, Spain, Germany, the United Kingdom,
+etc), which accounted for a total of 195,511 positive cases [2].
+There was a global panic due to the shifting of the COVID-19
+epicenters from China to Europe, mainly Italy, which reported
+the worst outcomes up to March 25, 2020 (69,176 reported cases
+and the maximum number of COVID-19 deaths of 6820) [2].
+Global disease outbreaks impact varied aspects of physical and
+mental health, even suicidality [3-5]. As observed in the
+infectious disease epidemic of severe acute respiratory syndrome
+(SARS) in 2003, exposure to new pathogens can manifest as a
+qualitatively distinct mental impact [6]. Social isolation
+measures 
+(large-scale 
+quarantines, 
+long-term 
+home
+confinements, and nationwide lockdowns) [7-11], although
+essential for controlling viral spread, go against the inherent
+human instinct of social relationships [12,13]. If these measures
+are implemented for a long duration, they can be detrimental
+to mental health, as observed in recent reports from China and
+Vietnam [14-17], and they are expected to result in modification
+of people’s lifestyle behaviors, such as increased adoption of
+unhealthy dietary habits and sedentary behavior. These changes
+can exacerbate the burden of the “pandemics” of behavioral and
+cardiovascular diseases that already prevail in modern societies
+[18,19]. The latest trends of re-emergences of such infectious
+disease outbreaks merit timely preparedness involving
+community engagement and focus on healthy lifestyle behaviors
+[20,21]. Although the mental impact of the COVID-19 pandemic
+is being addressed in a timely fashion [22,23], the associated
+real-time influences on people’s health perceptions and lifestyle
+choices remain underresearched [24,25]. Careful consideration
+of the demographic and cultural impact of tailored public health
+intervention strategies on human behavior is also greatly needed
+when designing such strategies. Here, we report the findings of
+a cross-national survey that aimed to generate rapid perspectives
+on the status of health-related perceptions and their influence
+on the likelihood of adoption of healthy lifestyle choices during
+the COVID-19 pandemic. The settings were China and Japan,
+two nations in the Western Pacific region that were greatly
+impacted by COVID-19; Italy, from the European region; and
+India, a highly populous South Asian country that was a
+potential threat region at the time of the survey [2,7-9,11].
+Methods
+Sampling and Data Collection
+Given the restricted mobility restrictions and confinement due
+to 
+the 
+COVID-19 
+lockdown, 
+we 
+conducted 
+a
+cross-sectional survey using a web-based platform. We
+disseminated the survey through the circulation of a Google
+Form via institutional websites and private social media
+networks, such as Facebook and WhatsApp. We also used the
+group email lists of a few social organizations, universities,
+academic institutions, and their interconnections to share the
+questionnaire links, which further facilitated the snowball
+sampling. The respondents were residents of China, Japan, Italy,
+and India who were aged 18 years or older. We anonymized
+the data to preserve and protect confidentiality. The study was
+approved by the institutional review boards and institutional
+ethics committees of the respective nations: Swami Vivekananda
+Yoga Anusandhana Samsthana (SVYASA), India; Sarva Yoga
+International, Italy; Shanghai Jiao Tong University, China; and
+Japan Yoga Therapy Society, Japan. Respondents were informed
+about the objectives of the survey and the anonymity of their
+responses. Informed consent was obtained through a declaration
+of the participants of their voluntary participation, the
+confidentiality of the data, and the use of the collected
+information for research purposes only. The survey period was
+April 3-28, 2020. Once submitted, the responses were directly
+used for the analysis, and revisions of the responses were not
+allowed.
+Questionnaire Structure
+We chose a short format for the questionnaire, with 19 questions
+to facilitate rapid administration. The first set of questions
+(Q1-Q5) were related to the respondents’ demographic details:
+age, gender, country of residence, working status, and the
+presence of any chronic illness or disability diagnosed by a
+physician. The next set (Q6-Q14) contained perception-related
+questions on self-rated physical and mental health, sleep quality,
+coping ability, energy status (a psychological state defined as
+an individual's potential to perform mental and physical activity
+[26,27]), coping flexibility, and perceptions related to
+interpersonal relationships as well as the fear of the pandemic.
+The questions were phrased as statements, with responses
+recorded on 3- or 5-point scales. For example, the respondents
+were requested to self-rate their mental and physical health
+status with the questions “How do you rate your physical health
+at present as” and “How do rate your mental health at present
+as” with answer modalities of (1) excellent, (2) very good, (3)
+good, (4) average, and (5) poor. These single-item self-health
+assessment questions are validated tools used in national surveys
+and epidemiological studies to assess health perceptions among
+individuals, strongly related to various morbidities, and
+mortality, and they have been validated across various ethnicities
+[28-33]. A further set of questions (Q15-Q19) focused on items
+related to the respondents’ recent lifestyle behavior choices:
+eating habits, engagement in physical activity or exercise, and
+substance use. Permitted responses for these behavior-related
+questions were either yes or no. For eating habits, the
+respondents provided self-rated scores for their time of eating;
+nourishment related to intake of vegetables and fibers; and daily
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 2
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+intake of “junk food” (described as packaged and processed
+sweets or salty snacks); the combined scores were dichotomized
+into “good” (score ≥3) and “poor” (score ≤2).
+Data Analysis
+An exploratory factor analysis using the principal axis factoring
+and varimax rotation suggested that three factors were present
+in the data. Items related to health perceptions were used to
+form a scale for perceived health status (the health scale); the
+scores were represented as mean (SD). For the remaining two
+factors, we could not form scales, as they scored Cronbach α
+values <.6; instead, we used the most relevant single item to
+represent the factor. The two primary outcomes of the study
+were the health scale and the adoption of healthy lifestyle
+choices. The health scale was derived as mentioned above;
+further health scale scores were categorized based on tertile
+distribution into low (poor), middle (average), and high (good)
+scores. Adoption of healthy lifestyle choices was defined as the
+engagement of the respondent in any two of three healthy
+lifestyle choices (eating habits, substance use, and exercise).
+Multivariate linear and logistic regression analyses were used
+to test the influence of the perceptions and the personal variables
+on the primary outcomes. Most of the items in the survey were
+recorded as 3-point responses. Hence, to achieve homogeneity
+in the analyses of the survey items, the 5-point Likert responses
+of the self-rated health items, excellent, very good, good,
+average, and poor, were collapsed into three categories: (1) very
+good/excellent, (2) good, and (3) average/poor. Analysis of
+variance was used to assess comparisons between continuous
+variables, and P<.05 was considered significant. Chi-square
+analysis was used for cross-country comparisons for categorical
+variables.
+Results
+The aim of this survey was to understand the cross-national
+psychosocial and behavioral impact of the lockdowns and social
+isolations imposed due to the COVID-19 pandemic. We received
+3370 responses: 1342 from India (39.8%), 983 from China
+(29.2%), 669 from Italy (19.8%), and 377 from Japan (11.2%).
+The demographic profiles of the respondents are presented in
+Table 1.
+Table 1. Countrywise representation of the personal characteristics of the survey participants.
+P valuea
+Italy (n=669)
+Japan (n=377)
+China (n=983)
+India (n=1342)
+Overall (N=3371)
+Variable
+<.001
+48.43 (13.65)
+53.49 (9.35)
+29.77 (11.98)
+29.42 (12.29)
+36.04 (15.54)
+Age (years), mean (SD)
+<.001
+Age group (years), n (%)
+31 (4.7)
+1 (0.3)
+490 (49.8)
+685 (51.0)
+1200 (35.6)
+18-24
+84 (12.5)
+4 (1.1)
+152 (15.5)
+267 (19.9)
+503 (14.9)
+25-34
+309 (46.2)
+217 (57.5)
+314 (32.0)
+330 (24.6)
+1176 (34.9)
+35-54
+169 (25.2)
+98 (26.0)
+21 (2.1)
+40 (3.0)
+330 (9.8)
+55-64
+76 (11.4)
+57 (15.1)
+6 (0.6)
+20 (1.5)
+162 (4.8)
+>65
+<.001
+506 (75.6)
+348 (92.0)
+802 (81.6)
+880 (65.6)
+2535 (75.2)
+Female gender, n (%)
+<.001
+395 (59.0)
+335 (89.0)
+406 (41.3)
+582 (43.4)
+1709 (50.7)
+Working, n (%)
+<.001
+314 (46.9)
+151 (40.0)
+84 (8.5)
+169 (12.6)
+647 (19.2)
+Has a chronic illness, n (%)
+aCross-country comparisons for categorical variables were conducted using chi-square analysis. Analysis of variance was conducted to assess comparisons
+among the continuous variable of age. A P value <.05 was considered significant.
+The mean age of the respondents was 36.04 years (SD 15.54)
+(Table 1); the average age of the Indian and Chinese respondents
+(29.42 years, SD 12.29, and 29.77 years, SD 11.98, respectively)
+was lower than that of the Japanese and Italian respondents
+(53.49 years, SD 9.35, and 48.43 years, SD 3.65, respectively).
+Overall, there was a higher representation of the female gender
+(2535/3371, 75.2%). Japan had the highest representation of
+women (348/377, 92.0%) and working people (335/377, 89.0%)
+(Table 1). Italy and Japan had the highest representations of
+respondents with a known status of chronic illness (314/669,
+46.9%, and 151/377, 40.0%, respectively).
+Table 2 shows the countrywise status of the perceptions of health
+and psychosocial factors reported in response to the ongoing
+outbreak of COVID-19. The health status score was highest for
+Indian respondents (9.43, SD 2.43) and lowest for Japanese
+respondents (6.81, SD 3.44). Overall, 846/3371 (25.1%) of the
+respondents had good health status; Japanese and Chinese
+respondents had the highest representation of low health status
+(236/377, 62.6%, and 562/983, 57.2%, respectively). Sleep
+quality was perceived well by the majority of Indians (917/1342,
+68.3%), and the majority of Japanese and Chinese respondents
+perceived their sleep quality as average/poor (264/377, 70%,
+and 554/983, 56.3%, respectively). Italian respondents had
+almost equal representations of good and average sleep qualities.
+Coping abilities during social isolation were perceived as good
+by 1264/3371 (37.5%) of the overall population, with the
+countrywise trend of India (672/1342, 50.1%) > Italy (283/669,
+42.3%) > Japan (131/377, 34.8%) > China (178/983, 18.1%).
+Fear response was almost equally distributed in positive or
+intermediate categories for most of the country respondents,
+except for Italians, among whom the intermediate or partial fear
+response was the most evident (469/669, 70.1%). Coping
+flexibility responses were very similar across all the countries
+except Japan, wherein the majority of respondents (317/377,
+84.1%) reported experiencing little challenging response to
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 3
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+sudden changes in living norms. Responses to interpersonal
+relationships followed the trend of India (733/1342, 54.6%) >
+Japan (183/377, 48.5%) > Italy (287/669, 42.9%) > China
+(337/983, 34.3%). Adopted lifestyle behavior yielded the trend
+of India (1129/1342, 83.9%) > Italy (361/669, 54.0%) > China
+(436/983, 44.4%) > Japan (137/377, 36.2%).
+Based on the regression analysis on the perceived health status,
+female respondents had a 0.14 lower score compared to male
+respondents (Table 3). Participants with a positive history of
+chronic illness and those who were not working also had lower
+health status scores, by 0.11 and 0.04, respectively, compared
+to their counterparts. Increased personal relationships and
+positive fear response were associated with increases in health
+status across all the countries, particularly Japan, which showed
+the highest value of β (.60). For Indian respondents, an increase
+in age was significantly associated with increase in health status
+by a score of 0.12.
+Increased interpersonal relationships was a significant predictor
+of adoption of health lifestyle choices across the respondents
+in all the countries except for Italy (adjusted OR 1.93, 95% CI
+0.65-5.79) (Table 4). Positive perception of fear was
+significantly associated with likelihood of adoption of healthy
+lifestyle choices only in Indian respondents (adjusted OR 2.41,
+95% CI 1.18-4.96). Perceived health status categories were
+significantly associated with the likelihood of adoption of
+healthy lifestyle choices across all the countries; most
+prominently, high health status increased adoption of healthy
+lifestyle choices by approximately 6-fold in China and Italy.
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 4
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+Table 2. Countrywise representation of perceptions and behavioral changes among the survey respondents related to the COVID-19 outbreak.
+P valuea
+Italy (n=669)
+Japan (n=377)
+China (n=983)
+India (n=1342)
+Overall
+(N=3371)
+Perception or behavior and response
+First factorb
+.01
+8.43 (2.56)
+6.81 (3.44)
+7.09 ( 2.92)
+9.43 (2.43)
+8.26 (3.36)
+Health status, mean (SD)
+150 (22.4)
+69 (18.3)
+71 (7.2)
+556 (41.4)
+846 (25.1)
+High, n (%)
+Medium, n (%)
+225 (33.6)
+72 (19.1)
+350 (35.6)
+413 (30.8)
+1062 (31.5)
+294 (43.9)
+236 (62.6)
+562 (57.2)
+413 (30.8)
+1463 (43.4)
+Low, n (%)
+<.001
+Self-rated physical health, n (%)
+173 (25.9)
+88 (23.3)
+467 (47.5)
+629 (46.9)
+1357 (40.2)
+Excellent/very good
+375 (56.0)
+135 (35.8)
+200 (20.3)
+573 (42.7)
+1283 (38.1)
+Good
+121 (18.1)
+154 (40.8)
+316 (32.1)
+140 (10.4)
+731 (21.7)
+Poor/average
+<.001
+Self-rated mental health, n (%)
+206 (30.8)
+93 (24.7)
+0 (0)
+645 (48.1)
+944 (28.0)
+Excellent/very good
+371 (55.4)
+122 (32.4)
+642 (65.3)
+535 (39.9)
+1670
+(49.5)
+Good
+92 (13.8)
+162 (43.0)
+341 (34.7)
+162 (12.1)
+757 (22.5)
+Poor/average
+<.001
+Self-rated sleep quality, n (%)
+328 (49.0)
+113 (29.9)
+429 (43.6)
+917 (68.3)
+1787 (53.0)
+Good
+240 (35.9)
+234 (62.1)
+477 (48.5)
+354 (26.4)
+1305
+(38.7)
+Average
+101 (15.1)
+30 (8.0)
+77 (7.8)
+71 (5.3)
+279
+(8.3)
+Poor
+<.001
+Self-rated coping abilities, n (%)
+283 (42.3)
+131 (34.8)
+178 (18.1)
+672 (50.1)
+1264 (37.5)
+Good
+298 (44.5)
+139 (36.8)
+516 (52.5)
+539 (40.1)
+1492 (44.3)
+Average
+88 (13.2)
+107 (28.5)
+289 (29.4)
+131 (9.8)
+615 (18.2)
+Poor
+Second factor , n (%)
+<.001
+Fear/anxiety related to COVID-19c
+125 (18.7)
+157 (41.6)
+470 (47.8)
+628 (46.8)
+1380 (40.9)
+Not at all (positive)
+469 (70.1)
+213 (56.5)
+485 (49.3)
+662 (49.3)
+1829 (54.3)
+Partially (intermediate)
+75 (11.2)
+7 (1.9)
+28 (2.8)
+52 (3.9)
+162 (4.8)
+Extremely (negative)
+<.001
+Self-perception of low energy
+261 (39.0)
+239 (63.4)
+282 (28.7)
+667 (49.7)
+1449 (43.0)
+Never
+390 (58.3)
+132 (35.0)
+672 (68.4)
+641 (47.8)
+1835 (54.5)
+Sometimes
+18 (2.7)
+6 (1.6)
+29 (3.0)
+34 (2.5)
+87 (2.6)
+All the time
+<.001
+Challenging response to sudden changes in living norms (coping flexibility)
+144 (21.5)
+44 (11.7)
+221 (22.5)
+436 (32.5)
+845 (25.1)
+Least/not at all/little
+309 (46.2)
+317 (84.1)
+411 (41.8)
+417 (31.1)
+1454 (43.1)
+Little
+216 (32.3)
+16 (4.2)
+351 (35.7)
+489 (36.4)
+1072 (31.8)
+Extremely/somewhat
+Third factor, n (%)
+<.001
+Interpersonal relationshipsc
+287 (42.9)
+183 (48.5)
+337 (34.3)
+733 (54.6)
+1540 (45.7)
+Increased
+310 (46.3)
+179 (47.5)
+550 (56.0)
+533 (39.7)
+1572 (46.6)
+Not changed
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 5
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+P valuea
+Italy (n=669)
+Japan (n=377)
+China (n=983)
+India (n=1342)
+Overall
+(N=3371)
+Perception or behavior and response
+72 (10.8)
+15 (4.0)
+96 (9.8)
+76 (5.7)
+259 (7.7)
+Reduced
+<.001
+Motivating influence of COVID-19 on lifestyle
+221 (33.0)
+132 (35.0)
+217 (22.1)
+605 (45.1)
+1175 (34.8)
+Completely
+360 (53.8)
+223 (59.2)
+695 (70.7)
+641 (47.8)
+1919 (57.0)
+Partially
+88 (13.2)
+22 (5.8)
+71 (7.2)
+96 (7.1)
+277 (8.2)
+Not at all
+<.001
+485 (72.5)
+283 (75.1)
+750 (76.3)
+1126 (83.9)
+2643 (78.4)
+Adoption of ≥2 healthy lifestyle choices
+<.001
+361 (54.0)
+137 (36.3)
+436 (44.4)
+867 (64.6)
+1801 (53.4)
+Adoption of healthy eating behavior
+<.001
+623 (93.1)
+355 (94.1)
+918 (93.4)
+1277 (95.2)
+3173 (94.1)
+Decreased dependency on and use
+of tobacco, alcohol, or any other
+substances
+<.001
+426 (63.7)
+272 (72.1)
+672 (68.4)
+910 (67.8)
+2280 (67.6)
+Increased engagement in exercise
+or similar activities
+aCross-country comparisons for categorical variables were conducted using chi-square analysis; all the P values were significant.
+bAn exploratory factor analysis using principal axis factoring and varimax rotation suggested that there were 3 factors present in the data. The first
+factor consisted of health-related perceptions; composite scores for perceived health were generated as summative scores of the included items.
+cFor the remaining 2 factors, scales could not be formed; rather, the single items that were thought to best summarize the respective factors were
+considered for further association analyses.
+Table 3.  Multivariate linear regression analysis (β coefficients, standard errors, and t and P values) of the association between health status, personal
+variables, and perceptions.
+Italy
+Japan
+China
+India
+Overall
+Predic-
+tors
+P
+t
+SE
+β
+P
+t
+SE
+β
+P
+t
+SE
+β
+P
+t
+SE
+β
+P
+t
+SE
+β
+Demographic variables
+.51
+–0.66
+0.02
+–.07
+0.12
+1.55
+0.02
+.08
+.07
+1.79
+0.01
+.07
+<.001
+3.74
+0.01
+.12
+<.001
+5.12
+0.01
+.14
+Age
+Gender (reference: male)
+.97
+–0.03
+0.52
+<.001
+0.77
+–0.30
+0.64
+.01
+.72
+–0.35
+0.23
+–.01
+<.001
+–3.24
+0.14
+–.09
+<.001
+–7.51
+0.12
+–.14
+Fe-
+male
+Working status (reference: working)
+.72
+–0.36
+0.55
+–.03
+0.48
+–0.71
+0.56
+–.04
+.59
+–0.54
+0.23
+–.02
+.75
+–0.32
+0.15
+–.01
+.04
+–2.04
+0.13
+–.04
+Not
+work-
+ing
+Chronic illness (reference: no)
+.34
+–0.96
+0.47
+–.09
+0.01
+–2.81
+0.35
+–.14
+.04
+–2.04
+0.31
+–.06
+<.001
+–6.12
+0.20
+–.16
+<.001
+–5.63
+0.15
+–.11
+Yes
+Perceptions
+Interpersonal relationships (reference: decreased)
+.03
+2.17
+0.68
+.27
+<.001
+4.86
+0.85
+.60
+<.001
+4.12
+0.31
+.21
+<.001
+6.48
+0.28
+.38
+<.001
+10.76
+0.21
+.37
+In-
+creased
+.12
+1.56
+0.66
+019
+0.01
+2.66
+0.84
+.33
+.28
+1.08
+0.29
+.05
+<.001
+3.71
+0.29
+.21
+<.001
+4.15
+0.21
+.14
+No
+change
+Fear response (reference: poor)
+<.001
+3.03
+1.02
+.50
+0.01
+2.72
+1.38
+.54
+<.001
+8.02
+0.52
+.71
+<.001
+8.69
+0.33
+.59
+<.001
+10.84
+0.30
+.54
+Posi-
+tive
+.08
+1.77
+0.97
+.30
+0.20
+1.30
+1.37
+.26
+<.001
+4.35
+0.51
+.38
+<.001
+5.22
+0.33
+.35
+<.001
+5.82
+0.30
+.29
+Fair
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 6
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX
+Table 4. Role of perceptions in the adoption of healthy lifestyle choices.
+Italy
+Japan
+China
+India
+Overall
+Perception
+Adjusted OR
+(95% CI)
+OR
+(95% CI)
+Adjusted OR
+(95% CI)
+OR
+(95% CI)
+Adjusted OR
+(95% CI)
+OR
+(95% CI)
+Adjusted OR
+(95% CI)
+OR
+(95% CI)
+AdjustedbOR
+(95% CI)
+ORa
+(95% CI)
+Health status (reference: low)
+6.22
+(1.90- 20.40)
+3.33
+(2.01-
+5.51)
+2.83
+(1.18-6.77)
+3.64
+(1.59-
+8.37)
+5.83
+(2.30-4.79)
+6.02
+(2.38-
+15.20)
+2.62
+(1.75-3.92)
+2.98
+(2.07-
+4.28)
+3.42
+(2.51-4.64)
+3.67
+(2.87-
+4.68)
+High
+2.46
+(1.03-5.83)
+2.10
+(1.42-
+3.12)
+1.06
+(0.54-2.08)
+1.33
+(0.72-
+2.45)
+2.43
+(1.72-3.45)
+2.61
+(1.85-
+3.69)
+1.57
+(1.07-2.31)
+1.76
+(1.24-
+2.50)
+2.00
+(1.59-2.50)
+2.09
+(1.72-
+2.54)
+Medium
+Interpersonal relationshipsc (reference: decreased)
+1.93
+(0.65-5.79)
+1.86
+(1.07-
+3.22)
+5.25
+(1.46-8.92)
+4.43
+(1.49-
+13.15)
+1.77
+(1.03-3.05)
+2.01
+(1.18-
+3.41)
+2.16
+(1.15-4.08)
+1.86
+(1.03-
+3.37)
+2.42
+(1.70-3.45)
+2.21
+(1.64-
+2.98)
+In-
+creased
+1.40
+(0.50-3.96)
+1.59
+(0.93-
+2.73)
+1.88
+(0.54-6.52)
+1.87
+(0.65-
+5.42)
+0.99
+(0.61-1.62)
+1.03
+(0.64-
+1.68)
+1.18
+(0.63-2.21)
+1.09
+(0.60-
+1.97)
+1.18
+(0.84-1.66)
+1.25
+(0.94-1.7)
+Not
+changed
+Fear responsec (reference: poor)
+2.20
+(0.41-11.71)
+1.62
+(0.86-
+3.04)
+4.85
+(0.73-32.19)
+1.84
+(0.34-
+9.99)
+2.18
+(0.96-4.94)
+2.38
+(1.06-
+5.33)
+2.41
+(1.18-4.96)
+2.72
+(1.38-
+5.36)
+2.50
+(1.54-4.05)
+2.43
+(1.69-
+3.50)
+Positive
+1.25
+(0.27-5.80)
+1.34
+(0.80-
+2.27)
+1.97
+(0.31-12.55)
+0.93
+(0.18-
+4.93)
+1.32
+(0.59-2.96)
+1.46
+(0.66-
+3.23)
+1.32
+(0.65-2.65)
+1.37
+(0.71-
+2.65)
+1.33
+(0.83-2.14)
+1.36
+(0.95-
+1.93)
+Fair
+aOR: odds ratio.
+bAdjusted for sex, age, work status, and history of chronic illness.
+cFactor represented by a single item that was thought to best represent the underlying notion.
+Discussion
+The aims of this short cross-national behavioral survey study
+were to generate rapid ideas regarding perspectives on health
+and lifestyle behavior and to provide initial insights into
+designing global but culturally tailored public health policies.
+Health Perceptions: Countrywise Status
+A differential countrywise response was observed toward
+perceived health status across the survey participants; Indians
+had a better representation of high health status (41.4%)
+compared to respondents from other countries (China, 7.2%,
+Japan, 18.2%, and Italy, 22.5%). Despite the inconsistencies in
+health perceptions, there was a consistent influence of social
+support measured by perceptions of interpersonal relationships
+and fear of perceived health status. However, there were
+countrywise differences in the magnitude of the impact of
+perceptions on health status; perception of interpersonal
+relationships was most pronounced in the comparatively older
+Italian and Japanese respondents (β=.68 and .60, respectively)
+and that of fear in the Chinese respondents (β=.71). These
+findings favor the implementation of regularized virtual
+interpersonal interactions toward combating the adverse health
+impact of the pandemic, particularly in countries with a higher
+proportion of older people [34]. Controlling the fear response
+through counseling would also aid the improvement of health
+outcomes in populations affected by pandemics. The findings
+of this survey related to the influence of gender on health
+perceptions (the health status score of female respondents was
+lower by 0.14 units compared to that of male respondents) are
+in line with the global trend of poorer health perception in
+women than in their male counterparts [35]. These real-time
+findings observed during the pandemic also relate with reports
+documented before the COVID-19 pandemic, with a generally
+higher prevalence of adverse mental health symptoms in women
+compared to men [36]. Overall, there seemed to be a differential
+influence of demographic variables on health perceptions across
+the global population during the pandemic.
+The comparatively high scores of the perceived health status in
+Indian respondents could be underlined by an early phase of
+the pandemic with slower progression in India during the survey
+period [11]. The younger age of the Indian respondents (mean
+age 29.42 years, SD 12.29) seemed to further facilitate
+interpersonal relationships (54.6%) during the lockdown, which
+also explains their better health status (β=.38) [34,37]. Younger
+age identity has been associated with well-being and better
+perceptions of health [38]. However, in this survey, an
+unexpectedly positive linear relationship was observed between
+increasing age and better perception of health status (β=.12) in
+young Indian respondents. This finding can be attributed to the
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 7
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
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+compounding effect of the COVID-19 pandemic on already
+existing emotional distress among young adults (related to their
+examinations, uncertainties, social relationships, etc) [39].
+Unfortunately, in line with previous reports [14,15], we could
+also observe a continued/posttraumatic impact of the pandemic
+in Chinese respondents, reflected in their comparatively low
+perception of health status (poor health status was reported by
+57.2% of these respondents). We believe the poor health
+perceptions in the Chinese respondents is due to the underlying
+influence of fear perceptions (β=.71). Further, since the country
+had successfully emerged from the first wave of the pandemic
+during the survey, and social norms had also almost returned
+to normal, with fewer imposed lockdowns, the moderate increase
+in interpersonal relationships (34.3%) may not be sufficient to
+facilitate health status.
+The observed low status of perceived health in the Japanese
+respondents (low health status, 62.6%) is in accord with a health
+paradox in that country, which is a tendency to perceive health
+poorly despite the advanced economy [40,41]. Although this
+influence is not direct, an indirect influence of the comparatively
+old, middle-aged demographic profile of the Japanese
+respondents along with the mediatory impact of chronic diseases
+on health status (β=–.14) could also underlie the lower health
+perceptions of the Japanese respondents [42]. The perception
+of poor sleep quality in the Japanese respondents also needs
+attention, as this finding is in line with reports of the suicidal
+tendencies in this country [43].
+On a positive note, amid the aggravated pandemic at the time
+of the survey, the majority of the Italian respondents who were
+middle-aged perceived only partial fear of the pandemic (70.1%
+response), and they reported better health perceptions (health
+status score 8.43, SD 2.56) than Japanese respondents (health
+status score 6.81, SD 3.44) and Chinese respondents (health
+status score 7.09, SD 2.92). Approximately 55% of the responses
+for self-rated physical and mental health were in the
+moderate/fair tier, which is in accord with the reported tendency
+of Italian people toward intermediate categories of health
+perception [44]. The lack of negative influence of middle age
+and chronic illness on health perception can be attributed to the
+highly efficient medical care and adequate access to social
+support provided in Italy during the lockdown (improved
+interpersonal relationships were reported by 42.9% of Italian
+respondents).
+Role of Perceptions in the Adoption of Lifestyle
+Choices: Countrywise Comparisons
+Despite the imposed social isolation and home confinement and
+the prevailing fear during the COVID-19 pandemic, we observed
+a positive behavioral response toward lifestyle. Overall, 78.4%
+of the respondents adopted at least 2 healthy lifestyle choices
+during the COVID-19 pandemic. The majority of the
+respondents (67.6%) reported increased engagement in physical
+activity or exercise as opposed to the expected sedentary
+behavior due to home confinement. This favorable although
+unexpected outcome can be attributed to the timely release of
+the advisory recommendations made by various global and
+government agencies, including the WHO, on home-based or
+other easy‐to‐perform exercises under physical restrictions
+[45,46]. One of the crucial affirmative responses observed in
+this survey was the overwhelming response toward substance
+use (94.1%), which is more justifiable by lack of availability
+[47] than motivational influence. Along similar lines, in a recent
+survey on the immediate response to COVID-19, a 3% reduction
+in smoking was reported in Italians, which was attributed to the
+fear of increased risk of respiratory distress or mortality [48].
+To this end, we suggest the implementation of internet-based
+and cost-effective behavioral therapies, particularly cognitive
+behavioral therapy, which may aid the successful alleviation of
+maladaptive coping tendencies, thereby reducing the risk of
+future health catastrophes in the post–COVID-19 era [49,50].
+Social connectedness is an important dimension that controls
+population health and healthy lifestyle behavior [51]. In this
+cross-national survey, perception of increased social support
+and capital, manifested through enhanced interactions among
+close friends and family members (measured as interpersonal
+relationships in the survey), seemed to fill the void of missing
+social connectedness and encouraged the adoption of healthy
+lifestyle choices (adjusted OR 2.42, 95% CI 1.70-3.45). The
+substantial representation of the adoption of healthy lifestyle
+choices in Chinese and Japanese respondents (~75%),
+irrespective of their overall poor health perceptions, could be
+related to reverse causality. In the Japanese respondents (who
+had an older, middle-aged demographic profile), their working
+status (OR 4.37, 95% CI 1.19-16.02) (Table S1, Multimedia
+Appendix 1) and interpersonal relationships (OR for the
+adoption of healthy lifestyle choices 5.25, 95% CI 1.46-18.92)
+also seemed to contribute significantly to the adoption of healthy
+lifestyle behavior.
+The influence of interpersonal relationships on the adoption of
+healthy lifestyle choices was not consistent across different
+countries and was absent in the Italian respondents. However,
+this finding aligns with the previously reported relationship
+between a healthy lifestyle and self-perceived health in the
+European population [52]. Perception of good health was a
+prominent predictor of adoption of a healthy lifestyle (adjusted
+OR 6.22, 95% CI 1.90-20.40) in the middle-aged Italian
+respondents, with a 36.6% proportion of older individuals (>55
+years). Even intermediate scores of health perceptions (health
+status) also significantly predicted the likelihood of the adoption
+of healthy lifestyle choices (OR 2.43, 95% CI 1.72-3.45) in the
+Chinese respondents compared to the respondents from other
+countries, explained by their demographic characteristic of
+younger age. These countrywise differential cultural influences
+of perceptions on health and health behaviors during pandemics
+indicate that endorsement of the same, such as family support
+and togetherness, should consider existing disparities, especially
+for western countries [13].
+The findings of this report, particularly those regarding varied
+health perceptions and their differential influence on the
+likelihood of adopting healthy lifestyle choices, should be
+considered within the purview of the survey period with
+countrywise phase variations of the pandemic. Chinese
+respondents displayed the continued impact of the pandemic,
+as they had already witnessed one phase of the pandemic [2].
+Younger Indian respondents scored better for their health- and
+behavior-related perceptions due to the stable and early phase
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 8
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
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+of the pandemic (as of April 22, there was a comparatively
+steady expansion of COVID-19 cases in India compared to other
+countries, with 18,985 confirmed cases [11]). However, the
+responses of Japanese and Italian respondents related to their
+older age; these countries were also witnessing rising waves of
+COVID-19 at the time of the survey [7,53]. Japan was under
+an extended state of national emergency, as the number of
+“untraceable” cases was soaring [7]. Italy was also under an
+extended period of lockdown and was one of the hardest-hit
+nations, with an apparent mortality rate of approximately 13%
+[53,54].
+The observed predominantly female participation in the survey
+indicates a lack of stringent sampling but also highlights the
+active involvement of women, who are considered to be at high
+risk of socioeconomic vulnerability toward disease outbreaks
+such as the COVID-19 pandemic. The positive response for
+self-care in women is also a sign of improving gender equity
+toward health awareness. The observed overwhelmingly female
+participation level (75.2%) could not be ascribed to the gender
+representation of countries such as India and China [55] but
+could be ascribed to the high readiness of the female population
+to interactively use the internet, in particular to research
+health-related information and programs, as observed in recent
+reports [56-58].
+The study is limited by the lack of inclusion of perceptions of
+preventive behaviors and did not compare the respondents’
+views on precautionary measures, such as the use of face masks
+[59]. In a recent cross-country comparison between Polish and
+Chinese respondents, higher use of face masks in Chinese
+respondents (Polish respondents, 35.0%; Chinese respondents,
+96.8%; P<.001) was found to be associated with better physical
+and mental impact of the COVID-19 pandemic [59]. Further,
+the observations of the adopted lifestyle choices presented here
+are derived from a short lockdown period during the COVID-19
+pandemic and are preliminary, influenced mostly by
+self-perception; demographic and cultural differences and
+realistic insight could only be obtained from a longer follow-up.
+Due to the self-reported nature of the observations, positive
+behavioral responses toward lifestyle are likely to be inflated.
+Good perceived health was associated with improved
+interpersonal relationships. Older respondents were least likely
+to report a positive relationship change, as observed in the
+responses of Italian and Japanese survey participants. However,
+there was a strong influence of improved interpersonal
+relationships on perceived health as well as adoption of healthy
+lifestyle choices in Japanese respondents. These findings
+indicate the potential of regularized virtual interpersonal
+interactions to attenuate the adverse psychosocial impact of
+such pandemics.
+In conclusion, the key finding of the survey is that the consistent
+positive influence of increased interpersonal relationships and
+good perceptions of health were found to have a significant
+influence on adopted lifestyle behaviors during the adverse time
+course of the COVID-19 pandemic. These favorable behavioral
+perceptions should be bolstered through enhanced health
+awareness, and regularized virtual interpersonal interactions,
+particularly in countries with an overall middle-aged or older
+population. Simultaneously, controlling the fear response
+through counseling would also help improve health outcomes
+in nations affected by pandemics. However, the observed human
+behavior has cultural influences, and it may not be globally
+generalizable.
+Data Availability Statement
+The data that support the findings of this study are available on
+request from the corresponding author.
+Acknowledgments
+The authors gratefully acknowledge the contributions of Dr Ravi Kulkarni and Dr Kousthubha for facilitating the data processing
+and providing technical support for preparing Google Forms, etc. There was no funding source for this study.
+Authors' Contributions
+MNK conceptualized the survey, performed the literature search, collected data from public sources, and contributed to the
+manuscript writing. VM wrote the manuscript and performed the literature search and statistical analyses. NR conceptualized the
+study and revised the manuscript. HR reviewed the manuscript. MNK and VM finalized the manuscript. The corresponding author
+had full access to all the data in the study and had final responsibility for the decision to submit for publication.
+Conflicts of Interest
+None declared.
+Multimedia Appendix 1
+Supplementary table.
+[DOCX File , 20 KB-Multimedia Appendix 1]
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+Health‚ and Gender and COVID-19 Working Group. Off the back burner: diverse and gender-inclusive decision-making
+for COVID-19 response and recovery. BMJ Glob Health 2020 May 07;5(5):e002595 [FREE Full text] [doi:
+10.1136/bmjgh-2020-002595] [Medline: 32385047]
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+Perrotta D, Grow A, Rampazzo F, Cimentada J, Del FE, Gil-Clavel S, et al. Behaviors and attitudes in response to the
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+Wang C, Chudzicka-Czupała A, Grabowski D, Pan R, Adamus K, Wan X, et al. The association between physical and
+mental health and face mask use during the COVID-19 pandemic: a comparison of two countries with different views and
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+Abbreviations
+SARS: severe acute respiratory syndrome
+SVYASA: Swami Vivekananda Yoga Anusandhana Samsthana
+WHO: World Health Organization
+Edited by G Eysenbach; submitted 18.08.20; peer-reviewed by P Mathur, R Ho, A Videira-Silva; comments to author 26.10.20; revised
+version received 03.12.20; accepted 11.04.21; published 01.06.21
+Please cite as:
+Manjunath NK, Majumdar V, Rozzi A, Huiru W, Mishra A, Kimura K, Nagarathna R, Nagendra HR
+Health Perceptions and Adopted Lifestyle Behaviors During the COVID-19 Pandemic: Cross-National Survey
+JMIR Form Res 2021;5(6):e23630
+URL: https://formative.jmir.org/2021/6/e23630
+doi: 10.2196/23630
+PMID: 33900928
+©Nandi Krishnamurthy Manjunath, Vijaya Majumdar, Antonietta Rozzi, Wang Huiru, Avinash Mishra, Keishin Kimura, Raghuram
+Nagarathna, Hongasandra Ramarao Nagendra. Originally published in JMIR Formative Research (https://formative.jmir.org),
+01.06.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License
+(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
+provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information,
+a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.
+JMIR Form Res 2021 | vol. 5 | iss. 6 | e23630 | p. 12
+https://formative.jmir.org/2021/6/e23630
+(page number not for citation purposes)
+Manjunath et al
+JMIR FORMATIVE RESEARCH
+XSL•FO
+RenderX

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+Holistic Approach for Prevention of Heart Disease and Diabetes 
+ 
+Gundu H. R. Rao1, and H. R. Nagendra2. 
+Emeritus Professor1, Laboratory Medicine and Pathology, University of Minnesota, 
+Rajiv Gandhi University of Health Sciences. Vice Chancellor2, Chairman, Swami 
+Vivekananda Yoga Anusandhana Samsthana, Bangalore. 
+ 
+ 
+Abstract 
+ 
+South Asians have a very high incidence of hypertension, metabolic syndrome, 
+Coronary Artery Disease (CAD) and Type-2 Diabetes (T2D).  Currently, there are 
+approximately 60 million diabetics in India. According to a World Health 
+Organization (WHO) estimate, T2D will increase by 200% in India, in the next two 
+decades. Once this disorder is diagnosed, there is no better alternative than, to 
+effectively mange the risk factors.  Those recognized with this disorder, will have to 
+take medication life long. This puts a tremendous economic burden, as well as great 
+burden on the liver. Therefore, it is essential to develop early diagnosis and better 
+management, of these metabolic disorders. Many studies done in the west, have 
+demonstrated that life style management is as effective, as medical management for 
+this disease. In view of these findings, in South Asian Countries, greater emphasis 
+should be given to the holistic management of those who are “at risk”, for 
+developing hypertension, obesity, metabolic syndrome, heart disease and type-2 
+diabetes. Life style management should include; smoking cessation, Yoga, exercise 
+and change in the diet. Preliminary studies done at Isha foundation, Coimbatore 
+and Swami Vievekananda Yoga Anusandhana Samsthana, Bangalore, suggest Yoga,  
+sathwik diet or a well balanced diet, effectively reduces the diabetes burden. 
+However, these studies have to be confirmed by appropriately designed randomized 
+clinical trials. There is a great need to develop alternative therapies, to reduce the 
+use of large doses of modern medicine.  We have initiated a survey, to find out, as to 
+what other traditional therapies (Unani/Siddha) have been found to be beneficial, in 
+the effective management of these diseases. Results of these surveys and validation 
+of those therapies, that are found to be effective including yoga, diet etc., will 
+provide us with holistic, alternate or complementary therapies for the management 
+of heart disease and T2D. 
+ 
+Introduction 
+ 
+According to practitioners of Traditional Medicine, Modern Medicine as we know today, 
+has failed to prevent chronic non-communicable diseases such as hypertension, obesity, 
+metabolic syndrome, type-2 diabetes, heart disease and stroke On the other hand, 
+complementary and alternative medicine (CAM), practitioners claim, that their approach 
+to the management of these diseases are superior to modern medicine, as their approach 
+to therapy is holistic. Irrespective of who is right or wrong, we have to come with an 
+integrated, comprehensive management of these diseases. Recent studies in the third 
+world countries show, that these diseases are increasing rapidly to epidemic proportions. 
+China for example, has over 90 million diabetics, whereas in India there are 
+approximately 60 million and the incidence of this disease is rising rapidly. Furthermore, 
+in these countries, there is probably equal number of individuals with pre-diabetic state.  
+More than 36 million people die each year from Non Communicable Diseases (NCDs), 
+this constitutes 63 per cent of global deaths, including nine million, who die before the 
+age of 60. More than 90 per cent of these early deaths are in developing countries and 
+most could be prevented. Heart disease causes the most NCD deaths (17 million per 
+year). Need of the hour therefore, is to come up with some novel ideas, to combat these 
+metabolic diseases with accessible, acceptable and affordable therapeutic management 
+strategies. 
+Role of South Asian Society on Atherosclerosis and Thrombosis 
+ 
+South Asians (Indians, Pakistanis, Bangladeshis and Sri Lankans) have the highest 
+incidence of hypertension, metabolic syndrome, type-2 diabetes and coronary artery 
+disease, compared to any other ethnic group in the world (1, 2). In addition, according to 
+WHO, India ranks number one in the list of countries, with highest incidence of type-2 
+diabetes (3). To create awareness, develop educational and preventive programs, we 
+started a society (South Asian Society on Atherosclerosis and Thrombosis: 
+www.sasat.org) in 1993. SASAT is not only organizing conferences in India, publishing 
+books on these subjects in India, but also working proactively in developing prevention 
+strategies. SASAT is affiliated with the North American Thrombosis Forum (USA) and 
+the International Union of Angiology (IUA). Now it is extending an invitation for the 
+American College of Cardiology ACC) to work with us in India, on creating awareness 
+about NCDs, developing early diagnosis of risks for NCDs, education, research and 
+prevention projects. According to our vision and mission, all acute vascular events are 
+preventable.  Early detection of the risks that promote these complex diseases and better 
+management of the NCD risks with the traditional therapies including holistic practices, 
+seem to be the most cost effective solution we have at this time, for significantly reducing 
+health care burden of these cardio-metabolic disorders. 
+ 
+ 
+In the early nineties, we the members of SASAT, presented to the WHO panel, a 
+comprehensive, integrated approach, for the prevention of these disease. Our main 
+emphasis was, that we should treat all CVD prevention and treatment efforts, across the 
+Globe equally. Having said that, we feel that we should start the prevention program at 
+the earliest possible stage in the development of human life. Seminal studies at the 
+Holdsworth Memorial Mission Hospital Mysore, India, have demonstrated that 30% of 
+the children born in India are of low birth weight (LBW).  This hospital has kept detailed 
+records of every child born since 1934. Based on the available data, Medical Research 
+Council (MRC) of UK (www.mrc.soton.ac.uk/index.asp?/page-97) under the leadership 
+of Prof Caroline Fall of Southampton, has conducted a series of studies. In summary, 
+these studies have shown that the children with LBW are predisposed to develop, 
+significantly more risk for obesity, hypertension, metabolic syndrome, type-2 diabetes 
+and CVDs than those children born with normal weight (4-7).  
+ 
+ 
+According to recent survey, greater than 30% of children in New Delhi Schools in India 
+are obese. This survey also observed that the parents of these children also had unhealthy 
+life style (personal communication). Studies from the St. Paul Heart Institute, Minnesota 
+(www.stphc.com), have demonstrated that obese children develop endothelial 
+dysfunction, the earliest signs of vascular disease. These studies further demonstrate that 
+changes in life style and healthy diet significantly altered the blood flow dynamics in 
+these children in favor of normalcy. There is a great need for developing an indigenous 
+hand-held device, to monitor endothelial dysfunction in school children, so that we could 
+initiate large-scale study, to detect and manage the early signs of vascular disease. Our 
+mission should be, to find the disease of the vessel at the earliest and treat the disease of 
+the artery, than to focus on the management or risk factors for the prevention of these 
+diseases (8). 
+ 
+SASAT initiated few years ago, a “21 State” survey under the leadership of Dr Rajeev 
+Gupta of Jaipur, called "India Heart Watch", to explore the role of life style on the 
+incidence of various risks for these complex diseases. SASAT is also working with India 
+Heart Alliance, another NGO, which is concentrating on “Workforce Wellness” program, 
+as a means for developing risk reduction strategies. Several studies in the USA have 
+demonstrated that a well-organized work place wellness program reduces the cost of 
+health care for the workers by at least 30%. According to the employee insurance scheme 
+(EIS) of India, it costs more than 2400 Crores of rupees to provide health care for the 40 
+million employees. If we can initiate and implement a robust workplace wellness 
+program with the EIS of India, we could achieve a 30% savings ($800 Crores). 
+ 
+Definition of the Terminologies: 
+ 
+Before going into the discussions on the management of chronic disorders by holistic 
+approach, we will have to define the term holistic and shed some light on areas that are 
+pertinent this topic. What is holistic approach? According to Hippocrates, the scholar and 
+philosopher, "The physician treats, but nature heals." Therefore, “holistic” means in 
+terms of therapy, treating the whole body, mind, spirit and all the external and 
+environmental influences, that is associated with day-to-day living. Whereas, if one asks 
+a wellness expert, he or she will say that absence of disease is not wellness and describes 
+optimal health as a state of being, that includes: Spiritual Wellness, Emotional Wellness, 
+Social Wellness and Intellectual Wellness. In modern medicine, symptoms are viewed as 
+disease, and treatments are aimed at suppressing rather than eliminating those 
+symptoms.  In the holistic view, symptoms are regarded as the body's expression of 
+imbalance (Eg: Ayurvedic Concept of Tri-Doshas) and appropriate attempts are made to 
+achieve normal homeostasis.  
+ 
+Continuing our discussions on definitions, let us look at the terms; alternate medicine, 
+complementary medicine, integrated medicine etc. An alternate therapy used in place of 
+the current modern medicine or biomedicine, is termed “Alternate Medicine”.  Any 
+therapy that can be used in addition to, or along with modern medicine is called, 
+“Complementary Medicine”.  If a combination of traditional therapy and modern 
+medicine are used, then it is called “Integrative Medicine”. Not all therapeutic modalities 
+of complementary and alternate medicine (CAM) are holistic in their approach. This is 
+true of the modern biomedicine also. Let us consider for example the management of 
+heart disease or diabetes and look at the approach of an allopathic doctor or a traditional 
+therapist. Allopath based on the symptoms manifested, will diagnose the risk factors 
+associated with these symptoms or disorders, such as diet, physical inactivity, blood 
+pressure, altered lipid or blood glucose levels and try to manage these risk factors. If we 
+consider the approach of a Vaidya, he or she will look at the physiological imbalances, 
+Dosha’s (Vata Pitta, and Kafa) associated with the individual, recommend panchakarma 
+procedure, to cleanse the body and try to restore the balance of the doshas with dietary 
+changes and herbal medicines (rasayanas). Similarly, a Yoga therapist, will recommend 
+an integrated approach, to the management that may include, physical exercises like 
+asanas, breathing practices (pranayama), various kriyas, meditation and sathwik diet. 
+What is wrong with this approach? In spite of the fact that these traditional therapies are 
+in existence for thousands of years, they do not have documented evidence about their 
+efficacy and safety. Since they are ancient therapeutic practices that we have inherited 
+over centuries, there is a strong feeling that they do not need any evidence-based 
+scientific proof. In view of this deficiency or lack of documentation of clinical data, on 
+the efficacy and patient safety of traditional medicine, regulatory agencies of European 
+Union and USA have banned the marketing of herbal medicine in Europe and USA. 
+ 
+Holistic Approach to Common Disorders 
+ 
+Let us consider the holistic approach for the management of the most common disorders 
+in India such as hypertension, obesity, metabolic syndrome and coronary artery disease. 
+According to studies done at the Holdsworth Memorial Mission Hospital, Mysore and 
+KEM Hospital in Pune, 30% of children born in India, are of low birth weight (LBW). 
+Children born with low birth weight have been followed for their predisposition, to the 
+above-mentioned disorders, with the “Mysore Cohort”. Results of these studies have 
+demonstrated, that LBW children develop metabolic disease, at much higher frequency 
+than those born with normal weight. If we want to develop preventive strategies using 
+holistic approach, we should start intervention, even before the conception of a child. We 
+should pay attention to the maternal nutrition, both micro and macronutrients. We also 
+have to develop a robust nutritional program for the neonatal babies as well as infants (9). 
+ 
+Risk Factors for Cardio-metabolic Disorders 
+ 
+Framingham studies initiated in the USA over 50 years ago identified risk factors that are 
+associated with the promotion of atherosclerosis, thrombosis and stroke. They include, 
+smoking, high blood pressure, altered blood lipids such as increased triglycerides, 
+cholesterol and decreased high-density lipoproteins and elevated blood glucose (10). 
+Since then several other risk promoters, have been added to this growing list of risk 
+factors. Based on this information, drug manufacturers developed a variety of drugs that 
+modulate the levels of these risk factors. Currently there is an on going debate, about the 
+superiority or otherwise of risk factor management, versus management of the vessel wall 
+disease. This debate becomes more relevant when one considers, that in spite of the drug-
+induced tight management of known risk factors, significant number of individuals 
+experience acute vascular events. This is true of even much publicized interventions such 
+as, use of coronary stents, for the management of blocked arteries.  Therefore, we the 
+members of SASAT strongly believe in the benefits of developing better prevention 
+strategies than just management of the risk factors or disease of the vessel. 
+ 
+Factors that Influence Life Style Disorders 
+Use of Tobacco and Tobacco Products 
+Number one public health problem related to life style is, smoking or use of any kind of 
+tobacco product. According to Global Public Health estimates, by 2030, 80 percent of 
+more than eight million tobacco-related deaths projected annually, will occur in low-and 
+middle-income countries. The enormity of this health care burden reflects in not just 
+steady population growth, but also the tobacco industry's aggressive efforts to target and 
+market to vulnerable populations. To reduce health disparities in a single act, the United 
+States should join the global community in ratifying the first international public health 
+treaty, the World Health Organization (WHO) Framework Convention on Tobacco 
+Control (FCTC). Tobacco addiction, the leading cause of preventable premature deaths in 
+the world, will claim as many as a billion lives in this century. To counter this human 
+catastrophe, 153 countries, including India and other neighboring countries, have ratified 
+the FCTC since 2003. The fact that even the so-called most advanced country, the USA, 
+has not joined the FCTC indicates, the enormity of such public health issues and the 
+powerful influence of industries. We have to establish a robust awareness program to 
+educate the public about the health consequences of using tobacco and its products. 
+ 
+ Excess Salt Consumption 
+Cardiovascular diseases are the leading causes of death and disability worldwide. 
+Elevated blood pressure (BP), cholesterol and smoking, are the major risk factors. 
+Among these, raised BP is the most important cause, accounting for 62% of strokes and 
+49% of coronary heart disease.  This observed risk is throughout the range of BP, starting 
+at systolic 115 mm Hg. There is strong published evidence, that our current consumption 
+of salt in excess, is the major factor increasing BP and thereby CAD. In addition, a high 
+salt diet may have direct harmful effects, independent of its effect on BP, for example, 
+increasing the risk of stroke, left ventricular hypertrophy and renal disease. The American 
+Heart Association (www.aha.org) recommends consuming less than 1500 mg of sodium 
+a day. Several countries have initiated salt reduction programs. We should create an 
+awareness program regarding the health consequences of excess consumption of salt. 
+Excess Sugar Consumption 
+The third most important lifestyle related risky habit is, excess consumption of sugar. 
+Consumption of sugar, which is helping to drive the obesity crisis and causing millions of 
+deaths worldwide each year, should be controlled like other threats to public health. The 
+researchers and experts in the field of endocrinology, sociology, and public health, argue 
+that the quantities of sugar consumed by most are sufficient to alter metabolism, raise 
+blood pressure, muddy the signaling of hormones, alter glucose metabolism, increase the 
+incidence of type-2 diabetes, significantly damage the liver. Worldwide consumption of 
+sugar has tripled in the last five decades and helped fuel the obesity, metabolic syndrome; 
+which can lead to diabetes, heart disease, and stroke. It is important to remember that 
+every type of carbohydrate that you eat is eventually converted into a simple form of 
+sugar known as glucose either directly in the gut or after it passes through the liver. 
+Simple truth is, all the rotis, bread, pasta, cereal, rice, wheat, ragi, jawar, sorghum, 
+potatoes, desserts, candies and soft drinks eventually end up as glucose.  
+Excess Carbohydrate Consumption 
+When we eat excess carbohydrates, the pancreas pumps out insulin, exactly as tailored by 
+our DNA blue print dictates. Hence, the individual variations exist in the metabolism of 
+nutrients (variations in the Doshas). If the liver and muscle cells are loaded with sugar, 
+these cells start to become resistant to the response of insulin. The insulin receptor 
+number on these cells starts to decrease. Since glucose cannot get into muscle or liver 
+cells, it remains in the blood stream. In view of this excess glucose in the blood, the 
+pancreas pumps more insulin and induces resistance in insulin receptor response. Both 
+excess sugar and insulin in blood is toxic. Bioinformatics reveal that the body expresses 
+hundreds of insulin dependent genes and produces a variety of proteins, modulatory 
+functions of which, is not clear at the time of this writing. Similarly, excess sugar 
+glycates variety of proteins, including hemoglobin and alters normal physiology of 
+vascular system. Although elevated glucose in the blood and the levels of HbA1c are the 
+gold standards, to monitor type-2 diabetes, exact role for glucose induced alterations in 
+the proteins and their effect on the progress of diabetes induced clinical complications are 
+not very well understood. Average Indian meal, has greater than 70% carbohydrates; we 
+should seriously work on creating an improved, balanced diet for healthy life style. 
+Excess Fat Consumption 
+Fat is one of the three major nutrients (along with proteins and carbohydrates), which 
+supply calories to the body. Fat provides essential fatty acids, which are not made by the 
+body and therefore, must be obtained from food. When you exercise, body uses up the 
+calories from carbohydrates in the first 20 minutes and then it begins to depend on fat for 
+source of energy. Eating too much saturated fat (in general the type of fat that solidifies at 
+room temperature; butter & ghee) is one of the major risk factors for heart disease. These 
+are the biggest dietary cause of high HDL cholesterol (bad cholesterol). When selecting a 
+fat or oil for cooking, limit saturated fat to less than 10% of calories. Foods made with 
+hydrogenated oils (Dalda, Crisco, Vanaspathi etc) should be avoided as they contain high 
+levels of trans fatty acids, which are linked to heart disease. Too much fat also increases 
+the risk of CAD, because of its high calorie content, which increases the chance of 
+becoming obese. 
+ 
+Excess Weight as Modulator of CVD Risk 
+Excess weight and obesity are also considered as leading causes of hypertension and 
+type-2 diabetes. According to population-based studies, two-thirds of obese people are at 
+risk for hypertension. A study conducted in Portugal, demonstrated a significant 
+correlation between excess body weight and blood pressure in children as well as 
+adolescent populations (11). They recommended using BMI and waist circumference as 
+test parameters for monitoring excess body weight. According to a CDC study waist 
+circumference and elevated triglyceride levels help identify people at risk for developing 
+metabolic syndrome. Obesity affects a number of hormonal functions including, renin-
+angiotensin-aldosterone system.  This system controls the level of sodium and water in 
+the body. Increased renal sodium re-absorption results in an altered blood pressure. 
+Several central and peripheral abnormalities lead to the development of high arterial 
+pressure in these individuals. Perturbation of vessel wall and blood cell integrity produce 
+an altered state of homeostasis and initiates endothelial dysfunction. Obesity as a leading 
+cause of hypertension can also be the initiator of endothelial dysfunction, metabolic 
+syndrome. This syndrome is a common cause for complex chronic disorders such as 
+dyslipidemia, hypertension, and insulin resistance. 
+ 
+Prevalence of Metabolic Syndrome 
+ 
+Metabolic Syndrome (MS) is basically the clustering of various altered metabolic 
+conditions such as insulin resistance, high triglycerides, dyslipidemia, high blood 
+pressure, abdominal obesity and impaired glucose metabolism (12). There is considerable 
+confusion about the definition of this syndrome proposed by various professional 
+organizations (NCEP-ATP111, IDF, WHO, CDC, etc) to identify who is at risk for 
+developing this syndrome and whether or not this syndrome is a risk factor for diabetes 
+and CVDs.  Clinicians are encouraged to follow first the known classical risk factors and 
+then take into consideration the abdominal obesity and MS, and this combined risk is 
+defined as cardio metabolic risk. In a recent survey of school children in New Delhi, 
+India, the prevalence of overweight or obesity was greater than 35%. The prevalence of 
+MS in Indians was 23.2%, 18.3%, and 25.2% according to the WHO, ATP111, and IDF 
+definitions respectively. The prevalence of MS for the age group 60-69 was, WHO 47.9%, 
+ATP111 33.5%, and IDF 43.7% respectively. Subjects with diabetes and obesity seem to 
+have a much higher prevalence of MS >70%.  
+ 
+Prevalence of Type-2 Diabetes 
+ 
+Indians have a high incidence of type-2 diabetes and cardiovascular disease, despite a low 
+prevalence of obesity. Based on preliminary collaborative studies done in Chennai, India, 
+by the researchers at Madras Diabetes Research Foundation and the staff at the 
+University of Minnesota, a hypothesis was developed to explain excess burden of T2D in 
+this population. They hypothesized that the excess of risk may be due to a high 
+propensity towards the abdominal fat accumulation in the Asian subjects.  They 
+compared waist measurements and BMI data from the CURES (Chennai Urban Rural 
+Epidemiological Study) survey of southern Indians, with those from three US ethnic 
+groups (Caucasians; 1809, African Americans; 1993 and Mexican Americans; 2116) 
+from NHANES III (Third National Health And Nutritional Examination Survey) data. A 
+total of 15,733 subjects from CURES ad 5,975 from NHANES111 met the inclusive 
+criteria (age 20-39, no diabetes).  Mean waist measurements were 89.8cm for US men 
+86.4cm for US women 78.4cm for Indian men and 77.6cm in Indian women.  BMIs were 
+25.9kg/m2 in US men 26.5kg/m2 in US women, 21.8kg/m2 in Indian men and 22.4kg/m2 
+in Indian women. To account for between-population differences in body size and 
+general adiposity, they divided the waist circumference by the BMI. The waist to BMI 
+ratio was significantly higher for Indian men and women compared to all US race/sex 
+groups. Results of these studies, demonstrate that the Indian population has excess 
+visceral fat deposits, relative to overall body distribution.  
+ 
+Goals of Medical Nutrition Therapy (MNT)  
+ 
+MNT for pre-diabetes emphasize the importance of lifestyle in decreasing the risk for 
+type- diabetes by increasing physical activity and promoting food choices that facilitate 
+moderate weight loss (13). Life style modifications reported to produce weight loss of 
+10% or 10 -12 Kg over 3-6 months. Change in life style and the related loss can be 
+sustained for 2-4 years. However. One should keep in mind that for CVD fitness and to 
+reduce risk for CVD one need to work out a minimum of 30 minutes a day with moderate 
+physical activity. Sixty minutes per day of physical activity is needed for preventing 
+weight gain and sixty to 90 minutes to avoid gain after weight loss. There is no gold 
+standard when it comes to what is the correct diet for diabetics. Adults should balance 
+their diet and consume 45-65% as carbohydrates for their daily energy needs, 20-35% 
+from fat and 10-35 from proteins. Jus to give an example of how complex is the 
+management of diet; let us examine the fat intake and its benefits and ill effects. Alpha 
+linolenic acid has many health benefits especially in the inhibition of inflammatory 
+process associated with CVD, autoimmune disease, diabetes and bowl disease. It also 
+serves as precursor for the n-3 fatty acids, EPA and DHA. In reality all seafood are 
+beneficial with regard to Omega-3 fatty acid content. A high n-6 to n-3 ratio in daily diet 
+appears to promote inflammation and oxidation. Original focus of researchers in this 
+approach was related to beneficial effects on cardiovascular and endocrine systems. 
+However, recent studies in neurosciences is suggesting, that one consequence of such a 
+diet, is increased inflammation and this may have adverse effect on brain and nervous 
+system and increase mental illness. Average Americans consume a diet with n-6 to n-3 
+ratio as high as 17:1, which is pro-inflammatory. A beneficial ratio is close to 2:1(14).  
+Integrated Management of Life Style Disorders: 
+Life style disorders such as hypertension, obesity, metabolic syndrome, type-2 
+diabetes, heart disease and stroke are very complex diseases. Understanding the 
+risk factors, anticipating the clinical complications associated with these risk factors 
+and effective management of these risks involves a team of specialists, health care 
+workers, internists, endocrinologists, dieticians, and experts in various allied health 
+fields. Just take the example of diabetes-mediated complications, such as 
+vasculopathy, neuropathy, nephropathy and retinopathy, all leading to the end 
+organ failure. Hypertension, obesity, metabolic syndrome and thrombotic complications 
+are chronic, complex disorders, which have reached epidemic proportions in industrial 
+nations as well as developing countries. In order to manage these public health problems, 
+one has to understand the underlying causes, diagnose the risks that promote the progress 
+of these diseases and effectively manage the risks, to reduce or prevent acute vascular 
+events leading to mortality or morbidity. According to experts, 30% of the children born 
+in some of the developing countries are of low birth weight. This is real, unacceptable 
+and preventable. There are 1.3 billion obese people worldwide. This also is real, 
+unacceptable and preventable. Creating awareness, developing educational, diagnostic 
+and prevention strategies are the most cost effective and proven paths available. Just a 
+few years ago by creating awareness and developing effective advocacy programs, use of 
+palm oil in the US fast food industry was virtually eliminated. Similarly awareness 
+programs, and life style modifications drastically reduced CVD mortality and morbidity 
+in USA and Finland (16, 17).  More and more countries have started preventive work at 
+local and national level.  An Italian study with a sample size of 52,300 documented an 
+increase in the prevalence of excess weight in adults and a positive association between 
+weight gain and chronic disease. Authors conclude that to reduce the prevalence of 
+chronic disease, a policy promoting a healthier life style is desirable (17).  
+Comprehensive preventive measures, such as exercise, dietary interventions, body weight 
+control and pharmacotherapy are cheaper compared to the cost of treating and 
+management of consequences from these chronic conditions (17-22).  
+ 
+Sedentary Life VS. Physical Activity 
+ 
+Of all the risk promoters associated with these metabolic disorders, sedentary lifestyle is 
+one of the major contributors to the initiation and progress of these diseases. Physical 
+inactivity is now the fourth leading independent risk factor for death, caused by 
+non-communicable chronic disease. Physical activity has numerous positive effects 
+
 on health of individuals. Regular to moderate-intensity physical activity reduces the risk 
+for acute vascular events significantly. The available data clearly indicates benefit effect 
+of physical exercise, Globally; across all countries, cultures, gender, age and ethnicity. 
+Physical activity is the most effective single therapy among all lifestyle interventions 
+including diet, various therapies, and psychosocial changes and practices. Studies of 
+short-term exercise program as well as long-term have shown improvement in endothelial 
+function, metabolic and cardiovascular parameters. For those who can afford, a robust 
+fitness program will be very useful. However, just brisk walking several times a week is 
+better than living a sedentary life (19-22). 
+Holistic Approach Through Integrated Yoga Therapy 
+Yoga practices of all kinds have been claimed to have positive effects on the health of an 
+individual (23-25). S-vyasa, the Yoga University (www.svyasa.org)  in Bangalore, has 
+been participating in a National program called “Stop Diabetes”.  They also have an 
+integrated yoga therapy that is customized for hypertensive subjects, obese individuals, 
+diabetics and post myocardial infarction (MI) and stroke patients. Two major studies 
+published widely of over 4000 patients have demonstrated patients randomized to 
+exercise-based cardiac rehabilitation post-MI, have a statistically significant all–cause 
+and cardiac mortality, compared to those receiving conventional therapy only. Similarly 
+the Isha Foundation (www.ishafoundation.org) near Vellaingiri Mountains in Coimbatore 
+District has special program for diabetics, “Isha-Yoga and Isha-Diet”. The diet at this 
+center is pretty close to a balanced diet and seems to be doing good for the followers of 
+this special diet. They have incorporated boiled peanuts as major source of protein, 
+reduced the fat and carbohydrate content, included sprouted legumes, fruits and 
+vegetables. Manchanda et al., at New Delhi, India demonstrated retardation of coronary 
+atherosclerosis with Yoga life style intervention. Based on the results of their study (n-
+42), they concluded that Yoga lifestyle intervention retards progression and increases 
+regression of coronary atherosclerosis in patients with severe coronary artery disease (23).  
+Yoga an ancient science of physical and mental activity, has gained popularity 
+throughout the world. In spite of this popularity, health care providers have been slow to 
+recognize the merits of this approach. In addition, there is lack of data from well thought 
+out randomized clinical studies with populations at high risk for hypertension, obesity, 
+metabolic syndrome, type-2 diabetes, heart disease and stroke. A review of Yoga 
+programs (1980-2007) for the four leading risk factors (overweight, high blood pressure, 
+high blood glucose and elevated blood cholesterol) of chronic diseases, concluded that 
+future studies should be designed and conducted, to identify programs best suited for 
+diverse populations as well as for specific chronic health conditions. They also 
+recommended that duration, intensity frequency and the types of yoga practices (asanas, 
+pranayama, kriyas and meditation) and their sequences, should be clearly described in the 
+clinical protocols. Authors also stressed the need to standardize and compare various 
+components of integrated yoga therapy programs for the research purpose (25). 
+Lifestyle Modifications 
+Lifestyle modifications address several CAD risk factors at once and in general free of 
+side effects. Vestfold Heartcare Study Group demonstrated the influence of life style 
+measures and five-year coronary risk by a comprehensive lifestyle intervention programs 
+in patients with coronary heart disease. The Diabetes Prevention Program Research 
+Group conducted one of the largest studies on the beneficial effects of lifestyle. In this 
+study, of the 3234 patients recruited, 1082 were placebo, 1073 took 850 Mg Metformin 
+twice a day and 1073 were administered intensive lifestyle intervention (Protocol of the 
+study: http://www.bsc.gwu.edu/dpp). Based on the results of their study, the authors 
+concluded that lifestyle changes and treatment with metformin, both reduced the 
+incidence of diabetes in persons at high risk. The lifestyle intervention was more effective 
+than metformin (15). 
+Designing, conducting and validating the beneficial effects of lifestyle interventions is 
+hard. Interventions that work in some societies may not work in the others, because of the 
+complexities that exist in the social, economic, cultural and dietary diversities that exist. 
+It is difficult to standardize each of the components of holistic and lifestyle interventions. 
+Since smoking, bad diet, excess weight, salt and sugar consumption are leading 
+promoters of risks associated with the development of hypertension, MS, T2D, and 
+vascular diseases, a concerted effort should be made, to develop strategies that can reduce 
+or prevent the development of these conditions at all stages in life, including during 
+intrauterine growth, in the nutrition of new born babies, young children, adolescents and 
+adults (15-18, 26-29).   
+ 
+Life style disorders such as hypertension, obesity, metabolic syndrome, heart disease and 
+stroke are complex diseases (28, 29). In a country like India, where the prevalence of 
+these diseases have reached epidemic proportions, providing modern health care to all 
+seems a herculean task. In addition, there is a growing disbelief in the role of modern 
+medicine in the area of prevention. Modern medicine by and large is based on the 
+management of symptoms and the risk factors associated with these symptoms. As such 
+concentrates heavily, on the risk factor management. Therefore, in order to provide 
+community at large, an easily accessible, acceptable and affordable health care, we need 
+to develop a fusion between what is best in the traditional Indian Medical System and the 
+modern medicine. For lack of a better terminology, we will call Indian Integrated 
+Medicine. In our enthusiasm to provide a holistic therapy, we should not ignore the fact, 
+that some of our traditional systems lack clinical data, to support their claims. For 
+instance the one of the best-cited study of Dean Ornish, used only 28 subject to show the 
+benefit of low fat diet (26, 27). We need to develop robust data on the benefits of holistic 
+approach. Till we have such an evidence-based data, it is our suggestion, that these 
+methods be used as complementary medicine and not as an alternate medicine.  
+ 
+Discussion 
+The goals and objectives in caring for patients with diabetes mellitus should be to 
+eliminate symptoms and prevent, or at least slow, the development of complications. 
+Micro-vascular (ie, eye and kidney disease) risk reduction could be accomplished, 
+through control of glycemia and blood pressure; macro-vascular (ie, coronary, cerebro-
+vascular, peripheral vascular) risk reduction can be achieved through control of lipids, 
+hypertension, smoking cessation, and aspirin therapy; metabolic and neurologic risk 
+reduction, through control of glycemia. Pathogenesis of cardio-metabolic disorders are 
+modulated and promoted by a variety of altered metabolic pathways and effective 
+management of these disorders, requires appropriate goal setting, dietary and exercise 
+modifications, medications, appropriate self-monitoring of blood glucose, regular 
+monitoring for complications, and laboratory assessment. If we can manage this complex 
+treatment plan with our holistic approach, it is great, if not, we need to consider 
+integrated approach of using what is best in the modern medicine and the traditional 
+systems. Majority of CAM programs at the Academic Health Centers in the USA have 
+adopted this approach in the management of diseases. 
+For example, the Center for Spirituality and Healing at the University of Minnesota, has 
+been offering complementary healing techniques using Spiritual Healing Practices of East 
+and West. Although we have over hundred Medical Colleges in India, there are hardly 
+any colleges, which have a designated department for CAM programs and offer holistic 
+therapies as one of the choices. Since 1979, over 19, 000 individuals have completed the 
+8-week mindfulness-based stress reduction (MBSR), at the Center for Mindfulness in 
+Medicine, at the University of Massachusetts. This center is one of the oldest and largest 
+Academic Medical-Center based stress reduction program in the world. Department of 
+AYUSH, Government of India, should take leadership in establishing post-graduate 
+education and research programs, similar to the post graduate programs in Biomedicine 
+established by the Indian Medical Council (AIIMs). The expert committee of the Rajiv 
+Gandhi University of Health Sciences (RGUHS), Karnataka, has recommended 
+establishment of such a platform in the State of Karnataka. We sincerely hope the 
+development of an Independent Institute for Complementary and Alternate Medicine, so 
+that the traditional healing therapies as well as holistic approaches to the management of 
+chronic diseases could be tested, standardized, promoted and implemented.  
+  References: 
+ 
+1. Rao GHR, Kakkar V. V: Coronary Artery Disease in South Asians: Epidemiology, 
+Risk Factors, and Prevention. JP Medical Publishers, India. 2001.  
+2. Rao GHR, Thanikachalam, S: Coronary Artery Disease: Risk Promoters, 
+Pathophysiology and Prevention. JP Medical Publishers, India. 2005.  
+3. Rao, GHR, Mohan V:  Type-2 Diabetes in South Asians: Epidemiology, Risk 
+Factors and Prevention. JP Medical   Publishers, New Delhi, India. 2006  
+4. Veena SR, Geetha S, Leary et al: Relationship of maternal and paternal birth weight 
+to features of the metabolic syndrome in the adult offspring: An intergenerational 
+study in South India. Diabetologia 2007, 50(1): 43-54. 
+5. Victoria CG, Adair L, Fall C: Maternal and child under nutrition: Consequences for 
+adult health and human capital. Lancet 2008, 371(9609): 340-57. 
+6. Fall C: Maternal Nutrition: effects of health in the next generation. Ind. J. Med. 
+Res. 2009, 130 (5): 593-99. 
+7. Yagnik CS: Fetal Origins of health and disease: Commentary: Fetal Origins of 
+Cardiovascular risk-nutritional and non-nutritional. Ind J. Epi. 2001, 30:57-59. 
+8. Divani AA, Luft AR, Flaherty JD, Rao GHR: Direct diagnosis is superior to risk 
+prediction tools for management of vessel wall disease. Frontiers in Neurology 
+2012 (In Press). 
+9. Mohan KL, Escott-Stump S: Krausse’s Food and Nutrition. Saunders Elsevier 
+2008, St Louis MO. 
+10. www.framighmaheartstudy.org/risk/index/html 
+11. Souza MG, Rivera IR, Silva MA et al: Relationship of obesity with high blood 
+pressure in children and adolescents. Arq Bras Cardiol. 2010 (Pub Med 20428712). 
+12. Ashner P: Metabolic syndrome as a risk factor for diabetes. Exp. Rev. Cardiovasc 
+Ther. 2010, 8:407-12. 
+13. Franz M: Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of 
+non-diabetic origin.  In: Krausse’s Food and Nutrition, Saunders-Elsevier, 2008. St 
+Louis MO. 
+14. Davis BC, Kris-Eitherton PM: Achieving essential acid status in vegetarians. 
+Current knowledge and practical implications. Am. J. Clin. Nutr. 78:6405, 2003. 
+15. Diabetes Prevention Program Research Group: Reduction in the incidence of 
+Type-2 diabetes with lifestyle intervention or metformin. N Engl J. Med. 2002, 
+346:393-403. 
+16. Pax XR, Li GW, Hu YH et al: Effect of diet and exercise in preventing NIDDM 
+in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study. 
+Diabetes Care.1999, 22:623-34. 
+17. Tuomilchto J, Lindstrom J, Erikson JG et al: Prevention of type-2 diabetes 
+mellitus by changes in life style among subjects with impaired glucose tolerance. N 
+Engl J. Med. 2001, 344: 1990-92. 
+18. Blair SN, Kohl HW, Gordon NF et al: How much of physical activity is good 
+enough? Ann Rev Pub Health. 1992, 13: 99-120. 
+19. Matherson GO, Khigl M, Dvorak et al: Responsibility of sport and exercise 
+medicine in preventing and managing chronic disease: applying knowledge and 
+skill overdue. Br J. Sports Med. 2011,45(16): 1272-82. 
+20. Roth FW, Gordon SE, Carlson CJ: Waging war on modern chronic disease: 
+primary prevention through exercise biology. J. Appl Physiol 2000, 88(2): 774-82. 
+21. Sugathan TN: Prevention of non-communicable diseases (NCDs). 2010, 131: 14-
+16. 
+22. Rastogi T, Vaz M, Spiegelman D. et al: Physical activity and risk for coronary 
+artery disease in India. Ind. J. Med. 2004, 33:759-67. 
+23. Manchanda SC, Narang R, Reddy KS: Retardation of coronary atherosclerosis 
+with yoga lifestyle intervention. Assoc. Phy. India. 2000, 48 (7): 687-94. 
+24. Joliffe JA, Rees K, Taylor RS: Exercise-based rehabilitation for coronary artery 
+disease. Cochrane Database Rev. 2000, (4) CD001800. 
+25. Yang K: A review of yoga programs for four leading risk factors for chronic 
+diseases. eCAM 2007, 4(4): 487-91. 
+26. CDC Report: Achievements in public health 1990-1999. Declines in death from 
+heart disease and stroke. www.cdc.gov/mmwr/preview/mmwrhtm/mm4830al/htm 
+27. Puska P: Coronary artery disease and stroke in developing countries: time to act. 
+Int. J. Epi. Assoc. 2001, 30:1493-94. 
+28. Calza S, Decark A, Ferraroni M et al: Obesity and prevalence of chronic disease 
+in the 1999-2000 Italian National Survey. MC Public Health 2008, 8:140-49. 
+29. Lee YH, Jeong HS, Kim NS et al: The effect of an exercise program on 
+anthropometric metabolic and cardiovascular parameters in obese children. Korean 
+Circ. 2010, 40:179-84. 
+ 
+  
+ 
+Conflict of Interest: The authors do not have any conflicts of interest, financial or 
+otherwise. 
+Acknowledgements: This article is based on a series of invited lectures given to the 
+students of s-VAYSA, Bangalore, in the summer of 2009. First author, Dr Rao thanks 
+members of the SASAT family, Vice Chancellor s-VYASA, Vice Chancellor, RGUHS 
+and the University of Minnesota, for the support and encouragement of his activities.  

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+© 2015 Heart India | Published by Wolters Kluwer - Medknow
+Immediate Effect of Indian Music on Cardiac Autonomic 
+Control And Anxiety: A Comparative Study
+Karuna Nagarajan, Thaiyar M. Srinivasan, Nagendra Hongasandra Rama Rao
+Department of Research, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusansadha Samsthana (S-VYASA) University, 
+Bangalore, Karnataka, India
+A B S T RA CT
+Background: Many studies have shown that music experience is the key to develop future therapies in order to 
+prevent the development of cardiovascular disorders. Aims: The present study aimed to evaluate the effects of 
+heart rate variability (HRV) on exposure to Indian raga Bhupali with that of two control groups of pop music and 
+no music or silence in a sample of healthy subjects. Materials and Methods: Autonomic functioning, anxiety level, 
+and subjective feeling were assessed in 28 healthy subjects, both male and female [group mean age ± standard 
+deviation (SD), 19.68 ± 2.57] during three sessions. The three sessions were the musical session intervention with 
+the Indian raga Bhupali, pop music with steady beats, and “no music session.” Assessments were made before 
+(5 min), during (10 min), and after (5 min) in each of the three states on 3 separate days. Results: During the Indian 
+raga, there was a significant decrease in the low frequency (LF) power (P < 0.01) and increase in the high frequency 
+(HF) power (P < 0.01) in the frequency domain analysis of the HRV spectrum. There was also a significant decrease 
+in the mean heart rate (HR) (P < 0.01) and a significant increase in the NN50 (P < 0.05) and RMSSD (P < 0.05) in 
+the time domain analysis of HRV. Both frequency and time domain measures are indicative of parasympathetic 
+activity. The anxiety level significantly (P < 0.001) decreased post the Indian raga session and significantly (P < 0.01) 
+increased post the pop session. The subjective assessment of perceived feeling using the visual analog scale 
+(VAS) comparing Indian raga with pop and silence sessions showed a significant difference of feeling positive (P 
+< 0.01). Conclusions: Exposure to the Indian raga Bhupali reduced sympathetic activity and/or increased vagal 
+modulation with reduced anxiety levels and subjective assessment of perceived feeling showed positive changes. 
+Key words: Aesthetic mood, Heart Rate Variability (HRV), Indian raga Bhupali
+Address for correspondence: 
+Ms. Karuna Nagarajan, Division of Yoga and Life Sciences,  
+Swami Vivekananda Yoga Anusansadha Samsthana (S-VYASA) 
+University, # Ekanth Bhavan, Gavipuram Circle, KG Nagar, 
+Bangalore - 560 019, Karnataka, India. 
+E-mail: [email protected]
+INTRODUCTION
+Music powerfully modulates social, emotional processes, 
+cognitive status, and mood, thus contributing to healing.[1] The 
+Greeks, Hebrews, and Persians used music systematically as a 
+therapy.[2] Music therapy can be used effectively as a preventive 
+measure, and it can be used as a supplement to the main treatment 
+after the onset of the pathological condition. The appropriate 
+type of music, with specific tonal quality, played at a suitable 
+time helps to drive out negative feelings such as dependency 
+and loneliness. Music creates an atmosphere of harmony and 
+well-being.[3] Musical compositions are complex blends of 
+expressively organized sound consisting of five elements, viz., 
+rhythm, melody, pitch, harmony, and interval. These five elements 
+Access this article online
+Quick Response Code:
+Website:
+www.heartindia.net
+DOI:
+10.4103/2321-449X.172350
+This is an open access article distributed under the terms of the 
+Creative Commons Attribution-NonCommercial-ShareAlike 3.0 
+License, which allows others to remix, tweak, and build upon the 
+work non-commercially, as long as the author is credited and the 
+new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+How to cite this article: Nagarajan K, Srinivasan TM, Rama Rao NH. 
+Immediate Effect of Indian Music on Cardiac Autonomic Control And 
+Anxiety: A Comparative Study. Heart India 2015;3:93-100.
+O riginal Article
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+Nagarajan, et al.: Autonomic variables with Indian melody
+94
+Heart India, Vol 3 / Issue 4 / Oct-Dec 2015
+to modify emotions, to let go emotions, to match their current 
+emotion, to rejoice or pacify themselves, and to relieve stress 
+and rejuvenate.[10] 
+It was reported that positive emotions are related to speeded-up 
+recovery from cardiovascular reactivity generated by negative 
+emotions for resilient individuals. Research has also shown that 
+positive emotions may have beneficial physical and psychological 
+health outcomes by serving a defensive role and thus, providing a 
+useful remedy to the problems associated with negative emotions 
+and illness.[11] 
+The Indian raga Bhupali, which belongs to Kalyan thaat, equivalent 
+to the Lydian mode[12] of Western music was used in our study. This 
+raga uses ri, dha teevra or sharp notes, which instill the shringara rasa 
+or aesthetic mood of love within the listener.[7] This raga is sung 
+in the evening. Listening to the right raga at the right time is said 
+to smoothen the natural transitions and attune the body and mind 
+to the circadian cycle.[2] Our proposal is that autonomic changes 
+observed in other studies in response to listening to music are 
+mainly elicited by changes in emotional and psychological states 
+and these states can be favorably changed by the combination of 
+notes or swaras used in the raga as mentioned above in the article. 
+The biological effects of Indian music, leading to its therapeutic 
+efficacy are not entirely known. In this study, we aimed at further 
+studying some biological correlate of listening to the particular 
+Indian raga, which instills a positive aesthetic mood within the 
+listener. Previous studies have demonstrated that the autonomic 
+nervous system may serve as a way by which music can be 
+effectively used for the therapeutic application. This is explored 
+by the assessment of heart rate variability (HRV). Therefore, the 
+objective of this study was to assess the effects of exposure to 
+the Indian raga Bhupali on HRV with that of two control groups 
+of pop music and no music or silence in a sample of healthy 
+subjects. Secondarily, we correlated autonomic responses to 
+musical stimuli with that of the state anxiety level before and 
+after each music style. No previous studies have investigated the 
+short-term effects of the Indian raga Bhupali and pop music on 
+HRV. The understanding of physiological responses induced by 
+music experience is a key to develop future therapies in order to 
+prevent the development of cardiovascular disorders.
+Heart rate variability and emotions
+HRV is a measure of  the continuous interplay between 
+sympathetic and parasympathetic influences on the heart rate 
+(HR) that yields information about cardiac autonomic flexibility 
+and thereby represents the capacity for regulated emotional 
+responding.[13] 
+In one of the studies, it was documented by McCraty that anger 
+in a normal sample elicited an increase in the low frequency and 
+low frequency (LF)/high frequency (HF) ratio components of 
+HRV, suggesting disruption in sympathovagal discharge caused 
+are vital when selecting music to invoke both psychological and 
+physiological responses within the listener.[4]
+Indian musicological analysis 
+Indian music therapy is about the correct intonation and 
+precise use of the basic elements such as nada (sound), shruti 
+(musical interval), swara (note), raga (melody) tala (beat), and 
+laya (rhythm).[3] The four elements noteworthy in this context 
+are swara or note, Indian raga or melody, rasa or aesthetic mood, 
+and thaat or mode. 
+Sa, ri, ga, ma, pa, dha, and ni are the seven notes or swaras of the 
+Indian musical scale. Each of the notes or swaras either lowered 
+or raised in pitch, are known as komal (flat note) or teevra (sharp 
+note). Shadja (Sa) and Panchama (Pa) are two steady or natural notes 
+having no distortion or displacement. Rishabha (ri), Gandhara (ga), 
+Madhyama (ma), Dhaivata (dha), and Nishada (ni) are accepted as 
+having two forms as stated above, namely, one high and one low. 
+It is total of 12 notes.[5] 
+Rasa or aesthetic mood is comprehended when an emotion is 
+awakened in such a manner that it has none of its cognitive 
+tendencies, and it is experienced in an impersonal contemplative 
+mood.[6] Raga is the sequence of selected notes (swaras) that lend 
+an appropriate rasa or aesthetic mood in a selective combination. 
+Depending on its tonal quality, a raga could induce or intensify joy 
+or sorrow, excitement or peace, and it is this quality, which forms 
+the foundation for therapeutic application.[6] Thaat or mode is a 
+certain array of the seven notes with a change in shuddha (pure), 
+komal (flat), and teevra (sharp). Every raga has a fixed number of 
+komal (soft) or teevra (sharp) notes, from which the thaat can be 
+identified.[7] The shringara rasa or aesthetic mood of love is able 
+to bring out the beauty and harmony that is present in everything 
+and every moment. It creates the frame of mind, which enables 
+us to focus on generating a lovely ambience within oneself and 
+with one’s friends and family.[8] 
+The ragas are classified according to the combination of shuddha 
+(natural), komal (flat), and teevra (sharp) notes or swaras used 
+and consequently the particular rasas or moods they are able 
+to produce. Ragas with shuddha or pure notes ri, ga, dha depict 
+the aesthetic mood or the rasa of love; komal or flat ri, dha create the 
+rasa of compassion and calmness; komal or flat ga, ni creates the 
+rasa of courage or self-assurance within the listener.[7] Listening to 
+Indian ragas, which depict the mood of love, compassion, peace, 
+and courage, may be used for dissolving negative thoughts and 
+thereby bringing balance in the mental and emotional states.[5] 
+The aesthetic mood of calmness is the culmination of other rasas 
+such as love, compassion, and courage and is transcendental in 
+nature.[6] The consolidation and evocation of rasa, then, represent 
+the function of all Indian fine arts, especially music and dance.[9] 
+Many studies have suggested that the most common purpose of 
+musical experiences is to persuade emotions: People use music 
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+Nagarajan, et al.: Autonomic variables with Indian melody
+95
+Heart India, Vol 3 / Issue 4 / Oct-Dec 2015
+by increase in the sympathetic contribution. Appreciation, on 
+the other hand, elicited an increase in the medium frequency 
+component and a slight increase in the LF component, suggesting 
+more parasympathetic than sympathetic activation during the 
+positive emotion.[14]
+The activation of the sympathetic branch of the autonomic 
+nervous system (ANS) increases HR while the activation 
+of the parasympathetic branch, primarily intervened by the 
+vagus nerve, slackens it. Variation in the HR can be caused 
+by a variety of  factors including breathing, emotions, and 
+various physical and behavioral changes. The HR changes 
+in response to internal body rhythms, many of which reveal 
+various homeostatic control systems. In general, high HRV 
+represents a flexible ANS that is responsive to both internal 
+and external stimuli and is associated with fast reactions and 
+adaptability. Diminished HRV, on the other hand, represents a 
+less transient, less flexible ANS that is less able to respond to 
+stimuli change. It follows that HRV may provide a promising 
+index of an athlete’s ability to respond to both physical and 
+emotional stress and thus, of the capacity to perform physically 
+at maximal levels.[13] 
+Hypothesis
+We hypothesized that the participants who listened to Indian 
+raga Bhupali would be influenced by the aesthetic mood of the 
+song that depicts shringara rasa or love. This state of mind would 
+bring about relaxation. Further, that it would increase cardiac 
+parasympathetic activity, which is exclusively responsible for 
+the HF peak of the HR power spectrum. This would also be 
+correlated with lower scores of state anxiety. We also predicted 
+that pop music which is much liked by teenagers may be exciting 
+and cause an increase in cardiac sympathetic activity responsible 
+for the LF peak of the HR power spectrum. The study also 
+had another control condition of no music or silence which we 
+predicted may not help to silence or relax the mind. 
+MATERIALS AND METHODS 
+Subjects
+Twenty-eight undergraduate college students, both male and 
+female, with age ranging from 18 years to 24 years (19.68 ± 
+2.57 years) were recruited for the study. They were all students 
+of the Residential Yoga University. All of them were of normal 
+health based on routine case history and clinical examination. 
+All participants expressed their willingness to participate in the 
+experiment, and the project was approved by the institution’s 
+ethics committee. The study protocol was explained to the 
+subjects, and their signed consent was obtained.
+Design
+Each subject was assessed in three sessions, into which they 
+are randomly assigned. Two of them are musical sessions and 
+one session was without music. One musical session was an 
+intervention session with the Indian raga Bhupali, based on 
+popular composition. The second — control session — was with 
+pop music with steady beats. The third — control session was 
+silence or “no music session.” All the three sessions consisted 
+of three states, i.e., “pre” (5 min), “during” (10 min), and “post” 
+(5 min) for HRV. The allocation of participants to the three 
+sessions was random using a standard random number table. 
+The assessments were made on three different days for each 
+recording, not necessarily on consecutive days but at the same 
+time of the day (i.e., the self-as-control design). The design is 
+presented schematically in Figure 1.
+Interventions
+Baseline HRV was recorded for 5 min. Subsequently, HRV was 
+recorded for 10 min while the individual was exposed to the 
+Indian raga Bhupali and again it was recorded for 5 min post 
+exposure to music.
+Indian raga
+We used two pieces of melody in the raga Bhupali. The songs 
+are popular classical-based film music  — a.Jyoti Kalash Jhalake 
+played in the confluence of three instruments, the sitar (Sunil 
+Das), flute (Rakesh Chaurasia), and santoor (Ulhas Bapat) and 
+b.Pankh Hoto Uda Aatire flute rendition by Praveen Gorkhindi. 
+Pop music 
+The term “pop” is originally derived from an abbreviation of 
+“popular.” It borrows elements from other preexisting musical 
+styles, which include urban, dance, Latin, rock, and country.[15] In 
+general, college students prefer them since it invokes the feeling 
+of excitement. 
+We used Electro pop beat — a. “Can’t Keep Me Away” 
+by Chinchilla Music Production and b. K-391 - Sky City 2013 
+by K-391. Both the pieces of music use synthesizers and various 
+electronic musical instruments. 
+Assessment
+HRV was recorded by using Biopac MP 100 (Biopac Systems 
+Inc., 42 Aero Camino, Goleta, CA 93117, USA) and analyzed 
+by Kubios HRV 2.00 software (Biosignal Analysis and Medical 
+Imaging Group, University of Eastern Finland). The HRV 
+power spectrum was obtained using Fast Fourier Transform 
+(FFT) analysis. The energy in the HRV series in the following 
+Pre 5 min
+During Indian raga 10 min
+Post 5 min
+D1 (5 min)
+D2 (5 min)
+Pre 5 min
+During pop music 10 min
+Post 5 min
+D1 (5 min)
+D2 (5 min)
+Pre 5 min
+During no music or silence 10 min
+Post 5 min
+D1 (5 min)
+D2 (5 min)
+Figure 1: Schematic representation of study design — D1 indicates 
+during1; D2 during 2
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+Nagarajan, et al.: Autonomic variables with Indian melody
+96
+Heart India, Vol 3 / Issue 4 / Oct-Dec 2015
+specific frequency bands studied viz., low frequency (LF) band 
+(0.05-0.15 Hz) and high frequency (HF) band (0.15-1.50 Hz) 
+and the LF/HF ratio. The low frequency and high frequency 
+band values were expressed as normalized units. The following 
+components of time domain HRV were analyzed: (i) Mean 
+HR (average number of times your heart beats in one minute), 
+(ii) RMSSD (root mean square of successive differences) and 
+(iii) NN50 (the number of interval differences of successive 
+NN intervals greater than 50 ms). Secondarily, we correlated 
+autonomic responses to musical stimuli with the anxiety level 
+before and after each music style and also for “silence” or 
+“no music” session. The State and Trait Anxiety Inventory 
+(STAI) was used to assess anxiety.[16] The STAI consists of 
+40 items divided into two components X1 and Y1, these 
+two components assess state and trait anxiety respectively in 
+both clinical and non clinical populations. We have used X1 
+component of STAI to assess state anxiety. Scores for both 
+scales range between 20 (low anxiety) and 80 (high anxiety).[17] 
+The perceived feeling was measured using the visual analog scale 
+(VAS). The VAS consists of a horizontal 10-cm line with one 
+end representing the maximum and the other end representing 
+the minimum of the variable to be measured.[18] The right 
+anchor of the scale was identified as “feeling very good” and 
+the left anchor was labeled “feeling not good” as in Figure 2. 
+Participants indicated their state of feeling by marking a point 
+after the experimentation. 
+Data analysis
+Data were analyzed using SPSS for Windows, Version 16.0. 
+Chicago, SPSS Inc. Released 2007. There were separate repeated 
+measures of analyses of variance (ANOVAs) for each of the 
+assessments, with four within-subjects factors [i.e., states (before, 
+during 1, during 2, and after) and sessions (raga, pop, and silence)]. 
+Post hoc analysis was with Bonferroni adjustment, comparing after 
+with before values.
+RESULTS
+Cardiac measures
+The group mean values ± standard deviation (SD) and the 
+percentage change pre versus post for frequency domain 
+measures of HRV spectrum for LF, HF, and LF/HF, and time 
+domain measures of mean HR, RMSSD, and NN50 in three 
+sessions (raga, pop, and silence) in pre, during, and post states are 
+given in Tables 1 and 2, respectively. Figures 3 and 4 shows the 
+trend of percentage change shown in frequency domain measures 
+and time domain measures of HRV spectrum respectively, 
+recorded post the Indian raga session and two control sessions 
+of pop music and silence.
+Analysis of variance
+The significant changes in both frequency and time domain 
+measures in thre sessions are given in Table 3.
+Post hoc analyses with bonferroni adjustment
+Post hoc analyses with Bonferroni adjustment were performed 
+and all comparisons were made with the respective “pre” states 
+summarized in Table 4.
+In summary, there was a significant decrease in LF (P < 0.01) 
+and mean HR (P < 0.01) after  the raga session compared to the 
+preperiod. There was a significant increase in HF (P < 0.01), NN50 
+(P < 0.05), and RMSSD (P < 0.05) after the raga session compared 
+to the preperiod. There was a significant decrease in HF (P < 0.05) 
+and NN 50 (P < 0.05) during the pop session compared to the 
+prestates. The anxiety level significantly (P < 0.001) decreased post 
+the raga session as summarized in Table 5. There was a significant 
+increase in state anxiety level (P < 0.01) after the pop Session. 
+The subjective assessment of perceived feeling using the VAS 
+comparing raga with pop and silence sessions showed a significant 
+positive difference (P < 0.01) as summarized in Table 6. 
+Figure 3: The trend of percentage change shown in the frequency 
+domain measures of heart rate variability spectrum recorded post the 
+Indian raga session and two control sessions of pop music and silence
+Figure 4: The trend in arrows and percentage change shown in time 
+domain measures of heart rate variability spectrum recorded post the 
+Indian raga session and two control sessions of pop music and silence
+Figure 2: Visual analog scale
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+Nagarajan, et al.: Autonomic variables with Indian melody
+97
+Heart India, Vol 3 / Issue 4 / Oct-Dec 2015
+Psychological stress measures 
+The anxiety level before and after the sessions of raga, pop, and 
+silence or no music was assessed using the STAI.
+VAS — Visual analog scale 
+The perceived feeling was measured using VAS for all the 
+participants following raga, pop, and Silence. Repeated measures 
+of ANOVA were performed with one “within-subjects” factor, 
+i.e., raga, pop, and silence sessions. 
+DISCUSSION 
+The present study examined the changes in subjective and 
+psychophysiological responses to the Indian raga Bhupali, pop 
+music, and no music conditions. The perceived relaxation induced 
+by Indian raga was shown in both frequency domain and time 
+domain measures of HRV. 
+The LF (normalized units) component significantly decreased 
+and correspondingly HF component significantly increased 
+Table 2: Time domain measures for 3 sessions in 4 states for mean HR, RMSSD, and NN50, and the percentage 
+change (pre versus post)a
+Measures
+Sessions
+Pre
+During 1
+During 2
+Post
+% change
+Mean HR
+Raga 
+80.71±11.04
+79.789.99
+79.10±9.74
+77.68±9.86**
+3.76 ↓
+Pop
+80.32±10.64
+80.61±10.65
+80.86±10.81
+79.54±11.50
+0.98 ↓
+Silence
+79.89±8.65
+79.03±8.42
+78.61±8.46
+78.68±7.96
+1.52 ↓
+RMSSD
+Raga
+50.46±28.28
+54.61±31.30
+58.89±35.46
+59.89 ±29.36*
+18.68 ↑
+Pop
+56.11±34.23
+49.50±28.41
+47.32±21.99
+47.5 23.39
+15.28 ↓
+Silence
+51.36±34.51
+50.46 ±39.24
+50.89±35.35
+50.21±28.97
+2.22 ↓
+NN50
+Raga 
+84.32±67.46
+98.25±73.26
+102.61±73.01
+108.28±69.29*
+28.41 ↑
+Pop
+93.86±62.81
+78.86±62.45
+84.11±64.76*
+85.4359.92
+8.98 ↓
+Silence 
+92.61±68.70
+81.71±69.04
+91.96±63.16
+86.86±66.76
+6.2 ↓
+SD: Standard deviation, HR: Heart rate, aValues are group mean ± SD, *P < 0.05, **P < 0.01, ***P < 0.001, ↑: Increase, ↓: Decrease
+Table 3: Summary of ANOVA showing statistically significant results 
+Variables 
+Factor 
+F value
+DF
+Huynh-Feldt epsilon
+Level of significance
+HF
+Session
+3.493
+(2,54)
+1.000
+P<0.05
+HF 
+Sessions*states
+3.420
+(4.99, 134.721)
+0.832
+P<0.01
+LF
+Sessions
+3.579
+(2,54)
+1.000
+P<0.05
+LF
+Session*states
+3.792
+(5.21,140.70)
+0.869
+P<0.01
+Mean HR 
+States
+7.922
+(2.249, 60.719)
+0.750
+P<0.01
+Mean HR
+Session*states
+2.461
+(69.054, 131.368)
+0.811
+P<0.01
+NN50
+Session*states
+3.795
+(6,162)
+1.000
+P<0.01
+ANOVA: Analysis of variance, HF: High frequency, LF: Low frequency, HR: Heart rate
+Table 4: Significant results of post hoc analysis where 
+the arrows show the direction of changes
+Variable
+Session
+During 1 
+During 2
+Post
+LF
+Raga
+NS
+NS
+P>0.01 ↓
+HF 
+Raga
+NS
+NS
+P<0.01 ↑
+HF
+Pop
+NS
+P<0.05 ↓
+NS
+Mean HR 
+Raga 
+NS
+NS
+P< 0.01 ↓
+NN 50 
+Raga
+NS
+NS
+P<0.05 ↑
+NN 50 
+Pop
+NS
+P>0.05 ↓
+NS
+RMSSD
+Raga
+NS
+NS
+P<0.05 ↑
+NS: Not significant, ↑: Increase, ↓: Decrease, HF: High frequency, 
+LF: Low frequency
+Table 1: Frequency domain measures for 3 sessions in 4 states for LF, HF, and LF/HF with a percentage change for 
+(pre versus post)a 
+Measures
+Sessions
+Pre
+During 1
+During 2
+Post
+% change
+Low frequency 
+(LF) Power 
+(n.u.)
+Raga
+50.29±19.95
+42.44±19.09
+43.60±16.0
+42.82±18.79**
+14.85 ↓
+Pop
+47.11±19.50
+53.49±18.79
+54.62±17.65
+48.12±18.06
+2.13 ↑
+Silence
+49.72±20.31
+50.81±21.46
+50.56±19.54
+54.20±19.81
+8.98 ↑
+High frequency 
+(HF) Power 
+(n.u.)
+Raga
+49.52±19.97
+57.34±19.13
+56.20±15.93
+57.06±18.81**
+15.21 ↑
+Pop
+52.65±19.58
+48.35±19.04
+44.74±17.34*
+51.69±17.99
+1.82 ↓
+Silence
+50.15±20.29
+48.89±21.39
+49.32±19.49
+45.41±19.53
+9.45 ↓
+LF/HF Ratio
+Raga
+1.57±1.99
+.89±.83
+.71±.60
+.89±.99
+43.31 ↓
+Pop
+2.46±7.03
+1.75±1.29
+1.89±2.35
+1.57±2.38
+36.18 ↓
+Silence
+2.64 ±6.91
+3.1±8.32
+2.93±8.51
+2.54±5.94
+10.72 ↓
+SD: Standard deviation, aValues are group mean ± SD, *P < 0.05, **P < 0.01, ***P < 0.001, ↑: Increase, ↓: Decrease
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+Nagarajan, et al.: Autonomic variables with Indian melody
+98
+Heart India, Vol 3 / Issue 4 / Oct-Dec 2015
+immediately after listening to the Indian raga Bhupali. This was 
+indicative of reduced arousal and a shift in the autonomic balance 
+toward parasympathetic dominance. There was a decrease in 
+the LF/HF ratio, which was not statistically significant. The 
+LF/HF ratio is correlated with sympathovagal balance.[19] The 
+LF component of the HRV is mainly related to sympathetic 
+activation when expressed in normalized units,[20] whereas afferent 
+vagal activity is a major contributor to the HF component. 
+Apart from this, there was a significant decrease in the HF 
+component during pop music, indicative of an increase in cardiac 
+sympathetic activity.[21]
+In the time domain measures, there was a significant increase in 
+RMSSD and NN50. These indices reflect short-term variation 
+and are correlated with the HF power or the parasympathetic 
+activity.[22] There was a significant decrease in the mean HR. 
+As described above, most of the changes immediately after 
+listening to Indian raga were indicative of reduced activity in the 
+different subdivisions of sympathetic nervous system though 
+some variables are regulated by several factors. The HR, for 
+example, is regulated by twofold innervations (sympathetic and 
+parasympathetic), as well as humoral factors.[23] 
+This makes the decrease in HR complex to interpret (i.e., it could 
+be due to increased vagal tone or due to sympathetic withdrawal). 
+This also applies to HRV components. On the contrary, there was 
+a significant decrease in NN50 of the frequency domain measure 
+during pop session, which reflects sympathetic activation. 
+Collectively, the results suggest that the immediate effect of 
+listening to Indian raga Bhupali is associated with changes in the 
+autonomic nervous system suggesting vagal control.
+This was also correlated with significant reduction in the anxiety 
+level assessed using the STAI and subjective feeling of the 
+session. Cardiac vagal tone has been proposed as a stable 
+biological marker for the ability to sustain attention and regulate 
+emotion.[24]
+Possible mechanism 
+Previous studies have demonstrated particular profiles of 
+autonomic responses on different styles of music. This has 
+prompted the need to explore the effects of Indian raga, which 
+has the effect of instilling positive emotions within the listener 
+before it can be proposed as an effective music therapy. 
+The factors which reflect an emotional and effective response 
+to music are soothing and relaxing music, urban factors such 
+Table 5: State Trait Anxiety (STAI) in conditions of Indian raga, pop music, and silencea 
+Variable
+Indian Raga
+Pop music
+Silence
+Pre
+Post
+% change
+P value
+Pre
+Post
+% change
+P Value
+Pre
+Post
+% change
+P value
+STAI 28
+34.00±10.50
+28.32±7.12
+↓16.71
+0.000***
+31.11±7.98
+35.43±8.66
+13.89↑
+0.003**
+33.39±9.16
+32.61±11.68
+2.34↓
+0.637
+*P < 0.05, **P < 0.01, ***P < 0.001, ↑ = Increase, ↓: Decrease, SD: Standard deviation, aValues are group mean ± SD 
+Table 6: Scores on visual analog scale following raga, 
+pop, and silencea 
+Sessions
+Raga
+Pop
+Silence
+Mean±SD
+8.14±1.32
+6.46±2.20**
+6.64±1.98**
+SD: Standard deviation, aValues are group mean ± SD
+[Downloaded free from http://www.heartindia.net on Thursday, July 28, 2016, IP: 14.139.155.82]
+Nagarajan, et al.: Autonomic variables with Indian melody
+99
+Heart India, Vol 3 / Issue 4 / Oct-Dec 2015
+as rhythm and percussion, sophisticated factors, which include 
+classical music, an intense factor such as loudness, forceful and 
+energetic music, and campestral factor comprising country 
+and folk songs.[25] We were confident that this stimulus had a 
+stress-reducing capacity independent of individual preferences 
+because of the combination of the notes, the aesthetic mood 
+it instills while listening, the slow tempo, and the popularity of 
+the piece of music we used. The point to be noted here is that 
+using researcher-selected music stimuli have been shown to have 
+greater effects on stress reduction than music stimuli selected by 
+the subjects themselves.[26]
+In general, rock music is preferred by contemporary college 
+students and heavy metal is mostly preferred by adolescent boys. 
+Concerns have been raised regarding psychological, emotional, 
+behavioral, and physical effects associated with this music 
+preference.[27] Study taking self-report reasons for pop music 
+preference revealed that characteristics such as the melody, mood, 
+rhythm, and lyrics of a selection were the important reasons for 
+preference.[28] But the results in one of the studies indicated that 
+the dominant factor affecting emotional response was the music 
+type (either relaxing or stimulating) and not preference.[29] In one 
+of the studies, the stimulating music aroused feelings of vigor 
+and tension more than the calming music while sedative music 
+eased tension. Favorite music, regardless of music type, lowered 
+subjective tension. Physiological responses (HR, respiration, 
+and blood pressure) were greater during stimulating music than 
+during calming music. Music preference did not, however, affect 
+the physiological responses.[30] 
+Passive listening to music accelerates breathing rate and increases 
+blood pressure, HR, and the LF: HF ratio (thus suggesting 
+sympathetic activation) proportional to the tempo and perhaps 
+to the complexity of the rhythm.[31] Slow tempo with soothing 
+notes may have had helped in parasympathetic activation, which 
+is shown in our study. Pop music with steady beats may have 
+increased sympathetic activation.
+Comparison with previous studies 
+of music and heart rate variability
+There was a differential influence of  music-listening on 
+autonomic activity; it was observed that music resulted in a faster 
+autonomic recovery after stress compared to the control groups.
+[32] The results showed that acute exposure to classical baroque 
+music reduced the sympathetic tone of the heart while excitatory 
+heavy metal music decreased the variability of the HR.[33] The 
+techno music with steady beats was associated with a significant 
+increase in HR, systolic blood pressure, and significant changes 
+in self-rated emotional states.[29] The effect of trophotropic 
+(relaxing) music on HR and HRV was investigated. The results 
+showed that relaxing music (Bach, Vivaldi, and Mozart) resulted 
+in a significant reduction of HR. The significance of these 
+results might be relevant for the use of music in coronary heart 
+disease is also discussed.[34] Listening to soft music and inhaling 
+Citrus bergamia essential oil (aroma therapy) was found to be an 
+effective method of relaxation, as indicated by a shift of the 
+autonomic balance toward parasympathetic activity in young 
+healthy individuals.[35] In comparison, our results correlated with 
+previous studies where the soothing effect of Indian raga showed 
+similar effects as that of Vivaldi, Mozart, and Bach. Pop music 
+with steady beats increased sympathetic activation. 
+CONCLUSION 
+The present study results suggested the importance of the 
+aesthetic mood of music in altering autonomic responses and 
+reducing the anxiety levels. This has also helped in recognizing 
+the mechanism through which Indian music may affect the 
+physiological change by instilling a particular aesthetic mood 
+within the listener. The Indian raga Bhupali may be effectively 
+used in cardiac regulation and may also facilitate recovery 
+from poststress anxiety suggestive of applications in clinical 
+settings. In general, knowledge of musical elements will help 
+the participants to appreciate and willfully submit to the musical 
+composition. In our study, the participants were from different 
+ethnic groups and not all of them had musical training or the 
+knowledge of the elements of Indian music. In spite of this 
+factor, the musical stimulus has brought about positive changes. 
+The study may be extended to various other Indian ragas in 
+the above applied areas by identifying sensitive physiological 
+variables. 
+Respiratory rate is also influenced by the autonomic nervous 
+system but we did not measure the respiratory rate during the 
+sessions. This accounted for a limitation in our study. 
+Acknowledgements
+The authors gratefully acknowledge Dr. Hariprasad V R, Dr. 
+Kashinath Metri and Dr Raghavendra Bhat for their guidance 
+and Dr. Balram Pradhan for his help in Statistical Analysis.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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subfolder_0/Immediate effect of hot chest pack on cardio-respiratory functions in healthy volunteers A randomized cross-over study.txt

@@ -0,0 +1,1103 @@
+Accepted Manuscript
+Title: Immediate Effect of Hot Chest Pack on
+Cardio-Respiratory Functions in Healthy Volunteers: A
+Randomized Cross-Over Study
+Author: Thoudam Manjuladevi A. Mooventhan N.K.
+Manjunath
+PII:
+S2212-9588(17)30057-5
+DOI:
+https://doi.org/doi:10.1016/j.aimed.2017.12.006
+Reference:
+AIMED 140
+To appear in:
+Received date:
+16-6-2017
+Revised date:
+28-12-2017
+Accepted date:
+29-12-2017
+Please cite this article as: Manjuladevi T, Mooventhan A, Manjunath NK,
+Immediate
+Effect
+of
+Hot
+Chest
+Pack
+on
+Cardio-Respiratory
+Functions
+in
+Healthy Volunteers: A Randomized Cross-Over Study, Adv. Integr. Med. (2017),
+https://doi.org/10.1016/j.aimed.2017.12.006
+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.
+Page 1 of 22
+Accepted Manuscript
+1 
+ 
+Immediate Effect of Hot Chest Pack on Cardio-Respiratory Functions in Healthy Volunteers: A 
+1 
+Randomized Cross-Over Study 
+2 
+Thoudam Manjuladevi,1 A. Mooventhan,2 NK Manjunath3 
+3 
+1Department of Yoga and Naturopathy, The School of Yoga and Naturopathic Medicine, S-
+4 
+VYASA University, Bengaluru, Karnataka, India 
+5 
+2Senior medical officer, Department of Yoga, Center for Integrative Medicine and Research 
+6 
+(CIMR), All India Institute of Medical Sciences (AIIMS), New Delhi, India  
+7 
+3Professor, Division of Yoga and Life Sciences, and Head, Department of Research and 
+8 
+Development, S-VYASA University, Bengaluru, Karnataka, India 
+9 
+Corresponding Author: 
+10 
+Dr. A. Mooventhan, 
+ 
+11 
+Senior medical officer, Department of Yoga, Center for Integrative Medicine and Research 
+12 
+(CIMR), All India Institute of Medical Sciences (AIIMS), New Delhi, India  
+13 
+Mobile: +91 9844457496 
+14 
+E-mail: [email protected] 
+15 
+Number of words 
+16 
+• Abstract 
+: 238 
+17 
+• Text 
+ 
+:2304 
+18 
+Figures 
+ 
+: 2 
+19 
+Tables  
+ 
+: 2 
+20 
+ 
+21 
+Page 2 of 22
+Accepted Manuscript
+2 
+ 
+Immediate effect of hot chest pack on cardio-respiratory functions in healthy volunteers: A 
+1 
+randomized cross-over study 
+2 
+ABSTRACT: 
+3 
+Background: Chest pack is one of the common hydrotherapeutic procedures. Though hot chest 
+4 
+pack (HCP) is commonly employed to improve various cardio-respiratory problems, there is no 
+5 
+scientific report validating its effect on either cardiovascular or respiratory functions. The current 
+6 
+study is first of its kind, conducted to evaluate the effect of cardio-respiratory functions in 
+7 
+healthy volunteers.  
+8 
+Materials and Methods: Thirty healthy female volunteers with the age range of 18-24 years 
+9 
+were recruited and randomly divided into 2-groups. Subjects of both the groups underwent 20-
+10 
+minutes each of HCP (study session) and supine rest (control session) sessions in 2-different 
+11 
+orders. In the first group, 15 subjects underwent HCP on day-1 and SR on day-2, while in the 
+12 
+second group the order of intervention was reversed. Assessments were taken before and after 
+13 
+each session. Statistical analysis was performed using statistical package for the social sciences, 
+14 
+version 16. 
+15 
+Results: A significant reduction in systolic blood pressure was observed both in study and 
+16 
+control sessions. However, a significant reduction in diastolic blood pressure, mean arterial 
+17 
+pressure, pulse rate, rate pressure product (RPP) and double product (Do-P) along with a 
+18 
+significant improvement in peak expiratory flow rate was observed only in the study session 
+19 
+unlike control session. Moreover, reduction in RPP and Do-P was better in study session than in 
+20 
+the control session. 
+21 
+Page 3 of 22
+Accepted Manuscript
+3 
+ 
+Conclusion: Results of this study suggest that 20 minutes of HCP might be effective in 
+1 
+improving cardio-respiratory functions of healthy volunteers. 
+2 
+Keywords: Blood pressure; Cardiovascular functions; Chest Pack; Hydrotherapy; Naturopathy; 
+3 
+Respiratory functions. 
+4 
+BACKGROUND: 
+5 
+Cardiovascular functions are controlled by neural factors as well as other factors like temperature 
+6 
+and hormones. Of these, the autonomic nervous system (ANS) which is a part of neural factor 
+7 
+plays a major role in maintaining and regulating cardiac functions, e.g. systolic blood pressure 
+8 
+(SBP), diastolic blood pressure (DBP) and heart rate (HR). Imbalances in these lead to 
+9 
+cardiovascular disorders such as hypertension, ischemia and infarction.[1] Cardiovascular 
+10 
+diseases (CVD) are the main cause of mortality worldwide[2] and the leading cause of death for 
+11 
+both men and women.[3] CVD is strongly associated with lifestyle, especially the use of tobacco, 
+12 
+unhealthy diet habits, physical inactivity and psychosocial stress. The World Health 
+13 
+Organization has stated that over three-quarters of the deaths from CVD could be prevented with 
+14 
+adequate changes in lifestyle.[2] Thus, lifestyle modifications are important factors in the 
+15 
+treatment, prevention and rehabilitation of cardiovascular disorders.[1] 
+16 
+Naturopathy is a science of health and healthy living[4] emphasizing on the holistic  approach as 
+17 
+compared to the compartmental approach,[5] achieved by inculcating healthy lifestyle in 
+18 
+accordance with the laws of Nature.[4] The said objective is achieved by proper use of different 
+19 
+constituents of naturopathy like hydrotherapy, diet therapy, fasting therapy, mud therapy, helio 
+20 
+therapy, and air therapy individually or in combination.[6] Various studies have evaluated the 
+21 
+usefulness of Naturopathy intervention (alone or in combination with other therapies) for various 
+22 
+Page 4 of 22
+Accepted Manuscript
+4 
+ 
+diseases 
+including 
+bronchial 
+asthma,[5,7,8] 
+systemic 
+lupus 
+erythematosus,[9] 
+cervical 
+1 
+spondylosis,[10] rheumatoid arthritis alone[11] and with type 2 diabetes and primary 
+2 
+hypertension,[12] 
+type 
+2 
+diabetes 
+mellitus,[13] 
+metabolic 
+syndrome,[14,15] 
+acquired 
+3 
+immunodeficiency syndrome[16] etc.  
+4 
+In hydrotherapy, water in any of its forms (like ice, water, and steam/hot air) is used 
+5 
+externally/internally for the promotion of health or the treatment of various diseases.[6,17,18] 
+6 
+Previous studies have reported ice application to head and spine in healthy individuals, resulting 
+7 
+in a significant reduction in SBP, DBP, pulse pressure (PP), mean arterial pressure (MAP), rate 
+8 
+pressure product (RPP), double product (Do-P)[18] and HR while significantly improving heart 
+9 
+rate variability (HRV) towards vagal dominance.[6] Whereas, head-out warm water immersion 
+10 
+was shown to increases HR and decreases SBP and DBP.[19] Likewise, Sauna therapy (hot air) 
+11 
+was reported to produce increase in left ventricular ejection fraction, improvement in flow 
+12 
+mediated dilation and increase in number of circulating CD34+ cells and reduction in plasma 
+13 
+levels of nor-epinephrine and brain natriuretic peptide.[20] Also through sauna therapy increase in 
+14 
+endothelial nitric oxide synthase activity and improve cardiac function in heart failure cases has 
+15 
+been observed.[21] Sauna therapy was also reported to cause reduction in total and low density 
+16 
+lipoprotein (LDL) cholesterol concentration while at the same time increasing high density 
+17 
+lipoprotein (HDL) cholesterol.[22] 
+18 
+Chest pack, a commonly employed hydrotherapeutic procedures, has been reported to be 
+19 
+effective in relieving cough and expectoration through reducing pulmonary congestion by 
+20 
+bringing the blood to the surface and its powerful action upon the pulmonary mucous 
+21 
+membrane.[23] Though chest pack is commonly applied over both the lung and  the heart,[23] 
+22 
+previous study has reported the effect of cold chest pack mainly on lung functions[8] and not on 
+23 
+Page 5 of 22
+Accepted Manuscript
+5 
+ 
+cardiovascular functions. Though HCP was reported to be useful for various cardio-respiratory 
+1 
+problems,[23] its physiology is not well understood and the findings need further validation 
+2 
+through scientific studies. And, to the best of our knowledge, there is no known study reporting 
+3 
+the effect of HCP on either cardiovascular or respiratory function. Hence, the present study was 
+4 
+conducted to evaluate the effect of HCP on cardio-respiratory functions in healthy volunteers.  
+5 
+MATERIALS AND METHODS: 
+6 
+Study Design: 
+7 
+The study used randomized cross over trail design. Thirty healthy female volunteers were 
+8 
+recruited and randomly divided into 2 groups using computerized randomization. Subjects of 
+9 
+both the groups underwent 20-minutes of HCP (study session) and supine rest (SR) (control 
+10 
+session) in 2 different orders. In the first group, 15 subjects underwent HCP on day-1 and SR on 
+11 
+day-2, while the order was reversed (SR on day-1 and HCP on day-2) in the second group. 
+12 
+Baseline and post-test assessments were performed before and after each session (Figure 1). 
+13 
+Subjects:  
+14 
+Thirty healthy female volunteers between 18-24 years of age were recruited from a residential 
+15 
+University in South India based on the following inclusion and exclusion criteria. Female 
+16 
+subjects with the age range of 18-30 years and willing to participate in the study were included in 
+17 
+the study. Subjects with the history of any systemic and mental illness, those that regularly use 
+18 
+medication for a disease and those who underwent chest pack or any other hydrotherapy 
+19 
+treatments in the past 1-week were excluded from the study. Study was conducted at Anvesana 
+20 
+research laboratories, S-VYASA University, Bengaluru, India. The study was approved by the 
+21 
+institutional ethics committee and written informed consent was obtained from all the subjects. 
+22 
+Page 6 of 22
+Accepted Manuscript
+6 
+ 
+Intervention: 
+1 
+Study session: Subjects underwent HCP, a cotton cloth approximately 2.5-m long and 0.5 m 
+2 
+wide was soaked in water at 40oC and wrung out completely. It was then wrapped over the chest, 
+3 
+covering both front and back, followed by a wrapping of woolen flannel of the same dimensions 
+4 
+and maintained for a duration of 20 minutes (Figure 2).[8] 
+5 
+Control session: Subjects underwent supine rest for the duration of 20 minutes.  
+6 
+Outcomes variables: 
+7 
+The primary (cardiovascular functions) and secondary outcome (respiratory function) variables 
+8 
+(mentioned below) were taken before and after each intervention session as mentioned below: 
+9 
+Cardiovascular Variables: SBP and DBP were assessed using a sphygmomanometer (diamond 
+10 
+BPMR-120 Mercurial BP Delux, Pune, India). Pulse rate (PR) was assessed by placing fingers 
+11 
+over the radial artery of the left hand. Assessments such as PP, MAP, RPP, and Do‑P were 
+12 
+derived using following formulas: PP was calculated as (SBP - DBP); MAP as (DBP + 1/3 PP); 
+13 
+RPP as (HR × SBP/100); and Do‑P as (HR × MAP/100).[18] 
+14 
+Respiratory Variable: Peak expiratory flow rate (PEFR) was recorded using the Mini-Wright 
+15 
+(CE0120) peak flow meter (Clement Clarke International Limited, Edinburgh Way, UK) as per 
+16 
+the standard method of Wright and Mckerrow.[24] Briefly, the subjects were instructed to take a 
+17 
+maximal inspiration and blow into the mouth piece of the device rapidly and forcefully while 
+18 
+standing. The values of PEFR achieved in 3 successive attempts were recorded and highest of the 
+19 
+3 values was taken for the analysis.[5,8] The investigator was kept blinded for the study and 
+20 
+control sessions.  
+21 
+Page 7 of 22
+Accepted Manuscript
+7 
+ 
+Sample size: 
+1 
+Thirty healthy female volunteers with the age varied from 18-24 years were recruited. Sample 
+2 
+size was not calculated based on any previous study or pilot study which is one of the limitations 
+3 
+of the study.  
+4 
+Randomization: 
+5 
+Subjects were randomly divided into 2 groups [i.e. 1) first group and 2) second group] using 
+6 
+computerized randomization.  
+7 
+Blinding/masking: 
+8 
+Since the same subjects underwent both study and control sessions, it was not possible to blind 
+9 
+the intervention from the participants. However, the investigator was blinded for the study and 
+10 
+control sessions. 
+11 
+Statistical Analysis:  
+12 
+Data were checked for the normality using Kolmogorov-Smirnov test. Statistical analysis of 
+13 
+within and between sessions was performed using students paired samples-t-test (when data that 
+14 
+was normally distributed) and Wilcoxon signed ranks test (when data that was not normally 
+15 
+distributed) with the use of Statistical Package for the Social Sciences (SPSS) for Windows, 
+16 
+Version 16.0. Chicago, SPSS Inc. p-value<0.05 was considered as significant. 
+17 
+ 
+18 
+ 
+19 
+ 
+20 
+Page 8 of 22
+Accepted Manuscript
+8 
+ 
+RESULTS: 
+1 
+The demographic and baseline characteristics of the first and second groups were matching and 
+2 
+no significant changes existed between the groups (Table 1). Results of the study showed a 
+3 
+significant reduction in SBP both in study and control session. However, a significant reduction 
+4 
+in PR, DBP, MAP, RPP and Do-P along with a significant improvement in PEFR was observed 
+5 
+only in the study session, while no such significant changes were observed in the control session. 
+6 
+Moreover, the reduction in RPP and Do-P was better in the study session than control session 
+7 
+(Table 2). None of the subjects reported any serious adverse effects during the study period. 
+8 
+DISCUSSION: 
+9 
+Parameters such as SBP, DBP, PP and MAP are known as the best predictors of CVD risks.[25] 
+10 
+PEFR has been used in many studies as one of the most important variables to evaluate the 
+11 
+pulmonary functions.[5,8] Results of this study showed a significant reduction in SBP both in 
+12 
+study and control sessions. It suggests that both 20 minutes of HCP and SR is effective in 
+13 
+reducing SBP. Significant reduction in SBP followed by 20 minutes of HCP might be due to its 
+14 
+effects on either baroreceptor reflex or reduction of HR/PR. Because, SBP = cardiac output (CO) 
+15 
+× peripheral resistance, wherein CO = HR × stroke volume and thus HR forms one of the 
+16 
+determinants of SBP.[1,18] However, the reduction in SBP followed by 20 minutes of SR is not 
+17 
+clear since there was no significant reduction in HR and thus needs to be explored in the future 
+18 
+studies.  
+19 
+Results of this study also showed a significant reduction in PR, DBP, MAP, RPP and Do-P along 
+20 
+with a significant improvement in PEFR only in the study session, while no such significant 
+21 
+changes were observed in the control session when compared with its respective baseline, 
+22 
+Page 9 of 22
+Accepted Manuscript
+9 
+ 
+suggesting that 20 minutes of HCP was effective in improving various cardiorespiratory 
+1 
+variables unlike SR. Significant reduction in DBP and MAP in HCP session, unlike in SR 
+2 
+session, can be attributed to the reduction in centrally mediated peripheral resistance or 
+3 
+vasodilatation through local thermal mechanisms. Also, Reduction in RPP and Do‑P seen in the 
+4 
+study session might be due to the reduction in PR and BP. RPP and Do‑P are the important 
+5 
+indirect indicators of myocardial oxygen consumption and load on the heart. Reduction of these 
+6 
+variables in the study session suggests a strain lowering effects on the heart. Besides, when HR 
+7 
+variability (HRV) analysis is not available, the RPP can be employed as a simple measure of 
+8 
+overall HRV.[18,26] Hence, a significant reduction in both RPP and Do-P after 20 minutes of HCP 
+9 
+application compared with SR again indicates its strain lowering effect and better autonomic 
+10 
+regulation of the heart. 
+11 
+Significant reduction in cardiovascular variables along with significant improvement in PEFR in 
+12 
+the study session unlike control session, suggests that the 20 minutes of HCP was effective not 
+13 
+only in improving cardiovascular functions but also effective in improving respiratory functions. 
+14 
+The improvement in the respiratory functions might attribute through increasing the blood to the 
+15 
+surface there by reducing the pulmonary congestions and/or through its powerful action upon the 
+16 
+pulmonary mucous membrane as stated in a hydrotherapy text.[23] 
+17 
+In a previous study, 30 minutes of cold chest pack was reported to increase the pulmonary 
+18 
+function in patients with bronchial asthma by means of increasing PEFR.[8] Similarly, in the 
+19 
+present study, 20 minutes of HCP has resulted in improving pulmonary functions (increased 
+20 
+PEFR). Though the temperature of the water used for the chest pack was different in these 
+21 
+studies, better improvement in pulmonary function was observed in both the studies. Hence, a 
+22 
+Page 10 of 22
+Accepted Manuscript
+10 
+ 
+comparative study on hot and cold chest pack is needed in future to address the efficacy of these 
+1 
+treatments with one another.    
+2 
+Acute myocardial infarction is thought to result from thrombosis or plaque rupture because of 
+3 
+coronary artery spasm. Alternating heat exposure (sauna bath) followed by rapid cooling by cold 
+4 
+water might induce vasospasm by stimulation of the alpha-adrenergic receptors in patients with 
+5 
+coronary risk factors.[27] Hence, cold applications to chest, immediately after the prolong intense 
+6 
+HCP, might cause adverse effects, which need to be studied in future. Thus it is not advisable to 
+7 
+use very cold application immediately after prolong hot application to chest. Also, hot 
+8 
+application in case of early pregnancy is a potential concern because of evidence suggesting that 
+9 
+hyperthermia might be teratogenic.[28] Hence, very hot application for a prolong time should be 
+10 
+avoided in pregnancy. 
+11 
+Results of the present study suggest that the HCP can be given to healthy volunteers who would 
+12 
+like to improve their cardio-respiratory functions and for the people who are at risk of 
+13 
+developing cardiovascular and pulmonary diseases to prevent the occurrence of these diseases. 
+14 
+Since the application of HCP improves various cardiovascular functions including reduction in 
+15 
+BP and cardiac work load (as indicated by reduction in RPP and Do-P), it might be useful in 
+16 
+people with high blood pressure, coronary artery disease and cardiac failure. Similarly, 
+17 
+improvement in pulmonary function followed by the application of HCP suggests that it might be 
+18 
+useful for the people with persistent cough due to pulmonary congestions, bronchial asthma, 
+19 
+chronic obstructive pulmonary diseases etc. However, further studies (clinical trials) are required 
+20 
+to warrant the beneficial effect of HCP on the above mentioned clinical conditions.    
+21 
+Page 11 of 22
+Accepted Manuscript
+11 
+ 
+Strength of the study: To our knowledge this is the first study to evaluate the effect of HCP on 
+1 
+cardio-respiratory functions in healthy volunteers. None of the subjects reported any adverse 
+2 
+effects during the intervention. Limitations of the study: Study was conducted on healthy female 
+3 
+volunteers that limit the scope of this study in its application to healthy male subjects and in 
+4 
+pathological conditions including cardio-respiratory problems considering the body composition 
+5 
+and physiological changes of male and female as well as healthy and ill peoples are different. 
+6 
+Missing sample size calculation and the small sample size utilized in the study can be construed 
+7 
+as a limitation. Assessment of other cardio-respiratory parameters, namely slow and forced vital 
+8 
+capacities, diffusion capacity, lung volumes, total lung capacity, HRV, peripheral arterial 
+9 
+resistance, continuous BP monitoring, and baroreceptor sensitivity would have given a better 
+10 
+understanding of the state of the pulmonary functions and the cardiovascular functions 
+11 
+respectively. The present study assessed only the immediate effects of HCP on cardio-respiratory 
+12 
+functions. Assessing HCP’s long-term application effects and its underling mechanisms could 
+13 
+elevate this technique as a potential preventive and curative therapy. Hence, further studies are 
+14 
+required (Randomized control trials) on a large sample size with longer duration and advanced 
+15 
+techniques to evaluate its precise physiological and therapeutic effects with underlying 
+16 
+mechanisms. 
+17 
+CONCLUSION: 
+18 
+Results of this study suggest that 20 minutes of HCP might be effective in improving cardio-
+19 
+respiratory functions of healthy volunteers. 
+20 
+SOURCE OF FUNDING: Nil 
+21 
+CONFLICT OF INTEREST: None declared 
+22 
+Page 12 of 22
+Accepted Manuscript
+12 
+ 
+ACKNOWLEDGEMENT: We thank for their help in editing the manuscript. 
+1 
+REFERENCES: 
+2 
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+3 
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+14 
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+7. Sathyaprabha TN, Murthy H, Murthy BT. Efficacy of Naturopathy and Yoga in 
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+8. Manjunath NK, Shirley T. Therapeutic application of cold chest pack in bronchial 
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+Page 13 of 22
+Accepted Manuscript
+13 
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+9. Mooventhan A, Nivethitha L. Effects of acupuncture and massage on pain, quality of 
+1 
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+2 
+Ayurveda Integr Med. 2014;5(3):186-9.  
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+10. Rastogi R, Bendore P. Effect Of Naturopathy Treatments And Yogic Practices On 
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+Cervical Spondylosis-A Case Report. Indian J PhysiolPharmacol. 2015;59(4):442-5. 
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+11. Shetty GB, Mooventhan A, Anagha N. Effect of electro-acupuncture, massage, mud, and 
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+sauna therapies in patient with rheumatoid arthritis. J Ayurveda Integr Med. 
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+2015;6(4):295-9. 
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+12. Mooventhan A, Shetty GB. Effect of Integrative Naturopathy and Yoga in a Patient with 
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+Rheumatoid Arthritis Associated with Type 2 Diabetes and Hypertension. AncSci Life. 
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+2017;36(3):163-166. 
+11 
+13. Bairy S, Kumar AM, Raju M, Achanta S, Naik B, Tripathy JP, et al. Is adjunctive 
+12 
+naturopathy associated with improved glycaemic control and a reduction in need for 
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+14 
+BMC Complement Altern Med. 2016;16(1):290. 
+15 
+14. Mooventhan A, Shetty GB. Effect of integrative naturopathy and yoga therapies in 
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+15. Gowda S, Mohanty S, Saoji A, Nagarathna R. Integrated Yoga and Naturopathy module 
+18 
+in management of Metabolic Syndrome: A case report. J Ayurveda Integr Med. 
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+Page 14 of 22
+Accepted Manuscript
+14 
+ 
+16. Joseph B, Nair PM, Nanda A. Effects of naturopathy and yoga intervention on CD4 count 
+1 
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+immunodeficiency virus sanatorium, Pune. Int J Yoga. 2015;8(2):122-7. 
+3 
+17. Mooventhan A, Nivethitha L. Scientific evidence-based effects of hydrotherapy on 
+4 
+various systems of the body. N Am J Med Sci. 2014 May;6(5):199-209. 
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+18. Mooventhan A. Immediate effect of ice bag application to head and spine on 
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+cardiovascular changes in healthy volunteers. Int J Health Allied Sci 2016;5:53-6. 
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+19. Digiesi V, Cerchiai G, Mannini L, Masi F, Nassi F. Hemorheologic and blood cell 
+8 
+changes in humans during partial immersion with a therapeutic method, in 38 o C water. 
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+Minerva Med. 1986;77:1407–11. 
+10 
+20. Ohori T, Nozawa T, Ihori H, Shida T, Sobajima M, Matsuki A, et al. Effect of repeated 
+11 
+sauna treatment on exercise tolerance and endothelial function in patients with chronic 
+12 
+heart failure. Am J Cardiol. 2012;109:100–4. 
+13 
+21. Sobajima M, Nozawa T, Shida T, Ohori T, Suzuki T, Matsuki A, et al. Repeated sauna 
+14 
+therapy attenuates ventricular remodeling after myocardial infarction in rats by increasing 
+15 
+coronary vascularity of non-infarcted myocardium. Am J Physiol Heart Circ Physiol. 
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+2011;301:H548–54. 
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+22. Pilch W, Szyguła Z, Klimek AT, Pałka T, Cisoń T, Pilch P, et al. Changes in the lipid 
+18 
+profile of blood serum in women taking sauna baths of various duration. Int J Occup Med 
+19 
+Environ Health. 2010;23:167–74. 
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+Page 15 of 22
+Accepted Manuscript
+15 
+ 
+23. Kellogg JH. Rational Hydrotherapy. 2nd edition. Pune: National Institute of Naturopathy. 
+1 
+2005. 
+2 
+24. Wright, B.M. and C.B. Mckerrow, 1959. Maximum forced expiratory flow as a measure 
+3 
+of ventilatory capacity. British Med J. 1959;2:1041-7. 
+4 
+25. Nivethitha L, Mooventhan A, Manjunath NK. A pilot study on evaluating cardiovascular 
+5 
+functions during the practice of Bahir Kumbhaka (external breath retention). Advances in 
+6 
+Integrative Medicine. 2017; 4: 7-9. 
+7 
+26. Bhavanani AB, Madanmohan, Sanjay Z. Immediate effect of chandranadi pranayama 
+8 
+(left unilateral forced nostril breathing) on cardiovascular parameters in hypertensive 
+9 
+patients. Int J Yoga 2012;5:108‑11. 
+10 
+27. Imai Y, Nobuoka S, Nagashima J, Awaya T, Aono J, Miyake F, et al. Acute myocardial 
+11 
+infarction induced by alternating exposure to heat in a sauna and rapid cooling in cold 
+12 
+water. Cardiology. 1998;90:299–301. 
+13 
+28. Crinnion WJ. Sauna as a valuable clinical tool for cardiovascular, autoimmune, 
+14 
+toxicantinducedAnd other chronic health problems. Altern Med Rev. 2011;16:215–25. 
+15 
+ 
+16 
+ 
+17 
+ 
+18 
+ 
+19 
+ 
+20 
+ 
+21 
+Page 16 of 22
+Accepted Manuscript
+16 
+ 
+Figure 1: Trial Profile 
+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 
+Assessed for Eligibility (n=41) 
+Recruited Subjects (n=30) 
+Exclusion (n=11): Did 
+not fulfill the criteria 
+Randomization (n=30) 
+First Order (n = 15) 
+Second Order (n=15) 
+Day 1 
+Day 2 
+Day 2 
+Day 1 
+Baseline 
+(n=15) 
+Baseline 
+(n=15) 
+Baseline 
+(n=15) 
+Baseline 
+(n=15) 
+HCP (n=15) 
+SR (n=15) 
+SR (n=15) 
+HCP (n=15) 
+Post-test 
+(n=15) 
+Post-test 
+(n=15) 
+Post-test 
+(n=15) 
+Post-test 
+(n=15) 
+Data Analysis (n=30) 
+Page 17 of 22
+Accepted Manuscript
+17 
+ 
+ 
+1 
+Note: HCP = Hot Chest Pack; SR = Supine Rest 
+2 
+ 
+3 
+Figure 2: Hot chest pack given to the study subjects (n = 30) 
+4 
+ 
+5 
+ 
+6 
+ 
+7 
+ 
+8 
+Page 18 of 22
+Accepted Manuscri
+TABLES: 
+Table 1: Demographic Variables of the First Group (n = 15) and Second Group (n = 15) 
+Variables 
+First Group (n = 15) 
+Second Group (n = 15) 
+p value (Independent samples-t-test) 
+Age (years) 
+20.60±1.50 
+20.13±1.46 
+0.395 
+Gender 
+Female (n = 15) 
+Female (n = 15) 
+_ 
+Height (meter) 
+1.61±0.07 
+1.61±0.05 
+0.816 
+Weight (kilogram) 
+52.80±5.20 
+52.00±4.86 
+0.666 
+Body mass index (kilogram/meter2) 
+20.43±1.38 
+20.18±1.73 
+0.665 
+Peak expiratory flow rate (l/min) 
+302.00±64.28 
+336.00±48.67 
+0.114 
+Systolic blood pressure (mmHg) 
+117.33±7.77 
+113.33±7.43 
+0.161 
+Diastolic blood pressure (mmHg) 
+77.07±7.81 
+73.47±9.75 
+0.274 
+Pulse rate (beats/minute) 
+77.20±7.09 
+73.80±5.21 
+0.146 
+Page 19 of 22
+Accepted Manuscri
+Pulse pressure (mmHg) 
+40.27±7.55 
+39.87±8.47 
+0.892 
+Mean arterial pressure (mmHg) 
+90.49±6.94 
+86.76±8.12 
+0.187 
+Rate pressure product 
+90.76±11.87 
+83.62±7.95 
+0.063 
+Double product 
+70.04±9.96 
+64.07±7.89 
+0.079 
+Note: First group = Subjects underwent hot chest pack on day-1 and supine rest on day-2; Second group = Subjects underwent supine 
+rest on day-1 and hot chest pack on day-2. 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Page 20 of 22
+Accepted Manuscri
+Table 2: Baseline and Post-test Assessments of Study (Hot Chest Pack) and Control (Supine Rest) Sessions  
+Between SessionAnalysis 
+Variables 
+Assessment 
+Hot Chest Pack Session (n= 30) 
+with Within Group Analysis 
+Supine Rest Session (n= 30) 
+with Within Group Analysis 
+t/z value 
+p value 
+Baseline 
+321.33±54.76 
+324.33±50.97 
+-0.493 
+0.626* 
+Post-test 
+343.67±46.94 
+334.00±55.12 
+1.501 
+0.144* 
+PEFR (l/mint) 
+ 
+t = -3.999 
+p < 0.001* 
+t = -1.607 
+p = 0.119* 
+ 
+Baseline 
+113.73±8.05 
+114.13±8.72 
+-0.251 
+0.803* 
+Post-test 
+109.33±9.00 
+111.33±7.51 
+-1.246 
+0.213¶ 
+SBP (mmHg) 
+ 
+t = 4.199 
+p < 0.001* 
+z =-2.325 
+p = 0.020¶ 
+ 
+Baseline 
+76.20±8.21 
+75.33±8.29 
+-0.599 
+0.549¶ 
+Post-test 
+73.13±7.57 
+74.47±7.78 
+-0.651 
+0.515¶ 
+DBP (mmHg) 
+ 
+z = -2.626 
+p = 0.009¶ 
+z = -1.231 
+p = 0.218¶ 
+ 
+Page 21 of 22
+Accepted Manuscri
+Baseline 
+76.47±7.00 
+76.67±7.46 
+-0.145 
+0.886* 
+Post-test 
+74.13±7.24 
+76.57±6.34 
+-1.610 
+0.118* 
+PR 
+(beats/mint) 
+ 
+t = 2.251 
+p = 0.032* 
+t = 0.080 
+p = 0.937* 
+ 
+Baseline 
+37.53±7.50 
+38.80±9.61 
+-0.622 
+0.539* 
+Post-test 
+36.20±6.73 
+36.87±9.17 
+-0.362 
+0.720* 
+PP (mmHg) 
+ 
+t = 1.149 
+p = 0.260* 
+t = 1.540 
+p = 0.134* 
+ 
+Baseline 
+88.71±7.35 
+88.27±7.12 
+0.328 
+0.745* 
+Post-test 
+85.20±7.42 
+86.76±6.36 
+-1.095 
+0.282* 
+MAP (mmHg) 
+ 
+t = 4.017 
+p < 0.001* 
+t = 1.838 
+p = 0.076* 
+ 
+Baseline 
+87.10±11.37 
+87.54±11.11 
+-0.232 
+0.818* 
+Post-test 
+81.02±10.50 
+85.32±9.81 
+-2.026 
+0.043¶ 
+RPP 
+ 
+z = -3.644 
+p < 0.001¶ 
+t = 1.319 
+p = 0.197* 
+ 
+Page 22 of 22
+Accepted Manuscri
+Baseline 
+67.91±9.17 
+67.85±9.93 
+0.036 
+0.972* 
+Post-test 
+63.12±8.21 
+66.50±7.89 
+-2.151 
+0.040* 
+Do-P 
+ 
+t = 4.273 
+p < 0.001 
+t = .957 
+p = 0.347 
+ 
+Note: All values are in Mean ± Standard Deviation. *= Paired samples-t-test; ¶=Wilcoxon Signed Ranks Test. PEFR = Peak 
+expiratory floe rate; SBP = Systolic blood pressure; DBP = Diastolic blood pressure; PR = Pulse rate; PP = Pulse pressure; MAP = 
+Mean arterial pressure; RPP = Rate pressure product; Do-P = Double product. 
+ 

subfolder_0/Immediate effect of stimulation in comparison to relaxation in healthy volunteers.txt

@@ -0,0 +1,621 @@
+Indian Journal of Traditional Knowledge 
+Vol. 9 (3), July 2010, pp 606-610 
+ 
+ 
+ 
+ 
+ 
+ 
+Immediate effect of stimulation in comparison to relaxation in healthy volunteers 
+Sushil SK*, Nagendra HR & Nagarathna R 
+Swami Vivekananda Yoga Anusandhana Samsthana, 19 Eknath Bhavan, Gavipuram Circle, Bangalore 560 019, Karnataka 
+E-mail: [email protected] 
+Received 14 March 2008; revised 20 October 2009 
+In this self-control, cross over study carried out over two consecutive days, 43 healthy male volunteers aged 20-45 yrs 
+practiced 20 minutes Kapalbhati and 20 minutes Breath Awareness. Subjects were assessed before and after both practices 
+for State Anxiety, sustained attention (Six Letter Cancellation and Digit Letter Substitution tests), and verbal and spatial 
+memory. After Kapalbhati, scores reduced significantly on State Anxiety, and increased on both sustained attention, and 
+verbal and spatial memory; statistical significance was high on all variables (p<0.001). After Breath Awareness, changes 
+were also significant (p<0.001) on all variables except State Anxiety (p>0.05).  
+Keywords: Yoga, Kapalbhati, Anxiety, Attention, Memory 
+IPC Int. Cl.8: A61P25/00 
+Modern business trends both reduce physical activity 
+and increase mental strain, making for life-styles  
+that are tamasic, yet hyperactive. Minimal physical 
+activity results in lethargy, yet rajasic influences of 
+ambition fueled by strong desire drive attached  
+modes of action. This combination creates stress and 
+fatigue. One solution is a two fold process of sadhana 
+contained in Mandukya Upanishad: laye sambodhayet 
+chittam (when the mind becomes lethargic, stimulate 
+and awaken it); and vikshiptam samyet punah  
+(when it speeds up and distractions set in, calm it).  
+A 
+pranayama 
+process 
+combining 
+Kapalbhati 
+(stimulating) and breath awareness (calming) can 
+achieve this, removing stress of all kinds, and 
+developing attention span and memory1. Studies 
+suggest that yoga breathing increases spatial rather 
+than verbal scores without a lateralized effect2. In  
+one study, the yoga group showed significant 
+increases in spatial memory test scores, while verbal 
+memory test scores remained the same in all  
+subjects3. Improvement in spatial memory scores 
+following yoga can be related to reduced anxiety, 
+which improves performance on memory tasks4. 
+Practicing yoga may help in memory development by 
+deepening 
+perception, 
+reducing 
+distractibility/ 
+increasing the attention span, activating dormant areas 
+and sifting useful memories from useless ones for our 
+overall development. kapalbhati, breathing practices 
+and pranayama techniques are known to develop  
+and to improve memory5. Study of a student group 
+(mean age 20.7 yrs), showed that forced left  
+nostril breathing increased spatial performance on a 
+cognitive task6. 
+Kapalbhati is a pranayama technique, which 
+invigorates the entire brain and awakens dormant 
+centers responsible for subtle perception7. The Hath 
+Ratnavali defines it as fast rotation of the breath from 
+left to right / right to left, or exhalation and inhalation 
+through both nostrils together. Kapalbhati helps 
+eliminate CO2, cleans air passages, stimulates 
+abdominal organs, and improves autonomic balance8. 
+Increased blood circulation and O2 levels revitalize 
+and activate brain cells concerned with memory and 
+other functions, increasing concentration, improving 
+memory, and stimulating intellectual faculties9. Other 
+studies found unilateral forced nostril breathing to 
+improve spatial and verbal performance, and that  
+30-45 seconds kapalbhati increases breath holding 
+time (important for yoga sadhana)10,11. For anxiety 
+and depression, alternating fast and slow breathing 
+practices for 20-30 minutes, starting with kapalbhati 
+(fast breathing) before pranayama (slower breathing), 
+stops persistent worry12. Relaxation with Guided 
+Imagery (RGI) script yields short term reduction in 
+State-Trait Anxiety Inventory (STAI) scores, as 
+shown in each of three tests on nursing students13.  
+A previous study has investigated the effect of 
+stimulants on psycho-motor performance. Subjects 
+—————— 
+* Corresponding author 
+SUSHIL et al.: EFFECT OF STIMULATION IN HEALTHY VOLUNTEERS 
+ 
+ 
+607 
+were served either a hot drink without coffee or a hot 
+drink with coffee before taking the digit letter 
+substitution (DLS) or six letter cancellation (SLC) 
+tests. Results indicated significant increases in scores 
+on both tests following coffee administration, 
+confirming coffee's stimulating effects on psycho-
+motor functions, and suggesting that that improved 
+test performance14. No previous study has assessed 
+kapalbhati on measures of anxiety, sustained 
+attention, or verbal and spatial memory, nor has it 
+been compared with breath awareness for its effects 
+on these variables. Hence, the reasons for this study 
+being carried out. 
+ 
+Methodology 
+ 
+Subjects  
+Forty three healthy males aged 20-45 yrs  
+(mean 28 yrs) volunteered from groups completing 
+SVYASA one month residential yoga courses. They 
+were divided into 2 groups labeled kapalbhati (KB) 
+and Breath Awareness (BA).  
+ 
+Inclusion Criteria  
+Subject health was verified by routine clinical 
+examination and general health questionnaire (GHQ) 
+scores (<4). None was taking medication. Aims and 
+methods of the study were explained to them; all gave 
+written informed consent. 
+ 
+Designs 
+This was a crossover self-control study. The KB 
+group did kapalbhati on the first day and breath 
+awareness the second day; for the BA group, the order 
+was reversed. 
+ 
+Assessments 
+Assessments were made before and after KB and 
+BA practice at the same time on two consecutive 
+days.  
+ 
+Instruments 
+STAI is a self-report instrument, for study of state 
+and trait anxiety. State anxiety (STAI A-State) 
+reflects transitory emotional states characterized  
+by subjectively perceived feelings of tension, 
+apprehension, and heightened ANS activity. Intensity 
+may fluctuate over time15. The test consists of a 
+worksheet with 4 statements describing different 
+states of anxiety, said to be the most common in 
+measuring present anxiety. Subjects select score 
+numbers against each statement indicating frequency 
+of occurrence of these states: almost never, 
+sometimes, often, and almost always. STAI-A scores 
+have a direct interpretation: high scores mean more 
+state anxiety; low scores mean less. The six letter 
+cancellation (SLC) test and digit letter substitution 
+(DLS) test require visual selectivity and repetitive 
+motor response. They assess selective, focused and 
+sustained attention, visual scanning and activation and 
+inhibition of rapid responses, helping isolate major 
+components 
+of 
+performance 
+like 
+detection, 
+perception, recognition, processing and integration. 
+Both have been standardized for Indian populations16.  
+They are valid for the study of immediate effects14.  
+The SLC test consists of a worksheet containing  
+22 rows × 14 columns randomly arranged letters of 
+the alphabet, and specifying 6 target letters to be 
+canceled. Subjects strike out as many target letters as 
+possible in the specified time (90 seconds). The DLS 
+test consists of a worksheet containing 12 rows × 8 
+columns randomized digits, with a key specifying 
+pairings between digits 1-9 and Roman letters. 
+Subjects substitute as many target digits as possible  
+in the specified time of 90 seconds16. These 2 tests  
+are standard measures of attention span, hence  
+their selection. The verbal memory test consists of  
+4 different sets of 10 nonsense syllables, e.g. ZOC 
+enough to be presented both pre and post the KB and 
+BA interventions. The spatial memory test consists  
+of 10 line drawings of easily described geometrical  
+or other shapes, that are simple and reproducible  
+(not square or circle). As for verbal memory, 4 similar 
+sets of drawings are used, one each, pre and post  
+KB and BA interventions3,17. Each test is projected  
+on a laptop for the subjects allowing 10 seconds  
+for each slide. Immediately after the slides, subjects 
+are shown a mathematical problem on the screen  
+(e.g. 3+5-2+4-2-5+6-3). Subjects are then asked to 
+recall and write down (or draw in the case of spatial 
+memory) as many of the 10 test items as they can 
+within 60 seconds. 
+ 
+Test Reliability and validity 
+Reliability refers to consistency of measurement, 
+reflected in score reproducibility. Validity concerns 
+how well a test measures what it purports to. The 
+STAI and sustained attention tests have been 
+evaluated for them based on standard criteria. A-State 
+anxiety scores have high degrees of internal 
+consistency15. Their point–biseral r (Pb) correlations 
+are 0.60 and 0.73, respectively15. For the SLC test, 
+reliability is ascertained based on temporal stability 
+and internal consistency18. In the first, the correlation 
+INDIAN J TRADITIONAL KNOWLEDGE, VOL 9, NO. 3, JULY 2010 
+ 
+ 
+608 
+coefficient was calculated using unpublished pilot 
+data collected on 29 healthy male volunteers. 
+Spearman’s correlation coefficient was calculated 
+between data collected before and after a 23 min  
+non-specific intervention: subjects read a book of 
+their choice, while remaining seated. The net score 
+variable for which correlation was calculated 
+remained stable (r=.781, p=.002). As the SLC test 
+consists of one variable, internal consistency cannot 
+be calculated. Content validity of this test is adequate 
+for its intended purpose. Corresponding data on  
+the DLS test are unfortunately not available. The tests 
+of verbal and spatial memory developed at SVYASA 
+clearly test the intended variable and are valid;  
+their reliability is currently being more precisely 
+evaluated.  
+ 
+Interventions  
+Instructions were delivered by audiotape for the  
+20 minutes performance of both practices; one minute 
+practice was followed by one minute relaxation, 
+repeated 10 times. Subjects sat with their spine 
+straight. For kapalbhati, instructions were as follows: 
+Sit straight keeping your head, neck, spine erect. Take 
+a deep inhalation, exhale forcibly, blast out the air 
+using abdominal muscle, inhale passively relaxing the 
+abdominal muscles, and repeat these movements as 
+quickly as possible starting with 60 strokes per 
+minutes and increasing gradually up to 80 strokes per 
+minute. There is no holding of breath. The rapid 
+active exhalation with passive effortless inhalation is 
+accomplished by flapping movement of the abdomen, 
+continued at a uniform speed of 80 strokes per 
+minute. It is continued for 1 minute, slowing down 
+gently at the end. Following each minute's KB 
+practice, relaxation instructions were given as 
+follows: Relax … relax …yourself. Allow your 
+abdominal muscles to relax; relax your whole body 
+and mind, enjoy the deep silence of the mind, relax… 
+relax…! Breath awareness practice was performed 
+similarly: one minute practice was followed by one 
+minute relaxation, repeated ten times. Instructions 
+were as follows: Sit comfortably, relax yourself, 
+become aware of your breathing, just observe your 
+breathing pattern, simply observe, do not manipulate, 
+just go on observing, maintain your awareness 
+towards breathing, just observe, now relax, relax 
+yourself totally from toes to head, allow relaxation  
+to continue all your body and mind..! The same 
+relaxation instructions were used as in the KB session. 
+ 
+Data analysis  
+Statistical analysis was done using SPSS (version 
+10.0). Data were assessed for normality using the 
+Kolmogorov-Shapiro Test. Paired ’t’ tests and RM 
+ANOVA tests were used to assess significance within 
+and between groups, respectively. 
+ 
+Results 
+The Kolmogorov–Shapiro tests of normality 
+showed pre data of SAS, SLC and DLS tests were 
+normally distributed for both groups, while pre-data 
+of the two memory tests were not normally 
+distributed. The group means values, standard 
+deviation values, p values and percentage change 
+values of both groups, i.e. of kapalbhati and breath 
+awareness are given below (Table 1). The STAI  
+A-State (SAS) test of relatively labile state anxiety, 
+Table 1— Pre-post changes in measured variables 
+KB 
+BA 
+Test 
+N=43 
+Mean 
+± SD 
+P- 
+value 
+Post-pre 
+% change 
+Mean 
+± SD 
+P-value 
+Post-pre 
+% change 
+Pre 
+8.16 
+2.44 
+7.79 
+2.05 
+SAS 
+Post 
+7.33 
+2.01 
+0.001 
+11.32 
+7.56 
+2.11 
+0.142 
+3.04 
+Pre  
+40.65 
+9.93 
+39.86 
+11.27 
+SLC 
+Post 
+50.28 
+9.62 
+0.001 
+23.69 
+45.77 
+12.81 
+0.001 
+14.83 
+Pre 
+56.53 
+11.15 
+54.67 
+9.64 
+DLS 
+Post 
+64.95 
+12.1 
+0.001 
+14.89 
+58.35 
+9.77 
+0.001 
+6.73 
+Pre 
+3.05 
+1.84 
+3.67 
+2.04 
+MMR- VBL 
+Post 
+4.07 
+2.27 
+0.001 
+33.44 
+2.33 
+1.71 
+0.001 
+-36.51 
+Pre 
+4.56 
+1.14 
+4.81 
+1.72 
+MMR- SP 
+Post 
+6.12 
+1.28 
+0.001 
+34.20 
+4.00 
+1.46 
+0.001 
+-16.84 
+SAS-Stai A State, SLC-Six Letter Cancellation, DLS-Digit Letter Substitution, MMR VBL-Verbal, & MMR SP-Spatial Memory 
+Legend: Table 1 presents Pre-Post Mean ± Standard Deviations, significance p values and percentage changes in value for all measured 
+variables (state anxiety, sustained attention, and verbal and spatial memory) before and after Kapalbhati (KB) and Breath Awareness 
+(BA). The contrasting increase and decrease in memory scores are of great significance. 
+SUSHIL et al.: EFFECT OF STIMULATION IN HEALTHY VOLUNTEERS 
+ 
+ 
+609 
+was significantly reduced after kapalbhati practice 
+(p<0.001), but the reduction after breath awareness 
+practice did not reach significance (p=0.142>0.05) 
+(Paired ’t’ test). Between groups results were 
+significantly different (p<0.02), as given in Table 2 
+below. Scores on the SLC and DLS tests of sustained 
+attention were significantly increased for both groups 
+(p<0.001) (Paired ’t’ test). In contrast, scores on both 
+the verbal (MMR VBL) and spatial memory (MMR 
+SP) tests showed significant but opposite changes. For 
+the kapalbhati group, both significantly increased 
+(p<0.001), but for the breath awareness group, both 
+significantly decreased (p<0.001) (Paired ’t’ test). 
+ 
+Discussion 
+It has previously been established that Kapalbhati 
+practice causes autonomic activation: increased  
+heart rate and systolic blood pressure were observed 
+as an immediate effect during 3 continuous kapalbhati 
+sessions of 5 minutes each19. This suggests that 
+practice 
+of 
+kapalbhati 
+increases 
+sympathetic 
+activity20. The study found reduction in anxiety score 
+after practice of kapalbhati (11.32%, p<0.001), but 
+the 3.04% reduction following breath awareness did 
+not reach significance (p=0.142). The difference in 
+anxiety reduction between kapalbhati and breath 
+awareness was significant (p<0.023). This result 
+therefore suggests that, although it temporarily 
+increases sympathetic activation, kapalbhati is more 
+effective than breath awareness in reducing subjects' 
+anxiety levels. This might be thought surprising, 
+because previous work suggests that yoga practice 
+reduces anxiety, because of its ability to reduce 
+psycho-physiological arousal21. This is clearly not the 
+reason in the study. However, a different study 
+supports the idea that practices producing arousal 
+may, in the end, be more beneficial: cyclic meditation, 
+which combines stimulating and calming techniques, 
+practiced with a background of relaxation and 
+awareness, in the end reduces physiological arousal 
+more effectively than supine rest in shavasana, which 
+is only calming22. For the SLC and DLS tasks, the 
+results suggest that kapalbhati augments attention, 
+both 
+enhancing 
+performance, 
+and 
+reducing 
+distraction. The study found increases in sustained 
+attention scores after practice of both kapalbhati 
+(23.69% & 14.89% for SLC & DLS tasks, 
+respectively) (both p<0.001), and breath awareness 
+(14.83% & 6.73% for SLC & DLS, respectively) 
+(both p<0.001), but, again, significantly more after 
+kapalbhati than breath awareness (both SLC & DLS 
+p<0.001). These results support the idea that 
+kapalbhati is more effective in increasing subjects' 
+sustained attention span than breath awareness. 
+Since Kapalbhati increases psycho-physiological 
+arousal, this finding is consistent with the study on 
+effects of drinking coffee, which suggested that 
+coffee's 
+stimulating 
+effects 
+on 
+psycho-motor 
+function, improve test performance14. With regard  
+to memory, one study of a group trained in yoga 
+found significant increase in spatial memory  
+test scores, while verbal memory test scores 
+remained the same3. Another study reported  
+effects on memory of 4 pranayama techniques:  
+right nostril breathing, left nostril breathing, 
+alternate nostril breathing and breath awareness 
+without manipulation of nostrils2. All 4 groups 
+showed a significant increase in spatial test  
+scores (mean 84%), while the control group  
+showed no change. It was suggested that yoga 
+breathing increases spatial memory scores without a 
+lateralized effect2. It has also been suggested that 
+improvements in spatial memory scores may be due 
+to anxiety reduction, which is known to improve 
+performance on learning and memory tasks4 e.g. a 
+study of undergraduates (mean age 20.7 yrs)  
+showed that forced left nostril breathing increased 
+spatial performance on a cognitive test of mental 
+rotation, manipulation and twisting of 2 and  
+3 dimensional objects6. In this light, the present 
+study's findings that verbal and spatial memory 
+scores both increased significantly after kapalbhati 
+practice (33.44% & 34.20%, respectively, both  
+p < 0.001), but decreased significantly after  
+breath awareness practice (-36.51% & -16.84% 
+respectively, p<0.001), is very important. It was 
+found that kapalbhati does not produce a lateralized 
+effect. Also, the opposite changes in kapalbhati  
+and 
+Breath 
+Awareness 
+demonstrate 
+that 
+the 
+hypothesis that all mind-body techniques have 
+similar effects is erroneous23. 
+Table 2 —Significance of p values between groups 
+Test 
+Significance 
+SAS 
+0.023 
+SLC 
+0.007 
+DLS 
+0.01 
+MMR-VBL 
+0.001 
+MMR-SPL 
+0.001 
+SAS-Stai A State, SLC-Six Letter Cancellation,  
+DLS-Digit Letter Substitution, MMR VBL-Memory Verbal,  
+MMR SP-Memory Spatial 
+INDIAN J TRADITIONAL KNOWLEDGE, VOL 9, NO. 3, JULY 2010 
+ 
+ 
+610 
+Conclusion  
+The study suggests that both kapalbhati and breath 
+awareness reduce anxiety and improve sustained 
+attention. However, kapalbhati was significantly more 
+effective in doing so than breath awareness. In 
+contrast, they act oppositely on verbal and spatial 
+memory: whereas kapalbhati significantly increases 
+both, scores on these variables significantly declined 
+after breath awareness. This suggests that breath 
+awareness is intrinsically dulling to the mind, though 
+further experiment is needed determine whether 
+verbal instructions yield better results than the 
+repeated audio tape instructions used in the 
+experiment. This would be a significant experiment, 
+because breath awareness and related techniques are 
+considered important components of many systems of 
+psycho-spiritual development.  
+ 
+Acknowledgement 
+This work forms part of the first author's  
+(SSK) 
+dissertation 
+to 
+be 
+submitted 
+to 
+the  
+Swami Vivekananda Yoga Anusandhana Samsthana 
+(SVYASA University) in partial fulfillment of his 
+PhD. SSK is grateful to the authorities of the 
+University for the opportunity given to him. The 
+authors are grateful to Ravi Kulkarni of SVYASA's 
+division of physical sciences for his assistance in 
+statistical analysis of data, and to Alex Hankey for 
+editorial assistance. 
+ 
+References 
+1 
+Nagendra HR & Nagarathna R, New perspectives in  
+stress management, (Vivekananda Kendra Yoga Prakashna 
+Bangalore), 1998. 
+2 
+Naveen KV, Nagarathna R, Nagendra HR & Telles S, Yoga 
+breathing through a particular nostril increases spatial 
+memory scores without lateralized effects, Psychol Rep, 81 
+(1997) 555-561. 
+3 
+Manjunath NK & Telles S, Spatial and verbal memory task 
+scores following yoga and fine art camps for school children, 
+Indian J Physiol Pharmacol, 48 (2004) 353-356. 
+4 
+Saltz E, Manifest anxiety: Have we missed the data?, 
+Psychol Rev, 77 (1970) 568 – 573. 
+5 
+Nagendra HR & Telles S, Yoga & Memory, (Vivekananda 
+Kendra Yoga Prakashna, Bangalore), 1999, 27. 
+6 
+Jella SA & Shannahoff – Khalsa DS, The effects of unilateral 
+forced nostril breathing on cognitive performance, Int J  
+Neurosci, 73 (1993) 61-68.  
+7 
+Muktibodhananda, Hath yoga pradipika, (Yoga Publication 
+Trust, Munger, Bihar), 2001 187, 220-222. 
+8 
+Nagendra HR & Mohan T, Yoga in Education, (Vivekananda 
+Kendra Yoga Anusandhana Samsthana, Bangalore), 2003. 
+9 
+Lysenbeth & Andrevan, Pranayama-The yoga of breathing, 
+(Unwin Paperbacks, London), 1985. 
+10 Block RA, Arnott DP, Quigley B & Guch WC, Unilateral 
+nostril 
+breathing 
+influences 
+lateralized 
+cognitive 
+performance, Brain Cogn, 9 (1989) 181-90. 
+11 Bhole MV, Effect of kapalbhati on breath holding time, 
+Yoga Mimansa, 18 (3&4) (1956) 21-26. 
+12 Nagarathna R & Nagendra HR, Yoga practices for anxiety 
+and depression, (Swami Vivekananda Yoga Prakashna, 
+Bangalore), 2004. 
+13 King Jane Valerie, A holistic technique to lower anxiety: 
+Relaxation with guided imagery, J Holistic Nursing, 6 (1988) 
+16-20. 
+14 Natu MV & Agarawal AK, Testing of stimulant effects of 
+coffee 
+on 
+the 
+psychomotor 
+performance, 
+Indian 
+J 
+Pharmacol, 29 (1997) 11-14. 
+15 Spielberger CD, Gorsuch RL & Lushene RE, State –Trait 
+Anxiety Inventory, (Preliminary Test Manual, for Form B & 
+X), (Florida State University, Tallahassee, Florida), 1968. 
+16 Lezak MD, Neuropsychological assessment, 3rd edn, 
+(Oxford University Press, New York), 1995. 
+17 Baddelay AD, Your Memory – A user’s guide, (Avery, New 
+York), 1993. 
+18 Singh AK, Tests measurements and research methods in 
+behavioral science, (Bharati Bhavan, Patna), 2002. 
+19 Stancak AJV, Kuna MS, Vishnudevananda S & Dostalek, E, 
+Kapalbhati– Yogic cleansing exercise and cardiovascular and 
+respiratory changes, Homeost Health, 33 (3) (1991) 126-134. 
+20 Raghuraj P, Ramakrishnan AG, Nagendra HR & Telles S, 
+Effect of two selected yogic breathing techniques on heart 
+rate variability, Indian J Physiol Pharmacol, 42 (4) (1998) 
+467-472.  
+21 21 Telles S, Rajesh B & Srinivas, Automatic and respiratory 
+measures in children with impaired vision following yoga 
+and physical activity programs, Int J Rehabilitation Health, 4 
+(2) (1999) 117-122. 
+22 Telles S, Reddy SK & Nagendra HR, Oxygen Consumption 
+and respiration following two yoga relaxation techniques, 
+Appl Psychophysiol Biofeed, 25 (4) (2000) 221- 227. 
+23 Herbert B & Miriam ZK, The Relaxation Response, (Avon 
+Books), 2000. 
+ 
+ 
+ 
+ 

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+3/9/2017
+Immediate effect of two yoga­based relaxation techniques on attention in children
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997234/?report=printable
+1/4
+Int J Yoga. 2010 Jul­Dec; 3(2): 67–69.
+doi:  10.4103/0973­6131.72632
+PMCID: PMC2997234
+Immediate effect of two yoga­based relaxation techniques on attention
+in children
+Balaram Pradhan and HR Nagendra
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore ­ 560 019, India
+Address for correspondence: Dr. H. R. Nagendra, Swami Vivekananda Yoga Anusandhana Samsthana, # 19, K.G. Nagar, Bangalore ­ 560
+019, India. E­mail: [email protected]
+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.
+Abstract
+Aims:
+To investigate the effect of two yoga­based relaxation techniques, namely, cyclic meditation (CM) and
+supine rest (SR), using the six letter cancellation task (SLCT).
+Materials and Methods:
+The subjects consisted of 208 school students, (132 boys, 76 girls) in the age range of 13 – 16 years. The
+subjects were assessed on SLCT before and immediately after both yoga­based relaxation techniques.
+Results:
+After both practices, the total and net scores were significantly increased, although the magnitude of change
+was more after CM than after SR in the net scores (14.5 versus 11.31%). The net score change in the CM
+session was significantly larger than the change in the SR, whereas, there was no significant change in the
+wrong cancellation score. After either practice, the total and net scores were significantly increased,
+irrespective of gender and age.
+Conclusions:
+Both CM and SR led to improvement in performance, as assessed by SLCT, but the change caused by CM
+was larger than SR.
+Keywords: Cancellation, meditation, relaxation, yoga
+INTRODUCTION
+A yoga practice derived from an ancient Indian yoga text (Mandukya Karika) called cyclic meditation (CM)
+is a technique that combines ‘stimulating’ and ‘calming’ practices, based on a statement in an ancient yoga
+text suggesting that such a combination may be especially helpful to reach a state of mental equilibrium,
+which consists of the practice of physical postures interspersed with relaxation, which has been used for
+stress relief.[1] After this practice there was a significant reduction in oxygen consumption when compared
+to an equal period of supine rest in shavasana.[2,3]
+Recent studies on CM have suggested that sympathetic activation occurs predominantly during the yoga
+posture phases of CM, whereas, following CM, the parasympathetic nervous system becomes dominant.[4]
+The results support the idea that a combination of yoga postures with supine rest (in CM) reduces the energy
+expenditure compared to supine rest alone and[5] CM enhances the cognitive processes underlying the
+3/9/2017
+Immediate effect of two yoga­based relaxation techniques on attention in children
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997234/?report=printable
+2/4
+generation of P300.[6] CM brings about a greater improvement in the performance of the cancellation task.
+[7] To avoid the effect of memory during repeated administration, parallel worksheets have been prepared,
+by changing the sequence of letters randomly in the working section, which was not taken care of in the
+earlier study.[8]
+Hence, the present study aims to evaluate the SLCT performance on school students, following two yoga­
+based relaxation practices.
+MATERIALS AND METHODS
+Subjects
+Two hundred and eight school students were selected in the present study with an age range between 13 and
+16 years (M=13.84; SD=0.98). All of them were healthy and proficient in English. They were trained for
+practicing both CM and SR for seven days. The participants were excluded from the study if they had a
+history of neurological or psychiatric disturbances, were younger than age 12 or older than 16 years of age,
+under medication, had a history of learning disability, or were not proficient in English. After a complete
+description of the study, the participants had given their written informed consent.
+Procedure
+The participants were assessed in two types of sessions, namely, CM and SR. For half the subjects, the CM
+session took place on one day with SR the next day. The other subjects had the order of the sessions
+reversed. The subjects were alternately allocated to either schedule, to prevent the order of sessions
+influencing the results. Each session had a duration of 22 minutes and 30 seconds. Assessments were made
+immediately before and after each session.
+Instrument
+The six­letter cancellation task consisted of a test worksheet that specified the six target letters to be cancelled
+and had a ‘working section’ that consisted of letters of the alphabet arranged randomly in 14 rows and 22
+columns. The participants were asked to cancel as many six target letters as possible, which were printed at
+the top of working section of the test sheets, in the specified time, that is, 1 minute 30 seconds. They were
+told that there were two possible strategies, that is, (i) doing all six letters at a time, or (ii) selecting any one
+target letter out of the six. They were asked to choose whichever strategy suited them. They were also told
+that they could follow a horizontal, vertical or a random path according to their choice.[8] The scoring was
+done by a person who was unaware when the assessment was made, whether the participant was engaging
+in CM or SR, and whether the assessment was ‘pre’ or ‘post’ the session. The total number of cancellations
+and wrong cancellations were scored and the net scores were calculated by deducting the wrong
+cancellations from the total cancellations attempted. As this test was administered before and immediately
+after the intervention, parallel work sheets were prepared by changing the sequence of the letters randomly in
+the working section. Hence, the subjects were divided in two sessions in equal numbers and altered the next
+day. Both the sessions received one set of worksheets before a session and parallel worksheets after the
+session. The SLCT was used in a similar design in an Indian population, indicating the validity of the task, to
+study the immediate effects.[8]
+Throughout the CM practice, the subjects kept their eyes closed and followed pre­recorded instructions. The
+instructions emphasized carrying out the practice slowly, with awareness and relaxation. The practice began
+by repeating a verse (40 seconds) from the yoga text, the Mandukya Karika;[9] followed by isometric
+contraction of the muscles of the body, ending with supine rest (1:00 minute); slowly coming up on the left
+side 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 minute 20 seconds); a gap of 1
+minute 10 seconds in tadasana, with instructions about relaxation and awareness; bending to the left
+(ardhakaticakrasana, 1 minute 20 seconds); a gap as before (1 minute 10 seconds); forward bending
+(padahastasana, 1 minute 20 seconds); another gap (1 minute 10 seconds); backward bending
+(ardhacakrasana, 1 minute 20 seconds); and slowly coming down in the supine posture with instructions to
+relax different parts of the body in sequence (10 minutes). The postures were practiced slowly, with
+awareness of all the sensations that are felt. The total duration of the practice was 22 minutes 30 seconds.[2]
+3/9/2017
+Immediate effect of two yoga­based relaxation techniques on attention in children
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997234/?report=printable
+3/4
+During SR, or the ‘corpse posture’ the subjects lay supine with legs apart and arms away from the sides of
+the body and with their eyes closed. This practice lasted 22 minutes 30 seconds, so the duration was the
+same as for CM.
+Data analysis
+Statistical analysis was done using SPSS (Version 10.0). The total number of wrong attempts and the net
+score data were analyzed using the repeated measures analyses of variance (RMANOVA). There was one
+Within Subjects Factor, that is, States with two levels (pre and post) and one Between Subjects Factor, that
+is, Groups with two levels (CM or SR session). Post­hoc tests with Bonferroni adjustment were used to
+detect significant differences between the mean values.
+RESULTS
+The group mean values and standard deviation for total scores, scores for wrong cancellations, and net score
+in CM and SR sessions are given in Table 1.
+DISCUSSION
+The performance in the letter cancellation task improved immediately after the two yoga­based relaxation
+sessions, namely, CM and SR. However, the magnitude of change in the net scores after CM was 14.5% and
+after SR was 11.31%. The net score change in the CM session was significantly larger than the change in the
+SR session. There was no significant change in the wrong cancellation score after CM and SR.
+In the present study, the change in the net score had a similar trend as in an earlier study that had an identical
+design.[7] However, in the earlier study, there was a 24.9% improvement in the net score after CM and
+11.6% after SR. This difference of change could be due to the fact that the mediator in the previous study
+had an average experience of 15.3±13.3 months, while in the present study the subjects had undergone only
+a seven­day training program. These results revealed that the average duration of the practitioners had an
+influence on the outcome measures. For example, the progressive relaxation technique found slight
+differences in the first and second weeks, but major differences were observed in the fourth and fifth weeks
+in the ‘Smith Relaxation State Inventory’ before and after the session.[10]
+Cancellation tasks involve sustained attention, concentration, visual scanning, and activation and inhibition
+of rapid responses.[11] Both the yoga­based relaxation techniques bring enhancement in the performance
+task. Another study, Sahaja Yoga Meditation can lead to additional improvement in executive functions,
+such as, manipulation of information in the verbal working memory, added improvement in the attention
+span, and visual­motor speed in patients with depression.[12]
+Yoga practice has been understood to help in reducing anxiety, based on a reduction in the levels of
+psychophysiological arousal. In the earlier studies, both CM and SR, practiced for an equal period, found
+improvement in the metabolic cost,[2,3,5] autonomic function,[4] and attention measure, using P300.[6]
+Further study is required for an understanding of the mechanisms involved while forming the task and the
+effect of age and gender groups.
+REFERENCES
+1. Nagendra HR, Nagarathna R. New perspectives in stress management. Bangalore, India: Swami
+Vivekananda Yoga Publications; 1997.
+2. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration following two yoga relaxation
+techniques. Appl Psychophysiol Biofeedback. 2000;25:221–7. [PubMed: 11218923]
+3. Sarang SP, Telles S. Oxygen consumption and respiration during and after two yoga relaxation
+techniques. Appl Psychophysiol Biofeedback. 2006;31:143–53. [PubMed: 16838123]
+4. Sarang SP, Telles S. Effect of two yogic relaxation techniques on heart rate variability. Int J Stress Manag.
+2006;13:460–75.
+5. Sarang SP, Telles S. Cyclic meditation a moving meditation reduces energy expenditure more than supine
+rest. Indian J Psychol. 2007;24:17–25.
+3/9/2017
+Immediate effect of two yoga­based relaxation techniques on attention in children
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997234/?report=printable
+4/4
+6. Sarang SP, Telles S. Change in P300 following two yoga­based relaxation techniques. Int J Neurosci.
+2006;116:1419–30. [PubMed: 17145677]
+7. Sarang SP, Telles S. Immediate effect of two yoga­based relaxation techniques on performance in a letter­
+cancellation task. Percept Mot Skills. 2007;105:379–85. [PubMed: 18065059]
+8. Natu MV, Agarawal AK. Testing of stimulant effects of coffee on the psychomotor performance: An
+exercise in clinical pharmacology. Indian J Physiol Pharmacol. 1997;29:11–4.
+9. Chinmayanada . Swami Mandukya Upanishat. Bombay: Sachin Publishers; 1984.
+10. Matsumoto M, Smith JC. Progressive muscle relaxation, breathing exercise, and ABC relaxation theory.
+J Clin Psycol. 2001;57:1551–7.
+11. Lezak M, Howieson DB, Loring DW. Neuropsychological assessment. New York: Oxford University
+Press; 2004.
+12. Sharma VK, Das S, Mondal S, Goswami U, Gandhi A. Effect of Sahaja Yoga on neuro­cognitive
+functions in patients suffering from major depression. Indian J Physiol Pharmacol. 2006;50:375–83.
+[PubMed: 17402267]
+Figures and Tables
+Table 1
+Total score, scores for wrong cancellation, and net score in an SLCT pre and post the CM and SR sessions.
+Values are in group mean and standard deviation
+Cyclic meditation
+Supine rest
+Pre
+Post
+Pre
+Post
+Total score for cancellation
+39.07±12.21 44.84±13.24
+38.67±12.16 42.87±13.16
+Score for wrong cancellation
+0.53±1.39
+0.68±1.62
+0.66±1.96
+0.58±1.78
+Net score for cancellation
+38.54��12.32 44.13±13.26
+38.01±12.2
+42.31±13.26
+P<0.001, RMANOVA with Post­hoc test Bonferroni adjustment, compared with respective pre score;
+P<0.05, RMANOVA with Bonferroni adjustment between sessions, compared with post score of CM and SR;
+Total scores differed significantly between States (F=222.92, P<0.001) and there was a significant interaction between
+session and state (F=6.79, P<0.01). Also, the net scores differed significantly between states (F=218.58, P<0.001) and there
+was a significant interaction between session and state (F=4.62, P<0.033). Post­hoc analyses showed that for both CM and
+SR, there was a significant increase in total scores (P<0.001 in both sessions) and net scores (P<0.001 in both sessions)
+compared to the respective pre­values. Also there was a significant change in post mean (P<0.024) values of CM and SR in
+both total and net scores
+Articles from International Journal of Yoga are provided here courtesy of Medknow Publications
+***@
+***
+***@
+***
+***
+@